Community-Engaged Research and Action to Reduce Respiratory Disease in Appalachia

Central Appalachian residents experience the nation’s highest rates of serious respiratory illnesses. Compared to the overall US population, Appalachian Kentuckians are 50% more likely to be diagnosed with adult asthma and chronic obstructive pulmonary disease. Growing evidence from regional epidemiologic studies suggests associations between these health inequities and residence in coal mining areas. However, this body of research is based primarily on ecologic studies, and thus is limited by an absence of individual, quantitative exposure assessment data for Appalachian residents. Furthermore such studies have not adequately controlled for important behavioral risk factors (smoking, diet, physical activity) and social determinants (extremely low socioeconomic status, occupation, age, gender) for respiratory illness. Appalachian Kentuckians have long recognized their vulnerability to these health disparities, voicing considerable concern about environmental exposures that may impact their respiratory health. Such recognition was the impetus behind the creation of the proposed research to action proposal and the organization of CREEEK (Community Response to Environmental Exposures in Eastern Kentucky), our community partner for the proposed study. To date, researchers have struggled to design studies examining the role of environmental exposures and behavioral and social determinants affecting health in Appalachia and develop strategies to reduce these inequitable rates of respiratory disease. To address the critical need to reduce respiratory health disparities, we propose three interrelated steps: (1) to investigate the extent, nature, and source of respiratory health inequities, we will implement a community-engaged assessment of environmental and individual-level exposures; (2) to enhance community knowledge about respiratory illness and refine a culturally appropriate environmental public health action strategy (EPHAS), we will conduct community dialogue and input sessions; and (3) to test the efficacy of this EPHAS, we will use a quasi-experimental pre-post intervention to measure improvements in respiratory health and other outcomes. Our long term goal is to sustainably leverage our community partnerships to reduce respiratory disparities in rural Appalachia. Aim 1: Within our academic-community partnership, conduct a community-based epidemiologic assessment to investigate the relationships between indoor and outdoor air pollutants and behavioral and social determinants on the risk of respiratory illness, especially asthma and COPD, among adults in rural Appalachia. Associated Activities: Environmental exposure assessment, including indoor and outdoor air-borne contaminants and behavioral and social determinant assessment, undertaken by community members using neighborhoods or hollows as the unit of analysis. Aim 2: Disseminate results to a broad array of community stakeholders to improve scientific understanding of environmental exposures. During this aim we will refine the EPHAS, a strategy developed in collaboration with community partners to reduce respiratory illness. Associated Activities: Follow-back reports, Community forums, CAB meetings, leading to a refined EPHAS. Aim 3: Implement and evaluate the EPHAS as assessed by the project’s impact on short and long term respiratory health outcomes and extent of community participation and satisfaction. Specific outcomes include: (1) appropriate health care use; (2) improvement in quality of life; (3) improvement in pulmonary function; (4) increase in respiratory illness knowledge and self-efficacy; (5) extent of community participation; and (6) satisfaction with programming. Associated Activities: Baseline-posttest quantitative outcomes assessment and qualitative process evaluation with 500 households. This community-academic effort represents the first of its kind to undertake a comprehensive environmental, behavioral, and social determinants assessment, leading to a community-endorsed environmental public health action strategy to rectify Appalachian respiratory illness disparities