PUBLIC HEALTH COALITIONS: PATTERNS AND PERCEPTIONS IN STATE IMMUNIZATION PROGRAMS

Abstract

The central question of this research is whether state public health programs collaborate with other public and private institutions to promote public health goals. Public health administration is highly bureaucratized and dependent upon government support, but administrators can establish coalitions as adjunct to more traditional means of providing public health services. We explain how public health coalitions are beneficial to providing public health services and then assess whether administrators in state immunization programs collaborate with both the public and private sectors. The results of a 50 state survey of state immunization program officials suggest that coalitions between state immunization programs and institutions of the public and private sectors are common. Moreover, most state program officials think that the more extensive use of immunization coalitions is important for improving state immunization coverage. Our findings also indicate that some states have not yet maximized the potential involvement of the private sector to collaborate in public health efforts. [PUBLICATION ABSTRACT]

Headnote

ABSTRACT

The central question of this research is whether state public health programs collaborate with other public and private institutions to promote public health goals. Public health administration is highly bureaucratized and dependent upon government support, but administrators can establish coalitions as adjunct to more traditional means of providing public health services. We explain how public health coalitions are beneficial to providing public health services and then assess whether administrators in state immunization programs collaborate with both the public and private sectors. The results of a 50 state survey of state immunization program officials suggest that coalitions between state immunization programs and institutions of the public and private sectors are common. Moreover, most state program officials think that the more extensive use of immunization coalitions is important for improving state immunization coverage. Our findings also indicate that some states have not yet maximized the potential involvement of the private sector to collaborate in public health efforts.

INTRODUCTION

Perhaps more than ever before, it is imperative that state public health administrators work collaboratively with other organizations and institutions to accomplish their mutual goals. Even though an impressive public health infrastructure exists at the federal level, state health departments remain responsible for organizing and overseeing public health initiatives within the individual states (Biggs and Helms, 2004). Yet, state-level public health administrators face severe resource constraints as increasing threats, such as disease outbreaks and bio terrorism, demand greater attention and resources. If working in concert with other institutions can in any way reduce costs or improve outcomes then this collaboration may be seen as a way to leverage an agency's responsibilities. Viewed in this way, the theory is that state level administrators would seek out opportunities to collaborate with other institutions to bolster their own state level public health programs.

Do state level public health administrators work collaboratively with other institutions to ensure better public health outcomes? The simple answer is yes, they do. Our study documents their efforts to collaborate with other institutions. We want to know to whom administrators turn to form state coalitions. We also want to know if public health administrators perceive these state level efforts as efficacious. First, however, we explore the nature of collaboration between public health and other institutions.

COLLABORATION AND COALITIONS

Collaboration between state public health departments and other public institutions is common. For instance, most people are familiar with the mandatory collaboration between state health departments and school systems. All state immunization programs rely on schools, both public and private, as gatekeepers to enforce compliance with immunization requirements. This is a statutory relationship. Likewise, employers, again both public and private, may be required to ensure that certain employees "comply with occupationally mandated protections for their health" (Biggs and Helms, 2004, p. 8). Again, this is a statutory relationship.

Public health programs also rely heavily on voluntary compliance, as in the effort to immunize infants who are not yet in school or daycare, and therefore not yet mandated to have the injections. Voluntary compliance, in this case, is usually the result of strong professional guidance by physicians, public health educational campaigns, and the informed decisions of parents to protect their young children. One might think of these efforts as collaborative, for without the guidance of physicians, in both the public and private sectors, and the voluntary compliance of parents, the immunization effort would surely fail. However, for the purpose of this paper, we are focusing on the collaboration between state health departments and other organizations or institutions, rather than focusing on the cooperation of individuals.

