Capacity to Address Determinants of Health Among a Social Justice Coalition in the United States

Abstract

This study describes the Arkansas Social Justice Coalition and early pre-post changes in the capacity of participating community-based organizations to address social and structural determinants of health during the formative stage of this coalition. We utilized population-level data to understand the coalition’s reach to counties experiencing health inequities. Community-based organizations (N=29) involved in this coalition all served rural counties and counties with greater burden from COVID-19 hospitalizations, heart disease mortality, and cancer mortality. Food quality and access, economic stability, and education were identified by coalition members as the primary determinants of health impacting their communities. Coalition members completed a baseline survey, participated in coalition activities focused on addressing these primary determinants of health, and then completed a follow-up survey 3-months later. Coalition members reported significant increases in several domains of their community-based organizations’ capacity to address select determinants of health across assessments. Specifically, there were significant increases in the average number of partnerships facilitated and the average number of educational sessions offered by the community-based organization that addressed economic stability, education, and food access and quality. The Arkansas Social Justice Coalition effectively created a network of 29 community-based organizations dedicated to addressing determinants of health to reduce the disproportionate burden of COVID-19, cardiovascular disease, and cancer affecting their communities. Engagement in the coalition resulted in early improvements in several capacity domains during our coalition’s formative stage, which may translate to improvements in long-term outcomes related to promoting health equity at the community level.

Background

Arkansas has a lower life expectancy (74.4 years) compared to the national life expectancy (77.0) (Arkansas Minority Health Commission, 2023), with heart disease, cancer, and COVID-19 being three of the four leading causes of death (National Center for Health Statistics, 2024). In 2022, Arkansas had higher age-adjusted death rates from COVID-19 (54.4), heart disease (224.1), and cancer (168.1) relative to most other states and regions within the United States (Ahmad et al., 2023; National Center for Health Statistics, 2022b, 2022a, 2023). In Arkansas, life expectancy has decreased across time and significant county-level, gender, and racial disparities exist (Arkansas Minority Health Commission, 2023). Black men have lower life expectancy (67.0 years) than White men (72.8), and Black women have lower life expectancy (75.0) than White women (78.1) (Arkansas Minority Health Commission, 2023). Arkansas rural counties with high rates of poverty and representation of racially marginalized individuals also have lower life expectancy rates as compared to urban counties with less poverty and racial diversity (Arkansas Minority Health Commission, 2023).

In response to COVID-19 health disparities, in 2021, the National Institutes of Health (NIH) funded 21 research teams through the Community Engagement Alliance (CEAL) Against COVID-19 Disparities program, facilitating the creation of the Arkansas CEAL Coalition (Jones et al., 2024). The Arkansas CEAL Coalition’s initiatives aimed to enhance community-based organizations’ and businesses’ (CBO’s) capacity to increase community COVID-19 protective behaviors (Jones et al., 2024). Coalition initiatives included: biweekly coalition and technical assistance meetings, financial and technical support to facilitate organization-initiated education and outreach activities (supported by CEALFunds), door-to-door campaigns distributing culturally-tailored COVID-19 toolkits, and the monthly Black Health Block newsletter (Jones et al., 2024). A prior paper evaluated the early impact of coalition participation on coalition members’ perceptions about changes in their CBO’s capacity to address COVID-19 from August-November 2021 to January-April 2022 (Jones et al., 2024). There were significant increases in the proportion of CBO’s receiving financial support to address COVID-19 and the number of COVID-19 workshops CBOs provided to their workers and clients between the baseline and follow-up surveys (Jones et al., 2024). This work, along with the work conducted by the other teams funded by CEAL funds, highlight the importance of community-engaged alliances to improve health by addressing determinants of health; see this reference for more information about CEAL and funded programs (NIH Community Engagement Alliance (CEAL), 2025).

The Arkansas CEAL Coalition received renewal funds from NIH in 2022 and 2023 and has maintained an average of 30 CBO representatives per coalition meeting since 2021 (Jones et al., 2024). In 2023, the Arkansas CEAL Coalition evolved into the Arkansas Social Justice Coalition, expanding to focus on COVID-19, cardiovascular disease, and cancer, with a specific focus on how social, political, and structural determinants contribute to related health disparities nationally and in our state. The Arkansas Social Justice Coalition, which is in its formative stage given our change in coalition foci (Butterfoss et al., 2006), is focused on bolstering CBO capacity to reduce inequities in COVID-19, cardiovascular disease, and cancer in their communities (Griffith et al., 2010). The initiatives of the Arkansas Social Justice Coalition include the following: biweekly coalition meetings focused on health inequities and social, political, and structural determinants; surveys of coalition members to understand CBO capacity and barriers and facilitators to CBO initiatives; mixed-methods evaluations to understand the needs of the communities served by the CBO’s (community survey, photovoice); leadership trainings for community members to enhance skills related to developing, implementing, and evaluating community-led interventions; events to facilitate collaborations between community and academic partners; and pilot funding and financial support for selected community-led interventions. Across these initiatives, there was a consistent, iterative feedback process that utilized comments from coalition members to inform next steps. For example, survey data, photovoice data, and qualitative feedback during meetings informed coalition foci and led to the generation and/or refinement of coalition initiatives and next steps.

