Review and Special Articles

What Explains Community Coalition Effectiveness?

A Review of the Literature
Ronda C. Zakocs, PhD, MPH, Erika M. Edwards, MPH

Abstract: Community coalitions have become popular vehicles for promoting health. Which factors
make coalitions effective, however, is unclear. The study’s aim was to identify coalition-
building factors related to indicators of coalition effectiveness through a review of the
empirical literature.
Published articles from 1980 to 2004 that empirically examined the relationships among
coalition-building factors and indicators of coalition effectiveness were reviewed. Two
indicators of coalition effectiveness were examined: coalition functioning and community-
wide changes. A two-phase strategy was employed to identify articles by reviewing citations
from previous literature reviews and then searching electronic reference databases. A total
of 1168 non-mutually exclusive citations were identified, their abstracts reviewed, and 145
unique full articles were retrieved. The review yielded 26 studies that met the selection
criteria. Collectively, these studies assessed 26 indicators of coalition effectiveness, with 19
indicators (73%) measuring coalition functioning, and only two indicators (7%) measur-
ing changes in rates of community-wide health behaviors. The 26 studies identified 55
coalition-building factors that were associated with indicators of coalition effectiveness. Six
coalition-building factors were found to be associated with indicators of effectiveness in five
or more studies: formalization of rules/procedures, leadership style, member participa-
tion, membership diversity, agency collaboration, and group cohesion. However, caution is
warranted when drawing conclusions about these associations due to the wide variations in
indicators of coalition effectiveness and coalition-building factors examined across rela-
tively few studies, discrepancies in how these variables were measured, and the studies’
reliance on cross-sectional designs.
(Am J Prev Med 2006;30(4):351–361) © 2006 American Journal of Preventive Medicine

Introduction mocracy by encouraging citizens to seek solutions to

their own problems and by fostering collaboration

C
ommunity coalitions have become popular
among multiple stakeholders to jointly tackle intrac-
vehicles for improving health at the local
table health problems that could not be addressed by
level. Defined as “inter-organizational, coop-
a single player alone. More importantly, community
erative, and synergistic working alliances,”1 coalitions
coalitions present ripe opportunities for adopting
often include local government officials, nonprofit
recommended community participatory action re-
agency and business leaders, and interested citizens
search principles, where community members work
who align in formal, organized ways to address issues
in partnerships with researchers to collectively define
of shared concern over time. Typically, they respond
local problems, identify and implement solutions to
to problems through a social ecologic lens2 by assess-
them, and evaluate their impacts.3
ing multiple determinants of health problems, and
Initiating and sustaining coalitions is no simple task,
executing multilayered strategies through various
however. It is a complex, dynamic process that involves
channels (e.g., mass media, schools) aimed at several
multiple coalition-building tasks, such as recruiting
target populations (e.g., adolescents, parents, provid-
members, identifying lead agencies, generating re-
ers). The community coalition model is intuitively
sources, establishing decision-making procedures, fos-
appealing; it resonates with American values of de-
tering leadership, building the capacity of members to
participate, encouraging consensus-based planning for
From the Department of Social and Behavioral Sciences (Zakocs, action, implementing agreed-upon actions by negotiat-
Edwards), Center to Prevent Alcohol Problems Among Young People
(Zakocs), and Data Coordinating Center (Edwards), Boston Univer- ing with key stakeholders in the community, refining
sity School of Public Health, Boston, Massachusetts strategy based on evaluation data, and establishing
Address correspondence and reprint requests to: Ronda Zakocs, mechanisms for institutionalizing coalitions and/or
PhD, Boston University School of Public Health, Social and Behav-
ioral Sciences, 715 Albany Street, Boston MA 02118. E-mail: their strategies.4,5 Given this complexity, those leading
rzakocs@bu.edu. coalitions must determine which types of coalition-

