Using collaborative coalition processes to advance community health, well-being, and equity: A multiple case study analysis from a national community transformation initiative

Abstract

Spreading Community Accelerators through Learning and Evaluation (SCALE) was a Robert Wood Johnson Foundation funded initiative from 2015–2017 to build capability of 24 community coalitions to advance health, wellbeing, and equity. The SCALE theory of change had three components: develop leadership capability, build relationships within and between communities, and create an inter-community system to spread promising ideas. The theory was operationalized through training academies, coaching, and peer-to-peer learning that explicitly addressed equity and systems change. In this paper, we describe how SCALE facilitated community transformation related to Collaborating for Equity and Justice (CEJ) principles one, three, four, and six.

We conducted a multiple case study approach with two community coalitions including site visits, interviews, and observation to illuminate underlying mechanisms of change by exploring how and why change occurs. Skid Row Women worked with women experiencing homelessness in Los Angeles to address diabetes and food systems. Healthy Livable Communities of Cattaraugus County used a portfolio of projects to create system changes to improve population health and increase access to services for people with disabilities in rural New York state.

Through our analysis, we describe how two coalitions used SCALE tools for collaborative coalition processes such as aim setting, relationship building, and shared decision making with community residents. Our findings suggest that advancing CEJ principles requires self-reflection and courage; new ways of being in relationship; learning from failure; productive conflict to explicitly address power, racism, and other forms of oppression; and methods to test systems improvement ideas.

Introduction

Community based collaborative approaches leverage the talents, resources and perspectives of diverse organizations and individuals to address large-scale, complex social challenges (Fawcett et al., 2010; Thompson et al., 2016). Collaborations can take a variety of forms such as cooperation, collaboration, informal network, coalition, partnership, strategic alliance or joint ventures (Backer et al, 2005, IOM, 2012), but they often begin when an organization or group of individuals realize that collective effort is necessary to address a community issue (Flood, Minkler, Lavery, Estrada, & Falbe, 2015). When effective, collaborations enable communities to take on larger social agendas, tougher issues, and longer-term challenges; encourage greater local participation and control; enhance efficiency and effectiveness by reducing duplication and competition; and stimulate creativity among stakeholders (Frost & Sullivan, 2013; Huang & Sheldon, 2014; Kanok, Schumann, & Flower, 2015, Mattessich, Murray-Close, & Monsey, 2001). Research on nearly three decades of community health improvement efforts found that the distinguishing factor between communities that successfully or unsuccessfully sustained improved health outcomes was strong collaboration across organizations and sectors (Pittman, 2013).

Further, equitable collaboration brings its own unique set of challenges (Thompson et al., 2016). For example, seven coalitions were funded by the Robert Wood Johnson Foundation to decrease asthma at the community level. The coalitions struggled with achieving ethnic and racial diversity within the coalition, obtaining support and participation of specific groups, mainly those with lived experiences (e.g., families of children with asthma), balancing needs of professionals and grassroots groups and/or members, managing conflict because of diverse interests, values, and approaches, sustaining participation over a large geographic area while implementing activities in prioritized communities, and recruiting leaders, especially those from the community (Butterfoss, Lachance, & Orians, 2006).

One specific type of community collaboration, the coalition, has been shown to be highly effective in improving community health and equity (Clark et al., 2014), and several scholars have studied the factors affecting the success of coalitions. A seminal paper by Kania and Kramer (2011) identified five attributes of coalitions that have achieved large-scale collective impact: a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and a backbone organization. Other authors such as Roussos & Fawcett (2000), have recommended similar criteria for coalition success such as having a clear vision and mission, action planning, developing and supporting leadership, documenting and providing ongoing feedback on progress, obtaining technical assistance and support, securing financial resources for the work, and identifying and measuring outcomes.

