Cardiovascular Diseases Health Literacy among Patients, Health Professionals, and Community-Based Stakeholders in a Predominantly Medically Underserved Rural Environment.

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.

Exploring Support for 100% College Tobacco-Free Policies and Tobacco-Free Campuses Among College Tobacco Users.

BACKGROUND: Tobacco-free campus policy is identified as an effective means to address tobacco use on college campuses; however, the prevalence of tobacco-free policies (TFPs) in the United States remains low. This study explores college tobacco users' support for a university's TFP and tobacco-free campuses (TFCs) in general. METHODS: A standardized and structured questionnaire was administered to 790 college tobacco users recruited in a university located in a tobacco-growing region of the United States, during April-May 2011, to collect information on support for TFPs and TFCs and sociodemographic-political characteristics. Descriptive and multivariable logistic regression analyses were conducted to identify key factors associated with support for TFPs and TFCs. RESULTS: Approximately 2 of 5 tobacco users favored TFPs and TFCs. Multivariable logistic regression models showed that demographic factors were mostly not significantly associated with attitudes of the college tobacco users. Instead, while knowledge about harmful effects of exposure to secondhand tobacco smoke significantly increased support for both TFPs and TFCs, parental and peer smoking and exposure to tobacco industry promotions significantly decreased the likelihoods of support compared with respective referent groups. CONCLUSION: Study findings suggest that campus advocacy and education campaigns for campus tobacco policies to pay attention to tobacco use behavior of familial relations, tobacco industry activities, and other political determinants of tobacco users' attitudes. Thus, this study should inform national initiatives to promote TFPs nationwide such as the Tobacco-Free College Campus Initiative.

Perceptions and Understanding of Patients with Cardiovascular Disease and Non-Licensed Caregivers about Patient-Centered Care: An Exploratory Study in Central Appalachia.

This study explored knowledge, understanding, and perceptions of patient-centered care (PCC) among patients with cardiovascular diseases and their non-licensed caregivers (NLCs) in Central Appalachia, a medically underserved rural environment. Seven focus group discussions (FGDs) involving 78 patients/NLCS were conducted across the six states of the region. Focus group discussions were audio-recorded, transcribed, and thematically coded. Major themes were: 1) access to quality health care providers (HCPs) and 2) patientprovider interactions. Subthemes for access to quality HCPs included a) long-term relationships with providers, b) high turnover of cardiovascular specialists, c) lack of traditional family physicians, and d) physician assistants/nurse practitioners versus physicians as primary providers. Subthemes for patient-provider interactions included a) reciprocal communication, b) individualized care, and c) meaningful voice in care decisions. These results underscore the importance of interpersonal relationships with providers in the delivery of medical care in the region.

A Qualitative Study to Explore Perception of Impacts of Preemption of Tobacco Regulation on Counties in Appalachian Tennessee.

Bottom-up processes, starting at the local government level, are valuable for more-stringent tobacco control measures. The existence of industry-backed state-level tobacco control preemption in states has impeded policy progress within the state and localities/communities. A national public health goal under Healthy People 2020 is to eliminate state-level preemption across the United States. This study explored individual-level perceptions of the impact of state-level preemption in Appalachian Tennessee-a high-smoking, low-income region. During 2015-2016, a community-engagement project to develop a Population Health Improvement Plan (PHIP) involving over 200 stakeholders and 90 organizations was conducted in Appalachian Tennessee to identify policies/programs to address tobacco use. Using a multifaceted framework approach that focused on prevention, protection, and cessation, interviews and meeting discussions were audio-recorded and transcribed. Content analysis using NVivo 11 was conducted to generate themes. Although the central focus of the PHIP was not preemption, the issue emerged naturally in the discussions as a major concern among participants. Cultural and normative factors in Appalachian Tennessee were identified as key rationales for participants' aversion to state preemption. Thus, repealing preemption would facilitate culturally tailored and region-specific policies/programs to the high tobacco use among Appalachian Tennessee communities where statewide/nationwide policies/programs have not had the intended impacts.

The Usage and Associated Factors of Alternative Tobacco Products among School-going Youth in Central Appalachia.

OBJECTIVE: To examine alternative tobacco product (ATP) use and associated factors among middle school students in Appalachian Tennessee. METHOD: Data (2015-2016; N=573) from school-based tobacco surveys in 11 middle schools in Appalachian Tennessee were analyzed. Multiple logistic regression model described factors associated with ATP use. RESULTS: More than one-tenth (13.2%) of participants have ever used ATPs. Approximately 9%, 7%, 6%, and 2% of participants have ever used e-cigarettes, cigarettes, smokeless tobacco, and little cigars or cigarillos, respectively. The following were significantly associated with ever use of ATPs: believing tobacco users have more friends, owning tobacco-branded item(s), living with a tobacco user, having ever smoked cigarettes, and living in homes where smoking is allowed. CONCLUSION: More than one in 10 of participants have ever used at least one ATP, and association with desirable objects and situations may promote ATP use. Interventions should seek to reduce these positive images and make all tobacco products unappealing.

A qualitative research synthesis of contextual factors contributing to female overweight and obesity over the life course in sub-Saharan Africa.

