Introduction to facilitation, peer groups, and collaboration

The use of groups in public health settings is quite common. You may lead a community discussion group about dealing with a health threat in your community. You may bring together a group of people experiencing a common issue such as addiction. You may be asked to bring representative members of your community together in a focus group to learn from and understand issues important to them. You may also need to make connections or collaborate with other organizations in your community to be able to accomplish a goal. In this chapter, we will review the skills necessary to facilitate any of these types of groups. You will be introduced to the different types of groups you may encounter as a public health worker. 

Section One: Developing Facilitation Skills

An essential skill for public health workers is the ability to facilitate. Meanings of the word facilitate include making something happen, and making something possible. 

Public health services require action, whether it is educating community members about disease prevention or responding to an outbreak of an infectious disease. One of the skill sets most important for public health workers is facilitation. For public health workers, facilitation skills are necessary for working with community groups, planning and conducting meetings, or training. While a supervisor or director might put together goals and objectives, the facilitator guides a group to plan and organize to achieve those goals effectively. To accomplish this, the facilitator must keep everyone on topic, and effectively move a group through a process, often using an agenda or list of issues for discussion.  Facilitation also means having skills to resolve conflicts and maintain good communication.

Principles of Facilitation

Facilitation has three basic principles:

• A facilitator is a guide to help people move through a process together, not someone who knows everything or has a fixed opinion. A facilitator should not offer opinions but instead should be able to draw out the ideas of the group members.

• Facilitation focuses on how people participate in the process of learning or planning, not just on what gets achieved.

• A facilitator is neutral and never takes sides. (Chapter 16, Section 2. Developing Facilitation Skills, n.d.)

The best meeting chairs see themselves as facilitators. They have to get through an agenda and facilitate discussion. They don't feel that they have all of the answers or should talk all the time. The most important thing is what the participants in the meeting have to say. If you have the opportunity to be a facilitator, focus on the topics up for discussion on the meeting agenda. Make sure everyone feels comfortable participating, and encourage participation. Here are some additional tips: 

• Create an agenda that allows for everyone's ideas to be expressed and understood. Move forward with the agenda items. 

• Make members feel good about their contribution to the meeting by listening and giving feedback on their comments. Whether you agree or not, this reassures them that their point of view was heard.

• An excellent facilitator can ensure the group feels that the ideas and decisions are theirs, not just the facilitators.

What a Facilitator Does

Facilitation is a skill that you can learn. To be an effective facilitator means:

• Understanding the goals of the meeting and the organization.

• Keeping the group on task with the agenda and moving forward. In other words, keep the meeting under control and don’t allow it to be taken over by any individual participant.

• Involving everyone in the meeting. Drawing out the quiet participants and controlling the ones who wish to take over the meeting.

• Ensure democratic decision-making. (Chapter 16, Section 2. Developing Facilitation Skills, n.d.)

HOW TO FACILITATE

Here are three things that a facilitator is in charge of when planning and running a meeting:

• Climate and Environment

• Ensure that the room is at a comfortable temperature–not too hot, not too cold. 

• Regardless of where the meeting takes place, ensure that the surroundings are clean, organized, and good for the discussion.

• Logistics and room arrangements

• A facilitator will arrange the meeting or training location in advance. Review the arrangements multiple times before the meeting to avoid misunderstandings or conflicts. 

• Have a backup plan.

• Ground rules–make sure that the ground rules are available in advance and reviewed at the beginning of the meeting. People should not be held responsible for rules they are not aware of. Some examples of ground rules are: 

• One person speaks at a time.

• Raise your hand if you have something to say.

• Listen to what other people are saying.

• No mocking or attacking other people's ideas. 

• Be on time coming back from breaks (if it's a long meeting).

• Respect each other.
  
  

How a Facilitator Runs a Meeting

Here are some suggestions for the steps of a successful meeting, along with some tips for being a successful facilitator:

START THE MEETING ON TIME

This principle requires no explanation. People will arrive late, but in most circumstances, you should start the meeting on time. Give respect to those who made the effort to be there on time. 

WELCOME EVERYONE

Verbally welcome everyone who comes, and make attendees feel welcome through your words and actions. Work with whoever has made the effort to come, and do not be concerned if the attendance is not what you had hoped. 

MAKE INTRODUCTIONS

Typically, facilitators may ask everyone in a room to introduce themselves. Depending on the size of the meeting, it is possible for introductions to take up most of the meeting’s time. There are numerous options for having participants introduce themselves that are efficient and do not take up a great deal of time. When planning introductions, ask yourself, “What is the most important thing for me to know about the participants?” and, “What is the most important thing for the participants to know about each other?” Familiarize yourself with some options so that you can choose a method appropriate for the kind or size of meeting you are facilitating. Come prepared with specific questions that you can ask, such as, “tell us something unique about yourself so we will never forget you”. 

An icebreaker is an activity to help members of a group feel more comfortable and at ease with each other. Icebreakers are helpful when members of a group don’t know each other, come from different cultural groups, speak different languages, or simply need to feel that they have permission to participate. Icebreakers are usually combined with introductions. 

One typical icebreaker activity involves giving participants a paper with a list of items that people may have, have done, or experienced. For example, this list might include, “Find someone who has a two-legged pet”, or, “Find someone who has traveled to Europe.” Participants are asked to go around the room and find someone who can best answer each question. 

When you plan an icebreaker activity, be sensitive to the culture, age, gender, and literacy levels of participants. For example, the activity just described which requires walking around and talking to other meeting participants may not be the best idea for a meeting with older individuals with limited mobility. You should always ask yourself in advance what you wish to accomplish with this activity. What is your objective? 

Finally, don't forget to introduce yourself. Be nice. Share your background so that individuals in attendance understand why you are doing the facilitation and your connection with the issues to be discussed.

REVIEW THE AGENDA, OBJECTIVES, AND GROUND RULES FOR THE MEETING

After the introductions, review what is going to happen in the meeting. Be open to comments and suggestions regarding the agenda. 

