Factors Associated with Physical Activity Increases and Decreases Among a Sample of Appalachian Residents During the COVID-19 Pandemic: A Cross-Sectional Study.

Introduction: Physical activity (PA) can prevent and reduce the deleterious physical and mental health effects of COVID-19 and associated lockdowns. Research conducted early in the pandemic demonstrates that a greater proportion of adults in the U.S. have decreased than increased PA, and the effects vary by sociodemographic factors. Ongoing evidence is important to identify patterns in PA changes during the pandemic. Purpose: This study aims to identify factors associated with increases and decreases in PA during the COVID-19 pandemic in a convenience sample of adults residing in Appalachia. Methods: Surveys were collected from a convenience sample of adults from eight counties in West Virginia from January to March 2021. Logistic regression analysis was used to identify sociodemographic, health, and rurality factors associated with (1) increased PA and (2) decreased PA during the pandemic, assessed retrospectively via self-report. Results: Analysis of 1,401 survey responses revealed that better self-rated health, lower body mass index, and higher income and education were associated with a greater likelihood of more time spent doing PA during the pandemic ( p ≤ .05). Respondents with lower self-rated health, higher body mass index, lower income, and lower levels of education-plus females and those living in a more urban county-were more likely to spend less time doing PA during the pandemic ( p ≤ .05). Implications: Analyses suggest that pre-pandemic disparities in PA by health, wealth, and education were exacerbated during the pandemic. These must be addressed before physical inactivity and ill health become endemic to the Appalachian Region.

Using adverse childhood experiences to explore the usefulness of community health needs assessments to monitor complex determinants of health at the local level.

BACKGROUND: Hospital led community health needs assessments (CHNAs) are intended to help medical care organizations assess determinants of health within the communities they serve. This study demonstrates the utility of data from non-profit hospital CHNAs to monitor complex health issues such as adverse childhood events (ACEs) at the local-level. METHODS: CHNA data were collected from August to November 2019 and analyzed July 2021. A series of logistic regressions were used to analyze associations between ACEs, mental health conditions, and self-rated health from a convenience sample of 2831 adults from two regional hospitals that service five counties located in central Appalachia. RESULTS: ACEs were associated with increased odds of experiencing all metal health conditions after adjusting for other exposures and demographics, including: bipolar disorder (AOR: 2.42, CL: 1.78, 3.30), chronic pain (AOR: 1.61, CL: 1.438, 1.87), depression (AOR: 2.05, CL: 1.76, 2.36), PTSD (AOR: 3.83, CL: 2.95, 4.98), and poor self-rated health (AOR: 1.88, CL: 1.65, 2.15). CONCLUSION: Findings suggest hospital CHNAs are a useful way to assess local data and should include factors known to antecede disease including associated risks and outcomes. CHNAs may provide an opportunity to fill important gaps in community surveillance and inform local prevention and treatment strategies.

Field Test of a Passive Infrared Camera for Measuring Trail-Based Physical Activity.

Introduction: Trails are ubiquitous and far-reaching, but research on the impact trails have on physical activity is limited by the lack of resource-efficient, accurate, and practical systematic observation tools. Commonly used infrared trail sensors count trail use and may broadly differentiate activity (i.e., bicyclist vs. pedestrian), but cannot detect nuances needed for outcomes research such as frequency, intensity, time, and type of activity. Motion-activated passive infrared cameras (PICs), used in ecological research and visitor management in wildlife areas, have potential applicability as a systematic observation data collection tool. Materials and Methods: We conducted a 7-month field test of a PIC as a systematic observation data collection tool on a hiking trail, using photos to identify each trail user's physical activity type, age, sex, and other characteristics. We also tallied hourly trail use counts from the photos, using Bland-Altman plots, paired t-tests, Concordance Correlation Coefficient, Kendall's Tau-b, and a novel inter-counter reliability measure to test concordance against concurrent hourly counts from an infrared sensor. Results: The field test proved informative, providing photos of 2,447 human users of the trail over 4,974 h of data collection. Nearly all of the users were walkers (94.0%) and most were male (69.2%). More of the males used the trail alone (44.8%) than did females (29.8%). Concordance was strong between instruments (p < 0.01), though biased (p < 0.01). Inter-counter reliability was 91.1% during the field study, but only 36.2% when excluding the hours with no detectable trail use on either device. Bland-Altman plots highlighted the tendency for the infrared sensor to provide higher counts, especially for the subsample of hours that had counts >0 on either device (14.0%; 694 h). Discussion: The study's findings highlight the benefits of using PICs to track trail user characteristics despite the needs to further refine best practices for image coding, camera location, and settings. More widespread field use is limited by the extensive amount of time required to code photos and the need to validate the PICs as a trail use counter. The future potential of PICs as a trail-specific PA research and management tool is discussed.