Recently, Wolff and colleagues (2017), proposed six additional principles to advance social change. Referred to as the Collaborating for Equity and Justice (CEJ) principles (Table 1), these principles emphasize social justice; citizen participation; local leadership capacity; focus on policy, systems, and structural change; scholarship and evaluation; and equity. The additions by Wolff and colleagues provide guidance on how community coalitions can move beyond project-based improvement and engage in transformation processes that intentionally include equitable decision-making and the lived experience of community members. Making equity explicit in collaborative decision-making and partnership processes works toward community transformation by changing the way systems function and whom they serve. The Robert Wood Johnson funded SCALE (Spreading Community Accelerators through Learning and Evaluation) initiative is a community transformation project specifically focused on building community capability to transform systems and improve health, well-being, and equity. Since the focus of SCALE is to develop local leaders and engage people with lived experience, the CEJ principles are an appropriate lens through which to explore the transformation process of SCALE community coalitions. This paper examines how CEJ principles were operationalized by two SCALE community coalitions: Skid Row Women (SRW) and Healthy Livable Communities of Cattaraugus County (CC).

Table 1.

Collaborating for Equity and Justice Principles

1. Explicitly address issues of social and economic injustice and structural racism.

2. Employ a community development approach in which residents have equal power in determining the coalition or collaborative’s agenda and resource allocation.

3. Employ community organizing as an intentional strategy and as part of the process. Work to build resident leadership and power.

4. Focus on policy, systems, and structural change.

5. Build on the extensive community-engaged scholarship and research over the last four decades that shows what works, acknowledges its complexity, and evaluates it appropriately.

6. Build core functions for the collaborative based on equity and justice that provide basic facilitating structures and build member ownership and leadership.

Overview of SCALE

In 2015, four organizations (The Institute for Healthcare Improvement [IHI], Community Solutions, Communities Joined in Action, and Network for Regional Healthcare Improvement) embarked on the Spreading Community Accelerators through Learning and Evaluation (SCALE) project. SCALE is an initiative of 100 Million Healthier Lives, a global movement convened by the Institute for Healthcare Improvement to advance health, wellbeing, and equity through new ways of collaborating. The movement’s goal is to improve 100 million lives by 2020. Between 2015 and 2017, SCALE provided training, coaching support, and improvement resources to 24 community coalitions across the US to enhance their capacity to improve health and wellbeing and spread this learning to other communities.

The SCALE theory of change outlined three components to accelerate community transformation: develop leadership capability, build relationships within and between communities, and create an inter-community system to spread promising ideas. Training was provided through four multi-day face-to-face training academies called CHILAs (Community Health Improvement and Leadership Academy). Additional training was provided virtually in small peer coaching circles and group webinars to share tools and lessons learned. Each coalition participated in SCALE through a core team involving three roles: a community lead, a local improvement advisor (LIA) trained to guide coalitions through the improvement process, and a community champion who lived in the community and had personal experience of the issue (e.g., homelessness) that the SCALE community was trying to improve. A glossary of SCALE terms is provided in Table 2.

Table 2.

Definitions of Selected SCALE Tools and Terminology

SCALE Term	Description and Purpose
Driver diagram	An illustration of the structures, processes, and norms that are believed to require change in the system; this is one way to illustrate the team’s shared theory of change.
Leading from within/leading from the heart	The inner and reflective work of leadership and one’s inner journey as a leader.
Action lab	Equity Action Lab uses a structured set of activities to bring together a diverse group of community stakeholders to set a goal that is important to them, and to design and take action over a 100-day period to make progress toward that goal (Community Solutions, Designing an Action Lab, 2016).
Open and honest questions	Communication skills designed to facilitate the exchange of ideas in a safe and non-judgmental setting.
PDSA	A Plan-Do-Study-Act cycle is an improvement method for iteratively testing a change on a small scale — by planning it, trying it, studying the results, and acting on what is learned.
“Yes, and…”	Instead of responding to another person with “Yes, but…” a response of “Yes, and…” allows the honoring of their truth and the addition of yours.
Bright spots	A set of activities, an intervention, or a program that a community is working on to improve health, wellbeing, and equity. It is scalable and shows evidence of the impact of the work on the population or subpopulation in the community.
Failing forward	The notion that mistakes are not only to be accepted as an occasional occurrence in improvement projects, but should be viewed as critical parts of the learning and improvement process. It embraces the belief that teams that fail forward quickly learn faster, reach higher levels of performance, and create a safe environment for a wide variety of ideas to be suggested and tried.

