Community Forum Identifies Opportunities to Engage with Eastern Kentucky Community Leaders about Chronic Disease and Environmental Pollution

Abstract

The NIEHS-sponsored Appalachian Health & Well-Being Community Forum held in Eastern Kentucky brought various community members together to communicate and establish better coordination of efforts to improve health and address regional environmental issues. The two-hour forum discussion provided bi-directional feedback about the needs and interests of community members. Top concerns of community members included obesity and obesity-related diseases and environmental pollution. Healthful lifestyles were identified as part of the remedy to protect health from potential adverse health effects associated with environmental pollution. This study highlights opportunities to engage with Appalachian communities around topics related to health and environmental pollution.

Introduction

The University of Kentucky Superfund Research Center (UK-SRC) encourages exchange of information with communities and meets the needs and interests of individuals and communities by providing educational support about nutrition, environmental issues, and other perceived areas of concern of community members through its Community Engagement Core (UK-CEC). Recently, UK-CEC had an opportunity to expand activities within Eastern Kentucky through its involvement in a National Institute of Environmental Health Sciences (NIEHS)-sponsored community forum (Schelp, 2017). NIEHS community forums… “provide a platform for an open dialogue to establish better coordination among the public and health professionals working on community exposures, industrial exposures, and other environmental issues” (Schelp, 2017).

Following a year of planning, interacting with, and listening to community leaders throughout Eastern Kentucky, UK-SRC held the two-hour Appalachian Health & Well-Being Community Forum to reflect the community’s needs and interests, to address well-documented and long-standing regional disparities in health and well-being, highlight the many promising community-level efforts that exist throughout Eastern Kentucky, and identify environmental and health concerns among the community members. The forum capped off a full day of tours and meetings with local health and environmental professionals in both Perry and Letcher counties in Eastern Kentucky (Figure 1).

Figure 1.

Map of Study Area

Eastern Kentucky is part of the Appalachian Region and has the geology to support coal mining. Therefore, residents are familiar with the economic benefits and hardships associated with coal mining including environmental pollution and health complications. Kentucky has potentially 1000 contaminated sites where there is either no known responsible or financially solvent party available to take action (Division of Waste Management, 2018); and in addition, Kentucky has 13 active Superfund sites listed on the National Priorities List. Eastern Kentucky in particular is also challenged by high rates of poverty, geographic isolation, low levels of education, low health literacy, limited grocery store access and few opportunities for physical activity (Halverson, Ma, & Harner, 2004). The burden of obesity-related chronic disease is higher in the Appalachian area of Kentucky relative to the rest of Kentucky and the nation (Foundation for a Healthy Kentucky, 2011–2016). The poor dietary practices of people in this area make them more susceptible to the health consequences of environmental pollution. Superfund pollutants have been found to contribute to increased risk for several chronic conditions (Hennig et al., 2007; Petriello et al., 2014; Ravoori et al., 2010). It is well known that nutrition impacts overall health and is essential in the prevention and management of chronic diseases. In particular, the consumption of phytochemicals which are found in plant-based foods have been shown to modulate the toxicity of environmental pollutants (Hennig et al., 2007; Hennig et al., 2012; Hoffman & Hennig, 2017). Given the unique challenges of this vulnerable Appalachian population it is important to learn from community members how UK-CEC can provide relevant resources to improve knowledge, attitudes and behaviors to reduce health risks linked to environmental pollution exposure using good nutrition.

The purpose of this study was to evaluate the Appalachian Health & Well-Being Community Forum to gain an understanding of forum attendees’ concerns regarding health, to learn of successes and on-going efforts, and to identify collaboration opportunities for the UK-CEC.

Methods

Community Forum

The forum was held at the Letcher County Cooperative Extension office, located in Whitesburg, KY (Figure 1). The community forum was publicized six weeks in advance in 4 neighboring counties (Harlan, Perry, Knott, and Pike) by posting flyers in local businesses, health clinics, extension offices and health departments; emailing the flyer to local government officials, health professionals and advocacy group leaders in each county; and advertisement in local newspapers and radio stations.

The two-hour forum consisted of written and verbal questions provided by the audience members to a four-member expert panel. The panel consisted of two local health officials, a nutrition expert, and a federal scientist. A rural health expert who was also a local community leader served as a moderator. During the forum, 20 questions from the audience were submitted in writing and/or verbally to the moderator.

