RRISK: a sustainable intersectoral partnership.

RRISK (Reduce Risk Increase Student Knowledge), a school-based harm minimisation program, aims to provide students in Years 10 and 11 with skills to make informed decisions to reduce risks associated with drug and alcohol use, driving and celebrating. RRISK provides a framework for an integrated response to addressing these issues. A detailed assessment of the intersectoral partnership that has conducted RRISK for five years reveals several elements that may explain its success.

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Success in health promotion is often contingent upon effective partnerships and coalitions (World Health Organization, Health & Welfare Canada & Canadian Public Health Association 1986; Harris et al. 1995; Gillies 1998; Health Canada 1998; Advisory Committee on Population Health 1999). There are, however, many challenges to establishing intersectoral alliances and then maintaining them in the longer term (Ashton & Hehir 2002; Kegler et al. 1998).

This is especially true for health promoters addressing adolescent risk-taking associated with drinking, drugs, celebrating and driving. Effective coalitions targeting these behaviours require commitment from a variety of agencies with widely differing objectives, paradigms and cultures (Butterfoss, Goodman & Wandersman 1996; Kumpfer et al. 1993). Key partners include health, education, law enforcement, local government, road safety education, roads and transport, public media and community organisations (Butterfoss, Goodman & Wandersman 1996; Elkington, Hunter & McKay 2000).

Educational agencies are clearly vital partners because, first, schools are a key setting for accessing and engaging with a large number of adolescents; second, student wellbeing is part of the education sector's core business; and, third, such agencies have to deal with the consequences of risk-taking (NHMRC Health Advancement Standing Committee and National Health & Medical Research Council 1996; Roberts, Kwan & Cochrane Injuries Group Driver Education Reviewers 2002). Law enforcement agencies are considered essential partners too, given they have a commitment to early intervention, public safety and injury prevention (National Health & Medical Research Council (NHMRC) 1996). Likewise, agencies involved in road safety education and licensing are also constantly addressing the interplay between adolescent drinking, drug use and driving (Roberts, Kwan & Cochrane Injuries Group Driver Education Reviewers 2002; Vernick et al. 1999). Community and media organisations focused on adolescent support can also be key partners as they are often skilled community mobilisers (Kumpfer et al. 1993; Hammond & Horswill 2002).

Developing partnerships with such diverse organisations can be somewhat daunting to health promoters (Health Canada 1998; Pekar & Allio 1994; Davies 1999). Despite a wide range of challenges and potential pitfalls, principles of intersectoral partnership have been identified and there are now some useful guides to developing successful working coalitions (Harris et al. 1995; Pekar & Allio 1994; DiSogra, Glanz & Rogers 1990; Labonte 1999; Moss Kanter 1994). Published case studies of long-term adolescent injury prevention coalitions are rare.

This paper reports an assessment of the strength of the five-year RRISK adolescent injury prevention partnership; it identifies the elements of the partnership and presents valuable lessons that can readily be applied when developing similar intersectoral initiatives.

The RRISK program

RRISK (Reduce Risk Increase Student Knowledge) is a school-based harm minimisation program in Northern NSW. It aims to provide adolescents in Years 10 and 11 (aged 14-18) with skills to make informed decisions about risks associated with drug and alcohol use, driving and celebrating. The RRISK program provides a framework for an integrated response to addressing these issues by supplying timely education appropriate to the developmental stage, social life and concerns of adolescents.

During the school year, participating schools are encouraged to:

* increase teaching of risk-related topics in formal lessons

* select either Year 10 or 11 to attend a one-day RRISK seminar

* support the training of students (peer facilitators) to run small-group activities for the RRISK seminars

* encourage teachers to take advantage of the professional development session provided during the one-day RRISK seminar

* raise school and community awareness of risk-related issues via regular newsletters inserts and a website supported by the local radio station.

The key event each year is the RRISK seminar, which supports the formal Personal Development, Health and Physical Education (PDHPE) senior curriculum with an interactive skills-based program that includes a range of strategies. These include presentations by experts and young people, opportunities for students to problem-solve in small peer-led groups and a drama presentation in which students, ambulance, police, emergency rescue workers and a crown prosecutor act out their roles in a simulated crash scenario.