Am J Prev Med 2006;30(4) 0749-3797/06/$–see front matter 351

© 2006 American Journal of Preventive Medicine • Published by Elsevier Inc. doi:10.1016/j.amepre.2005.12.004
building actions should be undertaken during what
points in time to produce desired outcomes. For exam-
ple, leaders need to know whether recruiting a large,
diverse group of stakeholders is more effective than a
smaller, more cohesive group. Similarly, should leaders
embrace a collaborative/empowering style or a direc-
tive/task focused style? In other words, those leading
(and funding) coalitions need guidance in selecting
evidence-based actions for building effective coalitions.
Determining what constitutes effective coalitions is
not simple either, as they vary in the types of health
problems addressed, structures and processes devel-
oped, and geographic areas and populations targeted.
Nonetheless, two general indicators may be used to
assess coalition effectiveness: internal coalition func-
tioning and external community changes. Internal co-
alition functioning measures how well coalition-
building actions have been executed, such as size of
membership, amount of resources generated, or qual-
ity of strategic plans.6 External community-level
changes measures results from strategic actions imple-
mented by coalitions, such as reductions in mortality,
morbidity, injury, or risky health behaviors.7 Although
community-level changes are the ultimate indicators of
coalition effectiveness, measures of coalition function-
ing may be plausible surrogates, as it may be that
coalitions with high internal functioning have a greater
chance of achieving external outcomes.
What evidence guides practitioners to build effective
coalitions? Community coalitions are composed of
small groups of individuals who have joined forces to
address local public health problems. Research con-
ducted by social psychologists on small-group function-
ing, therefore, may be relevant to understanding the
characteristics of effective coalitions. Indeed, aspects of
the group composition and structure (i.e., coalition-
building factors)— group size, member diversity, roles,
norms, cohesion, culture, conflict resolution, decision
making, and leadership— have been found to influence
aspects of group performance (e.g., indicators of effec-
tiveness).8 Most of these studies, however, are based on
artificial groups set in laboratory settings with conflict-
ing findings, providing little assistance to coalition
leaders.
Two other types of research may provide insight on
which coalition-building factors are essential ingredi-
ents for creating effective coalitions: (1) experimental
designs testing whether coalitions affect community-
level changes; and (2) individual case studies explicat-
ing lessons learned about how to build effective
coalitions.
Experimental studies examining whether coalitions
influence external outcomes, such as reductions in
community-wide rates of mortality, morbidity, injury, or
risky health behaviors, have produced mixed findings.
Case studies examining a single community coalition
either with a comparison site9,10 or without11–14 have
352 American Journal of Preventive Medicine, Volume 30, Number 4
reported modest positive effects. Experimental trials
examining multiple coalitions against comparison
groups have produced mixed findings, from no ef-
fects,15–22 to modest effects,23–28 to strong positive
effects.29 –32 Furthermore, none of these studies inves-
tigated which aspects of coalition building explained
negative, modest, or strong findings. In sum, these
experimental trials provide little guidance on which
coalition-building factors produce which outcomes.
In contrast to the experimental studies, a growing
body of literature has begun to provide answers on how
to build effective coalitions. However, to date, this
literature is largely anecdotal, built on conventional
wisdom and lessons learned from individual case stud-
ies of a single coalition, such as “how to” guide-
books,33–37 recommendations by seasoned practitio-
ners,38 – 41 narrative descriptions of a particular
coalition’s unique experiences explicating lessons
learned,42–58 and comparisons across multiple coali-
tions documenting barriers and facilitators.59 – 62
What remains missing is a list of evidence-based
coalition-building factors that have been empirically
linked to indicators of coalition effectiveness. Although
several recent literature reviews have synthesized the
nonempirical and empirical literature on community
coalitions,1,5,7,63– 67 none explicitly reviewed the empir-
ical literature to draw conclusions about which
coalition-building factors influence coalition effective-
ness. Accordingly, our aim was to conduct a review of
the empirical literature to identify which coalition-
building factors lead to indicators of coalition
effectiveness.
Methods
The literature was reviewed to answer this question: Based on
the empirical evidence, which coalition-building factors ex-
plain coalition effectiveness? The following inclusion criteria
and search strategy were used for identifying articles that
could answer this question.
Inclusion Criteria
Five criteria were employed for selecting articles to be re-
viewed. Each article had to:
1. Demonstrate that the coalition targeted local geographic
areas in the United States, such as neighborhoods, towns,
cities, or counties. Coalitions targeting state, national, or
international geographic areas were excluded.
2. Demonstrate that the coalition sought to improve
population-level health outcomes for the targeted geo-
graphic area, either for a variety of health issues or for
specific ones (e.g., substance abuse, tobacco control).
Coalitions seeking solely to improve coordination for
delivering health and/or social services or fostering com-
munity development were excluded.
3. Define and measure, either quantitatively or qualitatively,
indicators of coalition effectiveness. Indicators could assess
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 changes in coalition functioning such as membership size,
amount of resources generated, or quality of strategic
