Why State and Local Contexts Matter: The Intersection of Contexts and the Implementation of the Accountable Health Communities Model in Arizona

Background and Purpose: A collaborative partnership between academics and a healthcare organization was established to strengthen the social impact of the To Match and Align Through Community Hubs (2MATCH). The 2Match initiative aimed to facilitate the multisector coordination within the health care delivery system to address health disparities driven by social determinants of health (SDOH) in Maricopa County, Arizona. To do this, the collaborative examined the broader ecology of facilitators and barriers specific to specific downstream factors across multiple contexts (e.g., public health initiatives, government, organization policies) and the congruence between those factors and the 2MATCH initiative. For this study, the Policy Ecology of Implementation Framework (PEI) was applied to examine the role that context played in the implementation process of the 2MATCH initiative; specifically, how were initiatives across the state aligned with the 2MATCH project and how did these activities support its implementation.

Methods: A collaborative effort was made for the community partner to play a crucial role in the interpretation and validation of the findings. The analytical approach for this study was a directed content analysis of a case study was applied to investigate the implementation of the 2MATCH project within the broader context defined as the strategies implemented in Arizona that impacted the SDOH. Purposeful sampling of government websites, news media publications, and organization documents that were related to SDOH implementation in Arizona between 2017 and 2021 using search terms were used. Following the PEI framework, initial coding categories comprised of four ecological levels - the social, political, agency and organizational contexts - were identified and used to inform the analysis of the selected resources. Using a deductive approach, two researchers systematically categorized and independently coded the data. Discrepancies in coding were resolved through discussion and consensus by the two researchers. Throughout the analytical process, the community partner provided contextual knowledge about the initiative, assisted in the interpretation and validated the study findings.

Results: City, county, state, and non-government level initiatives were identified and 1) the initiatives intersected across the political context and over time; 2) city and county initiatives were sparse; 3) the initiatives across levels did not directly intersect with the 2MATCH project, and 4) the initiatives across levels indirectly supported the objectives of the 2MATCH project. Furthermore, the government along with non-government-led initiatives aligned with the 2MATCH project on some, but not all the targeted health-related social needs. The most common needs were housing, food insecurity, and transportation; however, there were no initiatives that directly or indirectly centered on utility needs or interpersonal violence.

Conclusions and Implications: The PEI Framework elucidated the contextual factors that facilitated the implementation of the 2MATCH project. Future research examining implementation strategies that may facilitate pathways across contextual levels, especially localized efforts outside of the traditional healthcare delivery system, to improve the adoption of multisector coordination are needed.