Coordinated action checklist: a tool for partnerships to facilitate and evaluate community health promotion.

Abstract

Coordinated action through partnerships is a core approach in community health promotion to deal with the multidimensionality of today's health and societal issues. The number of partnerships is increasing. However, facilitation and evaluation of partnerships is hampered by the lack and/or nonuse of feasible tools. As a consequence, health promotion through partnerships is not optimally facilitated and evaluated. This article describes the development and piloting of a tool and guidelines to facilitate and evaluate coordinated action in community health promotion. The initial development of the tool was based on relevant literature, a conceptual framework to support social environments for health, and an inventory of existing tools. Appreciative inquiry principles contributed to the formulation of items. The result, a checklist for coordinated action, was further developed and assessed for usability in six different partnerships: a national program, an academic collaborative and four local partnerships. Results of the checklist were cross-checked and discussed with partners. Piloting the checklist resulted in a feasible tool helpful to partnerships because of its ability to generate actionable knowledge. The checklist enables the facilitation and evaluation of community health promotion partnerships that differ in context and level (both local and national), phase of the program and topics addressed. Cross-checking and discussing results with partners and triangulation with interview data increases the reliability of the results of the checklist. Piloting in multiple cases contributes to the checklist's external validity.

Full text

Page 1

Introduction
In today’s health promotion the added value
of coordinated action for health is generally
acknowledged. In coordinated action, organizations
of two or more different sectors work jointly to
achieve an outcome (1). Coordinated action brings
about changes in the environment of health and
thereby improves the health of individuals and
populations and increases awareness of health
1. Correspondence to: Annemarie Wagemakers, PhD. Assistant to the Professor Public Health and Society, Public Health
and Society, Department of Social Sciences, Wageningen University, PO Box 8130, 6700 EW Wageningen, The
Netherlands. (Annemarie.Wagemakers@wur.nl)
2. Associate Professor, Communication and Innovation Studies, Communication and Innovation Studies, Department of
Social Sciences, Wageningen University, The Netherlands.
3. Researcher Community Health Service, GGD Gelre IJssel, The Netherlands.
4. Associate Professor, Public Health and Society, Department of Social Sciences, Wageningen University, The
Netherlands.
(This manuscript was submitted on November 6, 2009. Following blind peer review, it was accepted for publication
on January 26, 2010.)
Global Health Promotion 1757-9759; Vol 17(3): 17–28; 375166 Copyright © The Author(s) 2010, Reprints and permissions:
http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975910375166 http://ghp.sagepub.com
Original Article
Coordinated action checklist:
a tool for partnerships to facilitate and evaluate
community health promotion
Annemarie Wagemakers1, Maria A. Koelen2, Jeanette Lezwijn3and
Lenneke Vaandrager4
Abstract: Coordinated action through partnerships is a core approach in community health promotion
to deal with the multidimensionality of today’s health and societal issues. The number of partnerships
is increasing. However, facilitation and evaluation of partnerships is hampered by the lack and/or non-
use of feasible tools. As a consequence, health promotion through partnerships is not optimally facili-
tated and evaluated. This article describes the development and piloting of a tool and guidelines to
facilitate and evaluate coordinated action in community health promotion. The initial development of
the tool was based on relevant literature, a conceptual framework to support social environments for
health, and an inventory of existing tools. Appreciative inquiry principles contributed to the formula-
tion of items. The result, a checklist for coordinated action, was further developed and assessed for
usability in six different partnerships: a national program, an academic collaborative and four local
partnerships. Results of the checklist were cross-checked and discussed with partners. Piloting the
checklist resulted in a feasible tool helpful to partnerships because of its ability to generate actionable
knowledge.The checklistenablesthe facilitationandevaluationofcommunity healthpromotion partner-
ships that differ in context and level (both local and national), phase of the program and topics
addressed. Cross-checking and discussing results with partners and triangulation with interview data
increases the reliability of the results of the checklist. Piloting in multiple cases contributes to the check-
list’s external validity. (Global Health Promotion, 2010; 17(3): pp. 17–28)
Keywords: action research, collaboration, evaluation, community health promotion

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A. Wagemakers et al.