plans, or changes in the community, such as mortality,
morbidity, injury, or risky behaviors.
4. Define and measure, either quantitatively or qualitatively,
coalition-building factors defined as any characteristic that
described how a coalition functioned (i.e., leadership style,
decision-making procedures, strategic planning), and em-
pirically examine how or whether factors related to iden-
tified indicators of coalition effectiveness.
5. Have its findings published in a peer-reviewed journal or
government agency document from 1980 to 2004.
Search Strategy
A two-phase strategy was employed to identify articles meeting
the inclusion criteria. In Phase 1, six published literature
reviews of community coalitions were identified, their refer-
ence lists reviewed, and 111 unique articles that appeared to
relate to the criteria were retrieved.1,5,7,63,64,68
In Phase 2, three electronic reference databases were
searched: MEDLINE, CINAHL, and PsycINFO. Searches were
limited to English language articles published on U.S. popu-
lations from 1980 to 2004. Several phrases (e.g., community
coalition, community partnership, and community collabora-
tive) and combinations of MeSH descriptors (e.g., healthcare
coalitions/organizations ⫹ program evaluation) derived
from selected articles in Phase 1 were used. The Phase 2
search yielded a total of 1168 non-mutually exclusive ab-
stracts. Each author independently reviewed these abstracts
and retrieved 35 full articles that appeared to meet the
selection criteria.
A total of 146 full articles were retrieved from the Phase 1
(n ⫽111) and Phase 2 (n ⫽35) searches. Each author inde-
pendently reviewed the articles to determine whether they
met the inclusion criteria. Thirteen articles that empirically
examined the relationship between coalition factors and
effectiveness were excluded for the following reasons: no
definition or measure of coalition effectiveness given,53,69,70
focus on coordination of health/social service deliv-
ery,54,71–74 non–public health issues,75–78 or conducted out-
side the United States.79
Identifying and Categorizing Coalition-Building
Factors and Indicators of Coalition Effectiveness
For articles meeting the selection criteria, the following
information was abstracted: citation, health topic, number
of coalitions examined, whether study was guided by a
theoretical framework, design and analytical strategy em-
ployed, number and type of indicators of coalition effec-
tiveness assessed, and number and type of coalition-build-
ing factors found to be positively related to indicators of
coalition effectiveness. Because study variables were not
explicitly labeled as coalition-building factors or indicators
of coalition effectiveness, each study’s research question,
conceptual model, study design, and/or data analysis plan
were reviewed to determine which variables were tested as
coalition-building factors (i.e., independent variables, the
factors viewed as influencing outcomes) and which were
tested as indicators of coalition effectiveness (i.e., depen-
dent variables, the factors expected to change as a result of
April 2006
the coalition-building factor). Next, the number of vari-
ables used to measure coalition-building factors and indi-
cators of coalition effectiveness were counted for each
study, as listed in Table 1. Variables counted were those
tested in statistical analyses (for quantitative studies) and
those reported as hypotheses or in results (for qualitative
studies), regardless of the results. If a variable was mea-
sured and tested as a scale composed of six items, then it
was counted as one variable, not six.
Next, variables measuring indicators of coalition effective-
ness were arrayed and then qualitatively grouped into similar
categories. For example, several studies measured aspects of
members’ participation in coalitions such as number of
meetings attended, number of hours spent on coalition
activity, and roles that members played in the coalition.
Rather than labeling each variable as a different indicator of
effectiveness, they were combined into a single category
labeled “membership participation.” Based on this inductive
approach, the number of conceptually different indicators of
coalition effectiveness were counted and organized by coali-
tion functioning and community changes, as displayed in
Table 2.
Finally, the findings from studies meeting the selection
criteria were reviewed. Variables measuring coalition-build-
ing factors found to be positively associated with indicators
of coalition effectiveness in the final analyses were identi-
fied. If multivariate analyses were employed, results from
the final models were abstracted. Findings from the pre-
liminary analyses, such as correlation matrices, were not
reported. These coalition-building variables were then
qualitatively grouped into similar categories, as was done
for indicators of coalition effectiveness. Based on this
inductive approach, the number of conceptually different
coalition-building factors found positively related to indi-
cators of coalition effectiveness were counted and orga-
nized by number of studies reporting that relationship, as
displayed in Table 3.
Results
The review process yielded 26 articles that met the
inclusion criteria (Table 1). The mean number of
coalitions assessed per study was 29.9, with a range from
1 to 172. Twelve (46%) examined coalitions targeting
substance abuse. The average number of indicators of
coalition effectiveness assessed per study was 3.5, rang-
ing from 1 to 31. Coalition member self-report was most
commonly used to measure indicators of coalition
effectiveness (n ⫽16). The average number of coalition-
building factors examined per study was 8.8, ranging
from 1 to 32. Seventeen (65%) studies employed cross-
sectional survey designs measuring coalition-building
factors and indicators of effectiveness concurrently,
while two (7%) used an experimental design. Nineteen
studies (73%) used the coalition as the unit of analysis.
Only two (7%) tested existing theoretical frameworks,
while eight (32%) constructed unique conceptual
frameworks to guide the study.
Am J Prev Med 2006;30(4) 353
 354

