A method for evaluating rural health coalition function and structure related to long-term health outcomes
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Rural Americans have higher rates of preventable chronic disease, poorer health behaviors and outcomes, and limited access to healthcare services, as compared to their urban/suburban counterparts. Interventions targeting individual behavior change and policy aimed at creating healthy environments have been only marginally successful at improving rural health. Thus, federal governing bodies and national public health organizations recognize community engagement as a viable strategy to mitigate health disparities. One such strategy is the development of community health coalitions (CHCs). Although CHCs have had isolated instances of success, evaluating CHC effectiveness is methodologically challenging. Traditional CHC assessments are subjective, with no standard for validation. Thus, this dissertation describes the development and implementation of a novel mixed-methods, multi-level evaluation framework, comparing CHC partnership networks using social network analysis, CHC perceived effectiveness using the Coalition Self-Assessment Survey, local policy, system, and environment change interventions through a qualitative assessment of program reports, and county-level health statistics. In Indiana there is a robust network of CHCs partnering with Purdue Extension Educators (Ext) and Nutrition Education Program Community Wellness Coordinators (CWC). Ext receive broad training, address general health topics, and serve CHCs in an advisory capacity, taking on leadership roles as needed. In contrast, CWC receive focused leadership and research training, address nutrition-related health topics, and adopt a central leadership position in their partnerships. In year 1 partnership network interconnectedness positively correlated to perceived effectiveness for Ext-CHCs; however, for CWC-CHCs, network interconnectedness negatively correlated to perceived effectiveness. Additionally, CWC-CHCs reported more highly rated leadership and functioning, fewer problems for participation in their CHC, and had greater eigenvector centralization (indicating the presence of a network broker, i.e., a position of power), as compared to Ext-CHCs. At follow-up, increased collaboration centralization positively correlated to increased perceived effectiveness for Ext-CHCs, while increased communication centralization positively correlated to increased perceived effectiveness for CWC-CHCs. For both Ext-CHCs and CWC-CHCs, increased interconnectedness for good-high trust and formal ties positively correlated to increased perceived effectiveness. Findings are interpreted in the context of salient county-level health statistics and qualitative reports of CHC outcomes. This dissertation begins with (1) a systematic literature review on the impact of federal policy change on student dietary behaviors, then (2) present findings from a statewide survey examining differences in perceptions between school foodservice directors and CHC members regarding challenges related to implementing federal policy change and opportunities for school-based community engagement, then (3) explore rural CHC effectiveness across the public health logic model in a second systematic literature review, then (4) describe the development and pilot of a statewide CHC evaluation system, then present my findings from (5) year 1 and (6) follow-up, and finally (7) discuss conclusions and future directions.