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IUHPE – Global Health Promotion Vol.17, No. 3 2010
consequences involved in policy decisions and
organizational practice, within and among different
sectors.Centraltocoordinatedactionarepartnerships
for intersectoral collaboration and community
participation (2,3). The number of partnerships is
increasing rapidly because no agency alone has the
resources to address the wide range of determinants
of today’s multifaceted public health problems (4,5)
such as overweight and obesity, the rapid ageing of
the population and the greater longevity of people
with chronic conditions.
A review of collaborative partnerships found that
partnerships convincingly contribute to supportive
socialenvironmentsofhealth(6).However,evaluation
of partnerships is hampered by lack of information
on how interventions bring about change in the
social environment in favour of health (7,8). A lot
more happens through partnerships than is mea-
sured, evaluated and reported. There seems to be a
gap in knowledge on how to effectively facilitate and
evaluate coordinated action for health (8), and little
is known about appropriate strategies to evaluate
partnerships (9). One of the reasons for this gap is
the lack and/or non-use of feasible tools in practice
(6,10–12) due to unfamiliarity with existing tools
and guidelines. Science advocates the use of validated
tools, and practice longs for tools that fit the
multifacetedness of health promotion practice. This
meansthattoolsandmethodsneedtobescientifically
grounded, easy to adapt to specific needs in practice,
easy to analyse, and relatively low in time demand
and cost (13).
In previous research (14) a framework and
guidelines to facilitate and evaluate supportive
environments for health has been developed (see
Figure 1). The framework is based on our experiences
in case studies and a review of the literature on
participation and collaboration. The framework
visualizestherelationbetweenthesocialenvironment,
health predicting mediators (e.g. lifestyle) and
population health outcomes (e.g. health status) and
provides operationalizable variables that moderate
the relation between the social environment and
health predicting mediators. In the framework,
participation and collaboration, both core concepts in
health promotion (2,3), are used as entry points to
make the social environment of health researchable
and manageable by partnerships and communities.
Participationandcollaboration
operationalized into variables (middle column). The
havebeen
reasonforchoosingparticipationandcollaborationas
moderators is that they have an intermediary role in
health and social change outcomes (15,16) and are
central to the effectiveness of health promotion
(17–22). Also, case studies show that (community)
participation and (intersectoral) collaboration are
measurable (13,23–25). The left column shows that
the variables are applicable on an interrelated
continuum of four levels: individual, organizational,
coalition and community. The right column provides
some possible operationalizations of variables. The
framework serves as a summary of options available
to facilitate and evaluate changes in the social
environment for health. It can be used as a ‘menu
of menus’ by choosing levels, variables and
operationalizations (14).
Based on this framework, a checklist for
coordinated action has been developed.
The aim of this article is to (i) report on the
development and piloting of a checklist for
coordinated action, (ii) assess its ability to generate
actionable knowledge to the mutual benefit of
partners and partnership work, and (iii) assess its
usability. The checklist is piloted by a multiple case
strategy, that is, by implementing the checklist in
different settings. Multiple case studies provide a
basis for external validity, which means that the
checklist is relevant to other situations. Internal
validity is increased by the use of verification
techniques such as data triangulation and checking
results of the checklist with partners (1,26).
First, the rationale and methodology for the
developmentandpilotingofachecklistforcoordinated
action is explained. Second, in the results section,
the scores and actions generated in the pilots and
the usability of the checklist is evaluated. Third,
strengths and limitations of the checklist, its
accompanying methods and its output – actionable
knowledge – are addressed.
Method
The rationale for developing a checklist for
coordinated action derives from both the literature
and the practical experiences of community health
promotion. The route towards the development of
the checklist consisted of two steps: setting criteria
for the checklist and piloting the checklist in practice.
In piloting the checklist we used an action research
approach.

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Original Article
Figure 1.
A framework to facilitate and evaluate supportive social environments for health promotion
19
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A. Wagemakers et al.
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IUHPE – Global Health Promotion Vol.17, No. 3 2010
Criteria for the checklist
Three criteria were considered in the development
of the checklist.
First, an important success factor in coordinated
action is visibility because it is an incentive for
involvement and action (1). Therefore a tool needs
to visualize results, for example by scores (27,28) or
spiderwebs (12,29).