Health departments collaborate with other institutions and organizations, either as a function of law or because of the need for goal-oriented partnering, or both. To conceptualize the functions of collaboration between institutions, it might be helpful to think of them along a continuum, with statutory relationships on the one hand and goal-oriented partnering on the other. For instance, in demanding proof of immunization for admission, schools provide a statutory public health function. A public health department may monitor the school's compliance with this law. Again, this monitoring is a statutory function. It is important to recognize the nature of these functions. However, these same institutions may elect to also function in a goal-oriented partnership. Either the school or the health department may propose an initiative to educate parents in the community on the need for immunizations. If the school and the health department work together on this community education initiative, this effort becomes a goal oriented partnership. Therefore, statutory relationships can also lead to partnerships that go beyond stated law, if the need to work collaboratively to achieve a common goal is recognized by both institutions. Butterfoss, Morrow, Webster, and Crews (2003) say that in public health there is a new appreciation of the importance of "collaboration, partnership building and coalitions", and that mobilization of community partnerships to identify and solve health problems is considered "one of the core public health competencies" (p. 528).

Public health coalitions are formed when representatives of public and/or private (for-profit and nonprofit) organizations seek to solve social problems by working together. In general, a coalition can be considered "a union of people or organizations working to influence outcomes on a specific problem" (Rapp and Wotschak, 1996, p. 43). Coalition members may represent a single industry or they may be united by their geographic area. They are focused on a common goal, even if they disagree on other matters (ibid). They may choose a single task, such as a health fair to increase community awareness. Alternatively, they may choose multiple tools, such as community education, teacher training, and advocacy with the state legislature, all for one goal, such as reducing childhood obesity.

Coalitions frequently organize to advocate for health concerns. Hoadley, Cunningham, and McHugh (2004) say the "most effective advocacy organizations" are those who have formed coalitions with other groups who have mutual interests. Institutions and organizations all across the nation turn to coalitions to help accomplish their goals (p.150). For instance, successful efforts to advocate for health insurance for the poor have been reported at the state level. A coalition of concerned groups, including providers, successfully pushed for the restoration of recent Medicaid cuts in Massachusetts. Likewise, a group of health and human service advocates was effective in getting the state of Ohio to allow State Children's Health Insurance Program funds to be used to provide health insurance coverage to parents whose incomes fall below 100 percent of the poverty line (ibid). Grassroots advocacy coalitions made up of consumer, health and religious groups in Iowa, New Hampshire, Maine and Ohio, have forced changes in food industry practices (Light, 2004). These cases illustrate how many different types of coalitions can exercise political and programmatic influence.

Public health coalitions may likewise use multiple tools to improve public health outcomes. They may work to improve access to public health services at the state legislative level while working to increase participation in public health programs by both consumers and providers at the local level. Various types of public health campaigns have had mixed results, yet coalitions have emerged as "effective tools to improve the health of communities" (Butterfoss et al., 2003, p. 522). We see this as especially true in immunization coalitions.

IMMUNIZATION COALITIONS

Coalitions can play a key role in promoting immunizations and in motivating others, especially medical practitioners, to do so. Examples of successful childhood immunization coalitions abound, especially at the local level. Launched by a community partnership of 11 hospitals, Project L.O.V.E. (Love Our kids-Vaccinate Early!) demonstrated how a coalition of business and community partners in Columbus, Ohio, could help raise the immunization rates of children under age two by 117% in a two-year period (Rapp and Wotschak, 1996, p. 44). A more recent coalition in Columbus combined efforts of the public health department with that of the Mayor's Office, public schools, faith-based groups, and private providers. One of their goals was to reduce the number of children affected by school exclusions due to lack of immunizations. Using multiple strategies, this coalition was able to reduce school exclusion by about 60% (Click and Rodriguez, 2004).

Nuestros Niños (Our Children) Immunization Promotion Project was established in 1992 to address two problems: a measles outbreak in the El Paso/Juarez region and a seriously low rate of immunization (only 42% of El Paso children aged 2 and younger). The project combined a massive public health promotion, health education initiative and immunization services expansion in the three cities of El Paso, Juarez and Las Cruces. Therefore, it became a bi national, tri-city, tri-state partnership (Rivas, 2004). This collaborative effort between governments, along with a great deal of support from the business and professional communities, proved to be very effective in raising immunization rates.

