Research Objective: On behalf of the Appalachian Funders Network, with funding from the Robert Wood Johnson Foundation, East Tennessee State University and NORC at the University of Chicago documented the current burden of obesity, diabetes, and chronic disease mortality in central Appalachia. An analysis of county-level data was conducted in order to provide a picture of the health condition of the region. This study identified both the magnitude of obesity-related health problems in central Appalachia as well as promising practices, policies and strategies aimed at reducing obesity rates, especially among children. Study Design: A mixed methods approach was used to assess the policies and practices that have a positive impact on the reduction of childhood obesity and chronic disease in central Appalachia (TN, VA, KY, WV, NC, and OH). Along with a literature review and analysis of national and regional health data, the study included surveys and focus groups of community members, practitioners and funders to identify the region’s current obesity prevention efforts. Activities were broken into (1) healthy eating, including promotion of policies and/or changes to the built environment and promotion of healthy food; and (2) physical activity. Population Studied: The central Appalachian region ranks amongst the highest in the nation for percentage of obese high school students. There, children are disproportionately affected by rates of obesity by location; specifically, rural children differ from urban children, 16.5% to 14.4%, respectively, in prevalence of obesity. Focus groups comprising community members, practitioners and funders were held to obtain internal stakeholder input and secure community buy-in. Principal Findings: Across central Appalachia, participants in the surveys and focus groups identified a number of recommendations to advance regional efforts to reduce obesity and improve the overall population’s health. Survey results indicate the most promising and prevailing nutritional practices comprise community-based, locally led support strategies spanning multisector approaches to endorse schools' feeding programs, community and school gardens, and farmers' market SNAP programs via co- investment and funding. Concurrently, promising physical activity promotion practices include stepping up community walkability, enhancing physical education requirements, expanding and revitalizing trails, tracks, playgrounds, gyms and other exercise opportunities within built environments. Conclusions: This study provides evidence-based, promising practices to address obesity in rural communities. For long-term changes to occur programs that are successful need to be evaluated rigorously and shared widely. Implications for Public Health Policy or Practice: Improving the local food and physical activity environment in a community requires participation of many dedicated partners. Government, the health care system, schools, private businesses and community organizations all have critical roles to play in this effort. Cross-sector collaboration creates local ownership leading to more sustainable programs that are valued not only by the foundations and grantees but also by the larger community.

Research Objective: On behalf of the Appalachian Funders Network, with funding from the Robert Wood Johnson Foundation, East Tennessee State University and NORC at the University of Chicago documented the current burden of obesity, diabetes, and chronic disease mortality in central Appalachia. An analysis of county-level data was conducted in order to provide a comprehensive picture of the health condition of the region. Contributing factors, such as physical inactivity and food environment, were also investigated to determine how the built environment impacts obesity. Study Design: Several secondary data sources were utilized, including the County Health Rankings, CDC Diabetes Interactive Atlas, USDA Food Environment Atlas, and mortality data from the CDC National Center for Health Statistics, National Vital Statistics System. Variables analyzed included: adult obesity prevalence, adult diabetes prevalence, food insecurity, access to exercise opportunities, physical inactivity, and premature chronic disease mortality. The mortality analyses focused on four of the leading causes of death: heart disease, stroke, diabetes, and chronic lower respiratory disease, for persons age 25 to 64 from 2009 to 2013. When available, county-level estimates were used to create maps of the region, documenting the disparities compared to the rest of the nation. Population Studied: Health disparities were documented within the counties of central Appalachia, consisting of parts of Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia. Principal Findings: More than two-thirds (68.6%) of the 234 counties in central Appalachia have an adult obesity prevalence above the national median of 30.9% (defined as BMI over 30). Over 85% of the counties in central Appalachia have a percentage of physically inactive adults higher than the national median of 26.4% (defined as not participating in physical activity or exercise in the past 30 days). When analyzing the combined chronic disease mortality for heart disease, stroke, diabetes and chronic lower respiratory disease, the combined national mortality rate is 93.0 deaths per 100,000 population. Nearly 90% of central Appalachian counties have a higher combined morality rate, and the state mortality rate for the Appalachian region of all six states is higher than the national rate. The disparity is more pronounced in rural communities, as the rural counties of central Appalachia have a higher mortality rate than urban counties within central Appalachia and rural counties across the United States. The combined mortality rate for these four diseases is 74% higher in rural central Appalachia than urban counties nationally. Conclusions: Compared to the rest of the country, people in central Appalachia are more likely to experience and prematurely die from obesity-related chronic disease, including diabetes and heart disease. Residents of rural central Appalachia face even more significant disparities as compared to urban residents within the region and nationally. Implications for Policy or Practice: Obesity and chronic disease in central Appalachia are significant public health concerns that must be addressed in order to improve the health of the region.

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Background: Compared to other regions of the United States, people living in Appalachia bear a heavier burden from obesity related chronic conditions such as cardiovascular disease, stroke, diabetes, fibromyalgia, and sleep apnea as well as higher rates of premature mortality for those diseases. Childhood obesity in particular poses a burgeoning and understated threat to the public health system. Objectives: The purpose of this study was, working with the Appalachian Funders Network, identify the policies and practices that have a positive impact on the reduction of childhood obesity and chronic disease in central Appalachia (TN, VA, KY, WV, NC, and OH). Methods: Mixed methods approach was utilized. Survey of practitioners and funders identified efforts to reduce childhood obesity including obesity prevention, healthy eating and/or physical activity. Focus groups conducted across the region provided participant generated strategies to address gaps and needs. Results: Over 400 practitioners and 40 funders completed the survey. Eight focus groups were conducted across central Appalachia. Based on the finding, a set of recommendations to inform future grant making strategies will be compiled. Preliminary results demonstrate some areas of disconnect between funders and practitioners. Programs were more sustainable if funded from within the community rather than from an outside source. Further, the success of a program seems to be based on need and the collaboration of the practioners and funders. Conclusions: Using a mixed-methods approach, an aggregate of data provides a comprehensive picture of the current health condition of central Appalachia. Working with the Appalachian Funders Network, a group of 80 funders, the findings from this study have the potential to impact the work on practitioners and funders in the region. This collaboration hopes to promote a sustainable healthy lifestyle within Tennessee and greater Appalachia.