Make sure that participants understand the purpose and goals of the meeting. The most effective and productive meetings have outcomes with specific items that will be acted on. Review the ground rules that have been established, and offer clarification to anyone who might have a question.

ENCOURAGE PARTICIPATION

One of the most challenging situations for a facilitator occurs when you ask a question and no one responds. Encouraging participation is one of the primary responsibilities of facilitation. Demonstrate your ability to listen. Don’t respond until someone has completed their thought. Respond to comments in a way that doesn’t shut a person down, and cause them to lose their desire to participate. In other words, make sure that the participant knows they have been heard, and that respect is shown for what they have shared. A hasty or short reply, such as “we’ve already done that”, sends a message to participants that the facilitator doesn’t care about, or wants to hear about, what they are saying. 

STICK TO THE AGENDA

Occasionally when in a group setting, the participants may digress. This means that they may move away from the primary issue or topic being discussed. Digression wastes time and can make reaching a group agreement difficult. It is your responsibility as the facilitator to keep the discussion focused. You might say something such as, “I appreciate that, however, we digress…” and return to the issue being discussed.

AVOID DETAILED DECISION-MAKING

As with digressions, it is easy to get discouraged with small, insignificant details. As a facilitator, make sure that you keep the discussion on track to focus on the real issues at hand. Don’t get lost in discussions of the design of invitations, when the real issue is who to invite to a fund-raising event. 

SEEK COMMITMENTS

Meetings with lots of talk, but where nothing is decided, waste the time of those who are attending. Meetings should always end with specific action items and with individuals assigned to perform those tasks. In other words, an effective meeting is not just about discussion, it is about deciding upon a plan of action. You should never end without a specific plan being made for moving forward. Instead, get commitments that can be followed up and reported on at the next meeting. 

BRING CLOSURE TO EACH ITEM

Be mindful of the amount of time given for the meeting and the amount of time it is taking for the discussion of any particular agenda item. As a facilitator, recognize when the discussion of one item is taking too long, and find a way to bring closure to the agenda item, even if participants haven’t reached an agreement. You may wish to summarize the positions that have been taken on a particular issue or ask someone in the group to summarize the points where the participants agree, and then move forward. If one or two people disagree, state the situation as clearly as you can.

RESPECT EVERYONE'S RIGHTS

A great facilitator notices the people in the meeting who don’t speak up. You should encourage them to speak their mind. At the same time, some people want to do all the talking and dominate the meeting. People who are quiet but do have something to contribute may completely shut down, and their input will be lost. 

Sometimes people feel passionate about an issue and have a lot to say about it. Recognize their passion and interest. Find an appropriate moment to speak and move the discussion to other participants.

BE FLEXIBLE

Sometimes things will not go how they are outlined on the agenda. Some issues will end up taking more time than you anticipated. At other times, issues will be raised that are valid and important, but not on the agenda. Be flexible enough to know when adjustments to the agenda need to be made.

SUMMARIZE THE MEETING RESULTS AND NEEDED FOLLOW-UPS

Remember that a key to an effective meeting is to have specific follow-up actions that are given to individuals who will have accountability for taking those actions. sure Before the meeting closes, summarize the follow-up actions that were agreed to and need to take place. Always be positive, and praise the participants. Real, meaningful praise is motivational. For example, praising someone for taking the initiative on a project, or who made an extra effort is different from praising someone for finding the wifi password for the location where the meeting is taking place. 

THANK THE PARTICIPANTS

As a facilitator, it is never about you. Always acknowledge others. Thank all those who participated in any way. Thank the individuals who did specific things to make the meeting happen. 

CLOSE THE MEETING

One of the best ways to help participants feel good about a meeting and have the desire to return and participate in the future is to end a meeting on time. A best practice is to have a hard stop, which means that no matter what, the meeting will end at an appointed time. This shows respect for the time individuals have invested in coming to the meeting. Make sure that you have addressed and brought to conclusion all of the issues raised during the meeting.

Dealing With Disruptions

Along with these facilitation tips, you need to prepare yourself for times when individuals attempt to disrupt a meeting. The most common kinds of disruptors are people who try to dominate or take over the meeting, constantly digress from the agenda, have side conversations with the person sitting next to them, or think they are right and ridicule and attack others’ ideas.

Preventions

There are some things you can do to prevent disruption before it occurs and to stop it when it's happening in the meeting. Try using these preventions when you set up your meeting to discourage or lessen the chance of disruptions:

• Agree on the process. If your group can agree on the discussion process, that means they will take ownership and joint responsibility for how the meeting is run. They will have a personal stake in achieving the outcomes and goals.

• Listen carefully. It is obvious to others when you are not listening. You cannot simply pretend to listen. Use the principle of active listening. This means that you repeat what the person said to them so that you can be certain you understood what they were trying to communicate. In active listening, you begin your response with a phrase such as, “What I understand you said is…” or, “What I hear you saying is…”

• Show respect for experience. Recognize that your meeting participants have experience and knowledge of the issues being discussed. Do not talk down to them as if they don’t know or understand the topics being covered. Instead, encourage participants to share their experiences and what they have learned from them. 

• Find out the group's expectations. Your expectations of what is to be accomplished may be different from the expectations of your participants. There are many ways to find out what the group's expectations of the meeting are: Try asking everyone to finish this sentence: "I want to leave here today knowing...." You don't want people sitting through the meeting feeling angry that they're in the wrong place and no one bothered to ask them what they wanted to achieve here. These individuals may act out their frustration during the meeting and become your biggest disruptors.

• Stay in your facilitator role. Don’t try to be both a facilitator and a participant. When you start acting as a participant, you risk losing control of the meeting. You may offer strategies, resources, and ideas for the group to work with, but not opinions.

• Don't become defensive. Learn how to respond If you are attacked or criticized. Think before you speak. Take a deep breath. Respond by acknowledging any valid points of the criticism. That’s all. Make sure that the person knows you heard what they said. Do not become defensive, acting as if the criticism is personal, because this will cause people to shut down, not share their ideas, or not be honest in what they share. 

