The objective of this paper is to further the understanding of the links between leadership skills and a wide range of process and outcome factors of effective partnerships in public health. Collaboration across professional and agency boundaries has taken many approaches, involving shared decision-making, pooled budgets and integrated provision [1–6]. Partnerships are becoming the norm for capacity building and development in public health, health education and disease prevention [7–11]. Many granting Foundations such as W.K. Kellogg [12] have supported local partnerships for community-wide planning to achieve health objectives.

We use the terms ‘coalition’ and ‘partnership’ interchangeably to indicate the process by which stakeholders invest themselves with ideas, experiences and skills that collectively bear upon problems through joint decision-making and action [13]. Community partnerships (CPs) of professionals and community-based grassroots agencies influence long-term health and welfare, nurture social inclusion, reduce inequalities, and instil a sense of community [14]. However, these community-wide initiatives require extra effort and time where professionals and ‘lay’ people collaborate on an equal power basis, with respected inputs and similarly heard expressions [15]. Such partnerships face multiple internal and external ‘dynamic tensions’ [16, 17], and require effective leadership [18, 19].

Leadership is a ‘coalition-building’ factor associated with implementation, maintenance, organisation and effectiveness [20–22]. Leaders advance equal status, encourage joint working and enhance partners’ involvement in decision-making. Such actions increase members’ participation, satisfaction and commitment [23, 24]. Leaders’ characteristics, personal features and decision-making styles influence positive team outcomes [25], while leadership qualities, knowledge, commitment, competence, communication and interpersonal relations are critical in realising objectives [26]. In empowering agencies, leaders promote members’ cohesion and involvement in planning [27, 28].

In addition, successful CPs build on other factors: broad stakeholder and community representation, administrative/ management skills and quality communication [7, 29–31]; and staff and lay members’ expertise and experience [11, 32, 33]. The costs and benefits of participation are important [34, 35], as they enhance member and resource allocation satisfaction [36]. A supportive organizational climate with clear rules, procedures and roles promotes operational understanding in CPs [37], while collaborative decision-making and positive interactions build equitable staff-constituency relationships [30] that endorse a sense of ownership and community [37, 38].

This study was informed by multiple conceptual frameworks for successful CPs. These included membership, organisational and structure characteristics, resources and support, and function and roles [39–41]. The frameworks also addressed operational parameters (leadership and management skills, communication, decision making processes) [27, 28, 42–44] that require democratic, visible and supportive leaders [41].

Four aspects emerged from the literature: 1) CPs are vital in tackling common health concerns across partners and communities; 2) effective leadership is essential for CPs to achieve their health outcomes; 3) leadership does not exist in isolation and many non-leadership factors neatly interlace in effective CPs; 4) leadership is related to team efficacy, satisfaction, and outcomes [41], but current models fail to fully explain relationships between leadership and the factors that contribute to successful CPs.

Few have systematically examined the relationships between leadership and partnership outcomes [45]. Kumpfer et al. [41] emphasised the lack of understanding of the influence of leadership, proposing a model where leadership was related to team efficacy, satisfaction, and outcomes. This paper builds on Kumpfer’s model to further the understanding of leadership’s influence. It hypothesises that leadership will not only influence team efficacy, satisfaction, and outcomes, but also many other factors critical to successful CPs. The term ‘factor’ describes any given feature of effective CPs (e.g. flow of information, communication, interaction, or commitment factors), and ‘item’ indicates the number of questions that comprised each factor.

In CPs, local political, business, grassroots and civic leaders unite around a community agenda to develop coordinated responses to community health and social challenges [62]. Successful partnering requires effective leadership [63], and leadership style was consistently associated with effectiveness [20]. The CPs influenced health practitioners to be more community sensitive, so partnership leaders need an understanding of the health care system, providers, universities and communities to develop strategies to influence the health system [64]. Leadership is critical in coalitions [65], where leaders relate to their environment, building teams or collaborations [66, 67]. Besides authority, power and influence to guide members to goals [68] leaders require training and technical assistance to promote coalition building/sustainability [69, 70].

In this cross-site evaluation of 5 CPs [71] the tool addressed operational and organisational ‘process’ and ‘outcome’ factors, balancing process measures of how coalitions work and outcome indicators of whether CPs make a difference [72]. Process measures show how close coalitions are connected to the grassroots [38], and are essential to assess effectiveness [5, 73].

For some stakeholders, response rates were challenging to compute. This was not unusual: frequently in collective action, only a fraction of people/organisations with shared interests become involved [74, 75], usually at the minor level of belonging to an agency and paying dues.

The survey tool displayed excellent internal consistency, essential in evaluations of partnerships [73] (α>0.60 is acceptable, but values >0.80 are preferred). In this study, >80% of scales of multi-item measures had α ≥ 0.70 (range 0.66 – 0.93), supporting values reported by others [37, 40, 41, 76]. However leadership is often measured in different ways: incentive management [39], task focused [77], shared leadership [30], empowering or collective [36], or embracing multiple features [78]. The 11 features of leadership employed in the present analysis catered for a variety of leadership aspects, behaviours and styles.