Background: Prescription drug abuse is a public health problem in the United States and the region of Appalachia, specifically. Primary care and addiction medicine—as possible points of access for prescription drugs with abuse potential and points of intervention for prescription drug abuse—are among the medical fields at its forefront. Little is known, however, about perceptions of prescription drug abuse across the two patient populations. Objectives: The objective of this qualitative analysis was to explore perceptions of the scale and context of prescription drug abuse among primary care and addiction medicine patients in Appalachia. Methods: As part of a mixed methods study, semi-structured interviews were conducted with 20 patients from primary care and addiction medicine in Central and South Central Appalachia from 2014 to 2015. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was used to identify themes. Results: Three themes were identified: (1) pervasiveness of prescription drug abuse, describing perceptions of its high prevalence and negative consequences; (2) routes and routine practices for prescription drug acquisition and distribution, describing perceptions of routes of access to prescription drugs and behaviors exhibited to acquire and distribute prescription drugs; and (3) rationales for prescription drug acquisition and distribution, describing perceptions of the two underlying reasons for these processes—tolerance/addiction and revenue source. Conclusions/Importance: Perceptions of prescription drug abuse among primary care and addiction medicine patients in Appalachia are multifaceted, especially regarding prescription drug acquisition and distribution. Clinical practice implications for mitigating prescription drug abuse are discussed.

Abstract available in the American Journal of Pharmaceutical Education.

Background: Provider–patient communication underpins many initiatives aimed at reducing the public health burden associated with prescription drug abuse in the United States. The purpose of this qualitative analysis was to examine the characteristics of provider–patient communication about prescription drug abuse from the perspective of prescribers. Methods:From 2014 to 2015, 10 semi-structured interviews were conducted with a purposive sample of prescribers from multiple professions and medical fields in Central and South Central Appalachia. The interviews were conducted using a guide informed by Social Cognitive Theory and community theory research, audio-recorded, and transcribed verbatim. Thematic analysis, facilitated by NVivo 10 software, was used to generate themes.Results:Prescribers described 3 primary communication patterns with patients related to prescription drug abuse—informative, counteractive, and supportive. Prescribers also reported multiple factors—personal (e.g., education, experiences, and feelings of tension) and environmental (e.g., relationship with a patient, clinical resources, and policies on controlled prescription drugs)—that affect provider–patient communication and, by association, delivery of patient care related to prescription drug abuse.Conclusions:The findings suggest that provider–patient communication about prescription drug abuse is multidimensional and dynamic, characterized by multiple communication patterns and contributory factors. They have implications for (1) research aimed at advancing theoretical understanding of prescriber prescription drug abuse communication behaviors with patients and (2) interventions aimed at strengthening prescriber prescription drug abuse communication behaviors with patients.

Increasing understanding of the risk and protective factors for adolescent nonmedical use of prescription drugs (NMUPD) could inform prevention efforts. Several correlates have been identified, including parental factors, perceptions about use and accessibility, social norms, and age. However, these constructs have rarely been simultaneously examined using paired data from parents and adolescents. We aimed to examine the relative influence of these correlates among dyads (N = 349) of mothers and adolescent daughters. Using multiple logistic regression, daughters’ past NMUPD and inclination for future NMUPD were regressed onto descriptive norms for friend use, perceived drug accessibility and risk of harm from use, daughter age, mothers’ disapproval about use, mothers’ past NMUPD and inclination for future NMUPD, and the mother-daughter relationship quality. Akaike weights and lasso regressions were also estimated to evaluate the relative importance of each correlate. Higher descriptive norms for friend use, older age, and mothers’ inclination for NMUPD were risk factors for daughters’ NMUPD, while a closer mother-daughter relationship and mothers’ disapproving attitudes towards NMUPD were protective factors. The three analysis approaches were corroborative. Results suggest friend descriptive norms, mother-daughter relationship quality, and mothers’ attitudes about NMUPD are important prevention targets.

The College of Public Health at East Tennessee State University started a program in 2011 to teach the skills needed to protect and promote health and well-being in resource-limited settings. The need to provide public health services in resource-limited settings exists in both wilderness and isolated settings and when a disaster disrupts basic societal infrastructure. In these settings, lives may depend on the ability to provide water, sanitation, hygiene, shelter, first aid, and other basic services. Over the last decade, the college expanded the program considerably into what is now known as Project EARTH (Employing Available Resources to Transform Health) that now includes several different academic courses as well as programs designed to develop innovative solutions to address the needs of people in resource-limited settings. Working in a resource-limited setting requires effectively utilizing locally available resources to improve and protect people's health and well-being. Project EARTH focuses on teaching students to design and create specific products for these situations while progressively honing those cross-cutting skills necessary to work effectively in these settings-notably teamwork, creativity, and resilience. To this end, Project EARTH implements a sequential learning process that includes significant hands-on training and simulated experiences with debriefing opportunities at the end of each activity. Project EARTH may serve as a useful model for others considering a similar training program.