The program has been running for five years and participation has grown from eight to 24 schools (over 90% of high schools in the catchment area) with over 1,500 students and 80 teachers attending the seminars. Teacher and student process evaluations have been used to refine the program and the results indicate a high level of satisfaction among teachers and students with both organisational and content aspects of the program.

A rigorous and comprehensive evaluation of students' knowledge, attitudes and behaviours (KAB) was carried out in two cross-sectional surveys of 4,701 students in RRISK and non-RRISK schools as part of an evaluation grant funded by the NSW Motor Accident Authority (baseline and follow-up surveys were conducted in March 2003 and 2004 respectively). The results indicated that students who attended the seminars had statistically significant improvements in KAB outcomes five months after the seminars, when compared to students from RRISK schools who did not attend the seminars. Briefly, both younger (Year 10) and older (Year 11) RRISK "attendees" showed significant improvement relative to their "non-attendee" counterparts in: knowledge of safety aspects when buying a used car (the relative rate of improvement of attendees, compared to non-attendees, was 17% for Year 10 students and 21% for Year 11 students), in rates of agreement that: "I look out for my friends at parties so they don't get too drunk or stoned" (both Years 10 and 11 were 8% more improved than their non-attendee counterparts); and in the percent of parties attended, for which they planned a safe way home, prior to the party (25% for Year 10 and 29% for Year 11). Younger RRISK attendees (Year 10) improved in: rates of agreement that: "everyone who goes to parties should know CPR" (6%), and "I always check the driver isn't drunk before I get in a car" (6%). Older attendees (Year 11) improved in: perceived understanding of risk-related issues (5%); in rates of agreement that: "I only go to a party if a friend goes too" (6%), "I always check the driver isn't drunk before I get in a car" (10%), "at a party, if I leave my friends for a while, I always tell them where I am going" (8%); and in the percent of parties attended, for which they: "had a way my parents or guardian could contact me" (17%) (van Beurden et al. 2005; Zask et al. 2006).

The RRISK partnership

The RRISK program is overseen by a steering committee with its partners representing the following organisations: North Coast Area Health Service Health Promotion (NCHPU), NSW Department of Education and Training (DET), Catholic Education Office, Lismore (CEOL), and Lismore City and Tweed Shire Councils. Representatives from other stakeholder agencies closely linked with RRISK but not part of the steering committee are Southern Cross University (SCU, which hosts the RRISK forums) and the NSW Roads and Traffic Authority (RTA). The program is also supported by local police, ambulance, State Emergency Services, Lismore Crown Prosecutor and ABC North Coast.

Funding for the RRISK seminars and other events is provided by the RTA, NCHPU and Southern Cross University. In-kind support is offered by the key partner organisations in the form of a strong commitment of staff time and expertise.

As process and impact evaluations have indicated that the program is successful on a number of levels, it was decided that an analysis of the elements of the intersectoral partnership that drive the program may be of assistance to others' efforts to establish or maintain intersectoral partnerships in health promotion. The partnership evaluation was undertaken to:

* assess the strength of the intersectoral partnership and identify whether this has changed over time,

* examine partnership characteristics associated with the project's sustainability,

* identify important principles that may be applied in similar projects.

Methods

An independent evaluator (JE) was commissioned to conduct the interviews with partners and analyse the findings from these and the written checklists.

Sample and selection

Due to the limited resources for the partnership evaluation, it was decided to restrict the qualitative component of the partnership evaluation to 10 face-to-face or telephone in-depth interviews. All current partners of the RRISK Steering Committee (n=6) participated in the face-to-face interviews and completed the three validated checklists analysing elements of the partnership. A further four stakeholders who were not represented on the committee, but were considered to be the most significant other contributors to RRISK, were interviewed about their understanding of the functioning of the partnership, their involvement in it and their assessment of its strengths and limitations.

Interviews and instruments

Data were collected from each representative by:

* a recorded half-hour face-to-face interview covering: history of involvement; views of the partnership, its function, strengths and limitations; input into processes such as goals, meetings, communication processes and any suggestions for change; views of the program's future, including their organisation's involvement; and their concept of what makes a successful partnership; and

* a set of three validated checklists based on indicators of capacity to undertake health promotion (Hawe et al. 2000), which were mailed out to core partners. The three checklists assessed: strength of the partnership; potential for sustainability; and group function, including opportunity for innovation.

