Public Health Nursing Vol. 16 No. 1, pp. 17–220737-1209/99/$10.50q Blackwell Science, Inc.

Perceived Ownership in aCommunity Coalition

Charlotte Armbruster, M.S., R.N., Betty Gale,D.N.Sc., R.N., Jane Brady, M.S., R.N., and

Nancy Thompson, M.S., R.N.

Citizen participation is an important mechanism in healthAbstract Coalitions are emerging as a force for change in many promotion programs and a requirement of the Healthy Peo-communities and offer the opportunity for broad community ple 2000 objectives (U.S. Department of Health & Humaninvolvement in the planning and implementation of needed health

Services, 1990). Community coalitions are vehicles to pro-promotion and health education services. Perceived ownershipmote citizen participation as well as self-help and controlpromotes greater participation by the community but efforts to(Francisco, Paine, & Fawcett, 1993; Green & Raeburn,systematically evaluate ownership are lacking. The aim of this1988). Among participants, coalitions build confidence,study was to determine ownership of a local ElderCARE Coali-competencies, and social connections. With broad partici-tion’s activities and its health promotion program, Healthy WAY,

as perceived by coalition members. Fifteen of the coalition mem- pation by constituents, community coalitions promote own-bers returned the questionnaire that included the Community ership, thereby expanding resources and increasingOwnership Scale. As shown by mean scores, the agencies per- commitment to sustain long-term health promotion activi-ceived as having the most influence or greatest perceived owner- ties (McMillan, Florin, Stevenson, Kerman, & Mitchell,ship were the university college of nursing and the community 1995). Eventually, coalitions will expand health promotionaction programs. Coalition members represented a wide variety

beyond individual lifestyle and influence social policyof roles and responsibilities as well as length of time in thewithin the community.coalition (1 month to 6 years). Responses to open-ended ques-

Coalitions began in the late 1960s to create a powertions, analyzed by content analysis, supported the work of thebase for social services through political advocacy. Pro-coalition and identified the senior participants in the Healthy

WAY program as being ‘‘enthusiastic’’ but also needing to be grams that grow out of a basis of community ownershipmore ‘‘involved.’’ Process measures are important indicators of of both the problems and the solutions are most likely tohow close coalitions are staying to their grassroots constituency. succeed (Green & Kreuter, 1992). Furthermore, coalitionsImplications for public health nurses include participating as provide a framework for tailoring programs to local condi-partners in community coalitions and assisting coalitions in de- tions (McLeroy, Kegler, Steckler, Burdine, & Wisotzky,termining their sense of ownership and the need for change. 1994). While the democratic approach used in coalitions

may eventually change community norms (Thompson &Kinne, 1990), group members must be satisfied with theongoing participation process and decision-making oppor-

Charlotte Armbruster is a Faculty Associate and Betty Gale tunities to stay involved (Bracht & Tsouros, 1991).is an Associate Professor at the Arizona State University College

Community partnership models have received increasedof Nursing, Tempe, Arizona. Jane Brady is a Research Coordina-emphasis in the 1990s. Communities are beginning to taketor, Department of Obstetrics & Gynecology, Maricopa Inte-

grated Health System, Phoenix, Arizona. Nancy Thompson is an active role in identifying their own health problems andthe Oncology Program Coordinator, W. O. Boswell Memorial setting their own health goals (Abel et al., 1995); publicHospital, Sun City, Arizona. health nurses are becoming involved in these partnershipAddress correspondence to Charlotte Armbruster, Faculty As-

models (Courtney, Ballard, Fauver, Gariota, & Holland,sociate, Arizona State University, College of Nursing, Tempe, AZ85287–2602 1996). Flynn (1995) and others (Butterfoss, Goodman, &

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18 Public Health Nursing Volume 16 Number 1 February 1999

TABLE 1. ElderCARE Coalition PartnersWandersman, 1993; Francisco et al., 1993) proposed aconceptual model indicating that greater community partic-

● Adult Day Health Careipation leads to a stronger sense of perceived ownership,

● Area Agency on Agingand thus leads to effective health education programs (see ● Assistance for Independent Living AgencyFig. 1). Systematic efforts to measure perceived ownership, ● Community Action Program (CAP)however, have been lacking (Flynn, 1995). Therefore, the ● Community residentspurposes of this paper are (a) to describe one local commu- ● County department of public health

● Governor’s Council on Agingnity coalition and its health promotion program, (b) to● Hospice agenciesreport on the findings of a survey study of coalition mem-● Local hospital nursing administrative staffbers’ perception of ownership of activities and to discuss● Seniors/Healthy WAY participantsits results, and (c) to discuss implications for public health● Shared Living Facilitynurses.● University community/public health nursing faculty

