Heat waves represent a public health challenge that requires multiple responses and warnings to protect vulnerable populations. Although studies have reported an increasing trend of heat wave occurrence in many areas of the world, no clear trend exists in East Tennessee. Using data from Parameter-elevated Relationships on Independent Slope Models (PRISM), CDC WONDER and the United States Census Bureau, the relationship between mortality rates and year was estimated during heat wave events between 1999 and 2010. Five heat wave definitions were tested. Overall, 2007 and 2010 stand out as the years with the highest number of heat wave days in East Tennessee. August could be described as the hottest month. Three of the heat wave definitions tested show increasing non-accidental mortality rates with year. The relative risk for cardiovascular mortality is elevated among females compared to males for one of the heat wave definitions (Relative Risk (RR) = 1.33, CI= 1.08-1.65).

Because parental alcohol misuse is associated with numerous negative outcomes for drinkers and other family members, it is important to examine factors predictive of alcohol misuse patterns among parents living with at least one child under the age of 18. Two possible factors include economic insecurity and poverty. This study sought to address whether measures of economic insecurity (i.e., housing and/or food insecurity in the past 12 months) and a dichotomous measure of poverty predict parental binge drinking and parental heavy alcohol consumption in a large population-based sample. It was hypothesized that economic insecurity and poverty, analyzed separately, would predict both occurrence of parental alcohol misuse and amount of alcohol consumed. Results did not support hypotheses; rather, where significant, they indicated that measures of economic insecurity and poverty negatively predicted parental alcohol misuse. However, effect sizes were small and preclude practical application. Findings are discussed and future research directions are identified.

Background: Despite consensus guidelines, only about half of at-risk relatives in families with Hypertrophic Cardiomyopathy (HCM) undergo clinical screening and even fewer undergo predictive genetic testing, leaving those unscreened at risk for sudden cardiac death. The use of qualitative inquiry to examine family communication and complex factors influencing uptake of screening may inform interventions to increase uptake and prevent sudden cardiac death. Purpose: The purpose of this study was to describe the engagement of at-risk relatives in family screening for HCM. Specific Aims: The specific aims were to (1) Describe the experience of communication of genetic risk of HCM in families with a causative variant for HCM; (2) Use the Theory of Engagement to identify facilitators and barriers to family screening in families with a causative variant for HCM; and (3) Identify strategies to increase uptake of clinical screening and predictive genetic testing in families with a causative variant for HCM. Framework: The Theory of Engagement, adapted from McAllister, was used as an initial framework for the study. Methods: A qualitative descriptive design with purposive and snowball sampling was used and data were analyzed using qualitative content analysis. Results: The overarching theme of Bringing Genetic Risk to the Foreground was comprised of three major themes: Cues to Action, Preferences for Knowledge and Gateways to Screening, reflecting factors that affect engagement with genetic risk and family screening throughout the lifespan. Conclusions: Integrated longitudinal care and access to genetic specialists are needed for patients and families with a causative variant for HCM.

The leadership of several health districts in the rural Appalachian region of northeast Tennessee and southwest Virginia has expressed interest in addressing the educational needs of their employees. The majority of these workers have not completed an undergraduate degree, but they desire to further their education. The College of Public Health at East Tennessee State University has begun preliminary discussions with these leaders to identify potential approaches to address these needs. There appear to be four approaches that should be explored by regions facing similar challenges: on-line or on-line/on-site degree completion programs; course clusters provided for academic credit; partnerships with community colleges; and training programs offered for nonacademic credit.

Background: Understanding concentrated areas with high rates of opioid use disorder (OUD) allows for improved placement of Narcan access points through syringe services programs (SSPs). People Who Inject Drugs (PWID) have lower risk of contracting infectious diseases the closer they are to SSPs. Tennessee law prohibits SSPs within 2000ft of a school or park, impacting the placement of SSPs in non-urban areas. Testing factors related to SSP siting placement within a system dynamic model can better determine the relationship between PWID risk environment and SSP access and utility. Methods: We identified areas of greatest need for harm reduction interventions within a non-urban Tennessee county with Emergency Medical Services (EMS) Narcan administrations data (Aim 1). We then created a Google map to determine a theoretical ideal location for an SSP. We then applied the current legal restrictions to SSP placement to find the next-closest legal location (Aim 2). We then developed a theoretical system dynamic model of SSP access and utility and Risk Environment (Aim 3). Results: We determined “EMS Zone 1” has a higher rate of EMS Narcan administrations than most EMS zones in the county and a higher rate compared to the whole county (Aim 1). We located a theoretical SSP location with shorter walk, drive, and public transportation times compared to the existing location. The closest legal SPP location still had an improvement in travel times but lacked other utility factors (Aim 2). Our theoretical model indicates that laws limiting SSP placement increase the distance PWID travel to SSPs. The distance of support services to SSP sites has a negative relationship with risk environment and to accessibility and utility of SSPs (Aim 3). Conclusion: County-level geographic data is too crude to determine true “hot spots” of OUD. This new method using EMS data can provide entities a process for determining the best location for SSPs. Identifying measures of utility/accessibility for PWID can identify improved locations for SSPs but legal restrictions may lower utility/accessibility of SSPs especially for non-urban PWID. Current “Policy” or “Structural” level factors as described by the Social Ecological Model negatively impact PWID risk environment. Structural” or “Policy” and “Community” level interventions among state, city, and county governments have the highest potential to positively impact PWID risk environment.