Assessment and Response to Intimate Partner Violence in Home Visitation: A Qualitative Needs Assessment With Home Visitors in a Statewide Program.

There is growing recognition that home visitation programs serving at-risk families may be an appropriate mechanism for detecting and reducing intimate partner violence (IPV). More research is needed about how home visitors assess and respond to IPV, especially in rural and underserved areas with unique social and geographic challenges. This study describes the qualitative, needs assessment phase of a larger mixed-methods evaluation of IPV assessment, referral processes, and safety planning with clients within a statewide home visitation program. Three focus groups were conducted with home visitors (n = 16) in West Virginia's Home Visitation Program in May 2015. Home visitors represented four separate home visitation models and provided services across 12 of West Virginia's 55 counties. Guiding questions focused on home visitors' current protocol, experiences, barriers, and facilitators to (a) screening and assessment for IPV, (b) making referrals after disclosures of IPV, and (c) developing safety plans with IPV-exposed clients. Barriers identified by home visitors included the nature of assessment tools, issues with service availability and access in rural areas, and lack of education and training surrounding safety planning. Facilitators included building relationships and trust with clients, providing anticipatory guidance when making referrals, and tailoring safety plans to clients' unique situations. Participants also expressed a critical need to develop procedures for assuring home visitor safety when supporting IPV-exposed clients. These qualitative data highlight issues surrounding the management of IPV in home visitation and have the potential to inform future enhancements to programs that are specifically tailored to the needs of rural, disadvantaged communities.

School Climate as a Universal Intervention to Prevent Substance Use Initiation in Early Adolescence: A Longitudinal Study.

Initiation of substance use often starts during adolescence, with tobacco and alcohol use frequently preceding the use of marijuana and other illicit drugs. Studies suggest that a positive school climate may prevent substance use while promoting healthy student behaviors. The purpose of this study was to determine the longitudinal associations between school climate and substance use initiation in a group of middle school students. Parallel latent growth curve modeling was used to examine changes among study variables longitudinally using a sample of 2,097 sixth-, seventh-, and eighth-grade students across 16 regional schools located in three counties in West Virginia. Results suggest that a positive school climate may prevent substance use initiation (ß = -0.07 to -0.25, p < .01). However, perceptions of school climate decreased on their own over time (ß = -0.28 to -0.66, p < .01). Furthermore, substance use initiation also increased as students grew older (ß = 0.96 to 0.99, p < .01) and reduced the effects of school climate longitudinally (ß = -0.07 to -0.24, p < .01). Early substance use initiation may be a warning sign of other underlying student issues and requires additional school support to foster student success. Findings suggest that a positive school climate may delay substance use initiation and promote school success. School climate may, therefore, be useful as an intervention to support school-based health promotion.

Adoption and Reach of a statewide policy, systems, and environment intervention to increase access to fresh fruits and vegetables in West Virginia.