In terms of the first objective, the CPs targeted many educational, social, and community development objectives, as with similar efforts elsewhere [10, 47, 65, 79]. The initiative was sharing of models of academic-community partnering collectively focussed on the health needs of the population groups, communities and individuals concerned. Hence, academics had participated slightly longer, reflecting their initial involvement in the ‘pre-formation’ phase [80, 81].

Secondly, it has been shown that it was appropriate to use LSS and LSC when exploring associations between the leadership skills and CP factors. Thirdly, LSC was valid in differentiating among participants across 10 confirmatory items, where higher LSC was associated with positive perceptions to the items. The findings were in the predicted direction, and confirmed the consistency of LSC in differentiating among participants with different engagement levels. An exception was in relation to past CP experience.

Fourthly, affirmative feelings of partners about their leadership were consistently accompanied by positive perceptions across many factors of CPs’ functioning. Others [82] similarly identified 27 measures of coalition characteristics, where many measures were related to leadership performance. Indeed successful university-community collaborations for health curricula reforms require leadership strategies (e.g. consistency, range of leadership behaviours, participative governance) that are associated with positive outcomes [65].

These findings support that member, staff and organisational factors are intertwined in CPs [12, 39–41]. For instance, high LSC partners felt the personnel barriers in their CPs to be less threatening, a critical perspective for a coalition’s internal functioning, where high member turnover, low interest or infighting is disruptive [83]. Further, high LSC participants rated the CPs’ interactions more agreeably, confirming that CPs are flexible/ permeable structures interacting with their environments rather than tightly-bounded entities [84]. Similarly, high LSC members felt more sense of ownership, which promotes greater community participation [38], and valued the staff and community skills, highlighting that member expertise is vital for effective CPs [39, 77, 85].

High LSC members reported an effective information flow and that communication between staff and community members was good - a significant predictor of coalition satisfaction [18, 39]. They reported that their constituencies were more committed, an important factor as CPs’ leaders motivate their members’ commitment, nurturing it into a vision [77, 86, 87]. Different commitment levels result in varied investments of time, effort and resources [28, 88].

Partners with lower LSC felt that their participation entailed more difficulties and costs than benefits than those with higher LSC. Such reciprocity provides insights into whether to participate [35], the benefits/costs of alternative modes of structuring coalitions [84], and the importance of a favourable benefit/cost ratio [27, 89]. Active leaders may accept an equal ratio of benefits to costs [90].

For objective five, higher LSS partners felt positive perceptions on operational understanding of the CPs’ operations, communication mechanisms, and knowledge of CPs’ rules/ procedures. These findings are supported by other studies. Communication is a predictor of intermediary measures of coalitions [39], where open, frequent and varied communication channels are valued [77, 91]. Similarly, knowledge of the CPs’ rules/ procedures is critical, where members’ knowledge of coalition functioning affected later sustainability [92], awareness of rules/ procedures was predictive of agency commitment [39], and both were indicators of CP effectiveness [78, 93].

Regarding the last 2 objectives, leadership skills contributed to explaining the variance of 10 partnership factors ranging between 20% (communication mechanisms) to 7% (outcomes). This represents a ‘net’ effect, after controlling for all the factors under study [94]. The outcomes were provision of primary care services; influencing HPE; and increasing the medical, nursing and other health professions who practice primary care in underserved areas. Revisiting Kumpfer’s [41] model where leadership was related to three factors (team efficacy, satisfaction, and outcomes), the hypothesis of the paper is affirmed: leadership was not only associated with these three factors, and this study extended the associations of leadership to 30 factors, highlighting the importance of leaders’ skills in effective health-focussed partnerships.

In CPs public/private agencies, community leaders, academic and health services come together to tackle public health. Voluntary participation between partners who traditionally have not collaborated together requires skilled leadership. Members who perceived favourably the leadership of their CPs consistently scored better on 30 different partnership factors than those who rated leadership skills less favourably. The findings systematically examined relationships between leadership and many partnership processes and outcomes to emphasise the relevance of leadership skills. For researchers, this highlights the importance of including leadership features when undertaking coalition inquires in order to further the understanding of its intricate relationships and pre-requisites as regards stages of coalition formation. For CP practitioners, administrators, directors and coordinators, the findings demonstrate that their inputs, decision-making, interactions, communication and engagement are carefully viewed by partnership constituencies and simultaneously influence CP’s success. For policy makers, this highlights the need for developing and nurturing structures that provide appropriate leadership skills that are supportive and conducive to effective leaders from diverse stakeholders; as well as instilling appropriate incentives for leadership development at different levels. For grant-making bodies, this translates to highlighting the effects of appropriate leadership to potential grantees, encouraging and ensuring the inclusion of leadership technical assistance and training within a partnership’s budget as appropriate, as well as promoting the assessments of leadership aspects in partnership evaluations. Collectively such actions should make a difference.