Analysis

Interview transcriptions were analysed qualitatively for concordant views, comments and key exceptions. Partnership capacity checklists were analysed quantitatively. Each of the checklists covered several elements. Each element had from I to 15 items to assess the strength of that element with a maximum possible two points for each item ("Yes, fully" = 2, "Yes, in part" = 1, "No" = 0). With six partners completing the checklist, each item had a maximum possible score of 12 (reduced by two points for any partner who selected the option "Don't know / Not applicable").

Results

Partnership history and composition The RRISK program was reported to have grown out of several original partners' frustration with their efforts to reach school students with communications about road safety, drug and alcohol use and risk-taking. Gaining acceptance by schools was reportedly difficult and it was felt that a coordinated approach involving the education sector was needed. A number of meetings were held between consultants from the region's District Education Office, Catholic Education Office, the Health Promotion Unit and local councils to gain support for a coordinated response. At a stakeholder forum, evidence of the extent of adolescent risk-taking was presented and strategies for enhancing the existing road safety and drug education curriculum were discussed. Once a common purpose was established, key personnel from each sector formed a committee to develop the program.

All officers indicated that while their role had been constant, it had expanded with the program. Several indicated that their involvement had grown as they became more familiar with the program.

Satisfaction with the partnership's aims and processes

Areas of strong support, i.e. those which received high satisfaction rating, by the partners through the checklist process were:

* the alignment of program aims and strategies with those of their own organisation,

* the level of communication regarding the program,

* the manner in which activities of the partnership are "actioned",

* the use of process evaluation findings to review and set directions for the program,

* the levels of networking achieving outreach into the community.

Areas where some recommendations for adjustments were made by one or two partners, were:

* streamlining the meetings process,

* funding a project officer to coordinate it all,

* greater emphasis on gaining upper-level support of key organisations or on ensuring the integration of the program within school curricula and activities. (However, other respondents indicated duties related to RRISK were written into their job responsibilities or were expected to be reported on regularly.)

Assessment of the strength of the partnership

The partnership was viewed overwhelmingly by its committee members and external stakeholders as being uniquely strong. The aggregated score of the six partners regarding the partnership's strength was 287 / 312 or 92%. This indicates that there was clearly a strong level of confidence in the strength of the partnership and its capacity to deliver on its goals by the partners completing the checklist (Fig. 1).

Of 25 items on the "strength of partnership" checklist all but one item were considered to be fully met by the majority of the six partners. All partners felt there was the "right mix of ... adequate skills, knowledge and access to resources" and that their "involvement was worthwhile".

Non-committee partners (i.e. those not attending regular meetings) felt the RRISK committee was uniquely strong and particularly commented on: "representation from grassroots workers who know how things work 'on the ground'"; and "having a common purpose and commitment to a worthwhile program".

On almost all levels, the RRISK partnership was considered uniquely strong for an intersectoral committee. Some interviewees indicated that it was the intersectoral nacre of the committee that was its strength, while others indicated it was other attributes of the committee that helped it overcome common difficulties.

Group function and opportunity for innovation

There were 20 items on the checklist that explored partners' views on "group function and opportunity for innovation". These concerned goals, feedback on performance, the level of guidance given, the scope for critical questioning and available structures and networks to support the partnership/program. Out of a possible total score of 236, the partners scored this element at 221, or 94%. While all items scored highly, the highest scores (70/72) were given to the "scope for critical questioning within the partnership, including being encouraged to suggest new things"; and the "availability of structures and networks to support the program" (Fig. 1).

Sustainability of the partnership

The overall sustainability score was 122/136, or 90%, and all items on the checklist relating to the program's potential for sustainability were considered met to some extent (Fig. 1). Of the 13 items on the checklist regarding the potential for sustainability, 10 were considered to be fully met by the majority of the partnership. Those not considered fully met by the four of the six partners were: the program's ability to acquire or generate additional funds, its ability to retain people who have built skills through the program, and the absence of threats of future closure.