Methods

Site selection

SCALE employed a participatory formative evaluation approach to understand satisfaction, learning, and uptake of the capacity building activities across all 24 coalitions. Evaluation data were regularly shared and discussed with the coalitions and the SCALE implementation team to promote continuous quality improvement. The details of this evaluation are published elsewhere (Hayes, 2016). In addition to providing data to improve implementation, the evaluation provided the opportunity to explore the impact of SCALE on the transformation journey of a small number of community coalitions.

Evaluation resources constrained the ability to conduct a detailed study in more than a few locations. Each SCALE community coalition was unique, comprising different types of coalition partners working on a variety of community issues in diverse settings. Four criteria: geographic diversity, urban/rural setting, topic area, and readiness scores were used to select candidate communities for the case study. The readiness scores were based on two assessments: an initial assessment by the team selecting communities for participation in SCALE, and an independent assessment by the evaluation team using an established readiness heuristic (Scaccia, 2015). These scores provided an indication of the coalitions’ prior history and change experience. Based on these criteria, we sent initial inquiries asking for interest in deeper participation to five candidates, and visits were undertaken to all five coalitions. Two community coalitions, Skid Row Women of Los Angeles (SRW), led by the Downtown Women’s Center, and Healthy Livable Communities of Cattaraugus County (CC), co-led by the Cattaraugus County Health Department and the Cattaraugus County Department of Aging, emerged as a natural choice for this analysis based on their being on two extremes of the selection criteria and on their willingness to support an in-depth evaluation.

SRW has a 40-year tradition of working with women experiencing homelessness in Los Angeles, California and had a higher readiness score on both assessments. CC, established in 2011, works to create system changes to improve population health in rural New York state, and had a lower readiness score. A summary description of thesecommunities is presented in Table 3.

Table 3.

Description of Community Coalitions Studied by the SCALE Evaluation Team

Community Coalition Name	Coalition Partners	Location	Population	Project Description
Skid Row Women (SRW)	Led by the Downtown Women’s Center, other partners include United Homeless Healthcare Partners, Los Angeles Central Providers Collaborative, L.A. Care Health Plan, John Wesley Community Health Institute, and the University of Southern California School of Social Work	Urban West Coast (Los Angeles, California) community health clinic and partners serving a geographic area	Women experiencing homelessness	Yearlong diabetes group (N=50); learning collaborative created a walking group and began to develop best practices
Healthy Livable Communities of Cattaraugus County (CC)	Co-led by the Cattaraugus County Health Department and the Cattaraugus County Department of Aging. Partners have included health, colleges and secondary schools, health care, government, and community organizations such as the Healthy Community Alliance, the Southern Tier Health Care System, the City of Salamanca Youth Bureau, and Cattaraugus Community Action	Rural northeast (New York) county public spaces and workplaces	County residents and people with disabilities	Aim to raise their county health rankings in health outcomes by addressing the built environment, healthy eating and physical activity policies in schools and workplaces, food access for the low-income rural population, improving access for people with disabilities

Data Collection

As part of a larger SCALE evaluation, date collection included site visits, interviews, and collaborative reflective sessions to retrospectively identify critical moments in each coalition’s journey. Two members of the SCALE evaluation team visited each community coalition twice between August 2015 and December 2016. A semi-structured interview guide containing open-ended questions was used to explore a variety of topics including the community context, the operationalization of the SCALE theory of change, the community’s experience in interactions with the SCALE program team and coaches, tools and methods used for improvement, and observable outcomes. Each interview began with introductions, a description of the purpose of the interview, and an opportunity for interviewees to ask clarifying questions. Members were eligible to participate in the interview if they had a key role in SCALE (i.e., served as a coalition leader, local improvement advisors, community champions) or if they were recommended by a key coalition participant. Interviews were conducted at workplaces of community coalition members and ranged from 60–90 minutes in duration. All interviews were audio-recorded and transcribed verbatim. In addition, where possible, the evaluation team members asked to participate in routine coalition meetings and to tour the community sites where improvement activities were taking place. Field notes were taken in these observational sessions and follow up clarification questions based on these notes were asked as needed. Finally, the evaluation took advantage of the in-person SCALE CHILAs that the coalition members attended for further inductive discussions and refinement of the data.