Even local immunization coalitions can become institutions whose work can be coordinated for specific goals at the state level. A collaborative effort of Ohio's immunization coalitions was effective in the marketing of information and in the recruitment of vaccine providers into the statewide immunization registry system. More than 65% of the state's health care providers were contacted to enlist their participation (Modie and Rodriguez, 2004). Likewise, a statewide public/private partnership including the Virginia Department of Health, Sentara Healthcare, and Old Dominion University, formed to "promote immunization across the lifespan," (Tweed, Nasca, and Crews, 2004, p. 1). Although results of their pilot project, Stay On Track, are not yet available, the program is expected to increase the rate of fourth diptheria, tetanus, and pertussis (DTaP) shots for children in daycare in Hampton Roads, Virginia. In the early 1990s, Shots Across Texas became a successful statewide initiative by the Texas Department of Health to boost immunization rates via public/private partnerships (Cochran, Smith, Reid, Morrow, and Ramirez, 2003).

Given the increasing demand for more creative public health administration and noting these anecdotal success stories, we ask to what extent do state immunization programs enter into coalitions for the purpose of improving public health outcomes. This question has several dimensions. First there is the question of whether public health agencies enter into any coalitions. Both theory and case studies suggest that public health coalitions are useful, but bureaucratic impediments to partnering with the private and nonprofit sectors are nontrivial. Moreover, there is the corollary question of whether public health coalitions are functional policy tools for state administrators. If coalitions are only mechanisms for advocacy or developing professional networks, then administrators will have little confidence in the importance or impact of coalitions as public health policy tools. If coalitions are important policy tools, however, it becomes necessary to investigate what types of organizations serve as coalition partners with state public health agencies. State programs may network with several sources, including other state agencies, local nonprofit social service agencies, pharmaceutical companies, local businesses, and healthcare provider associations. Each of thee organization types can, in theory, make unique contributions toward public health outcomes, and the underutilization of some organizational types indicates lost opportunities in administering public health programs.

We choose state immunization programs for our comparative study because every state uses these public health programs to help ensure the timely vaccination of children. We survey state immunization program officials who have the administrative authority to develop public/private coalitions at the state level. They can use their networks to develop partnerships and can direct resources to support and to coordinate coalition activities. Moreover, state immunization program directors are in the unique position to assess the importance and impact of more extensive state level coalitions on childhood immunization. We report the configurations of state immunization coalitions and whether immunization program administrators perceive these coalitions to be an effective means of achieving the public health goal of full childhood immunization.

METHODS

Data were collected via a 50-state telephone survey of state immunization program managers in April and May, 2003. We used a structured survey instrument, and the response rate was 100%, with only a very few program managers deferring to senior program administrators to respond on their behalf. Although the survey in its entirety addressed additional programmatic issues, a significant portion of the survey was devoted to describing collaboration through coalitions with other institutions and to understanding how the program managers view the utility of state level coalitions.

To determine the number of states that develop immunization coalitions and how many different types of organizations are used in each state, we asked respondents the following question: "State program directors may develop coalitions with other public and private enterprises to promote full immunization. Please tell me whether your state immunization program routinely works with each one of the following types of organizations to promote full immunization." The list of possible choices included: other state agencies; hospitals and clinics; the media; the business community; their state medical association; religious and charitable organizations; school systems; local governments; the pharmaceutical industry; and the insurance industry. A simple yes/no response was requested to verify with which agencies or organizations each state immunization program routinely works with to promote full childhood immunization.

In addition, we asked two questions to determine how program administrators assess the importance and impact of immunization coalitions toward the goal of full childhood immunization. Administrators' perceptions of importance and impact tap into different attitudes toward administrative tools. In general, assessing importance taps into whether administrators see programs as a high priority on their administrative agenda. Assessing the impact of programs taps into administrator perceptions of whether they are effective programmatic interventions. In this case, administrators' perceptions of importance and impact of coalitions may diverge. For example, administrators may perceive coalitions to be effective programmatic interventions (high on impact), but not a high priority (not important), given extenuating circumstances. To provide this additional context for assessing the relative value of immunization coalitions, we suggest three potential interventions to raise immunization rates. Two of these - increasing the physician reimbursement rate for vaccine administration and the more rigorous enforcement of immunization requirements for day care and Head Start participants - are considered as more mainstream or traditional attempts to reach this goal. The third-the more extensive use of coalitions - is considered as an adjunct to the usual means of increasing immunization rates. Respondents were asked to assess the importance of these three potential interventions to the goal of improving immunization rates. Each respondent was offered a 5-point scale in which the value of one equals "not at all important" and five equals "very important." The value of three is considered an indifference point. Respondents were also asked to assess the impact of the same tools, i.e. the more extensive use of coalitions, increased reimbursement rates, and more rigorous enforcement of day care and Head Start regulations, to promote and sustain immunization rates. In this question a 50% increase in physician reimbursement rates was specified. Each respondent was offered a 5-point scale in which the value of one equals "very negative impact" and five equals "very positive impact." The value of three is considered an indifference point. Group means and standard deviations are reported for comparison.

