Which aspects of coalition functioning are key at different stages of coalition development? A qualitative comparative analysis.

Background: Coalitions are increasingly utilized to promote positive community health outcomes. Typically, coalitions produce more desirable outcomes when coalition functioning is strong and the coalition model is implemented with fidelity. Although theory indicates that coalitions proceed through predictable stages of development, minimal research explicitly examines functioning and fidelity at these different stages. Method: Within a larger evaluation of Washington State Community Prevention and Wellness Initiative, this cross-sectional study employs qualitative comparative analysis to illuminate the coalition functioning conditions necessary and sufficient to produce high model fidelity at different stages of development in 43 substance misuse prevention coalitions in one state. Results: In the formation stage, only the presence of high levels of coalition leadership was sufficient to produce high model fidelity. In the maintenance stage, three combinations of conditions were sufficient: (1) sustainability planning if, and only if, accompanied by the absence of coalition participation costs, (2) coordinator leadership, and (3) a combination of coalition leadership and team cohesion. In the institutionalization stage, two solutions were sufficient: (1) coalition leadership if, and only if, accompanied by the absence of sustainability planning, and (2) sustainability planning if, and only if, accompanied by the absence of coordinator leadership. Conclusions: This study illustrates several tangible steps technical assistance providers may take to increase the likelihood of achieving model fidelity. In the formation stage, skillful and inclusive coalition leadership is important. In the maintenance stage, technical assistance should focus on reducing participant-perceived costs; increasing sustainability planning; enhancing coordinator-specific leadership; and developing team cohesion and coalition leadership. For coalitions in the institutionalization stage, coalition leadership and sustainability planning may be prime targets for technical assistance.