Data Analysis

The evaluation team captured learning from in-person visits using a structured debriefing process, defined as a reflective feedback process to support knowledge development (Yin, 2014). After each visit, narrative summaries were developed and shared with key community coalition members for feedback. These two-page summaries included a description of the visit activities, a reflection of the discussions and a synthesis of the key accomplishment and challenges reported deductively based loosely on the SCALE project timeline and activities. Consistent with debriefing processes, these summaries were used to confirm the accuracy of the notes taken during the visits and to ensure that the conclusions derived from the notes aligned with the coalition members’ viewpoints. The verbatim interview transcripts (n=15) were used as the primary source of data, and the summaries, field notes, and community feedback were consulted for verification as needed. The analysis used a general inductive approach proposed by Thomas (2006), a systematic method of analyzing qualitative evaluation data when theory development is not the research objective.

The case study interview transcripts were coded to highlight concepts related to the SCALE theory of change and the principles of Collaborative Equity and Justice (CEJ) shown in Table 1. Two evaluators coded two interviews together to ensure consistency in coding and to refine the code book. The codes were applied to all case study interviews. Code reports were produced for each code and node matrices created by the software were used to aggregate the data from coded quotes, to summary sentences, to themes. Two sets of themes emerged from the synthesis activities: one set related to SCALE concepts and the other related to the CEJ principles. The SCALE themes aligned with CEJ principles were further organized into narratives to facilitate documentation and comparison. The SCALE evaluation was reviewed and determined to be exempt by the Institutional Review Board of the University of North Carolina [IRB 15–2621].

We use the community coalition as the unit of analysis to understand how the change process each coalition undertook under SCALE aligned with the CEJ principles. It is important to emphasize we are employing an instrumental case study approach rather than an intrinsic one. As described by Stake (1996), instrumental case studies provide insights about an issue rather than about individual cases. While this is a multiple case study analysis, our focus is to use these communities as exemplars to describe the extent to which the SCALE community improvement model conforms to the CEJ principles and not to explore the characteristics of the communities themselves.

Results

The work of SRW and CC as they followed the SCALE theory of change aligned strongest with four CEJ principles: one, three, four, and six. In this section, we describe how the SCALE approach encouraged a focus on these principles in practice, and how they were operationalized by the two community coalitions (Table 4).

Table 4.

Summary of Four CEJ Principles in SRW and CC Community Coalitions and the SCALE Design

	SCALE Design	CC	SRW
CEJ Principle 1: Explicitly address structural inequity and racism.	SCALE communities must work to advance equity in order to be part of the initiative. In-person meetings included sessions on racism and tools for coalitions to begin conversations on racism in their coalitions. Tips and motivation from peers in other communities on advancing this topic.	Understand root cause of poor health as structural — grinding poverty, lack of access, generational trauma of forced relocation of Seneca Tribe; work includes addressing health inequities through multiple interventions.	Drive to improve health for women experiencing homelessness; understand root causes of homelessness as structural inequity; Focused on advancing coalition’s understanding of racism, and facilitation skills to have meaningful discussions about racism.
CEJ Principle 3: Build resident leadership and power.	As a SCALE requirement, participating community coalitions had to include people with lived experience of the inequities being addressed (i.e., community champions).	Coalition was founded and built by government institutions and predominantly white individuals from institutions. Made steps forward in inviting people from underrepresented groups in to the coalition.	Worked to build leadership of women experiencing homelessness and experienced challenges in balancing women’s individual advocacy for their personal needs with larger coalition topics.
CEJ Principle 4: Focus on policy and systems change.	Multipronged approach to building leadership, relationship building skills, and improvement capacity aimed to build foundational skills in community transformation.	Started with their own workplaces to test and implement workplace policies that advance health; worked to improve accessibility of county buildings for people with disabilities.	Food systems change; set goal to develop best practices in health care for women experiencing homelessness and train other providers.
CEJ Principle 6: Build facilitating structures.	SCALE provided tools to support coalition teams, including meeting agenda templates, and team roles. SCALE acted as a neutral convener to bring in new partners and specified deliverables with deadlines that engaged multiple parties to move toward a shared aim (e.g., action labs). Tools to allow all to see themselves in the work, like driver diagrams and reviewing bright spots in the community, and the action lab to engage partners.	One individual owned facilitation, agendas, follow-up; subcommittee structure allowed focused topic-based work; utilized scale tools to engage many partners by building relationships and working toward shared aims.	Meeting facilitation led by a new leader who focused on her leadership development in this capacity; She focused on leading with the heart tools/techniques and strong meeting facilitation to keep coalition members engaged.