FINDINGS

The survey results indicate that every state uses immunization coalitions to promote full childhood immunization.

While it becomes obvious that all state programs work with other organizations, the number of organization types varies across states. Figure 1 illustrates the number of types of organizations represented in state coalitions.

Although all state immunization programs collaborate through coalitions with other organizations, some states have a much more diverse set of organizational coalition partners. For example, 10 states (20%) have as many as 10 different types of coalition partners. The modal number of types of organizational partners is nine.

Table 1 illustrates the types of organizations with which state immunization programs routinely work. This list was provided as part of the question. The percentage of state administrators giving a positive response that they routinely work with each is listed per organization type.

Perceptions of Importance and Impact of Proposed Interventions

Table 2 reports the mean response of state program managers to the two questions regarding the impact and the importance of three potential programmatic interventions, all with the same goal of improving immunization rates. These include the more extensive use of immunization coalitions, an increased reimbursement rate for providers of vaccinations (50% increase specified for the impact question), and more rigorous enforcement of day care and Head Start regulations regarding required vaccinations. Recall that respondents were given a 5-point scale in which the value one indicates the lowest level of importance and impact, three indicates an indifference point, and five indicates the highest level of importance and impact.

The findings in Table 2 suggest that state program administrators believe that a more extensive use of immunization coalitions is important and would have a positive impact on the goal of full childhood immunization. A t-test of the difference between means for both importance and impact and the indifference point (3) is statistically significant at a p-value of less than .001. The mean scores for more traditional interventions to increase childhood immunization rates are higher than the score for coalitions, but all three proposed interventions are greater than the indifference point.

DISCUSSION

State immunization program officials value collaboration through coalitions with other institutions and organizations. Our survey indicates that all state immunization programs work in collaboration with other organizations outside of their own agency. Our results also suggest that state administrators view coalitions with both public agencies and private industries to be an important policy intervention for the purpose of improving public health outcomes.

The immunization administrators enthusiastically suggested organizations which were not mentioned in our list (Table 1), but were nevertheless used in coalitions with their respective state agencies. Physician's associations, other than the state medical society, especially the societies of pediatricians and the family practitioners associations, were mentioned. Pharmacists are involved, along with rural and community health centers, as well as post secondary schools, such as universities. Some state representatives have been involved as advocates. Also highlighted were the general assembly in one state and the governor's office, including the work of the state's first lady, in another. Other statewide immunization coalitions, which we assume to be externally initiated, and local immunization coalitions, also actively collaborate with some state immunization programs. In some states civic groups, The Children's Defense Fund and The American Lung Association participate. Professional peer review, quality assurance groups, as well as both Medicaid and private managed care systems were suggested as well. Even the famous dog sled race, the Iditarod, has been helpful in the promotion of childhood immunizations. The program directors also stressed the importance of individual parents in their states' efforts.

Despite the positive attitudes toward public health coalitions, there is evidence that immunization coalitions are not being developed to their full potential in some states. The configuration of state immunization coalitions indicates a substantial collaboration with key partners from both the public and private sector, with three notable exceptions: the business community, insurance industry, and religious/charitable organizations. The fact that some state immunization programs have not developed partnerships with these last three institutions is puzzling. It seems that each of these types of organizations is a potential stakeholder in the childhood immunization effort. For business, there is a concern due to the loss of workdays when a parent must care for a sick child who has developed a vaccine preventable disease. Health insurance providers are generally supportive of cost-effective preventive care, which certainly includes providing childhood immunization coverage. Finally, religious (faith-based) and charitable (other not-for-profit) organizations often target their efforts to provide services for children, which frequently involves health care services. In spite of these linkages, only a minority of state immunization programs partner with these organizations. As one immunization official asserts: "Any program . . . that provides or contracts for children's services, or provides information to children and their parents has an opportunity and a responsibility to promote immunizations," (Garcia, 2000, p. 3). In short, there are still significant gaps in the configuration of state immunization coalitions that could be capitalized on for the mutual interests of the immunization program and the external business, insurance company, church or non-profit agency.

