Developing a Productive Workgroup Within a Community Coalition: Transtheoretical Model Processes, Stages of Change, and Lessons Learned

Abstract

Background: Addressing complex problems such as health disparities requires collaboration among individuals and agencies. Yet, methods by which productive and cohesive community-based volunteer workgroups are developed and activated to improve health outcomes are often not discussed.

Objective: Using the transtheoretical model (TTM) as a framework, we discuss effective processes for developing an action-oriented community-based workgroup committed to producing evidence-based information relevant to health policy.

Methods: Workgroup members answered open-ended survey questions and participated in focused coalition-wide discussions to identify factors that facilitated movement of the embedded workgroup from precontemplation to committed action. Frequency and content of e-mail exchanges and workgroup meetings were also considered.

Results and Lessons Learned: Activating the group's process of social support or helping relationships was essential throughout the stages of change to promote cohesion and trust. Consciousness raising (awareness), and dramatic relief (emotional arousal) were particularly critical for initial movement from precontemplation to contemplation to preparation. Using group time to promote member's self-reevaluation (how work is relevant) and self-liberation (commitment) prevented attrition and facilitated effort. As the workgroup enacted planned activities, stimulus control and reinforcement management processes facilitated movement through the action and maintenance stages of change.

Conclusions: By attending to both individual and organizational processes of change, we effectively created an action-oriented multidisciplinary workgroup focused on obtaining evidence to guide local and regional health policy decisions and improve health outcomes for under-resourced patients.

The positive effects of community coalitions, including working collectively, networking, sharing information and resources, and streamlining efforts, are well known.^1–4 However, the processes by which a community group can come together to choose, design, and execute complex tasks are understudied.^5–7 The current paper describes the development of a highly cohesive and productive workgroup within a community coalition, the Gulf States Health Policy Center (GS-HPC) Coalition. The overall GS-HPC and its breakout coalitions are composed of more than 90 organizations meeting monthly in four locations since January 2015; one of the GS-HPC coalitions, which typically met in Bayou La Batre, Alabama, provided the backbone structure for the workgroup.⁸

Using the TTM⁹ as a frame to understand the workgroup's development, we identify change processes (i.e., "continuous, interdependent sequence of actions and events, that explain the origins, continuance, and outcome of some phenomena"^10p.64) that have moved the workgroup from a voluntary group of strangers/professional acquaintances with self-identified interests and knowledge to an interconnected, multidisciplinary partnership actively engaged in developing and executing a complex health policy research project.¹¹ Tangible outcomes have been paramount¹² and include the creation and launching of a complex research study, the publication of a process paper written by two previously unconnected workgroup members,¹³ and the acquisition of resources to complete the research study while simultaneously serving under-resourced patients with diabetes. Future positive outcomes are anticipated, including (1) providing evidence of the effectiveness of improving the health literacy of under-resourced patients who are struggling to manage their diabetes, via results drawn from the research study, and (2) the establishment of a sustainable channel of communication between two agencies working to improve the health of the same under-resourced population (a federally qualified health care center [FQHC] and a charitable pharmacy).

TTM has a strong evidence base and deliberately focuses on potentially generalizable change processes, identifying both developmental stages and processes critical to specific stages. Moreover, the model is inherently flexible, a factor that was expected to facilitate the identification of "emergent" as opposed to "prescribed" change processes.⁷ Although the TTM has been typically used to understand changes made by individuals, it has been applied to changes within organizations.¹⁴ The TTM consists of two fundamental theoretical pillars: (1) stages of change, and (2) processes of change.⁹ The "stages of change" developmentally describe a group's readiness to engage in a new behavior (e.g., engage in health policy research) via five distinct stages: (1) precontemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance. Across these five stages, ten processes to promote forward movement have been articulated.¹⁴ These include: consciousness raising (i.e., increasing awareness), dramatic relief (i.e., emotional arousal), self-reevaluation (i.e., relevance to oneself), self-liberation (i.e., belief and commitment), environmental reevaluation (i.e., relevance to environment), reinforcement management (i.e., rewards for change), counterconditioning (i.e., new approaches), helping relationships (i.e., social support), stimulus control (i.e., restructure environment), and social liberation (i.e., empowering individuals).