CEJ Principle 1: Explicitly address structural inequity and racism.

In SCALE equity was framed as “the price of admission” — all who participated were required to work to advance equity. At SCALE in-person trainings, racism and structural inequities were emphasized as a root cause of poor health and well-being. Coalition teams were trained on tools, like the implicit bias test, to facilitate conversations about racism in their coalition. Peer coalition teams were encouraged to share learnings and tips about what worked in efforts to address structural inequities in their community settings. SRW and CC team members reported feeling inspired and motivated by the work others were doing to advance equity and found it valuable to be part of the SCALE network.

Both SRW and CC recognized the structural inequities present in their contexts. The communities shared similar barriers to well-being including food apartheid, unhealthy built environments, poverty, and inadequate health care access. Additionally, SRW identified “racism, mental illness, incarceration, trauma, and female equity” as key community challenges. CC’s major equity challenge was historical and present day structural violence against native populations and low-income communities. While both coalitions were committed to improving equity, they reported feeling overwhelmed by the enormity of the inequities. A SRW team member shared: “It is so big that I’m just trying to think about where can I affect change in our little microcosm”. Both coalitions sought to start small enough to advance short-term improvements while remaining cognizant that changes needed to be significant enough to contribute to the broader goal of systems change.

The two community coalitions focused in different areas to address equity in their settings. SRW focused on community relationships and advancing their understanding of structural racism. In community coalition meetings, the coalition lead facilitated discussions on racism and its impact, both within the coalition and on the health of women experiencing homelessness. Several team members reported that the use of equity tools provided by SCALE (e.g., diagrams depicting inequity, poems, and completing and debriefing the implicit bias test) during meetings strengthened their coalition bond through identification of shared values and built their knowledge and skills to normalize conversations about racism and inequity.

In CC, to address equity, they designed and implemented interventions at multiple levels. Specifically, they worked across sectors to target drivers of poor health including the built environment and access to health initiatives in schools and workplaces. They also strengthened their partnership with the Seneca Nation of Indians to expand the reach of the health equity work.

Despite these differences in approaches, both coalitions used knowledge and skills gained from SCALE to acknowledge and name structural inequities in their communities. However, both struggled with the enormity of the needed structural change. The SCALE emphasis on racial equity aligned to the principle that an explicit focus on inequity and racism is critical for communities seeking to promote community change, however further work is needed to move deeper – from acknowledgement to radical change.

CEJ Principle 3: Build community member leadership and capacity.

Building SCALE community member leadership is an integral part of the SCALE theory of change, and a primary focus of the training academies. SCALE required that community champions with lived experience of the inequity being addressed be included as part of the core coalition team. To meet this aim, teams received training on meaningful engagement with community members and sharing power to co-create change.

Both coalitions applied the knowledge and skills acquired from SCALE to advance leadership capacity in their communities, but in different ways. SRW focused on building the building the leadership capability of residents who experienced homelessness. The SRW coalition lead and local improvement advisor worked with community champions (community members with lived experience) to develop skills in public speaking and community advocacy. They also coached community champions on how to have an effective voice in community leadership and steering committee meetings, and helped them frame community issues through a public health lens. As one community champion said: “The SCALE steering committee chose me to be on that committee because I have a history. I have a history of drug addiction, I have a history of high blood pressure, diabetes, mental health issues because of the trauma and because of the, you know, different things in my life. So, I had the experience.” This community champion joined because she wanted to advocate for women experiencing homelessness and wanted to reduce the stigma of experiencing homelessness.