Food deserts-areas with limited access to affordable, healthy foods-are disproportionately in low-income areas of the USA and have been linked with poorer nutrition behaviors and health outcomes. From a social ecological perspective, increasing access to affordable fresh fruits and vegetables in communities should encourage consumption and health improvements. Change the Future West Virginia, a statewide intervention, was undertaken to make policy, system, and environment (PSE) changes to enhance access to fresh fruits and vegetables in schools, farmers markets, and retail food outlets. Previous local scale PSE change interventions have shown feasibility and population reach, but broader dissemination has not been evaluated. Thus, the purpose was to evaluate the Adoption and Reach of Change the Future West Virginia statewide nutrition-based PSE strategies, especially in food deserts. Evaluation data were collected monthly using an online performance monitoring tool, including open-ended items to assess barriers and facilitators of PSE changes. Schools from 48 of 55 counties with 261,829 enrollment (54% low-income) implemented 231 PSE activities, resulting in 35 counties serving locally produced foods. Adoption included two thirds (n = 82) of all farmers markets in the state-signed collaboration agreements, adding electronic benefit transfer machines at 29. Retail food Adoption included signed agreements with 22.1% (n = 101) of all grocery stores and 14.1% (n = 162) of all convenience stores in the state reaching 110,258 people (21.5%) in 27 food desert census tracts. Personnel consistency, local connections, and in-person meetings were important for PSE changes, highlighting the importance of human resources in the rural public health system and the potential of these intervention activities in rural, low-income states.

Evaluability assessment of "growing healthy communities," a mini-grant program to improve access to healthy foods and places for physical activity.

BACKGROUND: Mini-grants have been used to stimulate multisector collaboration in support of public health initiatives by funding non-traditional partners, such as economic development organizations. Such mini-grants have the potential to increase access to healthy foods and places for physical activity through built environment change, especially in small and rural towns in the United States. Although a promising practice, few mini-grant evaluations have been done. Therefore, our purpose was to conduct an Evaluability Assessment (EA), which is a process that can help promising programs that lack evidence advance toward full-scale evaluation. Specifically, we conducted an Evaluability Assessment of a statewide mini-grant program, called "Growing Healthy Communities" (GHC), to determine if this program was ready for evaluation and identify any changes needed for future implementation and evaluation that could also inform similar programs. METHODS: Telephone interviews with directors of six past mini-grant recipient organizations were conducted to assess implementation and evaluability. The six interviews were split equally among agencies receiving funding for food-oriented projects and physical activity-oriented projects. Within- and cross-case thematic analyses of interview transcripts were conducted. RESULTS: Organizational capacity was a universal theme, reflecting other key themes (described in detail in the manuscript) that affected program implementation and evaluation, including collaboration, limited time and measurement integration. CONCLUSIONS: The EA process provided pilot data that suggest that other state, regional, and national funders should provide centralized assistance for data collection and evaluation from the outset of a mini-grant award program.

Healthcare resource availability and cardiovascular health in the USA.

OBJECTIVES: Cardiovascular disease (CVD) remains the leading cause of death in the USA. Reducing the population-level burden of CVD disease will require a better understanding and support of cardiovascular health (CVH) in individuals and entire communities. The objectives for this study were to examine associations between community-level healthcare resources (HCrRes) and CVH in individuals and entire communities. SETTING: This study consisted of a retrospective, cross-sectional study design, using multivariable epidemiological analyses. PARTICIPANTS: All participants in the 2011 Behavioral Risk Factor Surveillance System (BRFSS) survey were examined for eligibility. CVH, defined using the American Heart Association CVH Index (CVHI), was determined using self-reported responses to 2011 BRFSS questions. Data for determining HCrRes were obtained from the Area Health Resource File. Regression analysis was performed to examine associations between healthcare resources and CVHI in communities (linear regression) and individuals (Poisson regression). RESULTS: Mean CVHI was 3.3±0.005 and was poorer in the Southeast and Appalachian regions of the USA. Supply of primary care physicians and physician assistants were positively associated with individual and community-level CVHI, while CVD specialist supply was negatively associated with CVHI. Individuals benefiting most from increased supply of primary care providers were: middle aged; female; had non-Hispanic other race/ethnicity; those with household income <$25 000/year; and those in non-urban communities with insurance coverage. CONCLUSIONS: Our results support the importance of primary care provider supply for both individual and community CVHI, though not all sociodemographic groups benefited equally from additional primary care providers. Further research should investigate policies and factors that can effectively increase primary care provider supply and influence where they practice.

Prevalence and Geographic Variations of Polypharmacy Among West Virginia Medicaid Beneficiaries.