Second, a tool needs to faciliate and support
communication. Communication, including feedback,
cross-checking and discussing results with partners,
promotes trust (9), increases satisfaction with
evaluation and consequently increases participation
(24,25), contributes to the evolvement of the
partnership (4), facilitates subsequent action (30) and
contributes to the validity of results (15,30).
Third,atoolmustbeusableinallphases.Toachieve
and sustain coordinated action (1,5) partnerships need
to be nurtured in all phases, e.g. initial mobilization,
planning, implementation and evaluation (31).
Several tools that measure participation and col-
laboration were assessed. The tool that best fits the
criteria is that developed by Verbeke et al. (28). An
asset of the Verbeke tool is that it addresses four
well-organized dimensions: task, relation, growth
and visibility. The task dimension relates to concrete
products and results such as the action plan. The
relation dimension concerns interaction among the
participants and can be compared to Sicotte et al.’s
intra-group processes (32) and Schulz et al.’s dimen-
sions of group dynamics (11). The growth dimen-
sion relates to the achievement and evolution of the
partnership and is closely related to the visibility
dimension that includes items on perceived image.
On the basis of Verbeke’s tool, a checklist was devel-
oped that reflects the previously mentioned criteria.
Developing and piloting the checklist
We used an action research approach to compose
and pilot the checklist in close collaboration with six
partnerships: a national program of the National
Institute of Sport and Physical Activity (NISB), an
academic collaborative (AGORA) and four local
partnerships in three cities and one town in the
Netherlands: Eindhoven, Zwolle, Delft and Epe.
Table 1 provides an overview of the partnerships.
The partnerships were convenient samples stemming
from the authors’ contacts with practice. In three
partnerships, one or more authors were part of the
partnership (B, C, F). In the other three partnerships
(A,D,E),thefirstauthorguidedtheuseofthechecklist.
In line with our guidelines (14) items were chosen
that can be considered as operationalizations of the
variables in our framework (Figure 1). The chosen
items were opportune for the specific situation and
contexts of the partnerships. Some items cover more
than one variable and vice versa. The checklist
addresses all levels of partnership work, from the
individual level to the community level. Therefore,
some items are formulated in the ‘I-form’ whereas
others address partners or the partnership.
To contribute to visibility, the checklist items
convert the opinions of partners into quantitative
variables by asking them to score the items on a
Likert-like scale. The five answer categories are: no
(score 0), probably not (score 25), no/yes (score 50),
probably yes (score 75) and yes (score 100). The
mean of items is calculated by adding the scores and
dividing the result by the total number of partners.
Dimensions are rated by adding the item scores and
dividing the result by the number of items.
To facilitate and support communication, the
appreciative inquiry principles (33) were applied in
composing the checklist. Appreciative inquiry is an
approach that inspires and stimulates partners by
appreciating the value of what already exists and
using this as a starting point for envisioning, dialogu-
ing on and innovating desired changes. Appreciative
inquiry has already been used successfully in health
promotion (34,35) and as an interview tool (36).
Applying the principles means that items and ques-
tions are formulated in a positive way. An example of
an item on the checklist is ‘The partnership is an asset
to health promotion’.
The checklist has been applied in succession, that
is, in one partnership after the other. After
each application, the checklist itself was evaluated
by the partnership, its coordinators and the authors.
Results of the evaluation were used to improve the
checklist for use in the next partnership. The first
checklist was composed of 20 items. The inclusion
and exclusion of items resulted in a core checklist of
25 items. In the fourth pilot, the partnership indi-
cated that an item on continuation after the project
period was lacking. As a consequence, the last item
of the checklist was included. Depending on the sit-
uation and specific wishes of the partnerships, more
items may be included.

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Original Article
Table 1.