• Power Players. Some feel a sense of importance or that their position is the “right” one. Their goal is to influence participants to “buy in” to their opinion or solution. To do this, they take a larger role in the meeting and may take up more than their share of the time. These individuals are looking for acknowledgment and respect. If possible, give them acknowledgement up front at the start of the meeting. Make them feel important by giving them specific assignments during the session.

Effective facilitation may seem to be a challenge, something like walking on a high wire while balancing weight on both ends of a pole and trying to juggle at the same time. You have to keep people happy, deal with unhappy people, moderate disagreements, and help a group of diverse people agree. But the key to all of it is listening. If you truly listen to participants they will feel heard, which is often what they want. As a facilitator, listening, bringing ideas out of people, and creating a safe place for them to share their ideas will help create unity in the group. 

Section Two: Stakeholders 

Who and What are Stakeholders?

A stakeholder is a term used to identify any individual, group, or organization that is directly affected by your evaluation or proposals. They need not be directly connected to a group. They have a “vested interest” or personal stake in what is being discussed. The result of the discussion will affect them directly, either positively or negatively, depending upon their position on an issue. 

• Primary stakeholders are those who are directly affected by a program or policy.  

• Secondary stakeholders are those directly involved with or responsible for the primary stakeholders. They may also be those who live close by or offer services to them. 

• Key stakeholders can pass regulations, enforce laws, and influence others.

For example, suppose a community wants to build a temporary housing complex for the homeless in the community. In that case, the homeless are the primary stakeholders. Some secondary stakeholders might include residents and business owners in the neighborhood where the building will be located, contractors, and taxpayers who will fund the facility. Key stakeholders might include city officials, policymakers, media, and clergy who influence community members and may influence whether this new building will be constructed. 

Stakeholders should be involved in your process. Be open with your decisions and ideas. Stakeholders may be able to tell you when a proposal is not possible. They may also provide valuable insight into the issues you are addressing. They may be able to assist you in reaching individuals you are targeting for services because they serve the same group. Don’t discount the stakeholders’ feedback. 

Section Three: Creating and Facilitating Peer Support Groups

What is a peer support group?

A peer support group is a group of people who gather to talk about common problems and experiences related to a particular issue or situation. This type of group is also called a self-help group. In a support group, people can talk to others who are going through the same thing they are, and they can share practical advice based on their own experiences. Some things common to support groups are that participants are all dealing with the same issue, they usually have a professional or volunteer facilitator to guide the discussions, they are typically small, and people go voluntarily. Sometimes, people are required to go to support groups, but usually, people choose to go because they want to be with others who understand what they're going through. 

Benefits of a peer support group.

There are many benefits to peer support groups. For example, if someone is dealing with a problem or illness and doesn't know anyone else going through the same thing, they can feel alone and like no one understands them. This changes when they join a peer group.  It costs very little to run a support group - just some advertising for the group and perhaps some refreshments. Talking to a counselor or doctor can be intimidating for some people, but talking to others in a support group can reduce anxiety, and improve self-esteem. Support groups can provide safe places for people to talk about personal issues, experiences, struggles, and thoughts. Some members can act as role models who inspire others because they are dealing with the same problems and making progress in their lives. Support groups empower people to work to solve their problems, and members can share information to keep each other up to date. Support groups formed to bring together people with similar problems or medical conditions can help people feel less isolated and more understood.

How to create a peer support group. 

Knowing the multiple benefits of support groups is the first step. To create a functioning peer support group, you have to first decide what your group's purpose will be and who you want to reach. You might find it helpful to write vision and mission statements for your support group.

Are there existing national, regional, or local groups that your group can be involved with?

A best practice is to not duplicate services that are being offered effectively elsewhere. Find out if there are already existing groups that provide opportunities for people in similar situations to get together to provide support. Ask if there are ways that you can partner with them. A larger organization may offer resources and assistance to help you set up a new support group. You will have the benefit of the name recognition of the larger organization, which can give your group more credibility. It may also make it easier for people who need your support group services to find you. Don’t "reinvent the wheel", in other words, there is no need to start a new group from scratch when there is already a group with the same purpose that is established and works well. Using a fictional example, let's look at how someone might set up a support group with the help of a larger organization.

Yoshiko's support group

Yoshiko's sister was recently diagnosed with muscular dystrophy. Feeling frustrated and isolated, Yoshiko wanted to start a support group for the disease's sufferers and their families. After carefully studying this section of the Community Tool Box, Yoshiko decided to find out whether the Muscular Dystrophy Association, a national organization, sponsored a support group in her town.

She visited the MDA's website and discovered that they offered a group in a nearby town, but there wasn't one in her city. After Yoshiko called the organization's national office and found out they could help her new support group, Yoshiko decided to start a local MDA support group rather than an independent one.

Consider whether the group will meet for a specific period or an indefinite period.

Depending upon the nature of the group, support groups can either be ongoing or take place within a specific time frame. As an example, a support group for people trying to overcome addictions can be scheduled weekly with no end date. People will come in and out of the group, and there is always a need. These groups are known as open support groups and are generally best for most people. 

A closed support group, on the other hand, is organized to be functional for only a designated time, such as a few weeks. People can only join at certain times or under certain circumstances. These are best for people working on a specific issue.

Select a group leader or facilitator

Selecting the right group facilitator is vitally important. The person facilitating needs empathy, as well as the ability to listen and draw people out. They should be able to make participants feel that they are in a safe place, especially if they are revealing difficult details about their lives. If possible, find a facilitator who has personally experienced the same challenges the group members are currently facing. 

How often should we meet? 

A typical support group meets once a week. Depending on the needs and the availability of the facilitator and the participants, the group may meet more than once a week or every other week. 

How long should meetings last?

An ideal duration for support group meetings is one hour, though some meetings that last for two hours may be necessary. Meetings need to have a specific stop time. This means that you conclude the meeting on time, no matter what is going on. This sends a message that you are not there to waste their time. 

How big should your support group be?