This article describes the movement of our community-based workgroup through the stages of change. We highlight some of the key TTM processes propelling the workgroup from precontemplation into actively conducting and coordinating a multiarm research project (i.e., action), facilitating a stronger interagency relationship designed to advance integrated health (advanced collaboration beyond the workgroup), while simultaneously producing academic research papers (task completion). Multiple lessons learned are noted.

BACKGROUND

At the outset, the overall GS-HPC was designed to strengthen the connection, mutual work, and feedback loop among community organizations, policymakers, and researchers. Four GS-HPC coalitions were convened in Bayou La Batre (Alabama), Gulfport/Biloxi (Mississippi), Birmingham (Alabama), and Hattiesburg (Mississippi). Members of the workgroup described in this article are all participants in the Bayou La Batre coalition, which drew primarily from agencies operating in and around Mobile (Alabama). Consistent with its mission (and other successful coalitions¹), the GS-HPC coalition included multiple stakeholders with well-rounded expertise, including members from county and state health departments, nonprofits, faith-based groups, schools and universities, health organizations, city and county government, social clubs, the extension system, wellness groups, business groups, chambers of commerce, and regional planning commissions. Members brought a range of skills, knowledge, and experience to the GS-HPC coalition, and represented organizations focused on a variety of health and socioeconomic issues.

Within each GS-HPC coalition, workgroups were initially formed with a self-identified shared identity. However, each workgroup was tasked with developing a specific community-based, health policy focus relevant to its collective identity.¹⁵ Once particular policies were identified, each workgroup was charged with designing a strategy with the potential to generate information germane to relevant health policymakers. Identified policies could be located at the agency-specific, local, state, regional, or national level. Thus, each GS-HPC coalition provided structure and guidelines for the work while also granting each community health workgroup considerable autonomy.

Figure 1 shows the individuals nested in the workgroup, which is a component of the overall GS-HPC. As shown, the research project designed and launched by the workgroup, which included researchers from the local university, draws together two central agencies that had not previously considered how to synergistically improve the health outcomes of shared patients. The workgroup's research project, currently in the data collection stage, was specifically designed to serve multiple purposes, including (1) gathering data to inform policymakers about the population health effects associated with the delivery of coordinated care, (2) instituting a workflow within the non-profit/charitable pharmacy that would provide additional educational information and supplies for impoverished patients with diabetes, and (3) establishing a sustainable channel of communication between the charitable pharmacy and a nearby FQHC that, at the outset of the project, shared patients but not health information. Thus, the research project undertaken by the group was both a vehicle for change and a successful outcome of a cohesive and high-functioning group. Inclusion of both short- and long-term goals provided opportunities for early "wins," which allowed group members to experience success while still maintaining focus on larger, systemic change.¹⁶ Finally, the execution of the research project, in and of itself, was constructed to unite the workgroup members around a common agenda in ways that would deepen the partnerships begun within the GS-HPC coalition.

Figure 1.

The Position of the Health Literacy Workgroup

METHODS

The GS-HPC identified three stages of development for the four broader geographically distinct coalitions. The GS-HPC's three stages were recruitment, creation of a community action plan, and implementation (Table 1). First, community members with diverse backgrounds and expertise were invited to participate in the coalitions (recruitment). Next, workgroups developed over the course of a year as part of regular meetings of the coalitions (community action plan). Workgroups then chose a policy to focus on and a strategy to inform that policy (implementation). During the recruitment phase, which lasted approximately 1 year, the workgroup in Bayou La Batre, Alabama, remained in the TTM stage of precontemplation. Preexisting characteristics of recruitment members are described as a component of precontemplation

Table 1.

Stages and Processes of Change, Key Actions, Member Responsibilities

Note. Other workgroup members provided structure as well as formal and informal support through the stages of change.

as membership features including skills, attitudes, opinions, and the degree to which members held leadership positions in their respective organizations have all been shown to be important contributors to a group's success.¹⁷

Next, to identify the factors that enabled the workgroup to effectively move from precontemplation to the preparation and execution of a complex research study, workgroup members acted as participant observers by both doing the group's work and by providing feedback on the group's process and development. We used a single case study design in which multiple types of data were considered.⁷ Specifically, the primary authors of the current paper (two researchers active in the workgroup [J.L.R., H.A.F.] and one writer who is one of the leaders of the overall GS-HPC Bayou La Batre Coalition [E.B.]) collected information from the full roster of workgroup members (n = 7) via individual and collective discussions, written recollections in response to e-mail prompts, and workgroup meeting notes and group-level e-mail exchanges. All seven workgroup members were also specifically asked to reflect on the following questions about the workgroup's developmental process and 85.7% (6 of the 7) responded in writing:

1. 1. To assess the movement from precontemplation to contemplation: "Many groups never find a focus, what do you think enabled this group to unite around a common mission?"