OBJECTIVE: Adult women are disproportionately affected by overweight and obesity in Sub-Saharan African (SSA) countries. Existing evidence on the sociocultural context remains unconsolidated. In this qualitative research synthesis, we aggregate research literature on contextual factors that potentially predispose adult women and adolescent girls to overweight and obesity to inform research, policies and programs over the life course. METHODS: PubMed, CINAHL, PsychInfo, ProQuest Central, EMBASE, and Web of Science were searched to locate qualitative research articles conducted in SSA countries beginning in the year 2000. After assessment for eligibility and critical appraisal, 17 studies were included in the synthesis. Textual data and quotes were synthesized using meta-aggregation methods proposed by the Joanna Briggs Institute. RESULTS: The synthesized studies were conducted in South Africa, Ghana, Kenya and Botswana. The three overarching themes across these studies were body size and shape ideals, barriers to healthy eating, and barriers to physical activity, with cultural and social factors as cross-cutting influences within the major themes. Culturally, the supposedly ideal African woman was expected to be overweight or obese, and voluptuous, and this was associated with their identity. Although being overweight or obese was not acceptable to adolescent girls, they desired to be voluptuous. Healthy food choices among women and adolescent girls were hampered by several factors including affordability of nutritious foods and peer victimization. Both adult women and adolescent girls experienced ageism as a barrier to physical activity. SIGNIFICANCE: This is the first qualitative research synthesis to amplify the voices of women and girls in SSA countries highlighting the challenges they face in maintaining a healthy body weight. Sociocultural, institutional and peer-related factors were powerful forces shaping body size preferences, food choices and participation in physical activity. Our study findings provide insights for the design of contextually appropriate obesity prevention interventions and lay the foundation for further research studies.

College students as facilitators in reducing adolescent obesity disparity in Southern Appalachia: Team Up for Healthy Living.

The proportion of obese adolescents in Southern Appalachia is among the highest in the nation. Through funding from the National Institute on Minority Health and Health Disparities--National Institutes of Health, the Team Up for Healthy Living project was a cluster-randomized trial targeting obesity prevention in adolescents through a cross-peer intervention. The specific aims of the project were to: 1) develop a peer-based health education program focusing on establishing positive peer norms towards healthy eating and physical activity (PA) among high school students, 2) test program efficacy, and 3) explore mechanisms underlying the program. The study was guided by the Theory of Planned Behavior, which presupposes that human behavior is primarily driven by attitude, subjective norms, perceived behavioral control, and social support. To deliver the intervention, undergraduate students from the disciplines of public health, nutrition, and kinesiology were hired as peer facilitators. Ten area high schools were invited to participate, were matched on demographics and then randomized to intervention or control. The primary outcomes of the study included body mass status, dietary behaviors, PA, and sedentary behaviors which were assessed at baseline and at three and twelve months post baseline. Intervention schools received Team Up for Healthy Living curriculum, which consists of eight 40-minute sessions. The curriculum focused on improving nutrition awareness, PA, leadership and communication. Control schools received their regularly scheduled Lifetime Wellness curriculum. The long-term goal of the study was to establish an effective academia-community partnership program to address adolescent obesity disparity in Southern Appalachia.

Physical activity patterns among women in rural Alabama.

OBJECTIVE: To explore factors associated with physically active women in a rural community. METHODS: Physical activity patterns were assessed in 585 women in rural Alabama. RESULTS: When combining leisure and nonleisure activities, 68% of women reported > or = 150 minutes per week. Active African American women tended to be younger (AOR 0.97), married (AOR 1.75), less likely to report arthritis (AOR 0.58), or give health (AOR 0.30) or motivational reasons (AOR 0.39) for not being more active; active white women were less likely to report lower health perception (AOR 0.51). CONCLUSION: Ethnic differences in factors associated with higher activity levels need to be considered in physical activity interventions.

Lessons learned from the Uniontown Community Health Project.

OBJECTIVE: To compile lessons learned from the Uniontown Community Health Project. METHODS: Lessons-learned information was gathered from project staff and community volunteers. RESULTS: Analysis led to the identification of 6 lessons: (a) Establish personal working relationships in communities; (b) find a local community coordinator to lead efforts; (c) be patient in implementing a community health advisor (CHA) model; (d) be flexible and emphasize simplicity when implementing community activities; (e) recognize that meeting research goals requires compromise; and (f) plan transfer of project activities to the community from the beginning. CONCLUSION: These lessons may benefit others implementing CHA programs.

Training community health workers to reduce health disparities in Alabama's Black Belt: the Pine Apple Heart Disease and Stroke Project.

African American women have significantly higher mortality rates from heart disease and stroke than White women despite advances in treatment and the management of risk factors. Community health workers (CHWs) serve important roles in culturally relevant programs to prevent disease and promote health. This article describes the Pine Apple Heart and Stroke Project's activities to (1) revise the Women's Wellness Sourcebook Module III: Heart and Stroke to be consistent with national guidelines on heart disease and stroke and to meet the needs of African American women living in rural southern communities; (2) train CHWs using the revised curriculum; and (3) evaluate the training program. Revisions of the curriculum were based on recommendations by an expert advisory panel, the staff of a rural health clinic, and feedback from CHWs during training. Questionnaires after training revealed positive changes in CHWs' knowledge, attitudes, self-efficacy, and self-reported risk reduction behaviors related to heart disease, stroke, cancer, and patient-provider communication. This study provides a CHW training curriculum that may be useful to others in establishing heart disease and stroke programs in rural underserved communities.