Background Indoor tanning (IT) before the age of 35 increases melanoma risk by 75%. Nevertheless, IT and sunless tanning product (STP) use have gained popularity among youth. However, there are limited data on the prevalence and sociodemographic correlates of both IT and STP use in a representative sample of American teens. Methods Teenage females (N = 778) aged 12–18 years were recruited as part of an on-going longitudinal study conducted between May 2011 and May 2013. Descriptive statistics explored IT and STP usage in teen females at baseline. Logistic regression was used to determine sociodemographic correlates of IT and STP use. Results Approximately 16% of female teens engaged in IT behavior and 25% engaged in using STPs. Female teens living in non-metropolitan areas were 82% more likely to indoor tan compared to those in metropolitan areas (OR = 1.82, 95% CI: 1.07–3.10). Age, geographic regions, and race increased the likelihood of IT and STP use. Conclusions Results indicate a significant proportion of teen females engage in IT and STP use. There was evidence that in teens that have never used IT before, STP use precedes IT initiation. Given the evidence for increased IT in rural populations, research focused on rural tanning bed use is needed.

Background: Interpersonal communication is inherent in a majority of strategies seeking to engage prescriber and pharmacist health care professionals (HCPs) in the reduction and prevention of prescription drug abuse (PDA). However, research on HCP PDA communication behavioral engagement and factors that influence it is limited. Objectives This study quantitatively examined communication behaviors and trait-level communication metrics, and qualitatively described prescription drug abuse-related communication perceptions and behaviors among primary care prescribers and community pharmacists. Methods: Five focus groups (N = 35) were conducted within the Appalachian Research Network (AppNET), a rural primary care practice-based research network (PBRN) in South Central Appalachia between February and October, 2014. Focus groups were structured around the administration of three previously validated trait-level communication survey instruments, and one instrument developed by the investigators to gauge HCP prescription drug abuse communication engagement and perceived communication importance. Using a grounded theory approach, focus group themes were inductively derived and coded independently by study investigators. Member-checking interviews were conducted to validate derived themes. Results: Respondents' trait-level communication self-perceptions indicated low communication apprehension, high self-perceived communication competence, and average willingness to communicate as compared to instrument specific criteria and norms. Significant variation in HCP communication behavior engagement was noted specific to PDA. Two overarching themes were noted for HCP-patient communication: 1) influencers of HCP communication and prescribing/dispensing behaviors, and 2) communication behaviors. Multiple sub-themes were identified within each theme. Similarities were noted in perceptions and behaviors across both prescribers and pharmacists. Conclusions: Despite the perceived importance of engaging in PDA communication, HCPs reported that prescription drug abuse communication is uncomfortable, variable, multifactorial, and often avoided. The themes that emerged from this analysis support the utility of communication science and health behavior theories to better understand and improve PDA communication behaviors of both prescribers and pharmacists, and thereby improve engagement in PDA prevention and treatment.

Opioid Use Disorder is defined by the NIH as “the chronic use of opioids that causes clinically significant distress or impairment.”1 Due to a number of factors, the overuse of opioids has become an epidemic in the United States. In recent years there have been a number of lawsuits against pharmaceutical companies and other parties who have benefitted from the proliferation of this issue. In most cases, it is up to the states or local governments who receive these funds to determine their best use. The purpose of this Thesis is to analyze the resources recommended by Ballad Health’s Community Health Needs Assessments, and five additional panels of experts in this field, and to compare these recommendations with available resources, along with making recommendations for the distribution and use of funds coming from a number of lawsuits and settlements.

Introduction & Background: Unhealthy diets and non-communicable diseases such as obesity are on the rise on a national and global scale, and there is an urgent need to initiate interventions. However, research suggests there is a lack of effective initiatives from major processed food manufacturers, which are a major contributor to the cause of these health issues. Thus, this study seeks to examine the role that food manufacturers have in contributing to the obesity epidemic and the strategies that they use to navigate around health policies. Purpose Statement Question: Is there evidence of a primary role that processed food manufacturers play in enabling the obesity rates nationally and worldwide through market strategies? Literature Review: A wide variety of databases within public health and medicine, such as PubMed, World Health Organization, and National Institutes of Health, were searched using keywords like “Big Food and obesity,” “marketing and obesity,” and “relationship between obesity and food corporations”. Studies that discussed the impact food manufacturers had on obesity and other non-communicable diseases or strategies that they used were selected. Findings: The different research studies analyzed provided evidence that processed food manufacturers, also known as “Big Food," play a significant role in contributing to public health issues, especially non-communicable diseases like obesity. The food industry uses old and new techniques to solidify its influence nationally while gaining power through global means and evading public policy restrictions Conclusions: There is a need for further research to identify these market strategies and effectively dismantle them.

The overarching goal of this dissertation was to elucidate the psychosocial and behavioral determinants of medication nonadherence among African Americans with hypertension. One in three Americans in the United States has hypertension, and the prevalence of hypertension among African Americans is among the highest in the world. In addition to healthy behaviors such as following a low-salt and low-fat diet, getting regular exercise, and reducing stress, patients with hypertension must also adhere to antihypertensive medications. Poor medication adherence may be driven by psychosocial and behavioral factors; however, the impact of these factors on medication adherence is unclear especially within the African American community. To date, a paucity of research has examined the relationship between psychosocial and behavioral factors such as reported racial discrimination, John Henryism (a measure of active coping and an unhealthy response to stress) and home remedies with medication nonadherence. However, each of these factors has individually been linked with poorer health outcomes among African Americans. Using data from the TRUST study (2006-2008) the association between these constructs and medication adherence was assessed within our sample of 788 African Americans and a comparison group of 137 White participants with hypertension. Ordinal logistic regression was used to assess the association between racial discrimination, John Henryism, home remedies, and medication adherence. The findings from this research indicated more reported racial discrimination, higher John Henryism scores, and greater use of home remedies were associated with lower medication adherence. These findings yield new knowledge about medication adherence and provide practical insights about the psychosocial and behavioral determinants of medication adherence.