(CON, WC)ELDERCARE COALITION

The ElderCARE Coalition was formed in 1991 to developnew health, safety, and support services through a commu-

like an advisory board that assigns its tasks to various staffnity partnership with older adults residing in a low income,members. According to Bracht et al. (1994), communitiessouthwestern urban neighborhood. As defined in the litera-need to design and form their own directions and developture (Butterfoss et al., 1993), coalitions are composed ofthe necessary skills and resources to manage theirindividuals representing diverse organizations and commu-accomplishments.nity sectors. The ElderCARE Coalition has members from

a university college of nursing (CON), a community action SURVEY STUDYprogram (CAP), a local hospital, the county health depart-

Designment, and other local agencies providing services to seniors(Table 1). The aim of the survey was to determine ownership of

The health promotion program, Healthy WAY, is spon- coalition activities and the Healthy WAY as perceived bysored and facilitated by the ElderCARE Coalition. This the coalition members. The study combined quantitativeprogram has served more than 400 older adults to date and qualitative methods. The design of the quantitativewith health promotion programs such as falls prevention, part of the study was descriptive and measures of centralwalking and fitness, nutrition education, disease prevention tendency were used for the analysis. Initial questions askedscreenings, and case finding. Follow-up and advocacy are sociodemographic information (gender, ethnicity, length ofcurrently provided by a nursing Wellness Coordinator involvement with the coalition, and role in the coalition).(WC). Philosophically, participants (consumers) of the The second set of questions addressed perceived ownershipHealthy WAY program are also coalition partners. The of the coalition and Healthy WAY program, based oncoalition operates in a nonhierarchical manner: All partners Flynn’s Community Ownership Scale (1995)*, and utilizedhave an equal voice and decisions are made by consensus. a four-category Likert scale (from none 4 1 to a lot 4 4).The coalition is an active working group and does not act The qualitative part of the study used open-ended questions

such as ‘‘What do you see as the most beneficial aspectof the Healthy WAY program?’’ and a space for comments.Content analysis included generating key ideas, words,phrases, formations of categories, and clustering of catego-ries into themes (Zemke & Kramlinger, 1985).

Setting and Sample

The setting was a community center in a low income, olderneighborhood. The services provided by the city includedan active youth program, and the services provided by theCAP included rent assistance, case management, a foodbank, home delivered meals, and a senior center program.

*Name, Community Ownership Scale, by permission of Ox-ford University Press.Figure 1. Conceptual Framework

Armbruster et al.: Perceived Ownership 19

The personnel of the senior center program did not have cation, but Flynn (personal communication, April 23, 1997)encouraged adaptation of the instrument and its use as acontrol over the ElderCARE Coalition but were collaborat-

ing partners in the facilitation of the Healthy WAY project. diagnostic and evaluative tool.The survey was distributed to a convenience sample of 19

RESULTS AND DISCUSSIONcoalition partners. Fifteen surveys were returned for anoverall response rate of 78.9%. The dominant ethnic back- The range of time during which respondents had beenground of the participants was White (93.3%, N 4 14); involved with the coalition was 1 month to 6 years. Theonly one member was African American (6.7%). Eighty average length of time was 31⁄2 years. This variation showspercent of the participants were female. both the commitment of members to the coalition over

The university institutional review board approved the time and also the ability of the coalition to continue tosurvey study. In a cover letter included with the survey, attract new members.the participants were informed of confidentiality, of ano-nymity of the responses, and that participation in the survey Quantitative Analysiswas an indication of consent. A verbal introduction and

The results from the Community Ownership Scale (Flynn,brief explanation of the survey was given prior to distribu-1995) are shown in Table 2. The CON was perceived astion to the coalition members. Participants were given onehaving the most influence on the overall goals of theweek to complete and return the surveys. Envelopes andHealthy WAY program (M 4 3.67), long-range plans (Mpostage were provided to those who wished to return their4 3.60), program evaluation (M 4 3.67), and hiring ofsurveys by mail.staff (M 4 3.00). Since the program focused on health,

Instrument these responses were not too surprising. Nurses are usuallycomfortable with the assumption of leadership and deci-The survey used the Community Ownership Scale whichsion-making roles (Stanhope & Lancaster, 1996) and inwas designed by Flynn (1995) specifically to measure per-this community partnership, were able to strongly influenceception of ownership in community coalition members.the shaping of the health promotion program. The WellnessOwnership was defined as perceived control over key com-Coordinator was also a university faculty member and wasponents of the Healthy WAY program and of coalitionperceived as having the most influence in the followingactivities, such as overall goals and program activities,areas: Outlining the annual program plans (M 4 3.73);deciding the structure of the coalition and committees, etc.evaluating the program (M 4 3.67); designing the programThese components are stated in the Appendix as the keyactivities (M 4 3.87); and deciding how the program activ-function list.ities were conducted (M 4 3.93).The content validity of the instrument was measured