It is best to have a group that's large enough to function well even when some of the members are absent but small enough for all the members to feel comfortable. As a rule, five to 10 people is an appropriate size. If there are more people than this in a meeting, it can be  difficult for the members in the group to have time to say what they need to say, and the group may become unmanageable and impersonal.

How do I promote my group? 

Use referrals. Network with other groups and professionals in your area. Let local clergy, doctors, administrators, agency directors, social workers, media personnel, nurses, and other such people know about your group, and encourage them to tell people about it. 

Use the media. Posters and flyers can be placed in businesses and other places in the community where they will likely be seen by potential participants. You might consider sending information about your group to local newspapers, television stations, or websites that promote local events. A newspaper article can generate a lot of attention.

Use personal invitations or word-of-mouth. Personal invitations can be one of your most effective tools. Encourage them to reach out to friends who might benefit. When your group starts meeting, encourage members to tell others about the support group.

How to keep a support group going? 

Support groups naturally change over time, but there are some things you can do to keep a support group going. Having a realistic perspective for the group is important as members share their failures and achievements. One of the most important things is to keep track of each member’s progress and ask them for feedback. Sharing responsibilities for the group and letting others take leadership roles will also help them feel more committed to the group. Be sure that everyone has a chance to participate and emphasize the importance of confidentiality. Members need to know that what they share stays within the group. If you have an open group, keep recruiting new people and have current members invite those they know that would benefit from the group. Encouraging outside contact among members can form lifelong friendships. 

Summary of Peer Support Groups

There is little doubt that peer support groups, well organized and well facilitated, can be very helpful in meeting the goals of public health agencies. When someone is dealing with a problem or illness, they might feel like nobody else understands them. Joining a support group can help them feel less alone and more understood. Support groups don't cost much to run and can empower people to solve their problems. Members can share information and feel a unique emotional connection. They act as role models for each other, which can be inspiring and encouraging. Support groups are a safe place to talk about personal issues, and talking to others can reduce anxiety, improve self-esteem, and help people feel better.

Section Four: Conducting Focus Groups

What is a focus group?

A focus group is a small-group discussion guided by a trained leader. It is used to learn about opinions on a specific topic and to guide future action. Focus groups are similar to needs assessments because they help people learn more about group or community opinions and needs. 

Examples of focus groups might include parents of preschoolers who meet to discuss child health issues. Parents share their views on local healthcare programs for children, their healthcare needs, and how your organization could help meet those needs.

A focus group of senior citizens is involved in the creation of a new senior center. What healthcare programs would they like to see offered? How can your organization partner with the center? What are their suggestions and ideas?

Your agency wants to open a group home for developmentally disabled adults in a quiet residential area. You host a focus group of prospective neighbors. What are their concerns? Can this work?

A focus group is different from the other types of groups discussed in this chapter in three basic ways:

1. A focus group has a specific, focused discussion topic. 
2. A focus group has a trained leader or facilitator. 
3. The participants in a focus group and the topics for group discussion are carefully planned to create a nonthreatening environment in which people are free to talk openly. Focus group members are actively encouraged to express their opinions.

Why do we need focus groups?

Focus groups help people learn more about group or community opinions and needs. An advantage of focus groups is the ability to get closer to what people are really thinking and feeling, 

How to facilitate a focus group?

Finding a trained facilitator is something that should be taken seriously. Your leader will determine the success of your group. When choosing a leader, you will want someone who is experienced and trained in leading a focus group, perhaps outside of your organization. This person will ideally know a great deal about the topic being discussed. Your facilitator should relate well with the participants and be able to make the participants feel comfortable in sharing their true thoughts.

Focus groups are ideal for asking questions that can’t be easily answered on a written survey. Facilitators are responsible for deciding what questions are to be asked, how to phrase the questions and the order in which the questions will be asked. For this reason, it is important to prepare the questions and topics to be discussed well before the meeting.   

You should also look for someone who can write the details of what takes place during the focus group session. Collecting information is the purpose of a focus group, so taking notes will help you share the information or put it to good use. Also, with the consent of the participants, the session can be recorded. 

Decide who should be invited.

Ideally, you should invite a representative sample of individuals whose opinions you want to learn about.

For example, if you are concerned about the opinions of medicare recipients, you would then want to identify and send your invitations to those individuals. If you are concerned about the opinions of local nurse practitioners, get a complete list and try to interest a representative group.

The focus group meeting

At the beginning of your meeting encourage open participation. Set a tone that will invite members to contribute. Make sure that all opinions on each question get a chance to be heard. Before moving to a new topic of discussion, ask if anyone has any other comments to make. This can be an effective way of gathering other opinions that have not yet been expressed. Make sure participants know what next steps will be taken and how they will be informed of any decisions based on their input. 

After the meeting

Evaluate what was said in the meeting and identify the patterns that have emerged. Ask yourself if there appears to be any issue on which there is general agreement. Are there significant issues that cause people to disagree? Provide timely feedback to your focus group participants. 

Use the results

If you are able to collect useful information through your focus group, you need to use it.  Take the input you received and use it to improve the situation that originally motivated you to create the focus group.

Summary of Focus Groups 

Focus groups are a way to help you get feedback on what your organization can do to be most responsive to the actual needs of your community. You shouldn’t assume that you know what the people in your community are thinking. They can also serve as a way to promote your group and get people interested in what you do. 

Here is an example of what a successful focus group can accomplish: In Orlando, Florida USA, some influential people got together to learn about making their community healthier. They brought together 160 people from all different parts of the city to talk about what they wanted for their community. They listened to what other people had to say and came up with 14 statements about what they thought Orlando should be like. This became the start of the Healthy Community Initiative. 

Section Five: Creating Coalitions

Sometimes problems in a community are too big to be handled by just one group or organization. In this circumstance, a coalition can be formed to address the problem. The goal might be something small, like getting money for an immunization project, or something big, like improving the quality of life for everyone in the community through the elimination of a hazard to public health. 

Coalitions exist to reach a set of goals, which could include influencing public policy, changing people's behavior, or building a healthy community. A healthy community includes things like medical care, environment, housing, education, culture, and employment. The coalition can be helpful when facing difficult problems in a community.

