Objective The central Appalachian region of the United States is disproportionately burdened with cardiovascular disease (CVD); however, the level of literacy about CVD among residents has not been well studied. This study aimed to examine the prevalence and factors of CVD health literacy (HL) among a sample of patients/caregivers, providers/professionals, and community stakeholders. Methods In 2018, data were collected from central Appalachian residents in six states: Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia. CVD HL status was determined by assessing correct responses to five interrelated questions about basic knowledge of CVD. Multiple logistic regression analyses were used to examine the associations between potential factors and CVD HL status. Results Of the total respondents (N = 82), <50% correctly answered all 5 CVD HL questions. Multiple logistic regression analyses showed that compared with respondents with advanced college degrees, those with a college degree or less were more likely to have low HL for "typical symptom of CVD,""physical exercise and CVD,""blood pressure and CVD,"and "stress and CVD."In addition, compared with respondents younger than 50 years, those 50 years and older were 3.79 times more likely to have low HL for "physical exercise and CVD."Conclusions These results suggest the incorporation of CVD HL into CVD care and that educational attainments should be part of CVD policies and programs in the region.

Foodborne illness is a serious and preventable public health problem affecting 1 in 6 Americans with cost estimates over $50 billion annually. Local health departments license and inspect restaurants to ensure food safety and respond to reports of suspected foodborne illness. The City of St. Louis Department of Health adopted the HealthMap Foodborne Dashboard (Dashboard), a tool that monitors Twitter for tweets about food poisoning in a geographic area and allows the health department to respond. We evaluated the implementation by interviewing employees of the City of St. Louis Department of Health involved in food safety. We interviewed epidemiologists, environmental health specialists, health services specialists, food inspectors, and public information officers. Participants viewed engaging innovation participants and executing the innovation as challenges while they felt the Dashboard had relative advantage over existing reporting methods and was not complex once in place. This study is the first to examine practitioner perceptions of the implementation of a new technology in a local health department. Similar implementation projects should focus more on process by developing clear and comprehensive plans to educate and involve stakeholders prior to implementation.

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On behalf of the Appalachia Funders Network (AFN), with funding from the Robert Wood Johnson Foundation, East Tennessee State University and NORC at the University of Chicago conducted a study to analyze the current burden of obesity and chronic disease in central Appalachia and identify promising practices and strategies that are having a positive impact on the reduction of obesity in the region. Central Appalachia consists of parts of Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia. Regional recommendations to reduce childhood obesity and improve the overall population’s health were developed based on a review of current literature, a survey, and focus groups with both community groups and funders.

On behalf of the Appalachia Funders Network (AFN), with funding from the Robert Wood Johnson Foundation, East Tennessee State University and NORC at the University of Chicago conducted a study to analyze the current burden of obesity and chronic disease in central Appalachia and identify promising practices and strategies that are having a positive impact on the reduction of obesity in the region. Central Appalachia consists of parts of Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia. Regional recommendations to reduce childhood obesity and improve the overall population’s health were developed based on a review of current literature, a survey, and focus groups with both community groups and funders.

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.

In the summer of 2015, the East Tennessee State University (ETSU) College of Public Health and regional health systems serving 29 counties in Northeast Tennessee and Southwest Virginia began the process of identifying a set of high-impact health programs for inclusion in a ten-year regional plan to break the cycle of inter-generational poor health outcomes in this region. It was decided that selection of effective health improvement programming must be driven by a comprehensive and deliberate effort to garner input from communities and stakeholders across the region. More than 170 professionals representing 96 health-related agencies volunteered to form steering committees around four topic areas: healthy children and families, population health, mental health and addictions, and research and academics. Each committee was tasked with; 1) providing information to the health systems on regional health priorities, 2) identifying effective approaches to addressing them, and 3) pinpointing opportunities for cross-sector collaboration. Community input was secured by holding meetings in ten area counties using the World Café model; a format chosen to encourage and facilitate discussion between participants around their local community's health concerns. In addition to priority setting for the 10-year plan, cross-sector commitment and community buy-in was established during this process that will serve as the basis for organizational planning of a proposed accountable care community (ACC). Challenges and opportunities uncovered during our efforts to improve regional health outcomes through a collaborative approach may benefit other communities working on similar projects.

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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