The current manuscript describes the Arkansas Social Justice Coalition and had two additional objectives. First, we quantified the reach of the Arkansas Social Justice Coalition by using public health data to identify if our coalition was reaching counties with greater rates of COVID-19 hospitalizations, heart disease mortality, and cancer mortality, and greater exposure to key deleterious determinants of health (as identified by coalition members). More specifically, we characterized the number of COVID-19 hospitalizations between 2020 and 2023 (Arkansas Department of Health, n.d.), the all cancer mortality rate in 2018–2022 (National Cancer Institute, 2025), and the heart disease mortality among US adults (35+) in 2019–2021 (Centers for Disease Control and Prevention, n.d.) between Arkansas counties who were served by the CBOs in the Arkansas Social Justice Coalition and counties not served by them. We also identified the reach of our coalition in relation to food insecurity because this was identified by coalition members as a key driver of the health for their communities. This objective will support future efforts to enhance our reach and initiatives.

Our second objective was to use a pre-post design to evaluate early changes in coalition members’ perceptions about their CBO’s capacity to address select social and structural determinants of health. The baseline assessment for this pre-post design occurred after the coalition focus transformed in 2023 to more broadly focus on reducing unjust disparities related to COVID-19, cardiovascular disease, and cancer and the follow-up assessment occurred 3-months later, after coalition members participated in coalition activities focused on addressing determinants of health as a strategy for reducing health disparities. Given our coalition’s change of foci, we conceptualized this project as an early evaluation of repeated measures of coalition capacity development during our formative stage (Butterfoss et al., 2006). Assessing changes in CBO capacity to address these select determinants of health is an important first step in evaluating our coalition (Kegler et al., 2020) because we hypothesize, based on the Community Coalition Action Theory (Butterfoss & Kegler, 2009; Kegler & Swan, 2011) and prior literature (Brown et al., 2019; Griffith et al., 2010; Heitz & Savaiano, 2021; Inzeo et al., 2019; Oetzel et al., 2022; Shockley et al., 2021), that changes in CBO capacity will ultimately reduce disparities related to COVID-19, cardiovascular disease, and cancer in Arkansas. This paper focuses on a subset of the key CBO capacity domains identified in the Community Coalition Action Theory (Butterfoss & Kegler, 2009; Kegler & Swan, 2011), such as new skills and partnerships, and determined as important for assessing capacity building based on a review published by Liberato et al. (2011). The Liberato et al. (2011) review identified nine comprehensive domains for assessing community capacity building based on established models (including the Hawe model, Rifkin model, Goodman/Labonte/Laverack/Fawcett model, Foster-Fishman model, Moore model, Johnson/Sofaer model, and Active Partners Benchmarks model) and community capacity frameworks that arose out of specific projects, including the three domains assessed in our study: learning opportunities/skills development, resource mobilization, and partnerships.

Methods

Participants

A baseline survey was distributed to all coalition members; 52 members representing different CBOs completed the baseline survey between October- November 2023. From February-March 2024, we administered a follow-up survey that assessed the same constructs; 38 members completed the follow-up survey. Of those, 29 had also completed the baseline survey. The primary analyses for this paper were conducted on these linked records (N=29). Coalition members participated in coalition trainings and activities between the surveys. The University of Arkansas for Medical Science IRB determined that the coalition survey was not human subjects research since no personal identifiers were used and we are measuring organizational factors among representative from CBO’s and not individual level factors (#263092).