2. 2. To assess the movement from contemplation to preparation: "Even with a focus, many groups never make it to the planning stage. What do you think helped move the group from thinking about the issue to making concrete plans?"

3. 3. To assess the movement from preparation to action: "Even in the presence of scarce resources, including time and money, this group successfully launched a research partnership to inform policy around integration and shared electronic records, facilitate patient wellness, and deepen community health partnerships in a sustainable fashion. What specific things do you think made that possible?"

GS-HPC staff members, including the GS-HPC director and coalition coordinator, also provided information obtained through several broader, coalition-wide discussions; the information was archived in GS-HPC meeting notes. Although not specific to the TTM processes, discussions generated in the larger coalition provided additional data for understanding change over time as workgroup members were specifically asked to respond to the following project-wide questions:

1. 1. What policy is your work designed to inform?

2. 2. What are your hopes for this project?

3. 3. How will you know if your workgroup is successful?

The GS-HPC functioned as the backbone structure for the workgroup in another way as well. Workgroup members used coalition time to draft an action plan in a format provided by the GS-HPC that included policy focus area, objective, activities, specific tasks, who, when, and how results were to be measured.

In addition to monthly GS-HPC coalition meetings, members of the workgroup met separately approximately one other time per month; these meetings are ongoing. Meeting notes from each occasion were reviewed. Electronic resources were also considered; a review of one of the authors' e-mails (J.L.R.) revealed 39 workgroup project related e-mails across 6 months. Thus, primarily qualitative data were collected from participant observers in person, via telephone and e-mail, through meeting transcriptions, and as part of an overall evaluation of the GS-HPC coalition. The current article was authored by all members of the workgroup; all included material was considered by the group and approved for publication. Reports from different participant observers were largely congruent; results represent consistent themes across material.

RESULTS

Precontemplation: The Formation of the Workgroup

Reflecting the make-up of the broader GS-HPC coalition, at the outset, the workgroup consisted of seven members constituting a broad range of roles (e.g., the director of a charitable pharmacy, two community pharmacists, a practicing PhD-prepared nurse practitioner, one clinical psychologist specializing in integrated health, one research-practitioner postdoctoral fellow, and one health policymaker) and representing diverse organizations (pharmacy, nonprofit agency, FQHC, university). There was also diversity among members with regard to sex (28.6% men), age/experience (from new professional to agency director to veteran semiretired practitioner), and race (28.6% African American; 71% White). Based on the initial interests of two key group members (a community pharmacist and a PhD-prepared nurse practitioner with diabetes-focused grant experience) and in the context of a geographic area-specific need,¹⁸ the workgroup chose to concentrate on improving diabetes-related health outcomes within underserved and under-resourced populations along the Alabama Gulf Coast. In particular, the initial focus of the group was on how pharmacists could be supported, through state-level policy, to improve the health literacy of uninsured or homeless patients who suffer from diabetes. However, as the workgroup evolved and distinguished itself from the larger GS-HPC coalition, establishing sustainable pharmacist–primary care provider communication through health information exchange (i.e., charitable pharmacy health information provided to the FQHC for shared patients and vice-versa) became increasingly salient.

At the outset, members joined the workgroup for different reasons; however, they shared the common value of improving health outcomes for low-income populations. Thus, little environmental reevaluation was necessary initially. Raising group consciousness began as members shared their hopes for the project and the policy(s) they wanted to inform. For example, the lead pharmacist sought increased integration of pharmacists as part of the health care team; through him, the coalition learned that Alabama lacked pharmacy-centered, medication therapy management and collaborative practice legislation found throughout the United States.¹⁹ The nurse practitioner was motivated by improved outcomes for diabetes patients. The nonprofit executive director of the charitable pharmacy sought increased resources and health education for her clients, many of whom were homeless and suffered from diabetes. The policymaker saw an opportunity to create research that could inform health policy across the state; he was also interested in health economics and the cost savings that could be realized with better diabetes literacy and health information exchange. The health researchers sought to create an effective study with practical results that could be used by policymakers. The psychologist was focused on expanding integrated health in FQHCs.