While participation in SCALE spurred SRW to adopt this CEJ principle, it also highlighted challenges associated with co-creating solutions. First, community members continued to struggle with a lack of access to housing and personal health challenges, having limited time for coalition activities. Second, shifting from community members advising the work to sharing power and decision-making with institutional leaders proved challenging. At times, community champions and institutional representatives did not agree on coalition direction and priorities. For example, SRW selected diabetes as a focus area because there was additional grant funding available, and the focus area aligned with SCALE requirements. However, one community champion disagreed. She preferred a focus on mental health, which was perceived as a critical need among her peers: “We can be at this round table talkin’ day in and day out, but if I’m, like, mental, I don’t give a damn about diabetes. Sorry. I don’t care. So what should we push for? Mental wellness, then we get to the physical. Let’s get that first.” Coalition members openly discussed this disagreement as a critical moment and difficult decision in their coalition.

In CC, building leadership and power at the community level was difficult because the coalition was more accustomed to collaborations between institutions, and did not have a history of a strong working relationship with the Seneca Nation. The CC coalition was established as a partnership between the Public Health Department and the Office on Aging and much of their work was conducted through their network of institutional partners and personal connections — as they described it, “other people who look like them” (i.e., white women). As such, their greatest challenge was to shift from a coalition built by institutions to working in partnership with the community and building resident power. They needed to build new relationships and new leadership practices. For example, the CC LIA reported using SCALE’s reflective practices to further develop her leadership to make space to let others lead: “Learning to shut up and let other people shine, and let other people take the lead, let other people come up with ideas, let other people brainstorm them, let other people volunteer. That has been a learning curve for me.” In addition, economic incentives created a challenge: the coalition’s work on tobacco cessation was perceived by some as “coming after the Seneca” because tobacco is one of their key economic drivers. Despite these challenges, CC made progress in their collaborations. Through their work to improve population health and accessibility to county buildings for people with disabilities, CC partnered with individuals from the Seneca Nation, people with disabilities, and other people from populations in the community who were unrepresented in their coalition.

The SCALE requirement to involve of people with lived experience aligns with the CEJ principle articulated by Wolff and authors (2017), for community engagement to “prioritize leadership by people who are directly involved in the issues rather than by those professionally involved in solving the issues.” The experiences of both coalitions show that while SCALE training and tools supported progress in building resident leadership and power, such progress was not absent of practical challenges. Implementing this CEJ principle requires an intentional and sustained effort and skill building in sharing power, dealing with conflict, and relationship and leadership development.

CEJ Principle 4: Focus on policy and systems change.

The SCALE theory of change posited that systems change required improving leadership capability, relationships within and between communities, and an inter-community system to spread promising ideas. System change methods were a major component of SCALE training including the Model for Improvement (Langley et al., 2009) and design thinking, methods for relationship building, and mechanisms for sharing promising ideas and problem solving across communities. Coalitions were required to develop improvement aims and outline drivers of change. Each coalition conducted an “action lab”, a concentrated effort to develop and iteratively test small-scale system improvements. In the SCALE theory of change, these efforts were less about producing immediate results, and intended to develop the practice of transformation through innovation and experimentation.

Both community coalitions used the action lab and reported it helped them engage new partners, build relationships within their communities, and create a sense of urgency and momentum. To reduce inequities for women experiencing homelessness, SRW used the action lab to convene women experiencing homelessness and agencies that typically did not work together and were traditionally competitors for grant funding. They shared resources, curricula, and lessons learned, to develop best practices for diabetes prevention and management for women experiencing homelessness to account for the unique barriers faced by this population including lack of access to safe places to exercise, lack of access to affordable nutritious food, and financial stress. Through their action lab, SRW created a network of partners that held similar values that could work together on future projects. CC used the action lab to bring partners together to improve health in the workplace. They used small scale testing to advance healthy meetings and 30 minutes of physical activity for employees each day.