The CAP was a social service agency with a 30-yearand reported when the instrument was used initially byhistory in the neighborhood. They were perceived as havingFlynn (1995). Flynn provided reasonable assurance of thethe most influence on coalition membership (M 4 3.40),content validity of the instrument with extensive reviewcommittee structure (M 4 3.80), meeting schedule andby expert panels. Validity of an instrument, however, mayorganization of staff (M 4 3.53), agenda setting (M 4vary from one sample or situation to another (Burns &3.93), leading meetings (M 4 3.47), developing theGrove, 1993).Healthy WAY budget (M 4 3.73), and deciding how theFlynn (1995) established three subscales to measuremoneys were spent (M 4 3.87). The CAP was the baseownership for each group as they perceived ownership forof operations for the coalition and the lead fiscal agent forthemselves. The three groups were community leaders,grants so their perceived (and real) ownership was strong.members of external agencies, and program staff. For the

The hospital, other community agencies, and senior par-community leader subscale, the reliability coefficient wasticipants were perceived as having the least influence. Thea 4 0.88, for external agency subscale it was a 4 0.91,grand mean ranges from 3.34 for CON to 2.09 for seniorsand for local staff it was a 4 0.72. These coefficients(Table 2). Overall, the mean scores reflect the collaborativewere an indication of a high level of internal consistencynature of the ElderCARE Coalition, even though the partic-and retesting was not done. Our survey was modified toipation of the seniors was perceived as marginal.include a more specific listing of the participants in the

ElderCARE Coalition, including CON faculty, Healthy Qualitative AnalysisWay WC, CAP staff, local hospital staff, other agencycoalition members, and senior participants. In addition, one The survey form had a space for Comments, which all

of the participants used. Content analysis yielded sevenquestion regarding decisions about how the Healthy WAYprogram budget is spent was added (Appendix). This may categories: Coalition structure and members; health pro-

grams; Wellness Coordinator; seniors; newsletter; andhave affected the reliability of the instrument in this appli-

20 Public Health Nursing Volume 16 Number 1 February 1999

TABLE 2. Relative Influence Over Key Functions Perceived for Each Group (by Mean)

Influence on . . . CON: WC: CAP: Hospital: Agencies: Seniors:M M M M M M

Overall goals 3.67 3.47 3.60 3.20 2.93 2.67Annual plans 3.60 3.73 3.67 3.13 2.93 2.53Long-range plans 3.60 3.33 3.87 3.13 3.13 2.67Program evaluation 3.67 3.67 3.47 2.80 2.53 2.40Design activities 3.40 3.87 3.67 3.20 3.07 2.47Conduct activities 3.33 3.93 3.40 3.07 2.80 2.53Coalition membership 3.20 2.60 3.40 2.60 3.07 2.13Coalition structure 3.47 3.07 3.80 2.93 3.13 2.20Schedule meetings 2.67 2.40 3.53 2.40 2.73 2.33Set agenda 3.27 2.80 3.93 2.67 2.73 2.20Lead meetings 3.07 2.60 3.47 2.40 2.33 1.73Hire Healthy WAY staff 3.00 1.80 2.93 1.80 1.13 1.00Organize staff 3.40 2.80 3.53 2.40 1.80 1.60Develop program budget 3.40 2.27 3.73 2.67 1.87 1.20Spend budget 3.40 2.47 3.87 2.67 2.07 1.67

Grand mean 3.34 2.99 3.59 2.74 2.55 2.09

questionnaire format. Highlights from the analysis are help in order to carry out the goals that had been set forthe Healthy WAY program by the coalition members.presented.