What is a coalition? 

In simplest terms, a coalition is a group of individuals and/or organizations with a common interest who agree to work together toward a common goal. That goal could be as narrow as obtaining funding for a specific intervention, or as broad as trying to permanently improve the overall quality of life for most people in the community. For the same reason, the individuals and organizations involved might be drawn from a narrow area of interest or might include representatives of nearly every segment of the community, depending upon the extent of the issue.

Coalitions may be loose associations in which members work for a short time to achieve a specific goal and then disband. They may also become organizations in themselves, with governing bodies, particular community responsibilities, funding, and permanence. They may draw from a community, a region, a state, or even the nation as a whole (the National Coalition to Ban Handguns, for instance). Regardless of their size and structure, they exist to create and/or support efforts to reach a particular set of goals.

Common goals for coalitions in public health include:

• Influencing or developing public policy, usually around a specific issue.

• Changing people's behavior such as reducing smoking or drug use.

• Building a healthy community through medical and preventive or wellness services. 

"The fundamental conditions and resources for health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity. Health improvement requires a secure foundation in these basic prerequisites." (Chapter 5, Section 5. Coalition Building I: Starting a Coalition, n.d.)

Why start a coalition and why might it be difficult?

There are several reasons why developing a coalition might be a good idea. In general, a coalition can help concentrate the community's focus on a particular problem, create alliances among those who might not normally work together, and keep the community's approach to issues consistent.

Consistency can be particularly important in addressing a community issue, especially if there are already several organizations or individuals working on it. If their approaches all differ significantly, and they're not cooperating or collaborating, it can lead to a chaotic situation where very little is accomplished. If, on the other hand, they can work together and agree on a common way to deal with the issue and on common goals, they're much more likely to make progress.

Some more specific reasons for forming a coalition might include:

• To address an urgent situation. An example would be a significant increase in cases of infectious disease.

• To empower elements of the community - or the community as a whole - to take control of its future. This could be addressing the presence of an industry in the community that is polluting the environment and contributing to illness.

• To obtain or provide services. It may take a coalition - either initially or over the long term - to design, obtain funding for, and/or run a needed health intervention in the community.

• To bring about more effective and efficient delivery of programs and eliminate any unnecessary duplication of effort. and allow for a greater variety of services. When discussing duplication of effort, "Unnecessary" is a keyword when talking about duplication of services. Ask yourself whether a unified approach can  increase or improve the services currently available.

• To pool resources. Several organizations and individuals together may have the resources to accomplish a task that none of them could have done on their own.

• To increase communication among groups and break down stereotypes. Bringing together groups and individuals from different sections of the community can create alliances where there was little contact before. Working together toward common goals can help people break down barriers and preconceptions, and learn to trust one another.

• To refresh the low energies of members of groups who are trying to do too much alone. A coalition can help to strengthen efforts around an issue. For people who've worked too long without any outside input, the addition of other groups to the task can be a tremendous source of new energy and hope.

• To plan and launch community-wide initiatives on a variety of issues. In addition to addressing immediate pressing issues or promoting or providing services, coalitions can serve to unify efforts around long-term campaigns in such areas as smoking cessation, and other similar issues affecting public health.

• To develop and use political influence to gain services or other benefits for the community. A unified community coalition can advocate for the area more effectively than several different groups and individuals working alone.

• To create long-term, permanent social change. Real change usually takes place over some time through people gaining trust, sharing ideas, and getting beyond their preconceptions to the real issues underlying community needs. A coalition, with its structure of cooperation among diverse groups and individuals and its problem-solving focus, can ease and sometimes accelerate the process of change in a community.

When should you develop a coalition? 

A coalition needs to have a purpose if it is to be successful. The purpose may be broad or narrow, but it's unlikely that a diverse group will come together unless there's a reason to do so. Social change coalitions must be held together by a coherent, shared vision. This is usually not possible without a group process that can articulate the vision, create a mission statement, and help others see it as a reachable goal. Members of the coalition must share the vision. 

An example of a coalition that included multiple agencies, including public health organizations is an anti-poverty agency in Hampshire County, Massachusetts. This agency took the lead in establishing a coalition of educators, health professionals, child care and human service providers, and parents to act as the required community oversight committee for a Department of Education grant that offered services to the families of children aged three and under. The group planned the grant proposal and then continued to act as the advisory group for the administration of the funds after the proposal was successful. The members of the coalition also used it to refine and improve their cooperation and collaboration with one another in all their work, resulting, over the long term, in better services across the board in the county

Have both a good reason for starting a coalition as well as the possibility that one can be started successfully in the community. 

There are certain times that are better than others to start coalitions. Some of these include:

• When dramatic or disturbing events occur. 

• When new information becomes available.

• When circumstances or rules change.

• When new funding becomes available.

• When there is an outside threat to the community.

• When a group wishes to create community change.

• When you have a good reason and there is a possibility that one can be created. 

When you see the time is right to form a coalition, there are some questions you need to ask to see if it will work in the community. Is the issue or problem clear enough that everyone can agree on what it is? If there's no agreement that it is an issue, it's unlikely that you'll be able to form a coalition around it. It needs to be clearly defined, even if the solution is not.

Sometimes the history of the community and community organizations may present barriers to forming a coalition. Community divisions along racial, ethnic, class, religious, or political lines; old feuds; turf battles among agencies; or past failed coalition efforts  can all create barriers. Ask yourself if there is at least some level of trust among the individuals and organizations who'd make up the coalition. If not, how do you go about building that trust and repairing past failures?

Even if there is enough trust to start a coalition, be aware that it is not only possible but likely inevitable that there will be bad feelings among some groups or individuals. That's a reality in any community, and the coalition will probably have to face it. In many cases, working together toward a common purpose can do a lot to change attitudes and to smooth over the past.

Is a coalition the best response to the issue? 