Overview of partnerships, characteristics and use of checklist
ABCDEF
Partnership
Project group
Heart for
Lakerlopen
Academic
collaborative
steering
group
AGORA
Collaboration National
between
practice and
science in
Gelre-IJssel
Region, the
Netherlands,
set up in
2006
Pilot programme Workgroup
Overweight
in the
Neighbourhood Food
NISB
Workgroup
Vitality
Pilot of NISB
Project group
Healthy Ageing
Part of AGORA
Healthy and
Affordable
Eindhoven
One of six
neighborhoods
in community
programme in
Eindhoven, a
big city in the
southern part
of the
Netherlands,
started in 2000
Zwolle
Workgroup,
part of
program
Healthy
Together,
in Zwolle, a
city in the
rural north-
east of the
Netherlands,
started in
2008
Nutrition
Delft
Workgroup
to set up
integrated
care facilities
in two
neighborhoods part of the
in Delft, a city Netherlands,
in the western started in
part of the
Netherlands,
started in
2007
Overweight
Epe
Program to
promote
healthy ageing
in a rural town
in the eastern
Features
programme
of the
Netherlands
Institute for
Sport and
Physical
Activity
(NISB), set
up in 2007
2007
Theme
Healthy
behaviour
Inhabitants
Healthy
ageing
Elderly
Overweight Loneliness
Target group
InhabitantsLow SES
women
Municipal
Health
Service,
Local
grassroot
organizations services
Low SES
children
Municipal
Health
Service,
Municipality,
Schools, Sport Municipality,
Elderly
Main partners MunicipalMunicipal Municipalities,
Municipal
health services
and sport
services
Municipal
Health Service,
Welfare
Organization,
Health Service, Health
Local grassroot Service,
organizations,
Welfare work
Wageningen
University,
MunicipalitiesMental Health
Care
January 2009
In meeting
Use checklist
January 2007
in meeting
1. April 2007
Individually
(combined
with interview) 2009
and discussed
in a meeting
2. May 2009
In meeting
1. June 2008
In meeting
2. September
December
2008
Individually
(combined with
interview) and
discussed in a
meeting
December
2008
Individually
In meeting
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IUHPE – Global Health Promotion Vol.17, No. 3 2010
In all six partnerships, the checklist was used to
facilitate and evaluate the partnership and its actions.
In AGORA and NISB, the checklist has been used
twice, respectively with a time-elapse of two years and
one year. In both partnerships, reasons to use the
checklistagainwerethatevaluationofthepartnership
was requested by the funding agency, the first positive
experience with the checklist and that former results
gained by the checklist could be compared with new
results. In AGORA (2007) and Zwolle, the check-
list was filled in as part of an individual interview. The
results, of both the interviews and the checklist, were
fed back and discussed in a meeting. In Eindhoven,
AGORA (2009), NISB (2008 and 2009) and Epe, the
checklist was individually filled in during a meeting
and discussed right away. In Delft, partners filled in
the checklist individually at their office and the
checklist was not discussed. Filling in took a few
minutes. The checklist functioned as a discussion
opener by asking partners on which items they scored
high (and low) and why. In the discussions again the
principles of appreciative inquiry were applied.

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A. Wagemakers et al.
Table 2.
Checklist for coordinated action and calculated mean scores of the partnerships
Partnership
A
B1
B2
C1
C2
D
E
F
Items and scores (means 0–100)
N = 7
N = 14
N = 12
N = 14
N = 13
N = 7
N = 8
N = 5
General
100
93
90
88
88
96
97
85
1 The partnership is an asset (to health promotion).
100
93
90
88
88
96
97
85
Suitability of the partners
77
83
85
76
79
88
80
71
2 To attain the goals of the partnership, the right partners
75
80
68
70
69
79
78
60
are involved.
3 Equity of the partners is essential for good collaboration.
82
79
98
75
81
89
84
85
4 The contribution of the different partners is to
61
73
65
70
71
86
72
65
everyone’s full satisfaction.
5 I have a special interest in participating in the
90
82
94
84
88
93
75
85
partnership because of my position or organization.
6 I am able to contribute to the partnership in a satisfactory
75
88
83
75
71
86
69
55
way (time, means, etc.).
7 I feel involved in the partnership.
79
93
94
84
88
93
91
75
8 I can contribute constructively to the partnership
79
89
90
75
85
93
91
75
because of my expertise.
Task dimension
78
59
76
63
76
87
70
74
9 There is agreement on the mission, the
71
45
63
63
73
82
72
75
goal and the planning within the partnership.
10 The partnership achieves regular (small) successes.
89
63
100
60
81
89
75
65
11 The partnership functions well (working
75
59
61
69
71
86
59
75
structure, working methods).
12 The partnership evaluates progress at
*
70
79
58
77
89
72
80
regular intervals and makes adjustments if necessary.