Measures

The survey was created collaboratively with coalition members. After the transformation to the Arkansas Social Justice Coalition in 2023, several initial coalition meetings focused on providing training on how social, structural, and political determinants contribute to disparities in COVID-19, cardiovascular disease, and cancer (Artiga & Hinton, 2018) as well as discussing community-specific examples. Subsequently, during a coalition meeting, coalition members completed a brief poll survey to rank the top three determinants of health that they thought negatively affected the health of their communities. In the brief poll, coalition members were presented with a list of examples of specific determinants of health, including political determinants of health (e.g., national, states, or local policies affecting health; voting policies and practices) and determinants described in the KFF model including economic stability (e.g., employment, income, expenses, debt, medical bills), housing, transportation and walkability, neighborhood environment (e.g., safety; parks/playgrounds), environmental factors related to the neighborhood/area where community is located (e.g., isolation in rural areas), education (e.g., literacy, early childhood education, schools, vocational training, higher education), food (e.g., access to healthy food, food security), community and social context (e.g., social connectedness; community engagement, discrimination, stress), and the healthcare system (e.g., insurance coverage, access to quality medical care, culturally-competent medical care, medical trust/mistrust) (Artiga & Hinton, 2018). Of these ten categories of determinants, coalition members identified these as the three primary determinants most affecting the health of their communities (% endorsed this option): economic stability (80%), food quality and access (45%), and education (40%). The survey was then created to assess CBO capacity to address these specific determinants of health; CBO capacity measures included CBO learning opportunities, partnerships, and resource mobilization (Liberato et al., 2011). Surveys were stored in Research Electronic Data Capture (REDCap) and coalition members were invited to participate in the survey via email invitations that included a survey link; follow-up emails were sent after the initial email to maximize survey participation.

Coalition Survey

CBO Characteristics.

At both survey assessments, coalition members reported on characteristics of their CBO including organizational type (food social service, general social service, faith-based, small business, daycare, educational institution, Greek organization, or other); the number of full-time and part-time employees, and volunteers; the number of years the organization has existed; and the coalition member’s role in the organization (leadership, employee, other). Members also identified the top three cities where their clients lived, allowing us to identify the respective county. This information was used to identify the rurality of the county (metro vs. nonmetro/rural) where each city was located using the USDA 2023 Rural-Urban Continuum Code (United States Department of Agriculture, 2024); a variable was created to identify if at least one of the three cities were rural.

CBO Capacity Building Domains: Learning Opportunities.

As noted earlier, our measures of CBO capacity represent a subset of the key domains for assessing community capacity that were identified in a review published by Liberato et al. (2011): learning opportunities/skills development, resource mobilization, and partnerships. This review defined learning opportunities/skills development as the identification of knowledge gaps and delivery of learning opportunities. In this study, we assessed both learning opportunities provided by the CBO to their members or workers as well learning opportunities provided by the CBO to their clients.

In the baseline survey administered during October 2023, participants answered four separate questions to identify if their organization had offered any educational sessions for their members or workers since October 2022 to address economic stability, education, food access or quality, or another determinant of health. The response options for each question were yes and no. Participants who had offered educational sessions also identified how many educational sessions that had offered for the respective determinant of health during the past 12 months (specifically, October 2022 - October 2023). In the follow-up survey in February 2024, the same set of questions were asked using a different time frame (October 2023 - February 2024) to assess changes in these outcomes since the completion of the baseline survey.

The binary questions allowed us to evaluate if the proportion of CBOs who offered educational sessions on these topics increased between the baseline and follow-up surveys; however, because the baseline assessed if the CBO had offered educational sessions over the past year while the follow-up survey asked about the last four months, the proportions also reflect differences in the offering of sessions based on the differences in the reference time frames assessed in the question stem for the respective surveys. Therefore, our primary interest is to evaluate if CBOs changed the average number of educational sessions offered per month to their members/workers between baseline and the follow-up surveys. To exclude non-event effects during the holiday season (late November to New Year), the number of sessions from the baseline survey was divided by 11 and the number from the follow-up survey was divided by 3 when calculating the average number of educational sessions offered per month.

This same question set structure was used in the baseline and follow-up survey to assess the number of education sessions the CBO offered to its clients.

CBO Capacity Building Domains: Partnerships.

Liberato et al. (2011) defined the partnerships domain of building CBO capacity as linkages or networking to work towards a common goal. In the baseline survey, members answered four separate questions about the number of different partnerships they had engaged in to address economic stability, education, food access or quality, or another determinant of health among their clients since October 2022. In the follow-up survey, members reported on the number of different partnerships they had engaged in to address economic stability, education, food access or quality, or another determinant of health among their clients since October 2023. The same approach, described in the previous paragraph, was used to calculate the average number of partnerships the CBO engaged in per month and the difference between baseline and follow-up surveys.

CBO Capacity Building Domains: Resource Mobilization.