Assuming that there is general agreement and no trust issues, there is still the possibility that some people will not see a coalition as the most effective way to handle the situation. Ask these questions and make sure you can answer “yes”  before you try to start a coalition:

• Can the issue be better addressed if all concerned parties are working together, and will a coalition help to accomplish that purpose?

• Will a coalition increase the likelihood that all the factors affecting the issue are identified and attended to?

• Will a coalition increase the coherence, strength, and effectiveness of the community's response to the issue?

• If the community already has several coalitions, is yet another the best response to this issue?

Who should be part of the coalition?

The broader the membership of any coalition, the better, but there are certain people and groups whose representation in a coalition that are essential:

• Stakeholders. These are the people who have a stake in the success of the coalition's efforts. They are the most affected by the issue. 

• Community Opinion Leaders or Influencers. It's very useful to include those who can influence large numbers of other people. People who are highly visible, or who have credibility in the community such as clergy, business, or civic leaders, may fall into this group.

• Policy Makers. The participation of local political leaders, state representatives, and others in policy-making positions will both add credibility to your enterprise and increase the chances that you can influence policy in your area of interest.

Summary of Coalitions

In situations where issues are too large and complex for a single organization to address, a coalition of groups and individuals working together may be the solution. A coalition can develop a coordinated response to an issue, increase the efficiency of service delivery, pool community resources, create and launch community-wide initiatives, build and use political clout to influence policy and work effectively toward long-term social change.

Section Five: Creating Collaborations

What is a Collaboration?

While a coalition involves two or more organizations working together around an issue they can’t address on their own, a collaboration involves two or more organizations working together on multiple issues and goals in a long-term commitment. Groups of funders, non-profits, or other stakeholders align around a shared vision and target resources and activities supporting that vision. Collaborations are the highest and most challenging level of working with other groups in a formal, organized relationship. Because of this complexity, it may take a long time before any significant process is made.

Public health problems can be big and complex, so collaborations are necessary. These collaborations may come in many different forms of groups working together. They may include networks, coalitions, movements, strategic alliances, strategic co-funding, public-private partnerships, and collective impact initiatives. Collaborations can also be smaller, with just a few people or organizations working together for a common goal.

An example of a smaller collaboration would be a local church joining the Red Cross and holding a blood drive in their building. Both organizations work together, helping to reach the same goal; a healthy blood supply for their community.

An example of a large collaboration is the International Space Station (ISS). Five space agencies from 15 different countries work together to run this co-operative program. This partnership has resulted in over 3,000 research investigations from researchers in more than 108 countries. 

 All members of a collaboration must understand the goals and motivations of the other members. Once individual goals are understood, goals for the collaboration should be created and recognized by everyone. Organizations that collaborate are only successful when they are clear about what they want to achieve and how their efforts can help advance those goals. Collaborations can only be successful when everyone involved has the same goal, which is bigger and more important than the member’s individual goals. 

Since collaborations are organized to work on multiple issues and may involve multiple agencies and organizations, building relationships between the members is important. Cultural differences must be considered when building relationships. Culturally competent collaborations have improved effectiveness and greater success in reaching their goals. Cultural competence is non-threatening because it acknowledges and validates who people are. A key trait in modeling this collaborative spirit is to listen to what those around you say and stay unattached to whatever outcome you had in mind from the beginning.

When Collaborations are Used.

“One of my colleagues has always used the phrase, ‘Do what we do best and partner for the rest.’ Ideally, we’re looking for a partner who can do something better than we can…” — Dr. Raymond J. Baxter, Kaiser Permanente (Bartczak, 2015, pg. 9)

Although the following is not an exhaustive list, collaborating with others may make sense when:
• Addressing an issue from multiple points of view could help accelerate progress.
• Interventions have not been coordinated enough to make a lasting difference.
• An issue or problem needs more resources or additional funding sources.
• The context or environment suddenly requires a more united or aligned response. 

Who should be part of a collaboration?

The most important factor in determining who should be part of a collaboration is their stake in the work and whether they can make a meaningful contribution toward the goal. Collaborative initiatives can involve many stakeholders, including funders, nonprofits, private sector groups, government agencies, and everything in between. Collaborative efforts include people and organizations who have a variety of needed skills and experience. 

Successful collaborators have good written and verbal communication with their partners. They focus on including all partners, they actively listen, and give honest feedback. They invest in relationships with other partners and with those inside their organization to achieve a desired outcome. They involve other stakeholders from diverse backgrounds and with experience that is different from their own. They remain open-minded. Essential qualities for good partners are to actively listen to what others have to say and value their contributions and have respect for others even when they do not agree.  

When working in collaboration with other people or organizations, it is very important to understand their goals for the collaboration. Listening to others and being open-minded will help everyone work together. 

Summary of Collaboration

Collaboration between organizations and agencies is one of the most effective ways of accomplishing goals in a community. Bringing two or more agencies together means finding common goals shared by those agencies and using those common goals to create win-win partnerships where both agencies benefit.

References

Bartczak, L. (2015). Building Collaboration From the Inside Out. Grantmakers for Effective Organizations. https://www.issuelab.org/resources/22852/22852.pdf

Chapter 5, Section 5. Coalition Building I: Starting a Coalition. (n.d.). Community Tool Box. https://ctb.ku.edu/en/table-of-contents/assessment/promotion-strategies/start-a-coaltion/main

Chapter 16, Section 2. Developing Facilitation Skills. (n.d.). Community Tool Box. https://ctb.ku.edu/en/table-of-contents/leadership/group-facilitation/facilitation-skills/main

Case Study: Malaria Elimination in Sri Lanka

Summary:

Sri Lanka was declared malaria-free on 5 September 2016 by the World Health Organization. This success resulted from the efforts of many people and groups over the course of 100 years.  These efforts included monitoring for disease, controlling the vector (the mosquitos), and treating the disease.  In 2008 there was zero mortality, or death, from cases arising in the country. The last known case of Malaria contracted in the country was in 2012.  The success resulted from financial support from the Sri Lankan government, the World Bank, and the Global Fund. Because many other parts of the world still suffer from the results of Malaria, much can be learned from this achievement in Sri Lanka.