BACKGROUND: West Virginia (WV) residents are at high risk for polypharmacy given its considerable chronic disease burdens. OBJECTIVE: To evaluate the prevalence, correlates, outcomes, and geographic variations of polypharmacy among WV Medicaid beneficiaries. METHODS: In this cross-sectional study, we analyzed 2009-2010 WV Medicaid fee-for-service (FFS) claims data for adults aged 18-64 (N=37,570). We defined polypharmacy as simultaneous use of drugs from five or more different drug classes on a daily basis for at least 60 consecutive days in one year. Multilevel logistic regression was used to explore the individual- and county-level factors associated with polypharmacy. Its relationship with healthcare utilization was assessed using negative binomial regression and logistic regression. The univariate local indicators of spatial association method was applied to explore spatial patterns of polypharmacy in WV. RESULTS: The prevalence of polypharmacy among WV Medicaid beneficiaries was 44.6%. High-high clusters of polypharmacy were identified in southern WV, indicating counties with above-average prevalence surrounded by counties with above-average prevalence. Polypharmacy was associated with being older, female, eligible for Medicaid due to cash assistance or medical eligibility, having any chronic conditions or more chronic conditions, and living in a county with lower levels of education. Polypharmacy was associated with more hospitalizations, emergency department visits, and outpatient visits, as well as higher non-drug medical expenditures. CONCLUSIONS: Polypharmacy was prevalent among WV Medicaid beneficiaries and was associated with substantial healthcare utilization and expenditures. The clustering of high prevalence of polypharmacy in southern WV may suggest targeted strategies to reduce polypharmacy burden in these areas.

The Impact of Community Input in Community Health Needs Assessments.

OBJECTIVE: To determine the impact of community participation on nonprofit hospital priorities as outlined in a Community Health Needs Assessment. DESIGN: Using 3 completed Community Health Needs Assessments, we compare key stakeholder survey responses with community survey responses and determine their contribution to the finalized priorities. SETTING: Three communities in West Virginia served by nonprofit hospitals (1 metropolitan statistical area, 1 micropolitan statistical area, and 1 rural community). PARTICIPANTS: Key stakeholders and the general population of communities served by the hospital. MAIN OUTCOME MEASURE: Finalized priorities as outlined in the Community Health Needs Assessment. RESULTS: Community participation had an impact on finalized priorities. CONCLUSION: Community participation is key in identifying unique health needs and should be incorporated into the assessment process by nonprofit hospitals, local health departments, and other public health practitioners. As reforms are considered to the Patient Protection and Affordable Care Act, it will be important to emphasize the importance of community input in identifying ways nonprofit hospitals contribute community benefit. CHNAs without adequate public input may not translate into implementation plans that accurately address pressing health concerns.

Measuring policy and related effects of a health impact assessment related to connectivity.

Health Impact Assessments are an important tool to help policymakers perceive the potential positive and negative contributions of decisions to public health. While they have been increasingly used in the United States, studies have not examined intermediate effects. Using key stakeholder interviews, this manuscript examines policy outcomes and other related effects of the HIA 21months after completing a Health Impact Assessment Report around connectivity policy. Further, it reflects on the measurement of these effects as part of the monitoring and evaluation stage of the Health Impact Assessment process.

Longitudinal Patterns of Emergency Department Visits: A Multistate Analysis of Medicaid Beneficiaries.

OBJECTIVE: The objective of this study was to examine the longitudinal patterns of emergency department (ED) visits among adult fee-for-service Medicaid. DATA SOURCES: Data were obtained from the Medicaid analytic eXtract files, Area Health Resource File, and County Health Rankings. STUDY DESIGN: A retrospective longitudinal study design, with four observations for each individual was used. The study population consisted of 33,393 Medicaid beneficiaries who met inclusion criteria. ED visits were time-lagged and time-varying patient-level factors were measured for each year. Time-invariant characteristics (gender and race/ethnicity) were measured in 2006. Multivariable hurdle models with logistic (ED use versus no ED use) and negative binomial regressions (ED visits among ED users) were used to analyze the ED visits over time. To account for correlation due to repeated observations, mixed effect models with robust standard errors were performed. PRINCIPAL FINDINGS: In both unadjusted and adjusted analysis, the likelihood of ED use did not change from year to year (AOR = 1.00, 95 percent CI: 0.99, 1.01). Among ED users, the estimated number of ED visits increased over time (IRR = 1.01, 95 percent CI: 1.01, 1.03). CONCLUSIONS: Primary care resources should be a major focus to reduce the increased burden on the EDs.