Indicators of the program's strong potential for sustainability as reported through the checklist and interview questions were:

* the longevity of the partnership, with most organisations within the partnership having been represented since the program's inception five years ago;

* the fact that the partnership and program were largely driven by two officers, the Lismore Council Road Safety Officer and the Area Health Service Drug and Alcohol Health Promotion Coordinator;

* strong confidence in the support offered to the program by organisations likely to run RRISK in the future, in terms of providing facilities and staff time for participation in RRISK; and

* a high level of support for the program from the wider community, mostly in terms of the demand created by shared goals between the program and the community.

Identified strengths of the partnership

The most commonly identified strengths of the partnership were:

* a set structure involving regular meetings, set processes, defined timelines, and an early start to planning each year;

* shared responsibilities and a sense of common purpose--on a single issue. "The project's aims are part of why the meetings are successful--everyone comes with clear aims in mind";

* the diverse responsibilities and skills of the different sectors;

* enthusiastic, non-possessive ownership of the program by the key players, which encourages participation by all;

* trust and goodwill between partners;

* partners' willingness to meet the needs of participating organisations. As one partner expressed it, "Everyone is prepared to talk things through. There is no feeling of being pushed or railroaded";

* the formation by partners of a strong and expansive network in the community--as well as commitment from both State and Catholic education sectors;

* self-evaluation and consequent ongoing program refinement. "The program's direction seems to be informed by evaluation. It makes sense to act on the lessons learned"; and

* membership at the grassroots level--so input into program planning is by individuals familiar with how things operate in schools and what needs to be done to put things in place.

Identified limitations of the partnership

Few limitations were noted regarding partnership functioning, other than having limited time to devote to getting as much done for the project as they would like. Two partners indicated that the time commitment for "a few one-day seminars" was not in line with the outcome and one partner described it as "a huge time commitment". Part of this concern was linked with the frequency of meetings, the distances needed to travel to meetings, the length of the meetings, and the amount of time required for communication. Other limitations were: the program's dependence on uncertain funding and dependence on individual commitment, sometimes without total support from their organisations, and there was some uncertainty about the level of community advocacy for the program.

Discussion

The checklists used in this study to assess the strength of the RRISK partnership were designed as indicators of capacity building in health promotion. In this context, the findings that the RRISK partnership is viewed internally and externally as very strong indicate that formation and maintenance of the partnership has contributed to increased capacity within the area to address adolescent risk-taking. It should be noted that the number of respondents/interviewees is small, although they do represent all primary partners involved in the partnership, and most key stakeholders. The strength of the partnership is reported to have increased over time, in part because of the growing history of the group, the support of the organisations represented within the partnership, the success of the program in terms of the number and enthusiasm of participating schools, and the relationship that has developed between partners. There was some indication that it was viewed most strongly by those most involved in terms of time commitment and those attending regular meetings, with those not attending regular meetings having a slightly more critical eye.

In keeping with key elements identified in other studies (Butterfoss, Goodman & Wandersman 1996; Laraque et al. 1995), the valued elements of the RRISK partnership are:

* the group's shared goals and respect for each other's points of view;

* the approach to and level of communication;

* the scope for critical questioning about how things are done and for offering new ideas;

* the mix of organisations represented and the individual backgrounds and skills that partners bring to the partnership; and

* the strategic approach to planning the program's work throughout the year, regular meetings and comprehensive meeting agendas that include all agencies' issues.

In all, there is a high level of commitment to the program from all internal and external partners and a fairly high level of confidence in the future of the program and its capacity for sustainability. This confidence appears to stem from high regard for the networks and structure that partners bring to the partnership, the support that key stakeholder organisations have offered the program in terms of staff time and resources, and the fit between the program's goal and the demand within the community. Partners were less certain of the level of advocacy for the program at high levels within organisations represented, i.e. at State level and by the wider community. However, it was not identified as being unavailable to the program--just not universally strong.