Relation dimension
84
59
69
66
70
91
67
71
13 The partnership partners communicate in an open manner.
*
61
60
80
77
89
56
75
14 The partnership partners work together in a
86
61
73
59
63
96
69
75
constructive manner and know how to involve
each other when action is needed.
15 The partnership partners are willing to compromise.
*
50
70
71
69
89
75
80
16 In the partnership, conflicts are dealt with in a
*
50
60
56
62
**
66
60
constructive way.
17 The partnership partners will carry out decisions
82
75
83
66
77
89
69
65
and actions loyally.
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Original Article
Table 2.
(Continued)
Partnership
A
B1
B2
C1
C2
D
E
F
Items and scores (means 0–100)
N = 7
N = 14
N = 12
N = 14
N = 13
N = 7
N = 8
N = 5
Growth dimension
72
71
82
72
77
71
73
70
18 I create goodwill and involvement for the
82
86
90
80
85
92
75
80
partnership within my organization.
19 Giving feedback to the local officials on
58
58
75
59
63
19
72
55
behalf of the partnership is satisfactory.
20 The partnership is willing to recruit new partners
79
79
81
79
73
89
88
80
in the course of time.
21 The partnership succeeds in mobilizing others for actions.
68
59
82
69
85
82
75
65
Visibility dimension
82
69
78
66
57
77
63
60
22 The partnership maintains the external relationships
*
58
65
64
77
89
66
60
in an accurate way.
23 The partnership is seen as reliable and legitimate by
*
71
86
71
44
69
59
55
external relations.
24 The image of my partnership in the outside
82
79
84
63
54
75
57
55
world is good.
25 The partnership takes care of continuation after
*
*
77
*
54
75
69
70
the project period.
Mean score of all items
78
71
79
70
73
84
73
70
Notes: The numbers are the mean scores of individual partners on a Likert-like scale; no (score 0), probably not (score 25), no/yes (score 50), probably yes (score
75) and yes (score 100); * = Item was not included in this case; ** = Item could not be anwered because no conflict had occurred.
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A. Wagemakers et al.
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IUHPE – Global Health Promotion Vol.17, No. 3 2010
Results
Scores and actions
Table 2 presents the mean scores of the pilots on
the core checklist of 25 items.
Discussion centred on establishing the reasons
behind the scores, both the high scores (successes)
and low scores (points to improve). Feedback and
discussion enabled clarification of the reasons for
high and low scores and, following from that,
action could be taken (see Table 3).
All the partnerships view themselves as an asset to
health promotion. In particular, the suitability of
partners, based on expertise and involvement, is
highly appreciated.
In Eindhoven, the score on the item ‘The contri-
bution of the different partners is to everyone’s full
satisfaction’ was relatively low. The discussion
revealed that the score was low because the number
of activities for inhabitants was far less than initially
planned. This is an example of a qualitative opera-
tionalization by the partners. After discussion, it
was agreed that an action plan would be developed
to set up activities for inhabitants.
In AGORA (in 2007), the results of the individ-
ual interviews and the score on the item ‘There is
agreement on the mission, the goal and the plan-
ning within the partnership’ revealed that partners
held different views on the mission and goals of the
healthy ageing program. Cross-check of those
results with partners further clarified that the views
on mission and goals ranged from (only) health
education to a broad range of facilities and services
that contribute to health and wellbeing, like for
example transport. Discussion sessions that fol-
lowed contributed to improved mutual understand-
ing and respect for different visions and disciplines.
Two years later, discussing high and low scores on
the checklist revealed that many (small) successes
had been recorded. The partners agreed that these
successes needed to be celebrated as well, and this
was done right away. The discussion also revealed
that continual attention must be paid to communi-
cation. Moreover, it was considered important to
involve more municipalities. As a result, it was
decided to add an alderman to the steering group.
In other partnerships, effected changes included
agreement to expand the number of meetings for
the partners to exchange experiences (NISB in
2008), the plan to initiate actions to embed the
project (Zwolle), and efforts to strengthen involve-
ment of organizations and the elderly (Epe). In
Delft, the results of the checklist were not discussed
with partners. On the basis of the Delft scores the
project coordinator decided to split the partnership
into smaller groups in order to increase efficiency. In
NISB (in 2009) the checklist was used during the
last meeting of the partnership and follow-up
focused on publicity of results and development of
future activities.