Liberato et al. (2011) defined the resource mobilization domain of building CBO capacity as internal and external resources that support a common goal. At baseline and follow-up, members answered four separate questions about the extent that they agreed that their CBO had sufficient resources to address economic stability, education, food access or quality, or another determinant of health among their clients. Response options were as follows: strongly agree, somewhat agree, neither agree or disagree, somewhat disagree, and strongly disagree. Response categories were collapsed for analyses and included agree (collapsing strongly agree, somewhat agree), disagree (collapsing somewhat disagree and strongly disagree), and neither agree nor disagree.

Health Outcomes for Arkansas Counties Served and Not Served by Coalition Members’ CBOs

Using the information about the counties served by the CBO’s, we used data from multiple existing sources to describe the counties served by the Arkansas Social Justice Coalition and characterize specific health outcomes between Arkansas counties served by the CBOs in the Arkansas Social Justice Coalition and counties not served by them. Data on the number of COVID-19 hospitalizations by county in 2020, 2021, 2022, and 2023 were downloaded from the website of Arkansas Department of Health (Arkansas Department of Health, n.d.). Data on the age-adjusted cancer mortality rate by county in 2018–2022 were from the data repository of State Cancer Profiles on the National Cancer Institute website (National Cancer Institute, 2025). Data on the heart disease mortality in 2019–2021 were from the CDC Heart Disease & Stroke Prevention Data Portal (Centers for Disease Control and Prevention, n.d.). Data on food insecurity were downloaded from PolicyMap based on data from Feeding America for 2022 (PolicyMap, n.d.-b, n.d.-a).

Analytic Approach

Baseline characteristics of the organizations are summarized and presented as frequencies and percentages in Table 1, with missing values noted but not included in percentage calculations. To investigate our first objective related to reach, data analysis programming was conducted using R, with the package of ggplot2 included for drawing the boxplots used to characterize health outcomes between counties served by CBO’s in the coalition versus counties not served (R Core Team, 2024; Wickham, 2016). The most recent county-level health outcome data were obtained directly from each data source, either as annual data or aggregated across a specified range of years, as reported by the source. No additional data merging was performed across sources or time periods. For our second objective of evaluating pre-post changes, the primary analyses included the sample with both baseline and follow-up data (N=29). Dependent variables consist of the capacity building domains of CBO learning opportunities, resource mobilization, and partnerships [3]. For categorical dependent variables, two-way contingency tables were used to display the paired data between Baseline and Follow-up. McNemar tests were employed to test whether the studied marginal proportions were the same between Baseline and Follow-up, e.g., H0: P(Yes at Baseline) = P (Yes at Follow-up). For quantitative variables, e.g. the average number of educational sessions per month, paired-t tests were used to assess whether the change in values from baseline to follow-up was significantly different from zero.

Table 1.

Characteristics of the community-based organizations that coalition members represent based on members who completed the baseline and follow-up surveys (N=29)

Organizational Characteristics (N=29)	n (%)
Organization description
Daycare/educational institution/Greek organization/other	10 (34.5%)
Food social service/general social service	8 (27.6%)
Faith-based	7 (24.1%)
Small business	4 (13.8%)
Number of full-time employees
0	12 (42.9%)
1–9	14 (50.0%)
10–25	2 (7.1%)
missing	1
Number of part-time employees
1–9	28 (96.6%)
10+	1 (3.4%)
Number of volunteers at organization annually
0–20	12 (41.4%)
21–50	12 (41.4%)
51–99	1 (3.4%)
100+	4 (13.8%)
Years organization has existed
0–5 years	8 (27.6%)
6–10 years	7 (24.1%)
11–30 years	9 (31.0%)
31+ years	5 (17.2%)
Role at organization
Leadership role	25 (86.2%)
Employee	2 (6.9%)
Other	2 (6.9%)
Rurality of the top three cities where organizations’ clients live
At least 1 of the 3 top three cities clients live are in a nonmetro (rural) countya	29 (100.0%)

Notes:

^aRurality was defined using the USDA 2023 Rural-Urban Continuum Code.

Results

The type of CBOs where coalition members worked were varied (Table 1). Almost 35% of coalition members worked with CBOs that were either a daycare, educational institution, Greek organization or other type of organization. About 28% worked in a CBO that was focused on food social service or general social service. Over 24% were faith-based organizations and 13.8% were small businesses. Most coalition members served in leadership positions in their CBO (86.2%). About 7% were employees and 7% served in another role.