Table 1. Articles meeting selection criteria (n⫽26)

Coalition- Tested
American Journal of Preventive Medicine, Volume 30, Number 4

Indicators of How indicator of effectiveness building Design/unit of analysis/ theory a

Article Health topic Coalitions effectiveness measured factors analyses priori
Armbruster (1999) 97
Elder health 1 1 Coalition member self-report 1 Cross-sectional Noa
Coalition members
Univariate analyses
Bazzoli (1997)98 Varied 172 1 Coalition records 4 Cross-sectional Nob
Coalition
Multivariate analyses
Butterfoss (1996)87 Substance abuse 1 8 Coalition member self-report 14 Cross-sectional Noa
Evaluator assess plans Coalition members and
committees
Multivariate analyses
Chinman (1996)99 Substance abuse 1 1 Coalition member self-report 1 Cross-sectional No
Committees
Bivariate analyses
Crowley (2000)100 Substance abuse 123 1 Coalition records 1 Cross-sectional No
Coalition
Path analysis
Feinberg (2004)101 Adolescent problem 21 1 Coalition member self-report 4 Cross-sectional Nob
behavior Coalition
Bivariate analyses
Florin (2000)90 Substance abuse 35 3 Community leader self-report 8 Cross-sectional No
Evaluator-assessed plans Coalition
Bivariate analyses
Garland (2004)102 Cancer control 63 1 Coalition records 17 Longitudinal Noa
Coalition
Multivariate analyses
Gottlieb (1993)103 Tobacco control 50 3 Coalition member and staff 4 Cross-sectional No
self-report Coalition
Coalition reports Multivariate analyses
Hallfors (2002)15 Substance abuse 12 3 Community resident self-report 1 Quasi-experimental No
of behaviors Coalition
Bivariate analyses
Hays (2000)88 Substance abuse 28 3 Coalition member self-report 5 Cross-sectional No
Evaluator-assessed plans Coalition
Multivariate analyses
Kegler (1998)6 Tobacco control 10 6 Coalition member and staff 17 Cross-sectional No
self-report Coalition
Evaluator-assessed plans Bivariate analyses
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Kegler (1998)82 Tobacco control 10 1 Coalition member and staff 12 Multi site case study No
self-report Coalition
Coalition records Cross-case comparison
Kegler (2003)83 Teen pregnancy 5 1 Coalition records 20 Multisite case study Yes
Interviews with coalition Coalition
members Cross-case analysis
Evaluator observations
April 2006

Table 1. (continued)
Coalition- Tested
Indicators of How indicator of effectiveness building Design/unit of analysis/ theory a
Article Health topic Coalitions effectiveness measured factors analyses priori
Kumpfer (1993) 85
Substance abuse 1 3 Coalition member self-report 7 Cross-sectional Nob
Evaluator-assessed plans Coalition members
Multivariate analyses
Lindholm (2004)104 Substance abuse 10 1 Interviews with coalition 4 Multisite case study No
members Coalition
Coalition records Qualitative analyses
Evaluator observations
Mansergh (1996)105 Substance abuse 2 5 Coalition member self-report 1 Cross-sectional No
Coalition
Bivariate analysis
Mayer (1998)106 Cardiovascular 2 1 Community organizer and 32 Focus groups No
disease state health department staff Coalition
assessment Narrative analyses of
transcripts
McMillan (1995)107 Substance abuse 35 3 Coalition member self-report 10 Cross-sectional Nob
Community leader self-report Coalition
Multivariate analyses
Polivka (2001)89 Early intervention 3 2 Coalition member self-report 2 Cross-sectional Nob
Agency members
Path analysis
Rogers (1993)81 Tobacco control 61 5 Coalition member and staff 24 Cross-sectional Nob
self-report Coalition
Multivariate analyses
SAMHSA (2000)80 Substance abuse 8 1 Community resident self-report 7 Multisite case study No
of behaviors Coalition
Analyses unclear
Shortell (2002)84 Varied 25 1 Coalition member self-report 19 Multisite case study Nob
Coalition
Cross-case comparison
Weiner (2002)108 Varied 25 3 Coalition member self report 8 Cross-sectional Yes
Am J Prev Med 2006;30(4)