Introduction:

Malaria is a disease spread by mosquito bites.  The mosquitos carry the parasite Plasmodium, and the disease affects less-developed parts of the world in tropical and subtropical areas.  The World Health Organization (WHO) estimates that in 2015 there were 214 million clinical cases of Malaria worldwide, leading to 438,000 deaths, most of them occurring in Africa in children under the age of five.

On 5 September 2016, the WHO officially certified Sri Lanka to be malaria-free.  Sri Lanka is a tropical island nation with a population of roughly 21 million.  It is located southeast of the Indian subcontinent, and cases of Malaria peaked at the end of the country's monsoons.

Over the last 100 years, Malaria has been one of the most damaging health burdens in Sri Lanka.  Epidemics have occurred occasionally, with the worst happening between 1934 and 1935.  It killed over 1.5% of the population.

From July 1983 to May 2009, the country experienced civil war.  There was a ceasefire period from 2002 to 2006.  This ethnic conflict was between the government and national forces and the Liberation Tigers of Tamil Eelam (LTTE). The conflict led to large portions of the population being forced out of their homes and communities, and many lost access to health services.  In the past, conflicts like this created opportunities for epidemics, but Malaria throughout Sri Lanka's civil war is unique.

Between 2000 and 2015, the country saw a reduction from 200,000 to zero indigenous cases. Indigenous cases originate within the country instead of individuals getting the infection in another country and then traveling to Sri Lanka.  The reduction of indigenous cases was due to efforts to control the vector, the mosquitos. These efforts were achieved through cooperation between the Sri Lankan government's Anti-Malaria Campaign (AMC), non-governmental organizations (NGOs), humanitarian organizations, military, LTTE, and the reduction in foreign nationals entering the country contained the epidemic within the national borders.  Because Sri Lanka is an island, the possibility of mosquitos coming from the mainland is significantly reduced.  Sri Lanka's success at eliminating Malaria is especially recognized because of the civil conflict it experienced.

PROGRAM ROLLOUT

History of malaria elimination

Throughout the 1900s, malaria epidemics happened in Sri Lanka every 3-5 years. Following the epidemic of 1934-1935, Sri Lanka began an indoor residual spraying (IRS) program with the pesticide dichlorodiphenyltrichloroethane (DDT), which successfully brought the number of cases down to only 17 in 1963.

However, the government withdrew funding and reduced the IRS efforts, resulting in more epidemics. A very large epidemic occurred in 1986-1987, with over 600,000 cases. The AMC began operating under the central AMC Directorate, where it reorganized its programs at the district level and replaced single-vector programs, such as IRS, with an integrated vector approach.

Surveillance, or disease monitoring

Surveillance, or disease monitoring, was an important part of working towards eliminating Malaria.  This surveillance consisted of tracking each case in the country, allowing for IRS and treatment programs.  Since 1959, Sri Lanka has used passive case detection (PCD).  This means all fever cases brought to public health facilities were investigated for Malaria. In the late 1990s, the AMC introduced activated PCD (APCD), which means fever cases were tested for Malaria with microscopes.  These efforts greatly improved medical diagnosis, patient treatment, and better quality IRS. APCD has since been the most important way to detect cases.  In 1995 they identified 89.8% of cases, and in 2005 they detected 94.0%.  Then, in 1997, the World Bank International Development Association helped establish active case detection (ACD) by providing mobile malaria clinics that could travel to remote populations, often in conflict or war zones.  This expanded access to services throughout the country. The majority of ACD diagnoses were made by using microscopes. In 2009, the AMC hired a private organization, Tropical and Environmental Diseases and Health Associates (TEDRA).  This helped with surveillance efforts, which focused ACD in conflict zones and high-risk populations, especially pregnant females.

Insect surveillance

After the 1934-1935 epidemic, Sri Lanka started an entomologic (study of insects) surveillance program designed to learn about mosquito breeding patterns or how the mosquitos reproduce.  Trained workers captured mosquitos.  Then genetic tests were used at laboratories to learn if the mosquitos were resistant to certain insecticides or chemicals designed to kill the mosquitos.  This work was important in guiding Sri Lanka's vector control efforts, which consisted mainly of IRS and bed net distribution.

Mosquito (i.e., vector) Control

IRS involves spraying insecticide, or chemicals, on the inside of homes in areas known to have Malaria.  The purpose is to kill mosquitoes and prevent disease transmission. Sri Lanka has a long history of IRS use, beginning with DDT in 1946.  The WHO recommendations in 1993 led to a more focused IRS approach, with priority given to areas where transmission was high in the past or areas of higher mosquito breeding sites.  The LTTE worked with the AMC to deploy the IRS in conflict zones; in 2000, the IRS covered 24% of the at-risk population.

Insecticide-treated nets (ITNs) and long-lasting insecticide-treated nets (LLINs) were also important to vector control. ITNs last about six months before requiring more insecticides but LLINs last for approximately three years. The Global Fund supported the introduction of ITNs in 1999 and LLINs in 2004. Approximately 300,000 LLINs were distributed from 2005 to 2007, and many households (90%) reported using their nets every night while sleeping. Mosquito nets were most helpful in remote areas and conflict zones where regular IRS could not be provided.

Medical Treatment

Sri Lanka's national healthcare system provides free consultation and treatment at public hospitals. From the mid-1990s to 2006, malaria cases were treated with chloroquine and primaquine (0.25 mg/day for adults), with a 5-day treatment in low-transmission areas and a 14-day treatment in high-transmission areas.  Since not all people could reach public hospitals, using mobile clinics to offer these treatment services was also very important for success.

The last malaria death arising from the country was in 2008, and the last case of Malaria arising from the country was in 2012.  But cases brought into the country are still an issue. The country performs screening at ports of entry to detect incoming cases. Treatment remains free at public health facilities, and residents traveling to countries where Malaria commonly occurs are provided free medicine to prevent the disease.

