摘要：Objectives. We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. Methods. We interviewed a sample of 1477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. Results. A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime ( P = .008) and nighttime ( P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry ( P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. Conclusions. Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change. Why coalitions? Proponents of the coalition approach to resolving health problems offer at least 3 reasons in answer to this question. One is that in a democratic society, people have the right—and indeed the obligation—to participate in the decisions and actions that affect their health and well-being. 1 Another is that the greater the participation in a decision or action, the wider the acceptance of the solution among those affected and the higher the likelihood that the solution will be used and valued. 2 , 3 The third reason is that the collective wisdom and unique experience of the participants in a coalition effort produce richer information and more relevant decisions. 4 As the antecedents of health problems have become more fully understood in public health, 5 – 7 there has been an increase in the perception that broad-based partnerships are needed to resolve them. Community coalitions, as opposed to coalitions as generally defined, function from the position that the most desirable solutions to health problems rest with the full range of community stakeholders (e.g., individuals, organizations, systems) and that there is a need for all to be represented in the process of resolution. 8 , 9 A guiding premise of most community coalitions is that without representation that includes community residents and community-based organizations with an intimate understanding of the day-to-day aspects of the health problem, solutions will fall short of the mark. Management of asthma, for example, is influenced by more than the actions of the asthma sufferer. The family and professionals providing clinical expertise are instrumental to asthma control. Those at work or school can provide assistance or moral support to people with asthma. Colleagues and friends need to be aware of preventive measures and need to know what to do in an emergency. Community awareness, support and action, environmental conditions, and far-reaching policies affect how an individual can manage the disease. Policies, of course, include mechanisms that make needed resources available and affordable for all stakeholders. Community coalitions have the ability to effect policy and system change in all of the circles of influence on disease prevention and management. 10