Coalition members
Multivariate analyses
Weiss (2002)86 Varied 63 1 Coalition member self-report 7 Cross-sectional Nob
Coalition
Multivariate analyses
Weitzman (2004)30 Alcohol prevention 10 31 College student self-report of 1 Quasi-experimental Noa
behavior College
Multivariate analyses
Total⫽26 Total substance Mean⫽29.9 Mean⫽3.5 Total coalition self-report⫽18 Mean⫽8.8 Total cross-sectional⫽17 Total yes⫽2
abuse⫽12
Range⫽1–172 Range⫽1–31 Range⫽1–32
a
Provided some type of conceptual framework, but was either a program logic model to guide evaluation or there was no literature review to support the framework.
b
Developed a conceptual framework to guide study based on a review of the literature.
355
Table 2. Indicators of coalition effectiveness examined in 26 studies
Coalition functioning (internal) Community changes (external)
Column A Column B Column C
Coalition member, staff, or community
leaders’ perceptions of changes Individual reports on behaviors
6,85,87,88,90
1. Quality of strategic plans 20. Coalition influenced changes in local 25. Coalition influenced individuals’
2. Member participation6,87,99,100a,108 agencies, programs, services, or risky behaviors15,30,80
3. Total number of actions policies81,100a,107,108 26. Coalition influenced individuals’
implemented6,82,102,103 21. Coalition has/is realizing access to services15
4. Member/staff satisfaction6,81,87,108 goal84,89a,101a
5. Member/agency 22. Coalition will successfully address
collaboration89,98,103,105 problem81,105a
6. Overall coalition 23. Coalition influenced community
functioning103,105,106 prevention system88,90
7. Member benefits and costs87,105 24. Coalition influenced changes in local
8. Amount of resources public policies/laws88
mobilized6,101a
9. Member knowledge problem85,100a
10. Member use of addictive
substances85
11. Extent of plan implemented6
12. Member perceived ownership97
13. Member empowerment107
14. Group empowerment107
15. Coalition
mobilization/maintenance83
16. Integration of grassroots
members104
17. Synergy86
18. Range of actions proposed90
19. Committee functioning105
a
Indicator measured by scale comprised of several variables.

Indicators of Coalition Effectiveness with indicators of coalition effectiveness (Table 3). Six
(11%) coalition-building factors positively correlated
From the 26 studies reviewed, 26 conceptually distinct
with indicators in five or more studies, 15 (27%) in two
indicators of internal and external coalition effective-
to four studies, and 34 (62%) in one study. The six
ness were found (Table 2). Twelve indicators (46%)
factors identified in five or more studies included:
were assessed by one study only. Nineteen (73%) were
formalization of rules/procedures (n ⫽9), leadership
indicators of coalition functioning (Table 2, Column
style (n ⫽8), active member participation (n ⫽7),
A); those most commonly investigated by multiple
membership diversity (n ⫽5), member collaboration
studies included quality of strategic plans (n ⫽5), mem-
(n ⫽5), and group cohesion (n ⫽5).
ber participation (n ⫽5), total number of actions im-
Five themes were noted across these findings. First,
plemented (n ⫽4), member or staff satisfaction (n ⫽4),
studies varied in how coalition-building factors and
and agency collaboration (member agencies working
indicators of coalition functioning were conceptually
jointly to develop and/or implement programs, poli-
defined. Across the 26 studies, 19 indicators of internal
cies, or services) (n ⫽4). In contrast, only seven (27%)
coalition effectiveness were examined (Table 2, Col-
were indicators of community-level changes (Table 2,
umn A). Ten of those were defined as coalition-
Columns B and C). Only two indicators measured
building factors in other studies (Table 3). For exam-
reported changes in individual risky behaviors, as ex-
ple, some studies defined member participation as a
amined by three studies15,30,80 (Table 2, Column C),
coalition-building factor, while other studies defined it
while the other five external indicators were measured
as an indicator of coalition functioning.
by coalition or staff members or community leaders’
Second, studies tended to operationally define the
perceptions of community-wide changes (Table 2, Col-
same coalition-building factor in different ways. For
umn B).
example, eight studies found relationships between
leadership style and indicators of effectiveness (Table 3,
Coalition-Building Factors Related to Indicators
first column). These eight studies, however, measured
of Coalition Effectiveness
leadership style in five different ways: incentive man-
Across the 26 studies, a total of 55 conceptually distinct agement,81 task focused,6,82 shared leadership,83,84 em-
coalition-building factors were found to be associated powering/collective,85,86 and multiple characteristics.87

