Community Coalitions Implementing and Sustaining Policy, Systems and Environment Strategies for Rural Health Equity

Rural communities have assets that can be leveraged to address health disparities, particularly through complex policy, systems and environment (PSE) change approaches. Eleven rural community coalitions across Georgia participated in The Two Georgias Initiative, a 5-year health equity project from 2017 to 2022 designed to address rural-urban health disparities. The coalitions addressed community health concerns through implementing county-specific PSE and programmatic strategies tracked through a Community Change Tracking Tool. This mixed-methods analysis assessed the variation in strategies implemented across domain- and PSE-type. In total, 141 strategies were implemented across 12 domains, ranging from three to 35 per coalition. The coalitions continued to work through the COVID-19 pandemic, pivoting to address emerging needs. Food access, health care access and healthy lifestyle education were the most common domains; and implemented strategies were distributed across policy (17.0%), system (28.4%), environment (29.8%) and programmatic (24.8%) approaches. While many strategies were designed to make changes accessible to whole communities, some focused on priority populations including low-income residents, youth and seniors. Key informant interviews (n = 121) revealed that implementation barriers included challenges with staff and partner transitions, and lack of capacity and resources. Staff engagement, community rapport and partner-provided resources facilitated the implementation of strategies across several coalitions, highlighting the important role partnerships and community buy-in have with community-based PSE implementation approaches. At Year 5, among nine coalitions who provided sustainment data, a higher percentage of PSE strategies (95.6%) were sustained compared to programmatic strategies (42.9%), demonstrating the importance of PSE change approaches in community health equity efforts.