Questionnaire

As participants arrived they were asked to complete and return an anonymous ten-page questionnaire before leaving the forum. The survey included questions from the validated Environmental Health Engagement Profile (EHEP) Kentucky Nutrition version (Jones et al., 2016). The EHEP assessed ways people engage in environmental health issues including people’s experiences, the risks, and protective actions taken to oppose environmental health hazards, individually and as a community. The EHEP consisted of five categories, Pollution Sensitivity, Pollution-Causes-Illness, Pollution Acceptance, Personal Environmental Action, and Community Environmental Action. Each category contained a Likert scale ranging from 0 to 10, with responses ranging from none to very serious, disagree to agree, and never do this to always do this. To assess community characteristics, the validated sixteen-question neighborhood assessment survey by Mujahid MS et al., was adapted and included to assess community characteristics that included the walking environment, physical activity opportunities, the availability of healthy foods, safety, and social cohesion (Mujahid et al., 2008). Responses to community questions were captured using a Likert scale; strongly agree, agree, neutral, disagree or strongly disagree. To assess frequency of fruit and vegetable consumption the Behavioral Risk Factor Surveillance System (BRFSS) questionnaire was included as a six-question self-administered format similar to Field et al., (Fields et al., 1998). The questions pertaining to self-reported health conditions were derived from the BRFSS questionnaire (United States Department of Agriculture, 2012) “Has a doctor, nurse, or other health professional EVER told you that you had any of the following health conditions?” The response categories included “yes” or “no”. Demographic information was also collected. Study activities were approved by the UK Institutional Review Board.

Data Analysis

Community Forum

Verbatim transcripts were created from the audio- and visual-recording of the forum. A thematic analysis of questions and responses was conducted. The transcripts were reviewed and coded independently by two coders, one of which was immersed in data collection and analysis. An initial code book was created by the first analyst. The second qualitative analyst independently reviewed and coded the transcript. The questions asked throughout the forum were analyzed to form open codes and each response was collapsed to axial codes to identify patterns and relationships of themes from within the data.

Questionnaire

Quantitative data was analyzed using SAS version 9.4. Descriptive statistics including frequencies, means, and standard deviations were calculated for demographic variables, EHEP, neighborhood characteristics and BRFSS survey responses. Goodness of Fit Chi-square analysis was used to detect significant differences between categorical variables. To detect significant correlations between continuous variables the Pearson correlation was used. A fruit and vegetable intake score was created from the BRFSS questions. The intake frequency was converted to an average of servings/week (0, 0.5, 1, 2, 3, 4, 5, 7, 14 or ≥ 21 servings/week) and then servings per day by dividing the weekly total by 7 days. The Likert scale categories for the community characteristics were condensed to three categories: strongly agree/agree, neutral, and strongly disagree/disagree. Differences were considered statistically significant at p ≤ 0.05.

Results

Of the 64 Appalachian Community Health & Well-Being Community Forum attendees, 30 represented local, regional or state organizations; 29 were affiliated with academic institutions including SRCs; and 5 audience members were NIEHS staff. Representatives from local organizations included 8 community programs of which 3 had an environment-focus; 1 local government agency; 2 media organizations; 1 health clinic; 1 health program; 2 regional community organizations with a health focus; 1 statewide health insurance company; and 2 regional education institutes (non-university).

Forum

The thematic analysis of the community forum transcript resulted in three major themes: concerns, solutions, and current programs. In order of mention during the forum, top concerns voiced were chronic diseases (21 mentions) and environmental pollutants (41). Table 1 summarizes proposed solutions and current programs voiced during the forum pertaining to top concerns. Health conditions such as Type 2 Diabetes, hypertension, and obesity were specifically identified as on-going health concerns. Community members expressed concerns between environmental issues and chronic diseases, poverty, air and water contamination, and using community engagement to improve situations of contamination. Community members were largely aware of the contamination issues that plague the region but were unsure of how to resolve them.

Table 1.

Chronic Disease and Environmental Pollution Identified as Top Concerns of Community Forum Audience.