356 American Journal of Preventive Medicine, Volume 30, Number 4 www.ajpm-online.net

Table 3. Coalition-building factors positively associated with indicators of coalition effectiveness in 26 studies
Five or more studies
(nⴝ6 factors) Four to two studies (nⴝ15 factors) One study (nⴝ34 factors)
1. Formalization/ 7. Open/frequent communication 22. Coalition readiness101
rules6,81,82,87,100a–103,108 channels6,81– 83 23. Collaboration before coalition6
2. Leadership style6,81– 87 8. Intensity/scope of actions 24. Comprehensive vision80
3. Active member implemented30,80,100a,106 25. Supportive organizational climate107
participation80,82,88,90,100a,107,108 9. Task/goal-focused climate6,82,87,90 26. Trust84
4. Diverse membership6,80,84,88,108 10. Staff time devoted to tasks6,82,83,90 27. Recognize life cycles84
5. Member agency 11. Conflict management80,84,108 28. Establish priorities84
collaboration84,87,88 –90 12. Agency member types97,98,108 29. Innovation87
6. Group cohesion6,82,84,87,104 13. Participatory decision making84,87,108 30. Researcher driven105
14. Member experience/expertise6,81,90 31. Written assessment/implement
15. Member benefits81,99,107 plan102
16. Training/technical assistance82,104,106 32. Data-driven planning106
17. Sectors (agencies) represented6,88 33. Gained political support84
18. Member ownership/commitment81,107 34. Prevention focused106
19. Effective administration81,86 35. Used media to promote coalition106
20. Efficient use of resources86,106 36. Used environmental strategies106
21. Target small geographic areas80,106 37. Dedicated project director84
38. Lead agency known entity83
39. Lead agency noncompetitor104
40. Lead agency director supportive84
41. Length of time members involved6
42. Membership size102
43. Member-perceived fairness108
44. Member satisfaction85
45. Member empowerment106,107
46. Member sense of community107
47. Member perceived community
problems107
48. Member anger/aggression87
49. Member self-discovery87
50. Member independence87
51. Member knowledge of other
agencies89
52. Staff relationships with members87
53. Staff expertise/experience6
54. Paid coordinator102
55. Personnel barriers103
a
Factor measured by scale comprised of several variables.

Third, studies that measured the same coalition-
building factor rarely examined the same indicator of
coalition effectiveness. For example, eight studies
found relationships between leadership style (i.e., coa-
lition-building factor) and indicators of effectiveness
(Table 3, first column). Among those studies, nine
different indicators of effectiveness were measured:
member satisfaction,81,87 member participation,87
member personal knowledge problem,85 member use
of drugs,85 number of actions implemented,6,82 quality
of strategic plans,85 coalition mobilization/mainte-
nance,83 perception that coalition realized goal,84 and
belief that coalition will reduce the problem.81
Fourth, studies that measured the same indicator of
effectiveness rarely examined the same coalition-
building factor. For example, four studies measured
perceptions that coalitions influenced changes in local
agencies, program, services, or policies (Table 2, Col-
umn B). Collectively, these four studies identified ten
different coalition-building factors that correlated with
that one indicator. None of the ten coalition-building
factors was found in more than one study.
Last, even when several studies examined the same
outcome and coalition-building factor, conflicting re-
sults emerged. For example, three studies measured
relationships between changes in individuals’ self-report
of risky substance abuse behaviors and intensity of
actions implemented by coalitions15,30,80 (Table 2, Col-
umn C). One study15 found no or negative relation-
ships between intensity of actions implemented and
substance abuse behavior, while the other two30,80
found positive relationships.
Discussion and Conclusions
Based on a review of the empirical literature, six
coalition-building factors appear to enhance various
indicators of coalition effectiveness as documented by
five or more studies. Specifically, coalitions that enact
formal governance procedures, encourage strong lead-