Factors Associated With Emergency Department Visits: A Multistate Analysis of Adult Fee-for-Service Medicaid Beneficiaries.

OBJECTIVE: The objective of this study was to examine the association of patient- and county-level factors with the emergency department (ED) visits among adult fee-for-service (FFS) Medicaid beneficiaries residing in Maryland, Ohio, and West Virginia. METHODS: A cross-sectional design using retrospective observational data was implemented. Patient-level data were obtained from 2010 Medicaid Analytic eXtract files. Information on county-level health-care resources was obtained from the Area Health Resource file and County Health Rankings file. RESULTS: In adjusted analyses, the following patient-level factors were associated with higher number of ED visits: African Americans (incidence rate ratios [IRR] = 1.47), Hispanics (IRR = 1.63), polypharmacy (IRR = 1.89), and tobacco use (IRR = 2.23). Patients with complex chronic illness had a higher number of ED visits (IRR = 3.33). The county-level factors associated with ED visits were unemployment rate (IRR = 0.94) and number of urgent care clinics (IRR = 0.96). CONCLUSION: Patients with complex healthcare needs had a higher number of ED visits as compared to those without complex healthcare needs. The study results provide important baseline context for future policy analysis studies around Medicaid expansion options.

Reviewing risks and benefits of low-dose computed tomography screening for lung cancer.

Lung cancer is the third most common cancer among men and women and is one of the leading causes of cancer-related mortality. Diagnosis at an early stage has been suggested crucial for improving survival in individuals at high-risk of lung cancer. One potential facilitator to early diagnosis is low-dose computed tomography (LDCT). The United States Preventive Services Task Force guidelines call for annual LDCT screening for individuals at high-risk of lung cancer. This recommendation was based on the effectiveness of LDCT in early diagnosis of lung cancer, as indicated by the findings from the National Lung Screening Trial conducted in 2011. Although lung cancer accounts for more than a quarter of all cancer deaths in the United States and LDCT screening shows promising results regarding early lung cancer diagnosis, screening for lung cancer remains controversial. There is uncertainty about risks, cost-effectiveness, adequacy of evidence, and application of screening in a clinical setting. This narrative review provides an overview of risks and benefits of LDCT screening for lung cancer. Further, this review discusses the potential for implementation of LDCT in clinical setting.

Changing Awareness of the Health Insurance Marketplace.

The Health Insurance Marketplace was designed to increase the affordability of health insurance. The success of the marketplace depends on people's awareness and use of it. In a statewide mail survey of West Virginians, we found that respondents' awareness of the West Virginia Health Insurance Marketplace increased from 2013 to 2014. However, large percentages of respondents continued to be unaware of the availability of federal subsidies and were unsure of their personal eligibility for these subsidies. It is essential that awareness and enrollment efforts continue and that they be expanded in novel ways to continue growth in access to health insurance through the marketplace.

Changes in Cardiovascular Health in the United States, 2003-2011.