Concern:	Solution and/or Current Programs	Quotes from Forum
Chronic Disease: Chronic disease, in a broad sense, was a major underlying concern of forum attendees regardless of the root cause of a particular chronic disease. Health conditions such as Type 2 Diabetes, hypertension, and obesity were highlighted as issues of concern.	Compliance to medical treatment and advice was suggested as a need and a solution because compliance to medical treatment and advice is low among patients at some regional healthcare facilities.	“Well, I think chronic care diseases is our problem and that is certainly led by diabetes which is fed by obesity and it spread out to high blood pressure. It’s just a myriad of diseases that all come in on that.” “I think poverty has to do with, it you have a chronic disease and your specialist is 2 hours away from you and you don’t have transportation to get around in your own community, how do you find the transportation to get there? ……‥ cancer patients that have had to go to Lexington and Louisville for treatment, and yes we can find transportation…‥ to get them there or a taxi that gets them there but they don’t have the money to eat on the day that they are there. They’re allowed to get on the bus but they can’t take anyone with them on the bus. So you go take a treatment for cancer and get back on a bus after you wait on everyone else to finish their treatment for that day and then climb back on that bus with no one to help you when you’re so sick to your stomach you can’t sit there and be able to make that trip back to the mountains. So, poverty does have a lot to do with access……”
	Good nutrition and physical activity were offered as solutions to preventing and managing chronic diseases, but barriers to engaging in healthy lifestyles were also discussed.	“That is not for people sitting in the crowd; that you are a normal weight to think ‘oh it’s not my problem, I am a healthy weight, I can eat what I want,’ that is not at all the case. Your diet matters, no matter what size you are. Physical activity matters, no matter what size you are.” Because folks of lower socioeconomic status have so many different struggles to deal with, its going back to what Fran is saying, is trying to understand what is going on in their world and as you’re learning that just meeting them where they are at. “Everything that you look at in chronic disease management has to do with poverty; you know the access to the things that you need, just because the service is there, our clinics are there, doesn’t always mean that the people can get through the door or that they know how to get through the door.” “…. it is challenging to bring about change and to break habits, it is hard to get people to change their lives when we are talking about fresh fruits and vegetables and those things. It is hard, …‥, to get people not to smoke. It is hard to bring about change but that is what we are about.” “So poverty does have a lot to do with access, it has a lot to do with what they learn, what they hear. We can’t use big medical terms to teach people prevention, we have to use terms that people can use on an everyday language that we know that they understand and what we are trying to say to them and that they can understand.” “So for example, if you do have the opportunity to talk to them about nutrition, you wouldn’t start with the National recommendations of trying to get 9 to 11 servings of fruits and vegetables but you’re going to start at are you able to get 1, and what’s available to you? It doesn’t matter, sure, fresh would be nice but if there’s canned fruit and vegetables available to you by going to your food pantry then encourage those option.”
	**The FARMACY™ program, implemented in several rural communities to combat chronic diseases, does so by making fresh fruits and vegetables available at no cost to qualifying patients suffering from a chronic health condition and are at or below the poverty line. Officials associated with the FARMACY™ program reported health improvements among participants.	“One example of that is a program called the Farmacy program and that is F-A-R-M-A-C-Y …‥ This program is a way that people with chronic disease who are at or below the poverty level can obtain free to them fresh fruits and vegetables from the local farmers market. The ideal being that the nutritional aspect of being able to eat fresh fruits and vegetables throughout the summer will have a positive impact and it does. Last year we’ve had positive results and I remember one stat off of the top of my head those participants we had had a 25% drop in blood pressure. This year we have expanded the program …‥”
