Thousands of communities have formed coalitions over the past 20 years to tackle a wide range of public health and social issues through collaboration [1–4]. As coalitions have become commonplace in health promotion practice, the literature has grown considerably, as have the number of theories and conceptual models of coalition behavior [5–9]. One of these theories, the Community Coalition Action Theory (CCAT), includes a series of "practice-proven" propositions that summarize what is known empirically and what is commonly believed about how community coalitions can lead to improved health and social outcomes . One of its propositions is that community context, including history of collaboration, geography, demographics, and local norms and values, influence coalition functioning and outcomes at each stage of coalition development.
This proposition is strongly supported in the wisdom literature, and to a lesser extent empirically [11–13]. Given that coalitions are rooted in complex and dynamic community systems, it is intuitive that external forces within the community at least partly shape coalitions. Despite several calls for case study research on the topic, relatively few studies have attempted to systematically document how context impacts coalitions [14, 15]. Although many researchers recognize the need for theory-based research on coalitions, including contextual influences on coalitions, much of the research conducted to date lacks an underlying theoretical framework [6, 16]. The current study is one of the first theory-based studies to systematically examine how community context influences coalitions in the formation stage of development.
Coalition theories and models, including the CCAT, suggest that coalitions develop in stages [10, 17, 18]. Movement through the stages is not always linear because coalitions can cycle back to earlier stages as they take on new issues, recruit new members or update action plans. The CCAT identifies three stages: formation, maintenance and institutionalization. Formation is the first stage, and associated tasks focus on creation of a new collaborative entity or reconstitution of an existing collaborative structure into a more formal coalition. Basic tasks in the formation stage include convening a core group of coalition members, typically with a strong and shared interest in the mission of the coalition [10, 17]. This core group then mobilizes and recruits coalition members who represent a broad cross-section of the community, including professionals who work in the community, residents who represent themselves or various constituencies such as parents or neighborhoods, and individuals who both live and work in the community . Identification of staff and coalition leaders also takes place in the formation stage. Staff are usually employed by the lead agency or group that convenes the coalition and may or may not also serve in a leadership capacity for the coalition. Important leadership functions that take place in the formation stage include the establishment of an organizational structure and processes that guide coalition functioning in communication, decision-making, and conflict resolution. In a study of seven asthma coalitions, Butterfoss et al. documented that the formation stage took an average of 12 months and was heavily influenced by the level of experience partner organizations had in working together in a coalition prior to the new initiative .
Commonly mentioned contextual factors with the potential to influence coalitions in the formation stage include geography, history of collaboration, economics, political climate, and community readiness [7, 10, 21]. These factors create the backdrop in which a coalition operates and intuitively have the potential to impact coalitions in a variety of ways. The handful of studies examining context generally describe the history of collaboration or community readiness prior to coalition formation. Butterfoss et al., for example, describe how asthma coalitions were formed out of existing collaborative relationships in order to respond to a specific funding opportunity . Similarly, Nezlek and Galano found that most of the teen pregnancy prevention coalitions they observed were also formed out of pre-existing collaborative relationships .
Community readiness assessments have been done in a range of communities on a broad array of topics, often as a precursor to coalition development [23–26]. These projects used the Community Readiness Model developed by Edwards et al., which views community readiness as topic-specific, with nine stages and six dimensions such as leadership support for prevention efforts and community climate or attitudes toward the issue . Feinberg et al. explicitly examined correlations between community readiness, coalition functioning and perceived effectiveness in 21 coalitions targeting adolescent problem behavior . At the coalition level, community readiness was correlated with both internal functioning and perceived effectiveness. In discussing their findings, the authors highlighted infighting as a possible explanation for how community readiness, or lack thereof, may impede a community's ability to establish an effective coalition.
Of the relatively few case studies that examined community context, each studied different dimensions of context in relation to different outcomes, so it is difficult to synthesize findings across studies. In a multiple case study of three substance abuse prevention coalitions, Reininger et al. documented how mistrust between groups negatively affected coalition formation, particularly through challenges in leadership and staffing . In a multiple case study of coalition factors affecting implementation, Kegler et al. observed how community politics around tobacco control in a tobacco-producing state influenced coalition formation and implementation by limiting who joined the coalition and restricting the range of possible action strategies . Based on their observations as evaluators, Wandersman and colleagues documented how historical racial tensions, geographic and political divisions, and competing prevention initiatives impacted a range of coalition variables, including structure, process, leadership and planning .
The purpose of this paper is to examine how community context influenced coalition formation in eight communities participating in a broad-based healthy communities initiative that required the formation of a collaborative governance structure. This is one of the only studies to purposely focus on community context and its impact on explicit coalition factors as identified in a specific theory. This study examines how history of collaboration, community politics and history, community norms and values, community demographics and economic conditions, and geography influence key CCAT constructs associated with coalition formation: lead agency selection, staffing and leadership, coalition membership, coalition process and coalition structure.