Community readiness to address rural health equity: Progress and challenges across eleven Georgia communities

Rural communities face persistent health disparities as well as unique barriers to improving population health. The five-year Two Georgias Initiative sought to build local capacity to advance health equity in 11 rural communities from 2017 to 2022. This multi-method study used coalition member surveys to assess changes in community readiness to address health equity and qualitative interviews (n=121) with local coalition leaders, coordinators and evaluators to understand how coalitions conceptualized health equity in the rural context, and to identify challenges faced in discussing health equity and its structural drivers. Community readiness to address health equity increased modestly over time (.5 on a scale of 1-9), with all coalitions progressing to the preparation or initiation stage. The greatest change occurred within the resident knowledge of efforts dimension, with the least change in leaders taking action to address health equity. Conceptualizations of health equity varied within and across coalitions. An emphasis on fairness and equal access was most common, with others highlighting the need to address root causes, prioritize vulnerable populations, or improve health of the whole community. Common barriers to deeper engagement with health equity concepts included the sensitive, emotional and often politicized nature of the topic, compounded by rural dynamics such as lack of anonymity, strong local norms and prevailing mindsets. Results suggest that groundwork can be laid for improving rural health equity, but that longer-term, concerted efforts with a clear objective are needed to address structural drivers of inequity.