Environmental Pollution: Community members discussed that the water is unsafe to drink and is also unsafe for recreational activities. Hence, a lost opportunity for physical activity. Water quality also affects families that are living in poverty that cannot afford to purchase bottled water or adhere to advisories. Air pollution and coal mining were two other sources of environmental pollution that were discussed, specifically the burning of coal and its impact on health and exacerbating chronic diseases. Although, at this time there are fewer coal mines in operation than previously.	Community engagement was offered as potentially being the most effective solution for addressing environmental pollution because it is an opportunity to make sure voices are heard, especially by those that can impact policy changes.	“I also had creeks that I got to play in, and didn’t care a bit to get in it barefoot, didn’t care a bit to jump in it and swim. I wouldn’t do that today for any reason or wouldn’t encourage anybody to do that and look at what we’ve lost by the recreation that we don’t have to be able to use our waters to put our boats in, and to ski, and those things that we would like to do that are physically active to keep us moving.” I’ve just been thinking about all these ways to be well, we really have to address some of the really serious environmental problems in our area. You can’t drink the Kentucky River, since Headwaters here, you really aren’t even supposed to go in it, I don’t think. There are studies that showing mining has health impacts, it’s easy to get feeling hopeless, like how as an individual, can I clean up the river or I can do this and that? So, we really need to get these things out, I think, and then find out ways on the local level, and the state level, and the federal level that we deal with these really big problems.” “You know some of these issues, the water can be cleaned up, it takes a will and it takes community action and then it takes policy change but I can think of in certain other major river systems in the US where there has been a really bad contamination, the waters may not be perfect anymore; I would not want to drink from the Hudson river anymore, but much in the Hudson you can swim in it, you can boat in it, and they are saying you might even be able to fish in it and that’s because some of the sources of pollution, both sewage and chemical pollution have been taken care of. So, I don’t think that you know feeling hopeless is going to help but actually starting to try and do something about it, working with the people who have the ability to do something to it, starting to make your voices heard, …” So I think there’s no simple answer but you all have to work together, in other words, it’s a problem for everybody.” “But also, just getting the conversation going in the community and getting that conversation that here is where you go for treatment, here is the things that we can do.”
	Collaboration with other disciplines including academic partnerships was also offered as a way to address environmental pollution.	“But, I would say you have some great partners at the University of Kentucky, you also have some great partners potentially, for example, Louisville, University of Louisville, and at some of your other universities and you know there could be people… Kentucky is not very far from North Carolina, I mean I understand it’s just a 6 hour drive, we have some opportunities to partner with people from other parts of the country, certainly in other parts of the mountains, as well. I hope that helps.”
	The Watershed Watch program, was cited as an ongoing program to improve water quality. The statewide organization coordinates a citizen monitoring program to improve and protect water quality through community awareness.	You know it’s not just industry that we look at in our waters and in our headwaters, we had two really good presenters today at the center that talked about how they’re measuring the contaminants in the water and E.coli is there because we still have straight pipes that are going into our rivers.
	Panelists also offered that funding is necessary to create programs and organizations to improve the pollution in the region and emphasized the importance of grant writing to provide necessary financial resources	“I think in southeastern Kentucky, we are very very interested in the environmental problems that you are dealing with here. We fund, as I said, 12 million dollars’ worth of work in Kentucky. Give us some more proposals and we will probably start funding more.”
	One panelist, representing UK-CEC, discussed the importance of healthy nutrition to combat the detrimental health effects of environmental pollution.	“I just wanted to add really quick that this isn’t an answer to what you can do to stop the contamination but in the event that you are exposed to environmental contaminants, whether it’s air pollution, PCB’s, TCE’s, just going back to a healthy diet. Fruits and vegetables contain component that can help detoxify these different chemicals that you are exposed to. So as you are working as a community to clean up areas to eliminate that toxic waste, just again eating healthy can very much make a difference.”