While some interviewees thought the partnership's capacity to function effectively would be compromised if either of the two key "drivers" or the organisations they represent were to leave, others considered having two "drivers" to be a key ingredient of the partnership's success. This issue raises the apparent importance of the impact of personalities and personal commitment on the one hand and the formal structures and processes on the other. While individual commitment may be a key ingredient to establishing an effective intersectoral partnership, it is essential that organisational commitment is also maintained. Such commitment ensures a sustainable and effective partnership. Perhaps one of the goals of committed individuals who want to see the partnership continue (even if they leave their positions) is to ensure that all key organisations embrace the project or partnership, write it into the relevant officer's job description and / or list of duties, provide their organisation with regular updates and advocate for the project or issue within their organisation and their own networks.

Conclusions and recommendations

The RRISK partnership exhibits many qualities of a successful intersectoral partnership. There are strong indicators that it is achieving sustainability, as well as demonstrating good attributes of group function and opportunity for innovation.

RRISK stakeholders have identified several elements of the partnership that they consider to be keys to its success, both in terms of the partnership's longevity and the partners' confidence in its ability to meet its objectives. These elements provide a valuable set of principles that can help other programs to establish and maintain effective intersectoral collaborations.

On the basis of these elements we recommend that such programs establish partnerships that are clearly focused on a single long-term goal, one that all partners share with each other and also with the wider community.

Before the program is initiated it is vital that commitment is gained from key stakeholder organisations and is endorsed by their senior management. This high-level support should then facilitate input from grassroots workers familiar with the realities of program implementation.

It is also crucial that all partners understand both the culture of the partnership and the key responsibilities of each member organisation. This culture should be one of joint ownership with mutual respect for all partners and their contribution. It should foster open communication and encourage critical questioning and innovation.

To remain effective, such partnerships need clear role definition and agreed processes, particularly for delegation of tasks. Meetings should be regular, with representation by all sectors that need to be "on board". Care must be taken to ensure that agendas cover the interests of each and every partner agency and that meetings are run efficiently.

ACKNOWLEDGMENTS

We wish to thank all members of the RRISK partnership. The RRISK evaluation project was funded by New South Wales Motor Accident Authority (02/437). Ethics approvals were NSW DET SERAP No. 02. 150 and NRAHS 181.

References

Advisory Committee on Population Health, H.C. 1999, Intersectoral action ... towards population health, Health Canada, Ottawa, Ontario.

Ashton, B. & Hehir, A. 2002, 'Working with private partner organisations to address public health nutrition issues--a case study', Nutrition & Dietetics, v.59, n.1, pp.43-47.

Butterfoss, F.D., Goodman, R.M. & Wandersman, A. 1996, 'Community coalitions for prevention and health promotion: Factors predicting satisfaction, participation, and planning', Health Education Quarterly, v.23, n.1, pp.65-79.

Davies, R. 1999, "Mobilising business through "partnerships for health promotion": New challenges and new opportunities', Promotion & Education, v.6, n.1, pp.21-24.

DiSogra, L., Glanz, K. & Rogers, T. 1990, 'Working with community organizations for nutrition intervention', Health Education Research, v.5, n.4, pp.459-65.

Elkington, J., Hunter, K. & McKay, L. 2000, A systematic review of the evidence on preventing injuries to young people 15-24 years, report to Spinesafe April, 2000, Jane Elkington & Associates, Gordon, NSW.

Gillies, P. 1998, 'Effectiveness of alliances and partnerships for health promotion', Health Promotion International, v.13, n.2, pp.99-120.

Hammond, T. & Horswill, M. 2002, "The influence of desire for control on drivers' risk-taking behaviour', Transportation Research, Part F, v.4, pp.271-77.

Harris, E., Wise, M., Hawe, P., Finlay, P. & Nutbeam, D. 1995, Working together: Intersectoral action for health, National Centre for Health Promotion, Commonwealth Department of Human Services & Health, Canberra.

Hawe, P., King, L., Noort, M., Jordens, C. & Lloyd, B. 2000, Indicators to help with capacity building in health promotion, NSW Health Department, North Sydney.

Health Canada 1998, Building partnerships for health: Lessons learned, Health Canada, Ottawa.

Kegler, M.C., Steckler, A., McLeroy, K. & Malek, S.H. 1998, 'Factors that contribute to effective community health promotion coalitions: A study of 10 project ASSIST coalitions in North Carolina', Health Education & Behavior, v.25, n.3, pp.338-53.