Usability of the checklist
Overall feedback from partnerships about the
usability of the checklist was positive: items were
understandable, the checklist could be filled in
quickly, counting scores was simple, adaptations
could be made easily and especially discussing
results with partners generated actionable knowl-
edge. According to the partners, the ‘I-formulated’
questions were easier to answer than items address-
ing all partners or the partnership. The scores on the
checklist were a good starting point for discussion.
In general, highly rated items were acknowledged as
non-problematic or as successes. The lower rated
items were of most interest for discussion because
they unravelled differences between partners and
points to improve. Overall, use of the checklist and
the accompanying methods (feedback and discussion)
was found to be complementary to day-to-day
partnership work, contributing to team building
and enabling partners to sustain coordinated action.
In addition, partnerships used the results for exter-
nal evaluation purposes, such as in progress
reports required by funding agencies.
Discussion
Checklist
Items on the checklist often address more than
one variable of participation and collaboration.
They can also be applicable for different levels (indi-
vidual, organizational, coalition and community),
and to a broad range of dimensions (task, relation,
growth, visibility) of partnership work. This can
be a limitation because only a few items can be
included in each dimension. Moreover, items can be,
and in our pilots were, interpreted differently by
partners. Both limitations however can be assets as
well. The strength of the checklist is not the number

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Original Article
Table 3.
Actionable knowledge generated by the checklist and follow-up
A
B1
B2
C1
C2
D
E
F
Partnership
Eindhoven
AGORA
AGORA
NISB
NISB
Zwolle
Delft
Epe
Successes
Partners are
loyal and theimage of the
partnership
is good.
Partners are
suitable,
have the
right
expertise and
feel involved.
Involvement of
partners and
(small)
successes are
achieved.
Right
partners are
represented
and partners
feel involved.
Partners
work
together in a
constructive
way and
successes are
achieved.
Partnership
calls itself a
‘dream team’
and role of
project
coordinator
is central.
Not
discussed.
Partners’
expertise is used
well and
communication
is open.
Points to be
improved
Participation of
inhabitants is
low.
Partners have
different
visions on
mission and
goal.
Communication
between
partners is
limited.
Knowledge
dissemination
to municipalities
is weak.
Partners lack
opportunities to
exchange
experiences.
The image and
visibility needs
to be improved.
Activities to
continue
collaboration
need to be
set up.
Embedding of
partnership in
local structures
is lacking.
Not discussed. Involvement of
other
organizations
and the elderly
is low.
Follow-up
Developing an
action plan to
involve
inhabitants.
Discussion
sessions to
clarify roles.
Structures for
communication
and knowledge
exchange.
Alderman in
steering group.
Special meetings
(e.g. work
visits),
newsletter and
email contact.
Articles based
on the results
of the pilot will
be published.
In new NISB
programm, the
partners will be
involved.
More attention
to growth and
visibility
dimension of
partnership.
Partnership
was split into
smaller groups
on specific
activities.
Meetings with
organizations
(e.g.
municipality,
church) and theelderly.
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of items but the inclusion of the ‘right’ items: items
that initiate discussion, which in turn generates
actionable knowledge at all levels and on all dimen-
sions. In our pilots it appeared that discussion about
the meaning of items between the partners helped to
reveal the actual dynamics of the partnership and to
unravel ongoing processes. A significant element of
the checklist is the scoring system because it
visualizes strengths (e.g. successes) and weaknesses
(points to improve) on items and on dimensions. In
AGORA and NISB, the 2009 results could be com-
pared respectively with the 2007 results, and 2008
results. In 2009, in both partnerships scores and dis-
cussion revealed that collaboration had improved
and that many successes had been recorded. In
AGORA, improvement has been considerable. In
NISB the improvement has been moderate, because
visibility needs to be improved in order to end the
pilot program in a proper way.
The positive approach, based on appreciative
inquiry, builds on strengths and assets of partnerships
andtheirworkandtherebycontributestothepartners’
enjoyment in using the checklist and to increasing pre-
paredness to take action. The positive approach possi-
bly also generates (purposely) bias. However, in most
of the pilots the discussion about successes and
points to improve came up simultaneously. Michael
(36) also reported that negative experiences were
conveyedaswellaspositiveexperiencesandthat,allin
all, appreciative inquiry contributed to a richer
undertanding. Therefore, the scores need to be
interpreted relatively and in combination with the
results of checking among partners, discussions and, if
possible, interviews. When the checklist is being
discussed, probing the reasons behind relatively high
and low scores works very well, as our pilots show.