For both SRW and CC, the action lab structure helped their partnerships clarify their vision for systems change, establish a system for learning, maintain momentum, and work efficiently toward achieving their goal. However, both SRW and CC team members described the tension between seeking systems change while running programs that promote individual behavior change despite the knowledge that these kinds of programs rarely result in sustainable population outcomes. The SRW program manager noted: “Food equity, that’s always a problem. We can have diabetes programs where we’re increasing their knowledge and self-efficacy with health behaviors, but in the end, a lot of women come up to me and say, ‘You know I know this…’ So, I think that’s such a challenge. It’s just that there are so many, larger complex issues in our society that kind of prevent them from accessing the right resources for food and exercise and all those things.” The CC community representative shared the same tension, but articulated how SCALE’s training helped her see beyond a programmatic focus and stay motivated: “There’s that narrow focus of what funding’s available, what can we do with this funding? Programs, programs, programs. SCALE training opened up [new thinking]: ‘All right, let’s take that off the table.’ But what would you like to see? That visioning process was so important for me to keep doing what I’m doing, but also see the bigger picture.”

In their systems change efforts, both coalition teams reported challenges in finding time and resources for improvement, engaging partners in systems change, and pausing to document small-scale tests for their learning. In the midst of these challenges and set-backs, coalition members on both teams noted that the concept of “failing forward” (i.e., learning from failure) learned from SCALE was an important leadership mindset shift that helped them understand failure as a learning opportunity that is an integral part of the systems transformation process.

Overall, the SCALE training on systems improvement provided communities with practical tools for systems transformation, indicating partial alignment with this CEJ principle. Wolff and colleagues (2017) recommend coalitions develop advocacy and political skills, which are not covered to the same extent in the SCALE curriculum.

CEJ Principle 6: Build core functions for the collaborative based on equity and justice.

CEJ principle six encourages coalitions to create a convening group responsible for coordination and communication. As mentioned previously, all SCALE coalition teams were required to create a convening group that included people most affected by inequity. SCALE also provided collaborative engagement tools, and modeled meeting agendas to include processes for building connections and relationships. Guidance SCALE provided to strengthen coalition functioning included asking “open and honest questions” to improve active listening, using “yes, and…” to honor the truth of the person and add your own, identifying bright spots to highlight promising work done across the community, and developing aims and driver diagrams to see how many parts of the work fit together and contribute to a shared aim. Overall, both SRW and CC reported the use of SCALE tools strengthened coalition functioning by providing methods to build relationships, run meetings, and engage a group.

The SRW lead considered the process of running meetings to be critically important: “I think a lot of us have coalition fatigue and pilot fatigue. So, we didn’t want [our coalition’s participation in SCALE] to just be a typical thing, and it was also new for people to be part of a project where it wasn’t only outcome-driven, but it’s also about the process. I think we’re always having to remind our coalition about that. Like, you guys, take a breath. In nonprofit scenarios, when people get grants, they just feel this huge pressure to perform, exceed expectations, and that’s great, but it’s also like you can lose sight of the process a lot along the way. So, having a mind toward process has been really important for us, and really thinking through even these small things about how to have a good coalition meeting.” SRW used multiple strategies learned from SCALE to build an effective meeting process. They used poems to create connections in their meetings and developed processes to make sure no voice was left unheard.

In CC, the LIA was responsible for facilitation, logistics, and administration of meetings. She brought new people to meetings, including a Seneca Nation partner. To avoid top-down decision making, they created a subcommittee structure that changed their work from being organized by grants to being organized by improvement aims. This approach helped build local infrastructure to move work forward simultaneously in different areas and draw on the expertise from members of the community. For example, an equity subcommittee focused on improving access to community spaces for people with physical disabilities. It leveraged funding from multiple sources, including SCALE. The subcommittee structure allowed more people at various levels to contribute, in contrast to the large meetings that were often dominated by key institutional leaders. Each CC team member noted the importance of the subcommittee structure to advancing work and making room for all voices. In the subcommittee structure, meetings were used to identify shared areas of work and resources for advancing those areas. A CC coalition member describes a specific connection made as a result of the new structure: “What SCALE has done is, now, the person who runs the food bank program is sitting on the same subcommittee with the people that are running the Veggie Mobile, and we’re starting to say, how do we work together to make that successful?”