Moving from Precontemplation to Contemplation

Through GS-HPC coalition exchanges, workgroup members self-identified as holding one (or more) of three primary roles: practitioner/program person, policymaker, or researcher. It became apparent that all three voices were needed to craft an effective, relevant, practical, and manageable diabetes-related research project that involved both the charitable pharmacy and the FQHC. As put by one work group member, "policy, practice, research—three pillars. The mix of these three elements was essential for success." Practitioners brought knowledge and passion around the topic and articulated likely challenges as well as practical solutions to workflow concerns. Policymakers helped to identify "low-hanging fruit" in the policy arena, including local (agency-level) policy around exchanging health information as well as state-level policy related to the role of pharmacists within integrated care. Researchers amassed and summarized existing literature. They also educated the workgroup about the processes and procedures associated with conducting research with human subjects (institutional review board submission and approval, qualifying and enrolling subjects, random assignment to research condition, standardized instructions). Other group members provided structure (e.g., agendas and meeting spaces) as well as informal and formal support (e.g., connecting to other institutions and organizations, recruiting additional group members).

As shown in Table 1, while the GS-HPC was recruiting members and getting established, workgroup-specific conversations served to increase awareness of need, passion for the project, and inspiration for change (i.e., consciousness raising and dramatic relief¹⁴). Time spent actively learning together, while sharing GS-HPC provided lunches, provided a platform from which to build trust and secure relationships among participants, (i.e., helping relationships). As put by one workgroup member, "Food is important. The process of eating together is like a family meal. It also helps that we sit in a U [the arrangement of the tables in a large group room]. Comforting, open, warm."

Across the first year of the GS-HPC, workgroup members shared information and expertise related to health policy, chronic disease management, diabetes, health literacy, underserved populations, medication counseling, pharmacist–provider integration, and the nuts and bolts of conducting community health research. The emphasis on showcasing in-room and local expertise also facilitated deepening connections and shared respect.^15,20,21 The explicit goal was collaboration rather than competition. As one member explained, "Post Katrina, we had all kinds of things: meetings, socials, charrettes. All that's gone now because we were centered around one problem and there was so much competition. This coalition is different. It's held together a long time because we get along without being territorial." Workgroup members were not fighting for limited resources, but were using existing talents, skills, and positions to learn about and tackle relevant local, institution-specific, and state health policies. Further, because each of the three pillars—practitioner, researcher, and policymaker—was viewed as necessary and valued in the group process, members organically developed an equitable group dynamic based on respect and power sharing.² Leadership was based on the task/skill required, rather than being lodged in one group member.²¹

It is worth noting that group members also differed in their preferred engagement style. In our case, the workgroup had a balanced mixture of visionaries, doers, leaders, helpers, strategists/planners, and task completers. Diversity was essential, as one workgroup member stated: "members weren't voluntold but at the end of meetings (particularly in the planning stage) they were encouraged to verbalize something they were going to accomplish by the next meeting." This shared group practice ensured the work was advancing between meetings and, as shown with other successful coalitions, a "can-do" attitude emerged.¹⁷

Although a shared vision was essential in moving the workgroup from precontemplation to contemplation as it allowed group members to see their commonalities (self-relevance linked to group relevance) and possibilities for change,²¹ the workgroup had to move from abstract vision to concrete goals to specific actions. The action plan structure provided by the GS-HPC provided a tool for this stage of the work. Multiple collaborative conversations took place to ensure the goals of the workgroup were compatible, explicit, and addressed all three pillars (thus promoting self-reevaluation/relevance, environmental reevaluation/relevance, social liberation/empowerment). Knowing the goals of each group member as well as for the group as a whole also highlighted potential reinforcement management strategies (rewards for change), which proved essential to maintaining investment in the group over time.