BACKGROUND: Cardiovascular disease is the leading cause of death in the United States, making improving cardiovascular health a key population health goal. As part of efforts to achieve this, the American Heart Association has developed the first comprehensive cardiovascular health index (CVHI). Our objective was to investigate the changes in CVHI in US states from 2003 to 2011. METHODS AND RESULTS: CVHI was examined using Behavioral Risk Factor Surveillance System data between 2003 and 2011 (odd-numbered years). Total CVHI decreased from 3.73±0.01 in 2003 to 3.65±0.01 in 2009. The majority of states (88%) experienced a decline in CVHI and an increase in the prevalence of "poor" CVHI between 2003 and 2009. Among CVHI components, the highest prevalence of "ideal" was observed for blood glucose followed by smoking, whereas the lowest prevalence of "ideal" was observed for physical activity and diet. Between 2003 and 2009, prevalence of "ideal" smoking and diet status increased, while "ideal" prevalence of blood pressure, cholesterol, blood glucose, body mass index, and physical activity status decreased. We observed statistically significant differences between 2009 and 2011, outside the scope of the 2003-2009 trend, which we hypothesize are partially attributable to differences in sample demographic characteristics related to changes in Behavioral Risk Factor Surveillance System methodology. CONCLUSIONS: Overall, CVHI decreased, most likely due to decreases in "ideal" blood pressure, body mass index, and cholesterol status, which may stem from low prevalence of "ideal" physical activity and diet status. These findings can be used to inform state-specific strategies and targets to improve cardiovascular health.

Exploring Health Insurance Status and Emergency Department Utilization.

Emergency department (ED) use, by both insured and uninsured, leads to significant health care costs in the United States. While frequent ED use is often attributed to the uninsured, there is some evidence that insured populations also report utilizing the ED when otherwise preventable or nonurgent. We conducted in-person surveys of patients visiting the ED at a large research hospital and examined the differences in their characteristics based on the health insurance status. While less than the uninsured, insured individuals still report barriers to access to care outside the ED that include lack of access to another health care facility and unavailability of a doctor's office or clinic.

Evaluation of West Virginia's Healthy Lifestyles Act Physical Education Component Using the YRBSS.

BACKGROUND: Public health researchers have demonstrated the potential for significant gains in physical activity through public policy. West Virginia passed House Bill 2816, known as the Healthy Lifestyles Act in 2005. This Act amended the code on the requirements of physical education and physical fitness in schools, creating minimum physical education requirements at each grade level. The goal of this policy evaluation was to identify if, 5 years postimplementation, students have increased physical education in schools. METHODS: Data from the 2003, 2005, 2007, 2009, and 2011 Youth Risk Behavior Surveillance System surveys were used to examine the time trend of weekly PE participation in WV Schools. RESULTS: There have been no significant changes in participation in physical education classes since before the implementation of the HLA. CONCLUSIONS: Simple policy changes by themselves may not effectively create change in physical activity environments, as policy is moderated by strength of language, implementation, and enforcement. Further studies are needed to determine why the HLA has not been successful in increasing physical activity of youth and what changes to the standards and mandates, ways implementation in schools could be improved, and/or the enforcement of these standards are needed for such policies to be successful.

Strategies for policy evaluation of health insurance marketplaces.

Millions of Americans have access to health insurance through new health insurance marketplaces. To serve the uninsured and underinsured populations, it is vital that key stakeholders put into place robust policy evaluation processes to capture data and provide timely feedback regarding exchange functions. This article lays a foundation for policy evaluation that includes health outcomes, economic outcomes, and consumer processes and perceptions. The evaluation methods outlined are easily adaptable to state, federal, and partnership marketplaces. The article provides a road map for insurance marketplace evaluation at any level and encourages a consistent approach that allows comparison across various marketplaces.

Awareness and Interest in the West Virginia Health Insurance Marketplace.

The objective of this study is to examine the level of awareness of and interest in the Health Insurance Marketplace in West Virginia. Primary survey data were collected in July/August 2013 from a stratified sampling of West Virginians. A mailed survey was completed by respondents in a cross-sectional study. Key variables included general awareness of the Health Insurance Marketplace and the availability of subsidies, the individual mandate, interest in using the Marketplace, and perceptions of respondents' ability to qualify for financial assistance. A total of 6000 surveys were mailed containing a 9-page questionnaire; 1198 completed surveys were returned. Two months prior to launch, awareness of the Health Insurance Marketplace was low in West Virginia, yet interest in the Marketplace was higher among those most likely to benefit--the uninsured and residents likely to qualify for financial subsidies. West Virginians reported being familiar with the individual mandate. Efforts should be increased among government and nongovernment organizations at the federal, state, and local levels to heighten awareness of the Health Insurance Marketplace in West Virginia and, particularly, the availability of subsidies. Many, once made aware, expressed interest in learning more.