Characterization of Arkansas Counties Served and Not Served by CBOs in the Arkansas Social Justice Coalition

The CBOs in our coalition served 38.67% of all Arkansas counties (29 out of 75 counties). All CBOs served clients from at least one rural county. Of the 29 counties served by our coalition, 15 (51.72%) are designated as “Red Counties” or counties designated by the Arkansas Department of Health as having the lowest life expectancies in the state (i.e., counties where the life expectancy at birth is more than six years below the life expectancy of the county with the highest life expectancy) (Arkansas Minority Health Commission, 2023). The CBOs in our coalition served 15 of the 28 “Red Counties” in Arkansas (53.57%).

The boxplots in Figure 1 demonstrate how the counties served by the CBOs in the Arkansas Social Justice Coalition faced challenges related to COVID-19, heart disease, and cancer as compared to counties not served by the Arkansas Social Justice Coalition. First, we examined COVID-19 hospitalizations during 2020–2023 as this provides information before the coalition was formed, across the time the original coalition was active and focused on COVID-19 (2021–2022), and information capturing 2023 when the coalition broadened to focus on COVID-19, cardiovascular disease, and cancer. For COVID hospitalization per 100,000 in 2020, before vaccines were available, counties served by CBOs in the Arkansas Social Justice Coalition had Median [IQR] values of 499 [381 – 737] compared to 415 [308 – 537] in counties not served. The hospitalization rate remained high in 2021, at 515 [432 – 721] for counties served and 599 [432 – 737] for counties not served. The rate has steadily declined since 2022. From 2021–2023, counties served by the coalition had lower median hospitalizations relative to those not served by the coalition; importantly, the box plots overlapped, and no statistical differences were examined.

Figure 1:

Characterization of health outcomes for Arkansas counties served and not served by coalition members’ community-based organizations.

Notes: A: COVID-19 hospitalization data is from 2020–2023. B: Heart disease mortality data is from 2019–2021. C: Age-adjusted all-cancer mortality data is from 2018–2022.

We used the most recent available data for heart disease mortality by county (3-year average, 2019–2021), reflecting the period before/during the start of the coalition. For heart disease mortality per 100,000, the Median values were 484 [436 – 504] for counties served by the Arkansas Social Justice Coalition versus 469 [422 – 494] for counties not served. Finally, we investigated cancer mortality, using the most recent available data for cancer mortality by county (5-year average, 2018–2022), reflecting the period before/during the start of the coalition. For age-adjusted all cancer mortality per 100,000, the Median values for counties served by the coalition were 184 [161 – 207] versus 174 [165 – 192] for counties not served by CBOs in the Arkansas Social Justice Coalition.

To further illustrate county-level disparities and coalition reach, Figure 2 provides a visualization of the county-level all-cancer mortality rates and identifies the counties served by at least one community-based organization involved in the Arkansas Social Justice Coalition. Overall, this figure demonstrates the strong presence of the coalition CBO’s across the state and in counties with the highest rates of all-cancer mortality. Of the 29 counties served by CBO’s in the coalition, eight had the highest rate of all-cancer mortality (>201.3–225.4 deaths per 100,000), seven had the second highest rate (>183.4–201.3), and four had the third highest rate (>172.5–183.4).

Figure 2:

Characterization of age-adjusted all-cancer mortality for Arkansas counties served and not served by coalition members’ community-based organizations.

Our coalition focuses on addressing the determinants of health and our members identified food quality and access as one of the three primary determinants affecting their communities. To further elucidate inequities and coalition reach, the figure in the Supplementary files depicts county-level food insecurity rates and identifies the counties served by at least one CBO involved in the Arkansas Social Justice Coalition. Of the 29 counties served by CBO’s in the coalition, 19 (65.52% of the counties served) had the highest classification of food insecurity rates (rates of 17.3% or greater) and eight (27.59% of the counties served) had the second highest classification of food insecurity rates (category with rates between 15.3–17.2%).

Early Pre-Post Changes in CBO Capacity

Leadership Opportunities

There were no significant changes in the proportion of members reporting that their CBO offered learning opportunities focused on economic stability, education, food access or quality, or another determinant of health between baseline and the 3-month follow-up (Table 2). The average number of monthly education sessions focused on economic stability, education, and food access and quality offered by CBOs for members/workers significantly increased from baseline to follow-up (Table 3). Additionally, the average number of monthly education sessions focused on economic stability, education, and food access and quality offered by CBOs for clients significantly increased from baseline to follow-up.

Table 2.