Coalition Structure and Members SeniorsIn the past, there had been six to eight senior programThe ElderCARE Coalition oversaw the activities of the

Healthy WAY program. The members were recruited from participants involved in the Coalition. In this study, therewere three seniors actively involved and regularly attendingcommunity agencies that shared an interest in the health

of seniors, from a number of interested faculty and students coalition meetings. The seniors were seen as ‘‘enthusias-tic’’ about the health program but needed ‘‘more involve-at several colleges of the university, and from the commu-

nity of seniors involved at the Senior Center. Comments ment’’ in the program planning and evaluation.included, ‘‘All the members of the coalition have an equal

Newslettervoice, vote and dedication to service’’; ‘‘the coalition is aA newsletter was published quarterly and required the coor-dynamic group that produces excellent results’’; ‘‘a specialdination of many individual efforts. Articles and informa-advantage that this coalition has is its association with thetion for each newsletter were actively solicited at eachuniversity’’; and, ‘‘the coalition’s efforts are appreciatedcoalition meeting and comments included a reminder thatby the people they are working to serve.’’‘‘current information’’ on Healthy WAY programs wasneeded as well as ‘‘improved communication’’ with otherPrograms

A variety of programs were offered in health education, senior centers.health promotion, and disease prevention including age-

Questionnaire Formatappropriate screenings occurring at different times and fre-Several respondents made comments specifically about thequencies throughout the year. Health and lifestyle assess-survey format. One person suggested that an additionalments were ongoing and there were also counselingshort questionnaire might have been helpful because someservices and immunization programs provided. It was ex-questions did not accurately assess the ‘‘current scenario’’pressed that the Healthy WAY program needed to moveand ‘‘structure’’ of the coalition. A need for questionsbeyond the current activities by offering other types ofregarding structure, function, growth, expansion, and stag-programs, for example, ‘‘outreach programs.’’nation with a format which would allow for prioritizationwas also identified.Wellness Coordinator

The WC was identified as being ‘‘very creative’’ but per- Limitations of the study included the small sample sizealthough the sample included 80% of the coalition mem-haps ‘‘needs assistance’’ in order to do all that is expected.

She may have been ‘‘stretched too far’’ and in need of bers. The format was not user friendly to seniors and parti-

Armbruster et al.: Perceived Ownership 21

care: a model to link service, education, and the community.cipants of the Healthy WAY program and, therefore, notFamily and Community Health, 18(1), 75–79.enough of them completed the questionnaire to be used in

Bracht, N., Finnegan, J. R., Jr., Rissel, C., Weisbrod, R., Gleason,this analysis. A pilot study would have been useful. AfterJ., Corbett, J., & Veblen-Mortenson, S. (1994). Communitythe current study, however, another survey was designedownership and program continuation following a healthand implemented by the WC which was acceptable anddemonstration project. Health Education Research, 9,reached a greater number of Healthy WAY program partici- 243–255.

pants. Data relating to their ideas for new programs, satis- Bracht, N., & Tsouros, A. (1991). Principles and strategies offaction with current programs, and level of involvement effective community participation. Health Promotion Interna-in wellness activities were obtained (Nunez, 1997). tional, 5, 199–208.

Burns, N., & Grove, S. K. (1993). The practice of nursing re-IMPLICATIONS FOR PUBLIC HEALTH NURSES search: Conduct, critique, and utilization (2nd ed.). Philadel-

phia: W. B. Saunders Company.Health coalitions are emerging as a force for change in Butterfoss, D., Goodman, R. M., & Wandersman, A. (1993).many communities and offer much opportunity for public Community coalitions for prevention and health promotion.health nurses to establish partnerships with professionals Health Education Research, 8, 315–330.from other disciplines, community leaders, and health care Courtney, R., Ballard, E., Fauver, S., Gariota, M., & Holland,consumers (Gale, 1998). In the establishment of partner- L. (1996). The partnership model: working with individuals,ships, a transformation is required—from a professional families, and communities toward a new vision of health.

Public Health Nursing, 13(3), 177–186.model to a partnership model of practice (Courtney et al.,Flynn, B. S. (1995). Measuring community leaders’ perceived1996). Partnership means participation and ownership, and

ownership of health education programs: initial tests of relia-Kang (1995) stated that ‘‘public health nurses must rise tobility and validity. Health Education Research, 10, 27–36.the challenge to build community capacity through facili-

Flynn, B., & Graham, K. (1997, November). Communicationtating community participation’’ (p. 312). The next logicaland Public Health Nurses. Paper presented at the Americanstep in the conceptual model, according to Flynn (1995), isPublic Health Association Annual Meeting, Indianapolis, IN.perceived ownership, which is also the link to maintaining

Francisco, V. T., Paine, A. L., & Fawcett, S. B. (1993). A method-effective health programs. Analysis of perceived ownershipology for monitoring and evaluation community health coali-

is a worthwhile activity for the public health nurse. Involv- tions. Health Education Research, 8, 403–416.ing seniors in decisions about their health care ensures that Gale, B. J. (1998). Faculty practice as partnership with a commu-their concerns about quality of life are included in program nity coalition. Journal of Professional Nursing, 14, 267–271.strategies (National Institute of Nursing Research, 1995). Green, L. W., & Kreuter, M. W. (1992). CDC’s planned approachSince the inception of this coalition 6 years ago, the philos- to community health as an application of PRECEED and anophy has included the components of partnering with sen- inspiration for PROCEED. Journal of Health Education,

