THEME 5: The Benefits of Coalitions

    • October 1, 2008

The breadth and diversity of the local Allies Against Asthma coalitions enabled them to mount a broad-based attack on childhood asthma.

"They didn't just focus on physicians or families or policy change. They worked on all of these in an effort to change the way the entire community addressed asthma," says Amy Friedman, MPH, deputy director of the national Allies program.

And that, Friedman believes, is the strength of a coalition: the ability to go after a problem at different points and from different directions.

Senior RWJF Program Officer Jeane Ann Grisso, MD, MSc, agrees. "The beauty and power of coalitions is that they often address multiple levels of a complex problem from different sectors simultaneously," she says.

Grisso, who oversaw the Allies program for RWJF, points to the diversity of the local coalitions as a significant factor in their ability to carry out multiple interventions. "It is especially exciting that health professionals worked with advocates and grassroots organizations."

Amplifying that view, leaders of the individual Allies projects identified a number of specific ways in which the coalition approach benefited their communities. A sampling follows.

Maximizing the Use of Resources

The Philadelphia Allies Against Asthma project covered a range of interventions—from educating parents about mold and cockroaches to helping health plan representatives create a standardized asthma action plan. Overseeing and coordinating it all were three paid staff, says Vanessa Briggs, executive director of the Health Promotion Council of Southeastern Pennsylvania, the nonprofit organization that convened the local Allies coalition and administered the RWJF funding.

With so few paid workers, says Briggs, the project could not have accomplished what it did had there not been a coalition of groups behind the effort. "I can't imagine one organization doing all of that without having a big staff."

The Philadelphia Allies coalition consisted of 102 people representing more than 40 organizations involved in areas spanning health care, education, insurance, and local and state health departments, as well as parents and caregivers.

According to Briggs, about 60 percent of the members participated in one or more of the nine working groups that implemented the project's components; other members took on special assignments. This broad-based stakeholder involvement permitted "a good, efficient use of resources," she says.

By design, RWJF's Allies Against Asthma national program supported community-based coalitions—not stand-alone institutions—to improve pediatric asthma control. Project staff from Philadelphia and other sites cited many benefits from this collaborative approach.

Raising Awareness of the Problem

"I think having a coalition was especially important to moving this forward," says Elisa Nicholas, MD, MSPH, founder of the Long Beach Alliance for Children with Asthma, the Allies coalition in Long Beach, Calif. "I knew to really tackle the problem, we had to go beyond the clinic walls and raise the awareness of everyone in the community of the asthma health problem."

To do that, the Long Beach effort involved various city departments (health department, air quality agency, school district and the legal aid organization) and community groups—not just health care providers—says Nicholas, who is chief of staff of Miller Children's Hospital and CEO of the Children's Clinic.

"Everything we do is through a coalition," says Elina Green, alliance project manager. The coalition approach increases the available expertise and permits staff to understand how an action or proposal will affect other interests, she says.

James Krieger, MD, MPH, director of the Seattle Allies, sees a broad-based coalition as especially important in any effort to change health care policy—either public policy or system policy.

Changing policy necessarily requires advocacy, and advocacy requires a coalition of forces, says Krieger, chief of epidemiology, planning and evaluation for the Seattle-King County Health Department. "It's kind of hard to do policy work without a coalition."

Helping Hard-to-Reach Families

Staff from severalAllies coalitions noted the value of working with organizations and individuals who have the trust and cultural compatibility to interact with members of a hard-to-reach community.

To engage families with pediatric asthma living in a poor, African-American section of North Milwaukee, it was essential to partner with a service organization based in that neighborhood, says John Meurer, MD, MBA, director of the Fight Asthma Milwaukee Allies (FAM Allies) coalition.

FAM Allies worked with Family House, a grassroots agency, to motivate parents of asthmatic children to improve asthma control in their homes and neighborhood.

Vicky Edwards, the Family House outreach coordinator, went door-to-door, identifying households with pediatric asthma and offering education and assistance. Slowly she developed a cadre of mothers willing to learn about asthma management and take steps to manage their child's disease.

Based on the encouraging results of its Family House partnership, the coalition planned to employ that same model in the city's Hispanic south side—working with a Hispanic-run organization to build capacity in the surrounding community.

Similarly, the Allies program showed the importance of including team members proficient in the relevant language. Phaktra Huch, a native of Cambodia, makes in-home education and assessment visits for the asthma coalition in Long Beach, which has a large Cambodian community.

She tells of visiting a non-English-speaking Cambodian household where the child had serious asthma and—Huch learned—no long-term control medication, such as inhaled corticosteroids, which are drugs used daily to prevent symptoms of asthma and reduce the frequency and severity of attacks. The family had been to a doctor, but he had not provided the medicine, the parents said.

Huch suspected a language problem and accompanied the family to another appointment. This time the parents left with a controller prescription.

In Seattle, Carmen Olvera, a Spanish-speaking community health worker for the city-county health department, part of the local Allies coalition, visited the home of a 2-year-old Hispanic asthmatic child with severe symptoms. The mother, who did not speak English, explained that she had been giving the child a controller medication with a nebulizer (a device that turns liquid medication into a fine spray), following instructions she got through an interpreter at the doctor's office.

"I said, 'Show me how you give the medicine.'" The demonstration immediately identified the problem: the mother was applying the liquid medicine incorrectly—so that the only thing coming out of the nebulizer was air.

"Somehow, it got mixed up," says Olvera, who noted that this is a frequent occurrence.

In Seattle, the coalition approach helped participating safety-net clinics improve their pediatric asthma care. Through the project's learning collaborative, staff of a clinic operated by Sea Mar Community Health Centers in a low-income Hispanic neighborhood learned about the county's in-home asthma education and assessment service—and began using it for patients. "Being part of that collaborative keyed us into those resources," says Cor Van Niel, MD, Sea Mar's asthma team leader.