Pre-post changes in learning opportunities offered by community-based organizations (CBO) between baseline and the 3-month follow-up (N=29)

Capacity Building Domain: Learning opportunities	N	Baseline	Follow up		Baseline: % Yes	Follow up: % Yes	p val.
			Yes	No
Has your CBO offered any educational sessions to address the following of health for its members/workers?:
Economic stability (e.g., employment, income, expenses, debt, medical bills)	27	Yes	12	6	66.7	48.1	0.13
		No	1	8
Education (e.g., literacy, early childhood, schools, vocational training, higher education)	27	Yes	11	7	66.7	48.1	0.18
		No	2	7
Food access and quality (e.g., access to healthy food, food security)	28	Yes	14	4	64.3	64.3	1
		No	4	6
Other determinants of health not already assessed	27	Yes	5	5	37.0	33.3	1
		No	4	13
Has your CBO offered any educational sessions to address the following of health for its clients?:
Economic stability	26	Yes	8	3	42.3	46.2	1
		No	4	11
Education	26	Yes	14	8	84.6	57.7	0.05
		No	1	3
Food access and quality	27	Yes	11	7	66.7	48.1	0.18
		No	2	7
Other determinants of health not already assessed	26	Yes	4	4	30.8	26.9	1

Table 3.

Pre-post changes in the number of learning opportunities offered by community-based organizations (CBO) and the number of partnerships between baseline and the 3-month follow-up (N=29)

Capacity Building Domains	N	Baseline: Mean	FU: Mean	Diff.	p val.
Learning opportunities
Average monthly number of educational sessions CBO offered to address the following of health for its members/workers:
Economic stability	12	0.40	1.03	0.578	0.01
Education	11	0.41	1.52	0.928	0.004
Food access and quality	14	0.44	1.06	0.747	0.01
Other determinants of health not already assessed	5	0.41	1.74	1.085	0.06
Average monthly number of educational sessions CBO offered to address the following of health for its clients:
Economic stability	8	0.38	1.25	0.777	0.03
Education	14	0.41	1.53	0.905	0.001
Food access and quality	11	0.37	1.46	0.970	0.002
Average Monthly Engagement in Partnerships to address the following determinants of health among its clients:
Economic stability	19	0.27	1.02	0.681	0.003
Education	20	0.33	1.01	0.736	0.02
Food access and quality	22	0.30	0.77	0.433	<.001
Other determinants of health not already specified	19	0.31	0.94	0.603	0.002

Partnerships

The average number of monthly partnerships coalition members engaged in to address economic stability, education, food access and quality, and other determinants of health significantly increased from baseline to follow-up (Table 3).

Resource Mobilization

There were no significant changes in the extent that members agreed that their CBO had sufficient resources to address economic stability, education, food access or quality, or another determinant of health among their clients (Table 4). Though not statistically different, the proportions of members agreeing that they had sufficient support to address economic stability, education, food access and quality, and other determinants of health all increased between baseline and follow-up.

Table 4.

Pre-post changes in the extent that coalition members agreed that their community-based organization (CBO) has sufficient resources to address economic stability, education, food access or quality, or another determinant of health among their clients between baseline and the 3-month follow-up (N=29)

Capacity Building Domain: Resource Mobilization	N	Baseline	Follow up			Baseline: % Agree	Follow up: % Agree	p val.
			Agree	Neutral	Disagree
Agreement CBO has sufficient resources to address these determinants of health among their clients:
Economic stability	26	Agree	3	2	2	26.9	38.5	0.60
		Neutral	3	0	3
		Disagree	4	1	8
Education	24	Agree	7	0	3	41.7	54.2	0.69
		Neutral	2	0	1
		Disagree	4	1	6
Food access and quality	24	Agree	2	1	3	25	29.2	0.72
		Neutral	2	3	3
		Disagree	3	1	6
Other determinants of health not already assessed	22	Agree	1	2	2	22.7	31.8	0.48

Discussion

The Arkansas Social Justice Coalition aims to increase capacity among CBOs in Arkansas to reduce COVID-19, cardiovascular disease, and cancer inequities. We leveraged existing data sources to identify if our coalition is reaching the areas in Arkansas that are disproportionately affected by these diseases. We found that the CBOs involved in this coalition all serve rural counties, serve almost 54% of the Arkansas counties designated as “Red Counties” by the Arkansas Department of Health (i.e., counties with the lowest life expectancies in the state), and serve counties with greater burden from COVID-19 hospitalizations, heart disease mortality, and cancer morality. To further investigate coalition reach, we examined maps illustrating county-level all-cancer mortality rates with the counties served by at least one CBO involved in the Arkansas Social Justice Coalition identified. In total, 65.52% of counties served by CBO’s had all-cancer mortality rates above 172.5 per 100,000—the national age-adjusted cancer mortality rate in 2022 was 141.5 (National Center for Health Statistics, 2025).