April 2006 Am J Prev Med 2006;30(4) 357

ership, foster active participation of members, cultivate
diverse memberships, promote collaborations among
member agencies, and facilitate group cohesion may be
more effective.
Based on the state of the literature, several cautions
must be voiced before any firm conclusions can be
drawn. First, studies examined a wide range of indica-
tors of effectiveness (n ⫽26), from assessing coalition
functioning to community-wide changes, but few stud-
ies measured actual changes in health behaviors. The
literature also includes a wide spectrum of coalition-
building factors (n ⫽55) found to be related to various
indicators of coalition effectiveness. The same factors
and indicators were rarely assessed across studies; when
the same factors and indicators were examined across
studies, conflicting results sometimes emerged. There-
fore, it is difficult to summarize which coalition-
building factors influence which types of indicators.
Second, even when studies examined the same
coalition-building factor, measurement method varied.
As discussed previously, leadership style was measured
in five different ways: incentive management, task fo-
cused, multiple leaders, empowering/collective, and
combination of styles. Similarly, member participation
was measured as the total number of members (quan-
tity) or by the efforts members made on behalf of the
coalition (quality). Variations in how coalition-building
factors were measured preclude identifying which as-
pects of leadership style or membership composition
are most relevant to producing outcomes.
Third, most studies employed cross-sectional designs,
making it difficult to infer any causal relationship
among factors and outcomes. For example, it may be
that as members begin to perceive coalitions as effec-
tive, they may become more satisfied or willing to
participate. Furthermore, given the lack of comparison
designs and the use of correlation analyses, it is difficult
to rule out other possible coalition or environmental
factors that may confound the findings. The literature
provides little evidence for inferring causality and asso-
ciations among coalition-building factors and indica-
tors of effectiveness.
In addition to cautioning interpretation of these
findings based on the current literature, the limitations
of this review must be considered. First, the search
strategy was limited to published literature in public
health, medicine, nursing, and psychology, due to the
focus on community coalitions aimed at improving
health outcomes. Although studies examining coali-
tions abound in the sociology, economic, and political
science literatures, this work focuses on how and why
coalitions develop in order to understand better the
political process or community development, rather
than whether or how they influence population health
outcomes. By not searching these other social science
literatures, some articles meeting the study’s selection
criteria may have been missed.
358 American Journal of Preventive Medicine, Volume 30, Number 4
Second, an inductive approach was employed to
categorize and then count the number of conceptually
distinct coalition-building factors and indicators of ef-
fectiveness measured across the 26 studies. Other inves-
tigators may have categorized variables differently and,
thus, differing numbers may be reported. Last,
coalition-building factors and indicators of coalition
effectiveness were labeled based on our interpretation
of how the study information was displayed (e.g.,
research question, design, analysis plan). Those carry-
ing out the studies may not have conceptualized the
relationships among these variables in the same man-
ner, however.
Nonetheless, given the popularity of coalitions and
the growth of research on coalition effectiveness, what
explains the wide variation in coalition-building factors
and outcomes examined and divergence among stud-
ies? What precludes us from drawing more firm con-
clusions about which coalition-building factors are es-
sential for coalitions to achieve their outcomes?
One explanation is the paucity of theory-informed
research. Only two of the 26 examined studies were
informed by an existing theoretical framework. It ap-
pears that investigators selected coalition-building fac-
tors and outcomes based on previous empirical find-
ings, experience, or trial and error. For example, of the
26 studies examined, nine (34%) examined ten or
more coalition-building factors without providing
strong justification for why these factors were selected.
This data-driven approach may be explained by the fact
that few theories exist that explicate coalition effective-
ness.5,91 Although descriptive theories explaining the
phases of coalition development have been available,3
only recently have comprehensive, causal theories been
proposed, such as Butterfoss and Kegler’s5 community
coalition action theory and Lasker and Weiss’s91 model
of community health governance. Both theories are
derived from the authors’ experiences in working with
community coalitions and reviewing the empirical lit-
erature. In addition, the authors justify the selection of
hypothesized coalition-building factors and expected
