Context: Partnerships are emerging as critically important vehicles for addressing health in local communities. Coalitions involving local health departments can be viewed as the embodiment of a local public health system. Although it is known that these networks are heavily involved in assessment and community planning activities, limited studies have evaluated whether health coalitions are functioning at an optimal capacity. Objective: This study assesses the extent to which health coalitions met or exceeded expectations for building functional capacity within their respective networks. Design: An evaluative framework was developed focusing on 8 functional characteristics of coalitions previously identified by Erwin and Mills. Twenty-nine indicators were identified that served as "proxy" measures of functional capacity within health coalitions. Setting and Participants: Ninety-three County Health Councils (CoHCs) in Tennessee. Main Outcome Measure(s): Diverse member representation; formal rules, roles, and procedures; open, frequent interpersonal communication; task-focused climate; council leadership; resources; active member participation; and external linkages were assessed to determine the level of functionality of CoHCs. Scores across all CoHCs were analyzed using descriptive statistics such as frequency distributions, measures of central tendency, and measures of variability. Data were analyzed using SAS 9.3. Results: Of 68 CoHCs (73% response rate), the total mean score for the level of functional characteristics was 30.5 (median= 30.5; SD = 6.3; range, 18-44). Of the 8 functional characteristics, CoHCs met or exceeded all indicators associated with council leadership, tasked-focused climate, and external linkages. Lowest scores were for having a written communications plan, written priorities or goals, and opportunities for training. Conclusion: This study advances the research on health coalitions by establishing a process for quantifying the functionality of health coalitions. Future studies will be conducted to examine the association between health coalition functional capacity, local health departments' community health assessment and planning efforts, and changes in community health status.

Rural counties in the United States vary drastically on metrics related to socioeconomic status and dominant economic industry as well as health behaviors and outcomes. This study sought to understand the underlying structural reasons why some rural counties have better or worse than expected health outcomes using a positive deviance (PD) approach. The study aimed to: 1) create an area deprivation index and divide counties into quartiles using the index; 2) identify positive, negative, and non-deviant counties using health outcome metrics; 3) analyze differences between deviance on a variety of local public health system metrics; and 4) analyze differences between deviance on a variety of health service system metrics. All data were secondary, with data on public health systems derived from NACCHO’s 2016 National Profile of Local Health Departments (LHDs) and data on healthcare systems derived from HRSA’s 2016-2017 Area Health Resource File. Multivariate analysis, nonparametric analysis, and multinomial logistic regression were conducted. Results indicated that public health systems in positive deviant counties were more likely to have their next year’s budget exceed their current budget compared to negative and non-deviant counties. Public health systems in negative deviant counties had much lower rates of completed community health assessments, community health improvement plans, and strategic plans. LHDs overseen by their local government were 6.20 (p=.001) times more likely to be positive deviant, and negative deviant counties were much less likely (OR=0.12, pp 17.28 physicians per 10,000 population), while negative deviant counties were less likely (OR=.35, pp=.38) compared to non-deviant counties. Future research should continue using the PD approach for population-level studies and seek to understand which components of local public health and healthcare systems are associated with better population health.