Evaluation

Grants began in July of 2017 with a one-year planning phase, followed by a three-year implementation phase through June of 2021, and a fifth year of bridge funding with an emphasis on sustainability, ending in June of 2022. During the planning phase, grantees established and/or expanded existing local coalitions, conducted a community assessment, and developed a Community Health Improvement Plan (CHIP). The following three years were spent implementing the CHIP, with the final year focused on ensuring the sustainability of the coalitions and their work.

The map below shows the 11 counties where the coalitions were based, with about half located in the northern part of the state and half in the southern part of the state. The star indicates where Emory University is located in Atlanta. All counties were rural, defined by the State Office of Rural Health in 2017 as counties with a population of less than 35,000 people.

Coalitions implemented more than 100 strategies. Strategies varied widely, so we classified them into 12 domains. The domains largely aligned with the five main categories of social determinants of health, as shown in the figure below. The most commonly addressed domains were health care access, food access, physical activity access, and healthy lifestyles education.

In addition to providing local evaluation support, the EPRC conducted a cross-site evaluation to answer questions about initiative processes and changes that resulted from the collective work of the initiative. The cross-site evaluation used mixed-methods to answer process and outcome evaluation questions.

We used a health equity lens throughout all steps in the evaluation, to assess what works, for who, under what conditions, and whether health inequities increased, decreased, or remained the same.

The table below lists our process and outcome evaluation questions that guided the evaluation.

We used a mix of qualitative and qualitative methods to answer our evaluation questions. Each instrument was used at two or more time points during the initiative to be able to measure change over time.

We developed a logic model that guided the evaluation, which suggested that the coalitions’ Year 1 activities (i.e., coalition formation, conduct CHNA, develop CHIP) would lead to changes in community readiness and organizational and community capacity to address health equity. Further, implementation of policy, system, and environmental changes would reduce gaps in structural determinants of health. In parallel, programs and services offered would provide short-term relief and support immediate needs that result from persistent inequities in access to health resources. The closure of gaps in the structural determinants of health and health behaviors would ultimately lead to improved health status overall and among priority groups.

Context: local culture, politics, and geography; limited resources; history of coalitions and collaborative efforts.

*Indicates local evaluator role

Kegler MC, Hermstad A, Haardörfer R, Arriola KJ, Gauthreaux N, Tucker S, Nelson G. Evaluation Design for The Two Georgias Initiative: Assessing Progress Toward Health Equity in the Rural South. Health Educ Behav. 2023;50(2):268-280. doi: 10.1177/10901981211060330. Epub 2022 Mar 19.

The broad scope of this evaluation resulted in extensive findings on key topics. Below are highlights from over the course of the 5 years of the initiative:

Multi-sectoral coalitions were formed in each of the 11 counties, with relatively high levels of coalition functioning (e.g., leadership, communication, decision-making, satisfaction, leveraging member resources) and strong representation from education, community-based organizations, health care, social/human services, business & faith sectors.

Coalition staff appreciated guidance received from the various support teams.
Changes in community readiness to address health equity at the county-level were modest, with most of the coalitions in the Preparation stage at the end of the Initiative.
Numerous indicators of community capacity to address health equity showed positive movement, including new opportunities for engagement by those with lived experience, new leadership development opportunities, strengthened planning and collaboration skills among coalition members, and expanded personal and professional networks.
Coalition members representing organizations reported moderate institutional efforts to address health equity, with collaboration ranked most highly and internal talks on systemic racism ranked the lowest.

The majority (70.5%) of planned intervention strategies were successfully implemented, even with major disruptions due to COVID-19.

Efforts to address food access, physical activity, healthy lifestyle education, nutrition guidelines and policies, and health care access were the most common across coalitions.
Coalitions contributed to a substantive amount of community change in these areas.
An impressive amount of community change with respect to policies, systems and environments resulted from the Initiative. However, reach and intensity of efforts was often modest and likely impacted primarily those directly touched by a program or community change. Population-level change was harder to document, likely due to the relatively short time-frame of the Initiative relative to the magnitude of the needs rural communities face and the major impact of the COVID-19 pandemic on many of the longer-term outcomes assessed.

Over 75% of the implemented strategies were likely to be sustained, and the coalitions were able to leverage over $12 million for community health improvement.

The Two Georgias Initiative was successful in creating and sustaining a broad array of community health improvements and laying the groundwork for continued efforts to address health equity in rural Georgia. The Initiative developed a model for creating, guiding and/or animating a collaborative spirit within participating communities in combination with strengthening capacity to address health equity. Leadership, mechanisms for interaction and alignment, inter-organizational and personal networks, skill-building, and an ability to leverage resources were seeded and nurtured for growth. Given that current inequities have been shaped and sustained over decades, and in some cases, centuries, it will take time to achieve the ultimate goal of health equity. Continued investment in rural communities will accelerate progress toward the shared goal of eliminating barriers to health for all.

Download the final 5-year cross-site evaluation report below:

The population-based survey was administered at two time points (T1 & T2) during the initiative: early in Year 2 at the beginning of implementation (2018-2019) and after the end of Year 5 (2022) when the initiative ended. We shared coalition-specific reports with each of the 11 coalitions at both time points. We also prepared aggregate reports that included pooled data from all 11 coalition counties. The table below shows survey modules by coalition.

T1 reports were developed in two parts. Part 1 included overall frequencies and descriptives of respondent demographics, as well as bar column or bar charts for key survey questions from each module of the survey. Part 2 included the same survey questions as Part 1, but the responses were stratified by race and/or income level to show group differences in responses.

• Kegler MC, Hermstad A, Haardörfer R, Arriola KJ, Gauthreaux N, Tucker S, Nelson G. Evaluation Design for The Two Georgias Initiative: Assessing Progress Toward Health Equity in the Rural South. Health Educ Behav. 2023;50(2):268-280. doi: 10.1177/10901981211060330. Epub 2022 Mar 19.
• Kegler MC, Gauthreaux N, Hermstad A, Arriola KJ, Mickens A, Ditzel K, et al. Inequities in Physical Activity Environments and Leisure-Time Physical Activity in Rural Communities. Prev Chronic Dis. 2022;19:210417. DOI: https://doi.org/10.5888/pcd19.210417. 2016 Jan;106(1):143-52.
• Kegler MC, Bigger L, Hermstad A, Eidson E, Thomas JG, Tucker SB, Haardörfer R. Differences in Health Care Access and Use by Gender, Race, Income, Age and Employment among Residents of the Rural South. J Healthcare Poor Underserved. 2023;34(1):1112-131. doi: 10.1353/hpu.2023.0008.
• Antonacci CC, Haardörfer R, Hermstad AK, Mayo-Gamble TL, Jacob Arriola KR, Kegler MC. Exploring dimensions of social capital in relation to healthy eating behaviours in the US rural south. Public Health Nutr. 2023;1-12. doi: 10.1017/S1368980023000022. PMID: 36645262.
• Antonacci CC, Hermstad AK, Haardörfer R, Kegler MC. Food Insecurity Moderates Association Between Perceived Fresh Fruit and Vegetable Access and Vegetable Intake in the Rural Southern US. European Society of Medicine. 2023;11(5).
• Arriola KJ, Merken TM, Bigger L, Haardörfer R, Hermstad A, Owolabi S, Daniel J, Kegler M. Understanding the Relationship between Social Capital, Health, and Well-Being in a Southern Rural Population. J Rural Health. doi: 10.1111/jrh.12782. Online ahead of print.