outcomes. These theories may provide a rich context
for informing future research studies. Without theoret-
ical grounding, the field may not be developing a
consensus for understanding the determinants of effec-
tive coalitions.
Another plausible explanation for the divergence in
findings may be the lack of collaboration across disci-
plines.91 Many social science disciplines—such as inter-
organizational relations (organizational development);
interest group politics (political science), social move-
ments and community structure (sociology), and mar-
ket efficiency (business/economics)— have studied co-
alitions intensely. Although scholars in these non–
public health fields study coalitions with different types
of members (e.g., CEOs or politicians) and outcomes
(e.g., increased market share or political decision mak-
www.ajpm-online.net
ing), public health researchers may greatly benefit
from their theories and empirical findings and/or
working collaboratively on research projects.
Of these social science fields, interorganizational
relations (IOR) provides the greatest potential for
explaining which coalition-building factors produce
effective community coalitions. The IOR field grew out
of organizational theory in the 1960s and seeks to
understand how organizations work together.92 Similar
to the public health field, IOR historically has made
little progress in explaining why, how, or whether
coalitions (and their characteristics) effect intended
outcomes.73,93,94 A recent number of studies, however,
have integrated IOR theory to assess how health service
delivery consortia affect health service delivery out-
comes73,74,95 and how organizations work together in
community coalitions.96 It is plausible, therefore, that
public health researchers might build on or integrate
conceptual frameworks and empirical evidence from
this field.
What initiatives could be undertaken to develop a
more cohesive, consistent literature explaining the
empirical relationships among coalition-building fac-
tors and indicators of coalition effectiveness that could
help guide practitioners? Specifically, how could pri-
vate foundations and government agencies facilitate
this objective? First, the field could benefit from mech-
anisms for developing and testing theories on coalition
effectiveness. For example, the W.K. Kellogg Founda-
tion has funded the Center for Advancement of Col-
laborative Strategies in Health at the New York Acad-
emy of Medicine to organize joint learning work groups
among coalitions funded through the Turning Point91
and Pathways to Collaboration (www.pathwaystocol-
labortion.net) initiatives to collectively develop explan-
atory models of how coalitions work to improve health
outcomes. The learning work group convened with
Turning Point coalitions resulted in the development
and publishing of the “model of community health
governance.”91 Building on this work group model,
foundations, federal government agencies, academic
institutions, and nonprofit organizations could jointly
facilitate consensus panels or other work groups
charged with synthesizing the theoretical and empirical
findings to develop other causal theories and then fund
studies to test their relevance.
Similarly, the field could benefit from mechanisms
supporting interdisciplinary scholarship and practice-
based experiences to develop a cross-cutting research
agenda. The National Institutes of Health (NIH) Road-
map Initiative (http://nihroadmap.nih.gov/index.asp)
or the National Institute of Occupational Health and
Safety (NIOSH) National Occupational Research
Agenda (NORA) (http://cdc.gov/niosh/nora.html)
provide examples of how convening a wide variety of
stakeholders can produce a research agenda that cuts
across many disciplines and topics. Developing a cross-
April 2006
cutting research agenda could rally both government
and foundations’ commitment to systematically fund-
ing studies to identify which coalition-building factors
produce effective coalitions. Findings from studies pro-
duced by this research agenda could then be used to
create an empirically validated list of coalition-building
actions similar to evidence-based registries maintained
by the Substance Abuse and Mental Health Service
Administration for mental health (i.e., Science to Ser-
vice) and substance abuse (i.e., National Registration of
Effective Programs) interventions.
In closing, community coalitions have become an
entrenched strategy within the health promotion tool-
box. Given the inherent challenges in facilitating them,
those leading and funding coalitions need guidance in
selecting evidence-based coalition-building actions that
most likely result in positive outcomes. The current
literature provides little consensus on evidence-based
coalition-building factors. Individuals and organiza-
tions vested in the community-coalition model may
consider joining forces to support coalition causal
theory development and interdisciplinary collaboration
that could produce a more reliable and consistent
evidence-based literature.
No financial conflict of interest was reported by the authors of
this paper.
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