One explanation for the gaps in developing more extensive coalitions is their perceived importance relative to more traditional policy interventions. State administrators find the more extensive use of coalitions to be an important intervention that has a positive impact on achieving the goal of full childhood immunization, but they also believe more traditional interventions are relatively more important and have a greater impact on this goal. Proposing to raise reimbursement rates for physician administration of vaccinations is a rather commonly suggested intervention. Our findings show that the administrators believe this proposed intervention is important and that its impact on immunization rates would be high. The proposed increased regulation of day care and Head Start immunization requirements received even higher marks from the administrators for both impact and importance as well. Therefore, it is reasonable to conclude that key program administrators develop immunization coalitions, but they may be unwilling to expend marginal time and resources on developing a wider range of coalition partners if more traditional approaches are available.

Nevertheless, what is significant, from our point of view, is that a proposed increased use of coalitions, a relatively new and less mainstream intervention, fares well in the administrators' perceptions. We believe this is an impressive endorsement of the utility of coalitions. Moreover, since childhood immunization is a prime example of public health policy, we expect that coalitions in other public health issue domains are likely to evince similar positive assessments, but face similar gaps in development.

CONCLUSIONS

In conclusion, we believe this survey reflects the long-term trend toward collaboration between public, private and non-profit sector organizations as an increasingly important tool for the direct and indirect delivery of public goods (Salamon, 2002). State immunization program administrators value the collaboration with other institutions and organizations outside of their own agency, and they agree that the use of coalitions is an important tool in reaching immunization related public health goals at the state level. The findings also suggest that immunization program administrators have a preference for developing coalitions with public agencies and professional associations rather than with the private sector, especially the business community, insurance industry, and religious or charitable organizations in the non-profit sector.

Ultimately, public health administrators working in all issue domains must weigh the benefits and costs of developing coalitions, but their decision-making should include a consideration of a broader range of partners, especially private for profit and non-profit organizations that have incentive structures consistent with the desired public health outcomes. In doing so, public health administrators can build a more robust public health infrastructure that extends available resources and enhances public wealth through greater civic engagement with the private and non-profit sectors. Yet, overcoming the barriers to collaboration, especially with the private sector, may be a challenge for public health administrators. What our research does not tell us is whether the private sector is hesitant to become involved in public health issues or whether there is reluctance on the part of public health administrators to approach them. Obviously some state level administrators are invested in these relationships.

Research is available on the process of public health coalitions at the community level (Butterfoss, Goodman, and Wandersman, 1996), and specifically on immunization coalitions (Rosenthal, Morrow, Butterfoss, and Stallings, 1998; Bakalian and Connelly, 2004), but more work needs to be focused at the state level. However, there should be more investigation into the process of, and especially into the barriers to, public health coalition formation initiated by the state level public health programs. For example, programmatic case studies of public health coalitions should be conducted to identify and to communicate best practices to state public health administrators. In future research, we intend to assess the impact of state level coalitions on public health outcomes. Also, are there some domains of public health which can maximize the use of coalitions better than other areas? Such research could help guide public health administrators in their use of coalitions and could potentially increase civic engagement, which may be a necessity as states face increasingly complex public health challenges.

ACKNOWLEDGEMENTS

The gracious cooperation of the state immunization program managers and their staff members is gratefully acknowledged. We are thankful for the comments of Clarke Cochran, PhD, and Lance Rodewald, MD. Brian Cannon of the Earl Survey Research Lab and Jennifer Ramirez, MPA, were instrumental in the data collection effort. Jennifer Trice was helpful in the manuscript preparation. The authors also thank Monty Van Wart, PhD, Evelyn Nobles, and an anonymous reviewer for their assistance with this project. The initial research was supported by a grant from the Merck Company Foundation. The findings and comments of this manuscript reflect the authors' opinions and are not necessary those of the Merck Company Foundation. An earlier draft of this paper was presented as a poster at the 38th National Immunization Conference in Nashville, in May, 2004.

References

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