Diverse interests, knowledge, skills, and roles allowed group members to make unique contributions to group discussions and suggest alternative ways of thinking (TTM process of counterconditioning or enacting new approaches¹⁴). For example, the practitioners, the "boots on the ground," reported that they are accustomed to working "in the trenches," where they sometimes feel they apply "band-aid" solutions to community problems. The research/policy focus enabled them to think systemically about issues and to focus on sustainable, upstream solutions. As one practitioner stated, "This was just mind-blowing for me. This coalition has been a tremendous education in doing things from a different perspective. I realize now that my work is important, but it takes all of us to make it happen and give it the greatest impact." Practitioners also learned policy is not "out there somewhere," as one member explained, but rather exists in their own backyards (e.g., within their own agencies), making system-level change more attainable. Likewise, researchers and policy experts benefitted from working alongside practitioners to develop specific, meaningful, and achievable goals. As one policy-focused member stated,

You get a vision of the close-up perspective from people who are intimately familiar with the individuals and problems, and combine that with the 10,000 foot view. It lets us see both the forest and the trees, and that's not common for coalitions. Usually they skew one way or the other. Having that mix is valuable for both the programs and the policy and in addressing the underlying causes of our problems.

As workgroup members moved from precontemplation to contemplation, the TTM processes of self-reevaluation led to self-liberation or greater commitment¹⁴ as workgroup members realized meaningful change was not only important, but possible. A shared workgroup identity emerged, or as one member stated, "We stopped working in silos. We connected the dots, shared information and contacts, and moved the ball forward."

Preparation

To advance the research project and foster self-determination and ownership over the effort, workgroup members began meeting outside of the GS-HPC coalition meetings. Meetings were coordinated, hosted, and led by the group members themselves and did not always include GS-HPC coalition staff members. Regular e-mail contact occurred and in-person workgroup meetings happened on average every six weeks. Hopes for the workgroup were articulated, which promoted additional self-reevaluation and environmental reevaluation (self and context relevance¹⁴). Practitioners were essential in the preparation stage as they were in the best position to predict needs, barriers, and real-life impacts of research and policy plans (Table 1), enabling researchers and policy experts to engage in more relevant, realistic, and effective work. Practitioner feedback saved time and resources; the program-oriented members also pushed for action for the people they were serving every day.

Social support (helping relationships¹⁴) provided by different individuals and agencies throughout the stages of change allowed the workgroup to navigate various challenges. During the preparation stage, it became apparent that enacting the research project would require developing a collaboration between two primary agencies (i.e., the FQHC, which served as many of the pharmacy patients' patient-centered medical home and the nonprofit charitable pharmacy). To address the need for collaboration, workgroup members brainstormed ways to establish a partnership with the FQHC because it was not an original member of the GS-HPC coalition. A variety of existing relationships were leveraged while establishing a new way of interacting between the agencies. The development of the partnership, which is ongoing, yielded an unexpected benefit to the group. As stated by the director of the charitable pharmacy, "In the 9 years that I have been with the pharmacy, I had never spoken directly with the physicians at the FQHC. Being a part of this team allowed me, for the first time, to speak with them all during a provider meeting."

Once the FQHC–pharmacy partnership was initiated, planning activities centered on how to establish a mechanism for sharing health-related information between the two entities. The establishment and regular use of this mechanism was subsequently identified as an important outcome of the research project. As such, the researchers then sought to quantify this outcome, including the degree to which communication between a patient's pharmacist and their primary care provider would promote greater health and reduce hospital admissions as well as whether the direct pharmacist—primary care provider information exchange would facilitate more positive patient perceptions of their health care.

By the end of the preparation stage, workgroup members had identified clear health policy research goals to evaluate the impact on patient outcomes of (1) different levels of medication therapy management delivered in a pharmacy setting and (2) facilitation of a directed exchange of patient information, between the charitable pharmacy and the nearby FQHC. Research methods were also established; institutional review board approval was obtained. Data collection is ongoing and longitudinal; all patients qualifying for the study have been diagnosed with diabetes or are officially prediabetic. The emphasis on actionable research allowed the group to access additional resources (e.g., participation gift cards from the Gulf Coast Behavioral Health and Resiliency Center located within the University of South Alabama), which increased momentum from the preparation stage to action.

Action and Maintenance

Once preparation activities were complete, the workgroup began the study. Launching the study with limited resources required leveraging helping relationships and the full participation of the group, or as one group member put it, "we pulled together resources from every direction." Supplies were donated; existing staff at the pharmacy were trained to enroll patients. Pharmacists-in-training provided different levels of medication therapy management to randomly assigned patients as part of the study protocol, which, in turn, provided an important educational experience for trainees. Meanwhile, a postdoctoral fellow working for the Gulf Coast Behavioral Health and Resiliency Center voluntarily assumed the role of project manager.