Kumpfer, K.L., Turner, C., Hopkins, R. & Librett, J. 1993, 'Leadership and team effectiveness in community coalitions for the prevention of alcohol and other drug abuse', Health Education Research, v.8, n.3, pp.359-74.

Labonte, R. 1999, 'Mutual accountability in partnerships: health agencies and community groups', Promotion & Education, v.6, n.1, pp.3-8.

Laraque, D., Barlow, B., Durkin, M. & Heagarty, M. 1995, 'Injury prevention in an urban setting: Challenges and successes', Bulletin of the New York Academy of Medicine, v.72, n.1, pp.16-30.

Moss Kanter, R. 1994, 'Successful partnerships manage the relationship, not just the deal. Collaborative advantage: The art of alliances', Harvard Business Review July-August, pp.96-108.

National Health & Medical Research Council (NHMRC) 1996, Unintentional injury in young males 15-29 years, National Health & Medical Research Council (NHMRC), Canberra.

NHMRC Health Advancement Standing Committee and National Health & Medical Research Council 1996, Effective school health promotion: Towards health promoting schools, National Health & Medical Research Council, Canberra.

Pekar, P. & Allio, R. 1994, 'Making alliances work--guidelines for success', Long Range Planning, v.27, n.4, pp.54-65.

Roberts, I., Kwan, I. & Cochrane Injuries Group Driver Education Reviewers 2002, School based driver education for the prevention of traffic crashes, (Cochrane Review), The Cochrane Library, Oxford.

van Beurden, E., Zask, A., Brooks, L. & Dight, R. 2005, 'Heavy episodic drinking and sensation seeking in adolescents as predictors of harmful driving and celebrating behaviours--implications for prevention', Journal of Adolescent Health, v.37, n.1, pp.37-43.

Vernick, J.S., Li, G., Ogaitis, S., MacKenzie, E.J., Baker, S.P. & Gielen, A.C. 1999, 'Effect of high school driver education on motor vehicle crashes, violations, and licensure', American Journal of Preventive Medicine, v.16, n.1, Suppl., pp.40-46.

World Health Organization, Health & Welfare Canada & Canadian Public Health Association 1986, Ottawa Charter for Health Promotion, World Health Organization, Ottawa.

Zask, A., van Beurden, E., Brooks, L.O. & Dight, R. 2006, 'Is it worth the RRISK? Evaluation of the RRISK (Reduce Risk Increase Student Knowledge) program for adolescents in rural Australia', Journal of Adolescent Health, v.38, n.5, pp.495-503.

Jane Elkington is the Director of Jane Elkington & Associates, a public health and safety consulting business. She is a member of the ministerial NSW Road Safety Taskforce and an executive board member of Youth Safe (a NSW non-government organisation, dedicated to the prevention of injuries to young people).

Eric van Beurden is Research and Evaluation Coordinator with Health Promotion, North Coast Area Health Service and an Adjunct Professor with the Graduate Research College at Southern Cross University Lismore.

Avigdor Zask is Research and Evaluation Officer with Health Promotion, North Coast Area Health Service.

Reyna Dight has worked for the NSW North Coast Area Health Service for the last 15 years as coordinator of Alcohol Projects.

Wendy Johnson has been the Road Safety Officer for Lismore City Council for ten years, developing, promoting and conducting road safety programs in the Lismore Local Government Area.

FIGURE 1 Aggregated results for the 6 interviewed RRISK
partners (expressed as percentage of maximum possible
scores) for the three Capacity Checklists: Group Function
and Opportunity for Innovation (1-5); Strength of Partnership
(6-10) and Potential for Sustainability (11-13)

1. Group goals                                     89%
2. Feedback about performance                      88%
3. Guidance given                                  86%
4. Critical questioning within the partnership     97%
5. Structures/networks                             97%
6. Composition of the BRISK partnership            94%
7. Issue setting                                   90%
8. Direction setting                               94%
9. Structuring                                     91%
10. Partnership's expectations about success       100%
11. Program design and implementation              83%
12. Organisational setting                         92%
13. The broader community environment              97%