Facilitating participation
The checklist was developed in a participatory
way, and consecutively applied and evaluated. This
resulted in continual improvement of the checklist.
To support participatory use, the checklist is flex-
ible, both in items to be included and accompanying
methods to discuss the outcomes. Partnerships that
use the checklist, should realize that the main func-
tion of the numbers in the checklist is to summarize
strengths and areas for improvement at a glance and
that the main asset of the checklist is to stimulate
feedback and discussion.
In feedback and discussion, partners are chal-
lenged to reflect on the dynamics of their work,
ongoing processes, outcomes, their own and other
partners’ position and contribution and so on. This
was confrontational in two partnerships, but in the
end sustained coordinated action. Confrontation
presents an opportunity to clarify different views.
However, partners need to feel safe and comfortable
to do so. When a partnership is not running
smoothly, we advise to conduct individual inter-
views in combination with the checklist. This may
help to unravel what is going on and facilitate dis-
cussion. By discussing the different views, the part-
ners set in motion a learning process that potentially
creates a way to combine different views, and reach
consensus and thus leads to an innovative project.
In general, active facilitating increases the chance of
successful collaboration and desired outcomes for
all partners (37).
Actionable knowledge
In this study, we used an action research
approach, resulting in the generation of actionable
knowledge in all partnerships. Cook (38) recom-
mends ‘action’ as a legitimate component in
research designs for programmes that aim to effect
community-level change. A tool needs to meet valid-
ity criteria: both internal validity (10), which is
addressed by using verification techniques (partici-
pant check, triangulation), and external validity,
which is based on practice-based research with
attention to context and to connectedness of
program levels (39). Paying greater attention to the
issues of external validity and to intermediate or
process outcomes enhances relevance to particular
settings and will lead to better applications and
program (40,41). Therefore, we expect the results of
this study to be relevant to other partnerships.
However, a number of relevant issues still need to be
addressed. These issues are the further refinement
and improvement of the checklist and its use, the
optimum composition and number of required
items, the most appropriate accompanying methods
and the features and context of partnerships that
need to be taken into account. Up to now, our
research is characterized by its explorative nature.
To address the mentioned issues and to further val-
idate the checklist, more research is needed. Future
research can be focused on the continuation of the

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Original Article
27
IUHPE – Global Health Promotion Vol.17, No. 3 2010
present research: evaluate the use of the checklist in
more partnerships and to re-use the checklist at mul-
tiple times in the same partnerships. Also, future
research can focus in more detail on how items are
interpreted by partners.
Conclusion
The action research approach facilitated the
development and piloting of a checklist with 25 core
items. The checklist is a useful means for partners to
overview their working and monitor their successes
as a partnership promoting change. In combination
with feedback and discussion, the developed check-
list enabled the facilitation and evaluation of com-
munity health promotion partnerships that differ in
context, phase of the program, scale (national and
local), topics addressed (overweight, healthy ageing)
and number of partners. The use of the principles of
appreciative inquiry in the checklist and methods
contribute to improving communication and com-
munication structures, to visibility, to clarifying
outcome expectations, to celebrating (small) suc-
cesses and to facilitating regular evaluation.
Cross-checking and discussing results with part-
ners and triangulation with interview data increases
the reliability of the results of the checklist. Piloting
in multiple cases contributes to the checklist’s exter-
nal validity. The parallel investigation of the
checklist in different partnerships resulted in all
cases in actionable knowledge. The checklist helped
partnerships in this study to understand processes
and to create community and systems change and
hence can potentially contribute to achieving
population-level health outcomes.
Acknowledgements
The article is partly based on data gathered as a
part of the pilot project
Framework, carried out in 2007. This pilot was
organized by the Netherlands Institute for Health
Promotion (NIGZ) and funded by the Netherlands
Organization forHealth
Development (ZonMw). AGORA’s healthy ageing
project is funded by ZonMw. We are grateful to all
partnerships who participated in developing and
piloting the checklist. We also thank Jenneken
Naaldenberg for her comments on a draft version
of this article.
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