Overall, CC and SRW coalition members reported that the SCALE requirement to have a leadership structure that included community members and providing strategies for engagement and communication strengthened relationships, partnerships, collaboration, and coordination, and enabled the advancement of complex change processes as outlined in this CEJ principle.

Discussion

In summary, while SRW and CC worked with different populations, contexts, and aims, participation in SCALE supported both coalitions to approach their work in a way that aligned with CEJ principles one, three, four, and six. SCALE tools focused on relationship building, leadership skills, and systems change provided a foundation to address structural inequity and racism, share power and build relationships to engage community members equitably, focus on policy and systems change, and build core functions for the collaborative based on equity and justice. These efforts were not without their challenges including the frustration of making small improvements while recognizing the enormity of the needed structural change; building new relationships and sharing power and decision making that leads to conflict; and managing a functioning coalition. Advancing CEJ principles requires self-reflection and courage; new ways of being in relationship; learning from failure; productive conflict to explicitly address power, racism, and other forms of oppression; and methods to test systems improvement ideas. As Wolff and coauthors (2017) state in their seminal paper introducing the CEJ principles, “coalitions and collaborations need a new way of engaging with communities that leads to transformative changes in power, equity, and justice.” Judging from the experience of these two coalitions, the SCALE approach has embraced and promoted this vision.

Limitations

There are several limitations to this study. First, we have drawn conclusions about the alignment between SCALE and the CEJ principles based on an analysis of just two out of 24 communities. Second, because the evaluation was not designed to examine the alignment between SCALE and the CEJ principles, the data collection did not specifically ask about the CEJ principles. Third, our conclusions are drawn based on a comparison of themes that were inductively derived from interview transcript, and it is possible that connections we have made are mediated by other unknown theories or processes. Finally, to affect long lasting change, community coalitions must adopt the CEJ principles as an everyday mode of action, even when they are no longer part of SCALE. We will not know whether the actions reported by the coalitions that are aligned with the CEJ principles will sustain when SCALE funding is no longer available.

Implications for theory and practice

Collaborative approaches hold tremendous promise for community-level change. A review of 48 community change initiatives found that most communities that were part of such approaches experienced improvements at a program, organizational, or neighborhood level. However, despite noteworthy progress, most change efforts did not result in the degree of community health improvement envisioned. In fact, few efforts resulted in policy and systems reform, and few (if any) demonstrated changes in population health (Kubisch et al., 2011). Community transformation is challenging because it involves changing relationships, structures, and norms within a complex system (Trickett et al., 2011). System-level changes require long-term, sustained commitment (Fawcett et al., 2010). The gap between what can be accomplished in months and the enormity of the needed system changes to create equitable opportunity for marginalized communities creates challenges even for the most motivated coalitions (Shortell et al., 2002). Taking focused action in the face of deeply rooted historical and present-day inequities is essential for improvement. The CEJ principles are intended to be a new approach for community collaboration explicitly focused on structural transformation, but do not recommend one particular model or methodology through which to implement them.

Our analysis of two coalitions in the SCALE initiative indicates that the approach followed by SCALE has the potential to be one method through which the CEJ model for collaboration can be applied. Our results illustrate that an approach such as SCALE that strongly encourages the building of personal relationships, requires an explicit focus on racism and equity, demands that coalitions include people with experience in the community in positions of leadership, and teaches skills and methods to bring about system transformation has the potential for creating the kinds of coalitions that the CEJ recommends are needed to tackle inequity and injustice. More research is required to study the mechanisms and theories through which this approach creates the capability for community collaborations to take on deep rooted structural barriers to community health and well-being. At the same time, there is the need for more detailed evaluation of the implementation of the SCALE activities in other communities to determine whether the alignment with CEJ principles that have been identified in this study are replicated or reinforced elsewhere. We have made a promising start, and hope that these findings will encourage other researchers and practitioners to build and test similar approaches to generate a deeper body of knowledge about community transformation that promotes equity and justice.