Rural Innovative Multi-sectoral Preventive Approaches Community Trial for Population Health Improvement (Rural IMPACT for Population Health Improvement)

About This Grant

Members of rural communities often face difficulties in accessing diabetes prevention services, an outcome of multi-level system processes that perpetuate urban biases in the provision, production and consumption of health promotion and disease prevention services. Effective approaches to improving access remain elusive because there is a fundamental mismatch between conventional population health improvement approaches and the way in which a community system coordinates itself to make decisions. Conventional approaches usually involve a top-down strategy that standardizes solutions and commands alignment among all agents within the population health improvement systems without considering the unique constraints within rural communities. Community systems are messy, dynamic, and require resilience to address an array of challenges within a nested heterarchical landscape. Requiring alignment with static standards does not allow communities to coordinate themselves through self-organization and trial-and-error learning. The purpose of this two-phase proposal is to test the overall hypothesis that health promotion strategies need to fit the system structure in which they are operating in order to improve population-level outcomes. The first phase of the proposal is an observational study to understand how communities and clinics are currently coordinated to make decisions about service provision and production. In the second phase we will implement a 2 by 2 factorial cluster randomized trial assigning 10 communities to community-driven or standard practice and 18 health care clinics to clinic-engaged or standard practices to test alternative rules for community- and clinic-level decision-making and system coordination processes. We will leverage partnerships with our Rural Health Networks-multi-sector county-level coalitions whose mission is to improve the health of rural populations—to accomplish the following three multi-level aims: 1) investigate the existing community- and clinic-level system structure rules (policies, practices, norms) that lead to the provision, production and consumption of diabetes screening and prevention services both within the community system and the corresponding local healthcare system; 2) examine the change in diabetes prevention system structure over time as a result of manipulating the community and clinic coordination systems to enhance self-organization and learning; and 3) determine the relative impact of community and clinic coordination processes on opportunities to access diabetes screening and prevention services as measured through surveys, focus groups and asset mapping, and on the change in screening rates as measured by the electronic health record (EHR) and surveys.