We characterized the median COVID-19 hospitalizations across 2020–2023 for counties served and not served by CBO’s involved with the coalition. This data provides contextual information about COVID-19 from before the coalition was formed (since the time frame for the COVID-19 data used includes 2020, before the coalition was formed), across the time the original coalition was active and focused on COVID-19 (2021–2022), and information capturing 2023 when the coalition broadened to focus on COVID-19, cardiovascular disease, and cancer. The boxplot reflects how the coalition was established to serve those counties affected greater by COVID-19 in 2020 (i.e. higher median hospitalization rate) when vaccines were not available. The median value of hospitalization declined more rapidly since 2021 for the counties covered by the coalition versus those not covered; however, we are unable to draw conclusions on coalition impact based on the current analysis. This point merits further investigation using population-level data to formally test coalition impact, an approach recommended in a review of evaluation methods for assessing the effectiveness of coalitions (Kegler et al., 2020). Our coalition will continue to use population-based county-level data to 1) identify counties experiencing COVID-19, cardiovascular disease, or cancer inequities (including those not currently served by CBO’s in our coalition), 2) track changes in the coverage of counties served by CBOs in our coalition across time, and 3) assess changes in various county-level metrics related to COVID-19, cardiovascular disease, or cancer outcomes and determinants of health, and the potential impact of the coalition on these metrics. The utilization of population-based data along with mixed-methods data from our coalition members improves our ability to assess our coalition reach and impact across time (Kegler et al., 2020).

A unique aspect of our coalition is that our focus adapted across time in response to the health and funding climate: What started as a coalition solely focused on COVID-19 inequities, and a public health crisis, transformed to be a sustained community health network focused on COVID-19, cardiovascular, and cancer inequities. This natural transition allowed our coalition to build upon the mobilization of CBO capacity and sustained implementation achieved during the initial coalition period (Jones et al., 2024), supporting our transition into a new formative stage given our coalition shift in foci (Butterfoss et al., 2006). Lessons learned from this coalition could inform future research aiming to identify the best strategies for incrementally building CBO capacity across time, building capacity that supports diverse community health goals, and for creating coalitions that can be sustained via diverse funding options. This broadening of our coalition focus was also responsive to state and CBO-specified health needs. In fact, this pivot allowed our coalition members to identify the determinants of health that were impacting the health of their communities most, with members identifying economic stability, education, and food quality and access as the most influential determinants. These perspectives informed our coalition initiatives and aligned with existing data. Arkansas has a higher poverty rate (16%) compared to the national rate (13%), and fewer Arkansans have obtained a bachelor’s degree relative to the national average (26% vs. 36%, respectively) (United States Census Bureau, n.d.). Arkansas leads the country in household food insecurity (the national average is 12.2%), with almost 19% of Arkansans being food insecure (Rabbitt et al., 2024). Of the 29 counties served by CBO’s in the coalition, 19 (65.52% of the counties served) had the highest classification of food insecurity rates (rates of 17.3% or greater) and eight (27.59% of the counties served) had the second highest classification of food insecurity rates (category with rates between 15.3–17.2%). Taken together, this bolsters the need for community-engaged alliances to reduce the social, structural, and political determinants of health that are perpetuating the disproportionate burden of disease in Arkansas relative to the nation (i.e., geographic inequities) as well the numerous inequities occurring within Arkansas.

A key strategy for addressing health inequities associated with these determinants of health is bolstering CBO capacity to address these determinants in their communities (Griffith et al., 2010). Our work builds upon prior work focused on increasing CBO capacity in order to enhance the impact of community-based prevention interventions (Griffith et al., 2010; Ramanadhan et al., 2020). To assess the early impact of coalition activities on CBO capacity during our formative stage, we evaluated pre-post changes in three CBO capacity measures related to addressing the CBO-specified determinants of health (food quality and access, economic stability, and education): CBO learning opportunities, resource mobilization, and partnerships (Liberato et al., 2011). We assessed these constructs at baseline (after the coalition focus transformed to include a focus on COVID-19, cardiovascular, and cancer inequities) and then 3-months later (after coalition members participated in coalition activities focused on addressing determinants of health as a strategy for reducing health inequities).

