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Executive Summary

Introduction

King County Allies Against Asthma (AAA) was a project of the King County Asthma Forum (KCAF) designed to improve the health of low-income children with asthma located in Central and South Seattle and Southwest King County. King County AAA was one of seven sites from around the United States that received a four-year grant from The Robert Wood Johnson Foundation (RWJ) Allies Against Asthma project. The national RWJ AAA project was intended to develop models that improve access to and the quality of clinical care, reduce and prevent asthma symptoms and environmental triggers, foster patient and community education, and strengthen community-based asthma coalitions.

This report covers the planning phase of AAA, which encompassed the calendar year January 1, 2001 to December 31, 2001. The planning year evaluation used a qualitative case study design drawing on a variety of data sources including key informant interviews with AAA stakeholders, closed-ended surveys of KCAF members, program records, grant proposals, meeting minutes, coalition-wide e-mail messages, progress reports, observation, and other program records.

Program Description

The King County Asthma Forum (KCAF) is a coalition of schools, public health and housing agencies, academic institutions, hospital systems, health plans, community clinics and other health providers, and community organizations created in 1998 through a joint effort of the American Lung Association of Washington and Public Health - Seattle & King County. The mission of the KCAF is to bring together individuals and agencies to establish an on-going asthma network to communicate about, collaborate on, and coordinate projects that improve and support asthma prevention, diagnosis, and management in King County.

KCAF was awarded $149,811 by RWJ for an initial planning year to develop a strategy for addressing childhood asthma in these communities. The goals for KCAF during the AAA planning year can be grouped into two broad areas: (1) to complete a community assessment process and develop a comprehensive three-year implementation plan to be approved by the national Allies Against Asthma program; and (2) to take steps to strengthen KCAF as a coalition, including having functioning committees, increasing community participation, establishing a community presence and reputation, and increasing cultural competence among KCAF members.

Evaluation Findings

Evaluation findings are organized by the two overarching goals of the AAA planning year: to carry out a community-driven process to develop a three-year intervention plan and to strengthen KCAF as a coalition.

Goal 1: Developing an Allies Against Asthma Intervention Plan

As part of the process of developing an intervention plan, the KCAF conducted a community needs and asset assessment, developed priorities, and formulated a detailed intervention plan. Assessment activities included two community summits, ten focus groups, and thirteen key informant interviews. Additionally, the Communications Action Team (a committee of the coalition) mapped community assets within the larger target area. Data were also examined from a variety of sources including prevalence data from the Behavioral Risk Factor Surveillance System (BRFSS), hospital discharge data, and asthma treatment information from clinical records.

Several major themes emerged from the community assessment process and KCAF planning meetings. The first and perhaps most significant key theme that emerged was the need for improved self-management and control of triggers in the home. A second was for improved clinical care. A third was for increased understanding and education for all people and at all places where the child spends time: home, childcare, recreation, schools, and throughout the community. A fourth was increased coordination and sharing of consistent information across sites.

The intervention plan that was adopted incorporates these priorities into multiple strategies at the levels of the home (which includes child and family), clinic, school, childcare site, community, and institution (including policy makers). The strategies include improving asthma self-management, enhancing the quality of the environment in a variety of settings (e.g., home, school, childcare facilities), improving clinical management, increasing community awareness and promoting effective asthma control policies.

The AAA planning process was evaluated along several dimensions, including stakeholder opportunities for input, organization, inclusiveness and results. Most informants were satisfied with the way the process was organized and carried out and also with the Community Action Plan that was produced. Stakeholders were particularly satisfied with the effort to provide opportunities for input; for example as one respondent said (Note: throughout the report, text in smaller font and italics are quotes from the key informant interviews):

The grassroots input was excellent and there was a lot of opportunity for input. They also tried to organize and publicize the meetings to give the community a chance to participate. It was a very pluralistic process.

However, there was also agreement that despite strong efforts to include community residents and community-based organizations in the planning process, these efforts had not generally been successful. As one key informant said:

It was difficult getting community people involved in the process. Moving meetings out into the community was a good change. I think the meetings were very scary for community members, locations were tough too, when they were not being moved around.

Goal 2: Strengthening KCAF as a Coalition

KCAF carried out a number of activities to strengthen itself as a coalition including formalizing the governance structure, creating standing committees, doing outreach to increase community participation and promoting cultural competency among members. Data from key informant interviews and a closed-ended coalition member survey were used to assess the effectiveness of these coalition-building efforts.

The coalition member survey results showed that satisfaction with communication, trust and leadership of the coalition were relatively high (rankings of 3.7-3.8 on a 1-5 scale), while items related to community involvement - diversity of membership, community presence - were rated lower (3.0-3.1).

Key informants listed commitment of the members as a main coalition strength including how much they care about their work, each other, and their willingness to set aside personal and organizational goals for the broader good; for example:

I am impressed by the energy and passion/enthusiasm members have. They are determined and are willing to put in time.

Responses to the question about KCAF challenges focused primarily on the recurring theme of a lack of community representation:

At the steering committee we are not as rooted in community-based organizations as we would like to be. But sometimes this is an elusive and idealistic goal, but we always want to keep it on the table and keep striving for it.

An additional challenge during the planning period for the coalition was a lack of adequate staff resources:

The whole effort has been primarily based on good faith efforts of volunteers. We have had very little staffing to date.

A final challenge that emerged was around governance and organizational structure. Common respondent themes focused on lack of clarity and loose boundaries between Allies and the Forum, difficulties integrating various asthma projects associated with the Forum, and a lack of clarity between the committees and projects:

This (integration of various projects) is a very critical area and is unclear. No one reality seems to exist that we can all agree upon. The coalition must do something about this, so we are all able to see the same reality.

Summary/Lessons Learned

King County Allies Against Asthma achieved all of the major objectives it set for itself during the planning year including carrying out an extensive needs assessment process, setting priorities, and developing an intervention plan. The King County Asthma Forum was also largely successful in achieving its major objectives, including strengthening itself as a coalition and developing functioning committees. The major challenge identified for both AAA and KCAF was a lack of community participation in either the KCAF coalition or the AAA planning process.

Key lessons learned during the planning year included:

• Governance structures evolve over time. Coalition development and creation of an effective governance structure is an evolutionary process; the governance structure will need periodic assessment to ensure it continues to optimally support the work.
  
  
• Membership recruitment is challenging during a planning process. Expecting active growth of coalition membership during the planning year is unrealistic.
  
  
• It is difficult to organize interventions in large, diverse neighborhoods. The geographic diversity and breadth of the target communities inhibits the ability to deeply penetrate a neighborhood with organizational efforts and may require designing several innovative methods for sharing and disseminating information.
  
  
• Multiple, creative recruitment strategies are required. Participation and membership needs to be broadly defined with multiple points of entry into activities.
  
  
• Effective participatory community-based planning takes time. One year is not an adequate amount of time to conduct a community-based planning process with the purpose of developing a health improvement project. On the other hand, having an intensive process with a defined timeline required stakeholders to work closely together, resulting in a durable relationship built on trust and mutual respect. The "social capital" has become a valuable asset for the KCAF.
  
  
• Paid staff, a core of dedicated leaders to help keep the process moving, and an institutional base of support (as provided by Public Health - Seattle King County) are all critical for success. Adequate staffing is critical in the early phases and beyond to facilitate penetration into a community while simultaneously meeting the complex demands of the funding agency and the local stakeholders.

KCAF incorporated many of these lessons as it moved forward into the implementation phase of the Allies Against Asthma program. For example, the intervention activities are used a variety of outreach strategies to recruit participants.