Sustainable action was facilitated by flexibility in workgroup leadership; different group members led the project at different points in time. For example, the initial leader of the group was the visionary community pharmacist who was active in state-level policy decisions; his preexisting connection to the head of the charitable pharmacy was the impetus to focus local efforts in that location. In turn, the meeting room at the charitable pharmacy became the central location for workgroup meetings and activities; agendas for these meetings were generated by the head of the pharmacy. Although the group members identified as researchers often lead dissemination efforts, the day-to-day activities of the research project are conducted at the pharmacy. Of note, workgroup members located at the pharmacy have frequently taken the lead when asked to report on the study's progress.

Workgroup members are excited about the outcomes emerging during the action stage of development. Working together, two group members wrote and published an article entitled, "Improving health in an integrated care system: Empowering pharmacists to function as key agents of change."¹³ The collaborative endeavor was the first publication for the community practitioner and inserted new energy into the workgroup. Additionally, and perhaps more importantly, new partnerships were formed and existing partnerships have been strengthened. By restructuring old ways of working (i.e., stimulus control) via new pharmacist practices, and by finding ways to reward new ways of working (i.e., reinforcement management) via dissemination and feedback at regular provider meetings, long-standing local organizations are working together in new ways and are sharing resources to benefit patient health.

Consistent with the TTM framework¹⁴ for understanding organizational change, helping relationships, stimulus control, and reinforcement management were also essential in the maintenance stage. Mutual learning and social support provided by the coalition and other members of the workgroup increased accountability and promoted shared responsibility (thus simultaneously promoting and maintaining individual change); however, the meeting structure and broad contributions of the overall coalition provided a platform (helping relationship; reinforcement management) that encouraged the workgroup to move through the stages of change as an entity. Members communicated regularly to address emerging issues, provide updates, and determine next steps, in essence providing structure, stimulus control, and management to the larger workgroup entity. Ongoing modifications to, and reinforcement of, the pharmacy workflow to facilitate new data collection and communication pathways were facilitated through support provided by other workgroup members and from partnering agencies including the FQHC and the local university. As system changes were occurring, being able to observe direct benefits to the patients they served remained an important reinforcement management strategy for practitioners; conducting relevant research with buy-in prevented attrition from the workgroup.

LESSONS LEARNED

Based on responses to questions posed to workgroup members about the group's developmental process regarding the common mission, planning, hopes, and indicators of success, the following lessons were learned. These lessons were approved by all group members.

1. 1. Successful partnerships need time to develop, as well as a context to promote meaningful participation by all group members.

2. 2. A collective mission is imperative (i.e., to improve patient outcomes, especially for the most vulnerable patients). As one group member put it, "we all had a desire to help to the underserved population to obtain the health status we all deserve."

3. 3. Groups need diverse knowledge, perspectives, and skills.²¹ As one member noted, "We were all aware of the great needs of the uninsured population in our community and their lack of access to medication and coordinated health care, particularly between their pharmacy and their primary care provider. However, it was the diverse make up of our group from a professional standpoint that gave us a richer and more complex multidisciplinary view of the necessary work."

4. 4. The active exchange of information (i.e., mutual learning) from group members holding diverse perspectives brought energy and creativity to the group. For example, one coalition member noted: "[There is] something humbling about this coalition, we're all so used to being in our bubble, even when dealing with health issues, policy, we come together and realize what we do on a daily basis doesn't just affect our clients. [It] makes you want to approach the work with a different perspective. [It] makes me eager for … the next step of the coalition."

5. 5. Group members held diverse personal characteristics, including career stage, age, personality, and ethnicity, which was valued. However, the group shared a sense of humor and joy in the work that has also emerged as essential. As one group member put it, "It was such a pleasure to work with this team. Personally, I looked forward to seeing and hearing from everyone. I have never been around people with such great positive energy." Another group member stated, "I didn't expect to laugh so much while we were engaged in impacting a difficult health problem."

6. 6. Setting specific goals, timelines, and tasks proved critical to the group's ability to design and execute an original research project. As put by one group member, "I believe we were able to move beyond the planning stage because we set specific goals each time we met."