23(3), 140–144.iors. While the Coalition has had many successes, there isGreen, L. W., & Raeburn, J. M. (1988). Health promotion. Whatstill much work to do to include the consumers in the

is it? What will it become? Health Promotion, 3, 151–159.ownership of the coalition. As indicated by the results ofKang, R. (1995). Building community capacity for health promo-this study, a structure in which all community agencies

tion: a challenge for public health nurses. Public Health Nurs-participate and make decisions must be created. Publicing, 12(5), 312–318.health nurses must be proactive in evaluating not only client

McLeroy, K. R., Kegler, M., Steckler, A., Burdine, J. M., &or community health status outcomes but also programWisotzky, M. (1994). Community coalitions for health promo-effectiveness outcomes. Working with coalitions has beention: summary and further reflections. Health Education Re-

identified as an important nursing strategy and activity search, 9, 1–4.(Flynn & Graham, 1997). Providing leadership and assis- McMillan, B., Florin, P., Stevenson, J., Kerman, B., & Mitchell,tance in the facilitation and nurturance of coalitions is a R. E. (1995). Empowerment praxis in community coalitions.crucial skill for nurses in the community. Additionally, American Journal of Community Psychology, 23, 699–727.planning for evaluative processes when a coalition is just National Institute of Nursing Research (1995). Community-basedgetting started is a strategic action. Developing and imple- health care: nursing strategies (NIH Publication no. 95–3917,

ed.). Bethesda, MD: U.S. Department of Health and Humanmenting surveys in well-established coalitions can helpServices.members become more aware of their involvement in the

Nunez, D. (1997). [Healthy WAY Program Survey Results]. Un-organizational processes. It also provides an opportunitypublished data, Arizona State University, Tempe.for reflection and change.

Stanhope, M., & Lancaster, J. (Eds.). (1996). Community healthnursing (4th ed.). St. Louis: Mosby.REFERENCES

Thompson, B., & Kinne, S. (1990). Social change theory: applica-tions to community health. In N. Bracht (Ed.), Health promo-Abel, E., Boland, M., Durand, B., Geolot, D., Goodson, J., Isham,

G., & Steel, L. (1995). Work force and community health tion at the community level (pp. 45–65). Newbury Park: Sage.

22 Public Health Nursing Volume 16 Number 1 February 1999

U.S. Department of Health and Human Services (1990). Healthy Each of the 15 items was structured as shown above. Thepeople 2000: national health promotion and disease preven- only difference from item to item was the substitution oftion objectives (DHHS Publication no. PHS 91–50212). Wash- the phrases on the Key Function List for the italic sectionington, DC: U.S. Government Printing Office. above.

Zemke, R., & Kramlinger, T. (1985). Figuring things out. Read-Key Function List:ing, MA: Addison-Wesley.

2. Outlining the annual program plans.3. Deciding about long-range plans.APPENDIX4. Ways to measure the effect.

ElderCARE Community Ownership Scale*

5. Designing the program activities.6. Deciding how the program activities are conducted.The following series of questions are regarding the amount

of influence that you think each of the following parties 7. Selecting the volunteer membership of the coalitionhas over different aspects of the Healthy WAY program at and its committees.the present time. The parties are, CON, Healthy WAY WC, 8. Deciding about the structure of the coalition and itsCAP staff, local hospital, other agency coalition members, committees.and the seniors. 9. Setting the schedule of the coalition and its

For each of the following questions please indicate committees.whether you think each party has no influence, a little 10. Setting the agenda for the meetings of the coalitioninfluence, a moderate amount of influence, or a lot of and its committees.influence at the present time. Please give us your best 11. Leading the meetings of the coalition and itsguess even if you are not sure for a particular question. committees.

12. Hiring and evaluating the Healthy WAY staff.1. How much influence would you say that . . . has 13. Deciding how the Healthy WAY staff is organized.

on defining the overall goals of the Healthy WAY 14. Developing the Healthy WAY program budget.program? Would you say none, a little, moderate, or 15. Making decisions about how the Healthy WAY pro-a lot? gram budget is spent.CON: none a little moderate a lot

*Name and adaptation of Community Ownership ScaleHealthy WAY WC: none a little moderate a lotreprinted with permission from the author and Oxford Uni-CAP staff: none a little moderate a lotversity Press.Local hospital: none a little moderate a lot

Other agency coalitionmembers: none a little moderate a lotSenior programparticipants: none a little moderate a lot