There were no significant changes in the proportion of members reporting that their CBO offered learning opportunities focused on economic stability, education, food access or quality, or another determinant of health; this may be artifact of the briefer time period for offering these learning opportunities assessed at follow-up or the lack of specificity in our questions assessing these broad constructs (e.g., economic stability). However, the average number of monthly education sessions focused on economic stability, education, and food access and quality offered by CBOs for members/workers and for clients significantly increased from baseline to follow-up. There were no significant changes in the resource mobilization measures; however, though not statistically different, the proportions of members agreeing that they had sufficient support to address economic stability, education, food access and quality, and other determinants of health all increased between baseline and follow-up. Lastly, the average number of monthly partnerships coalition members engaged in to address economic stability, education, food access and quality, and other determinants of health significantly increased from baseline to follow-up. These increases in CBO capacity are significant given prior work has identified CBO capacity as an important intermediate outcome for ultimately promoting long-term outcomes of community transformation, social justice, and health equity (Oetzel et al., 2022).

Taken together, our findings illustrate our community-centered approach to transitioning the focus of an existing coalition to the most influential determinants of health as identified by the coalition members; our innovate use of existing data to investigate our coalition’s reach and the existing health inequities and inequities in exposure to deleterious determinants to health, which in turn informs our efforts to expand our reach and initiatives; and how coalition involvement led to significant early improvements in some domains of CBO capacity. Prior work has demonstrated that multi-sector community partnerships that address determinants of health are a powerful tool for promoting health equity (Brown et al., 2019; Heitz & Savaiano, 2021; Inzeo et al., 2019; Shockley et al., 2021) and have the potential to prevent 970 premature deaths and save $105 million in medical costs and $408 million in productivity losses over 20 years (Honeycutt et al., 2024).

Limitations and Future Directions

Our limited sample size for the longitudinal sample (N=29) likely reduced our ability to detect significant differences in our categorical outcomes across time. It is also possible that the coalition members who answered both the baseline and follow-up surveys represent a more engaged subpopulation of our coalition members, thus potentially limiting the generalizability of our findings to coalition members who are less engaged. Similarly, social desirability may have motivated coalition members to overreport their engagement in outcomes. Yet, the importance of our findings is highlighted when considering that our sample size reflects 29 individuals from different CBOs who are serving areas with significant health disparities across an underserved state. These 29 CBOs reflect a network of people and organizations committed to addressing determinants of health to reduce inequities, and this network increases Arkansans access to health-related resources (Ken-Opurum et al., 2020). Our limited time period between assessments, which was required given the one-year grant period associated with the administration of this updated survey, also likely reduced our ability to detect changes in outcomes. Yet, our findings elucidate early changes in capacity development during our coalition’s formative stage. Our future work will administer this survey to our coalition annually over the next four years, allowing for a longer-term evaluation of changes in coalition capacity across time and across different stages of coalition development (Butterfoss et al., 2006). Future work in this area would benefit from larger sample sizes, assessment of long-term outcomes (e.g., reductions in COVID-19, cardiovascular diseases, and cancer and reduction in associated inequities), and balanced use of additional rigorous yet feasible research designs (e.g., randomized trials; analyzing the statistical effect of the coalition using population-based data) (Kegler et al., 2020; Ken-Opurum et al., 2020). Further, future work should include objective assessments of CBO capacity, for example, by using study process tracking information to collection data on capacity metrics.

Conclusions

The Arkansas Social Justice Coalition effectively engaged 29 CBOs across an underserved state to create a network of organizations dedicated to addressing determinants of health to reduce the disproportionate burden of COVID-19, cardiovascular disease, and cancer among their communities. Coalition members identified the most influential determinants of health which informed coalition initiatives. Leveraging existing data allowed for the investigation of our coalition’s reach and the existing health inequities and inequities in exposure to deleterious determinants to health, which in turn will inform our future efforts to expand our reach and initiatives. Engagement in the coalition resulted in early improvements in several CBO capacity domains, which are often considered intermediate outcomes with the potential to affect long-term outcomes related to promoting health equity at the community level (Oetzel et al., 2022).

Contribution to Health Promotion.

• This study describes how the Arkansas Social Justice Coalition effectively created a network of 29 community-based organizations dedicated to addressing determinants of health.

• Community-based organizations (N=29) in this coalition all served rural counties and served counties with burden from COVID-19 hospitalizations and heart disease and cancer mortality.

• Food quality/access, economic stability, and education were identified by coalition members as the primary determinants of health impacting their communities.

• Coalition members participated in coalition activities focused on addressing these primary determinants of health in their communities.

• During the coalition’s formative stage, coalition members reported significant increases in domains of their community-based organizations’ capacity to address select determinants of health.

Code Availability:

Code may be available upon reasonable request to the corresponding author.