7. 7. Group members stayed in contact over e-mail, met in person regularly, and kept each meeting focused on action and next steps. Several of the members credit specific group members with being "great leaders" who kept the group on task.

8. 8. The main challenges were related to the speed of project execution and the roles of group members over time. Practitioners were ready to initiate the project immediately, whereas researchers sought to carefully design and vet all aspects of the study through the local university's institutional review board. Collection of measures relevant to the low-literacy population was unexpectedly time intensive and required group decision making.

9. 9. Members were highly skilled and successful in their own professions, necessitating the identification and promotion of individual member motivations for participating in a voluntary workgroup. Member's time is a valuable asset that must be prioritized.

10. 10. As the workgroup moved into the action and maintenance stages, new members were recruited to address emerging needs, which strengthened the combined skill sets and expertise of the group and increased the likelihood of success. However, adding members brought new challenges including how to effectively integrate them into an already active workgroup.

11. 11. On-going challenges include the need to continuously acknowledge and use the various expertise of the group members in order to enhance their motivation to stay involved and committed. Across the project, several instrumental group members have experienced significant changes in their jobs (retirement, changed positions), health, or personal status, which has impacted their available time and energy. Efforts to combat these realities included varying time, place, and format of meetings / exchanges (in person versus electronic). Having members take "ownership" of the workgroup, the project, and the outcomes continues to be instrumental.

DISCUSSION

Community health research aimed at supporting under-served populations and conducted by groups of volunteers²² empowers communities to engage with complex systems and move from knowledge to action.¹¹ Community coalitions provide a basis for developing and enacting changes in community health and health policy.¹ However, great ideas do not necessarily translate into great actions; movement from thinking about to enacting change can be conceptualized via movement through five stages (precontemplation, contemplation, preparation, action, and maintenance¹⁴). The current article represents a unique addition to literature on coalitions and change processes. Although the TTM has been proposed to evaluate organizational as well as individual-level change,¹⁴ it has not previously been used to conceptualize progress made by a multidisciplinary, volunteer-led workgroup nested within a community coalition with the general aim of conducting health policy research.

Awareness of need (consciousness raising) combined with an emotional response (dramatic relief), generation of new ideas and belief in the possibility of change (counterconditioning; self- and social liberation) all promoted early engagement and moved workgroup members from precontemplation to contemplation. Self-reevaluation or relevance was essential from precontemplation through to maintenance, whereas relevance to the environment (environmental evaluation; multiple environments were considered as noted in Figure 1) encouraged specific and concrete planning in the preparation stage. Helping relationships and the mutual support and learning that occurred between members was imperative throughout the stages from precontemplation to maintenance. Finally, modifications to the environment (stimulus control) as well as highlighting intrinsic and extrinsic rewards (reinforcement management) allowed the workgroup to enact meaningful change in action and maintenance stages.

The primary limitations of applying the TTM to understand progress made by the workgroup were related to the conceptualization and application of processes of change¹⁴ and the identification of "change agents."²³ Some processes were important across all stages of change (i.e., helping relationships) but were conceptualized differently (i.e., support between individuals [e.g., group members] vs. support from the group to agencies [e.g., FQHC]). However, changes in workgroup membership and shifting roles and responsibilities of members over time meant key personnel involved in enacting change often varied at each stage. Thus, it was imperative that stages and processes of change were applied to the progress of the workgroup as a whole rather than individual group members. This might be facilitated by renaming some of the ten processes of change to highlight their organizational nature (i.e., self-reevaluation = group relevance; self-liberation = group commitment; social liberation = group empowerment).

One of the most exciting outcomes achieved by the work-group was the development of new relationships and both internal and external health-enhancing communications pathways.²¹ In addition to maintenance of gains made at earlier stages of change,¹⁴ new partnerships can be used to facilitate future projects, including funded activities, among group members. By engaging in a community-centered research project, workgroup members are cementing a habit of relating that has already reached beyond the GS-HPC coalition. A health-focused practitioner–policy–researcher partnership has the potential to provide long lasting benefits to individual group members, under-resourced consumers, health efforts, and communities. The workgroup members' ability to provide services to consumers, while gathering important policy-informing data, has demonstrated the need to draw together a cross-sector partnership to tackle complex social issues and effect system-level change.²⁰