Impact

Sri Lanka's efforts led to successful malaria elimination status in 2016.  There was a drop in the number of cases from 264,549 in 1999 to 736 in 2010 and 175 in 2011, only 124 of which were indigenous, meaning they originated with infection within the country. Deaths due to Malaria declined from 76 in 1995 to 40 in 2005, as the last indigenous death was in 2008.

Cost

Since the elimination campaign has been ongoing since the early 1900s, an accurate estimate of the total cost of efforts is not possible. However, the Sri Lankan Government, USAID, UNICEF, the Global Fund and the WHO were major contributors to Sri Lanka's malaria elimination success.  The Sri Lankan government and the Global Fund were the greatest funding sources.  The dollar amounts mentioned in this section are in USD.

In 1996, the World Bank contributed $18.8 million to the Sri Lankan health services project, which focused on a range of health issues, including Malaria. In 1999, the Sri Lankan government partnered with the WHO Roll Back Malaria program. The Sri Lankan president agreed to support several activities involving the prevention, early diagnosis and treatment of malaria and research  initiatives pertaining to drug resistance, drug therapy, and surveillance. The World Bank financed these activities.  The World Bank also supported the creation of ACD to complement the already established APCD.

Financial support from the Global Fund contributed significantly to malaria elimination efforts. Beginning in 2003, Sri Lanka applied for and received funding for its malaria program in Rounds 1 (2002), 4 (2004), and 8 (2008) of funding from the Global Fund.  So far, the Global Fund has signed $42,058,140, committed $38,157,830, and disbursed $35,662,201 toward malaria elimination in Sri Lanka. This funding has been used for expanding IRS, active surveillance through mobile clinics, diagnosis and treatment, and LLIN distribution.

Malaria activities in Sri Lanka are financed primarily through domestic sources, representing 58% of total funding ($8.8 million) in 2014. Domestic spending includes the Sri Lankan government funding for the AMC, solely directed towards malaria-specific initiatives. Only 0.94% of total government spending on health (an estimated $934.1 million) was devoted to Malaria in 2014, marking an increase from 0.80% that was spent the year before.  With a donation of $3.7 million, the Global Fund accounted for the remaining 42% of the total funding for Malaria in 2014.  Funding sources vary widely across districts as the AMC, the Ministry of Health, and the Global Fund determine which districts to include in grant proposals. 

With the last indigenous malaria case in 2012, Sri Lanka now focuses on preventing reintroduction. The existing surveillance and screening programs must be maintained to ensure elimination is permanent. The Sri Lankan National Malaria Strategic Plan (NMSP) estimated that an annual budget of $10 million (from 2015 to 2018) is required to prevent reintroduction. However, assuming a steady economic growth rate of 6.4%, including existing human resource and capital costs that the NMSP budget did not consider and basing the projection off of the current strategies rather than proposed activities, the University of California, San Francisco Global Health Group, estimated an annual budget of $14 million (from 2015 to 2020) to prevent reintroduction.

Reasons for success

The AMC was the main driver of malaria elimination thanks to the approach of vector control, surveillance, and case management.  After joining the WHO Roll Back Malaria partnership in the 1990s, the government had multiple partnerships with funders such as the World Bank and the Global Fund and local and international NGOs, which helped build its anti-malaria programs.

In addition to excellent programming and partnerships, Sri Lanka's strong institutions were critical to its success.  The country has a high adult literacy rate (91.2% between 2008 and 2012), contributing to high public compliance with available healthcare measures. It also has a national healthcare policy that provides a strong primary healthcare system by offering free healthcare to all citizens through a network of government hospitals and healthcare centers.

Throughout Sri Lanka's civil war, the regions where conflict was most common experienced increased parasite incidence as their primary healthcare services were disrupted. The AMC recognized the lack of treatment and prevention measures in these areas. NGOs and the military built up treatment protocols along with regional malaria teams. The LTTE were affected by high infection rates and eventually agreed to support control efforts. Despite the ongoing conflict, this was important in ensuring treatment and prevention for as many people as possible. The AMC, UNICEF, the WHO, and the Sri Lankan NGO Sarvodaya worked to distribute ITNs across the country, with the Global Fund supporting the introduction of LLINs later during the civil war. The Sri Lankan Red Cross, the International Committee of the Red Cross, Medecins Sans Frontieres, TED HA, and local health workers provided access to diagnostic and treatment services, largely through mobile clinics. By 2005, the

Infection rates in both conflict and non-conflict areas had stabilized and were well below previous levels. Sustained ACD, treatment, and vector control in these areas was an important factor in the eventual elimination of Malaria.

The use of DDT in the IRS program had excellent results, but it reduced its efforts, leading to a high increase in cases. An effective entomological surveillance program was critical in informing targeted IRS for high-risk areas, which became more important as malaria prevalence declined. In addition,

ITNs and LLINs were particularly effective in areas inaccessible to IRS teams.

The development of surveillance systems allowed for high case detection. More experts in using microscopes were able to use APCD in publicly run health facilities, and ACD could work more remotely in difficult-to-reach areas. In 2009, the AMC developed standard operating procedures for each confirmed or suspected infection, including post-treatment follow-up, household malaria screening, and IRS within a 1-km radius of the case.

Building and maintaining partnerships with NGOs and other parties is critical to ensure that almost all citizens have access to prevention and treatment measures, regardless of the country's sociopolitical environment. This requires leadership that is committed to providing support for these efforts. Secure

sources of funding are required to operate these programs not only throughout the elimination process but also afterward to avoid relapse. Thus, national governments must be willing to dedicate significant funds alongside their partners.

While Sri Lanka's elimination is impressive, the country must remain vigilant to prevent reintroducing the disease. Community-centered approaches have strengthened biomedical ones, and this cooperation was the ultimate driver of success. This is consistent with the principles of public health and has the potential for global impact.

The information in this case study was taken from CC License:

Simac, J., Badar, S., Farber, J., Brako, M. O., Giudice-Jimenez, R. L., Raspa, S., Achore, M., & MacKnight, S. (2017). Malaria elimination in Sri Lanka. Journal of Health Specialties, 5(2), 60. https://doi.org/10.4103/jhs.JHS_25_17