^**Through the FARMACY™ program, the Mountain Comprehensive Health Corporation (MCHC) located in Eastern Kentucky offers free fruits and vegetables to their qualifying participants by providing vouchers that can be redeemed at the local farmer’s market. To qualify for vouchers a MCHC patient must be a pregnant woman regardless of income; Type 1 diabetic regardless of income; diagnosed with Type 2 diabetes, obesity, and/or hypertension AND their income falls below 100% of the Federal Poverty Guidelines.

Questionnaire

The questionnaire was completed by 20 community members from Letcher and surrounding counties. Table 2 summarizes the results of the EHEP questionnaire. The average age of questionnaire respondents was 48 ± 3.77 years, BMI 29.5 ± 1.33, 68% female, 80% possessing a bachelor’s degree or graduate/professional degree. The top self-reported health condition was arthritis (30%) and average daily consumption of total fruits and vegetables was 5.0 ± 0.50 servings per day.

Table 2.

Average of Each Pollution Category and Indicator of the Environmental Health Engagement Profile (EHEP) Kentucky Nutrition Version.

Category	Mean ± SEM
POLUTION SENSITIVITY SCALE (5.67 ± 0.32; 0- none of this kind of pollution in community to 10 - very series issue)
Asbestos in buildings	5.65 ± 0.53
Toxic places like abandoned factories or dumps	7.15 ± 0.57
Improper disposal of garbage or hazardous waste	7.75 ± 0.51
Chemicals in rugs, furniture, and car upholstery	4.75 ± 0.46
Pesticides- insect sprays, lawn chemicals, etc.	5.35 ± 0.47
Mold in buildings	6.85 ± 0.43
Radiation from nuclear power plants	0.75 ± 0.52
Contaminated drinking water	8.35 ± 0.89
Pesticides, hormones, antibiotics in our food	6.60 ± 0.57
Polluted rivers, harbors, lakes, or ocean	8.15 ± 0.40
Air pollution from factories and power plants	4.00 ± 0.73
Lead from peeling paint	5.55 ± 0.49
Animal-waste-pet droppings, farm animal manure	3.55 ± 0.40
Air pollution from trucks, buses, and cars	4.95 ± 0.52
Chemicals in food and beverage containers, such as cans and plastic bottles	5.90 ± 0.46
PCBs from landfills or from discarded electrical equipment getting into water and food	5.74 ± 0.57
Contaminants such as pesticides in fruits and vegetables	5.45 ± 0.55
Contaminants like mercury, dioxin or PCBs in fish, meat or poultry	5.42 ± 0.62
POLLUTION CAUSES ILLNESS SCALE (6.27 ± 0.37; 0 disagree completely to 10 - completely agree)
When people get sick, it is often because of pollution in the environment	6.10 ± 0.60
The mental development of children is harmed by toxins in the environment	7.00 ± 0.62
Many people in my community have health issues because of the pollution	7.20 ± 0.49
The air in my community looks or smells polluted.	3.21 ± 0.52
Most cancer is caused by pollution in the environment	5.79 ± 0.52
The drinking water in my community causes health issues	7.11 ± 0.76
People who work with chemical often get sick from it	7.74 ± 0.58
Asthma is made worse by pollution in the air	8.05 ± 0.57
Some schools in my community are contaminated and unhealthy	6.42 ± 0.55
The environment where I work might hurt my health	3.74 ± 0.67
People should worry about toxic things in their homes	7.15 ± 0.60
I spend time worrying about pollution being bad for my health	6.15 ± 0.62
People may get sick because they don’t eat the right foods to protect themselves from pollution	6.11 ± 0.71
POLLUTION ACCEPTANCE SCALE (2.32 ± 0.40; 0 disagree completely to 10 - completely agree)
Pollution is just a part of modern life, so we can’t do much about it	1.88 ± 0.54
I don’t consider environmental issues nearly as important as other issues in my family or community	2.43 ± 0.51
I am too busy to do anything about how the environment affects health	2.23 ± 0.56
People don’t need to worry about toxic things, because our bodies can overcome the toxins	1.73 ± 0.54
People often exaggerate the amount of sickness caused by pollution	1.93 ± 0.46
Many people I know don’t seem to get sick, even though they don’t try to keep contaminants out of their food.	3.45 ± 0.65
If you want to eat a normal diet, you can’t spend any time worrying about contaminants in your food	1.93 ± 0.57
Eating a healthy diet will not make a difference in my health if I live near pollution	3.13 ± 0.65
PERSONAL ENVIRONMENTAL ACTION SCALE (6.35 ± 0.32; 0 never do it to 10 - always do when it makes sense)
I stay away from a place if I think the air will be especially dirty there.	6.35 ± 0.64
To keep out bad air, I close my windows.	3.20 ± 0.64
I drink water that is bottled or filtered- not just from a faucet.	8.65 ± 0.49
I avoid being around people who are smoking.	7.15 ± 0.71
I avoid using inspect sprays and pesticides because they could make people sick.	7.65 ± 0.59
I limit how much fish I eat because fish might contain toxic chemicals	4.50 ± 0.56
I talk to my doctor or nurse about how to reduce the effects of pollution on my health.	2.30 ± 0.62
I pick up trash that I see in the street or around my community.	6.90 ± 0.60
I do what is necessary to make sure my home is free of toxins, like lead and radon.	7.05 ± 0.71
I eat healthy foods to make up for the effects of pollution.	6.15 ± 0.68
I wash my fruits and vegetables thoroughly before using them.	8.20 ± 0.35
I try to eat 5 or more servings of fruits and vegetables every day.	7.80 ± 0.56
I eat organically grown food as much as I can.	6.95 ± 0.55
COMMUNITY ENVRIONMENTAL ACTION SCALE (6.84 ± 0.38; 0 never do it to 10 - always do when it makes sense)
I join with other is trying to keep polluting businesses out of our community.	6.38 ± 0.70
I attend meetings about environmental health issues in my community	7.33 ± 0.47
When something is polluting our community, my neighbors and I get it stopped	4.28 ± 0.52
I tell others about how the environment can affect health.	7.03 ± 0.43
I talk with my friends and neighbor about how we can get healthier foods in our town.	8.43 ± 0.39
I talk with my friends and neighbors about how we can get cleaner in our town.	7.63 ± 0.59

Top 5 indicators in each category are bolded. Italicized are nutrition-related indicators. SEM = standard error of the mean.

Scores of 8 – 10 for each indicator within the EHEP categories, or 0 −2 for the Pollution Acceptance scale, were considered highly ranked. The category with the most robust responses was Pollution Acceptance, 2.32 ± 0.40, low scores indicate people strongly agree that exposure to pollution is avoidable. Community Environmental Action, 6.84 ± 0.31, shows the extent to which people collaborate with others to reduce environmental health threats in the community; and Personal Environmental Action, 6.35 ± 0.32, demonstrates the extent to which people take precautions to protect themselves from environmental hazards. Among the 16 nutrition indicators only 4 were rated within the top five of a given pollution category. Among the community characteristic assessment, social cohesion had the highest level of agreement, with 100% agreeing that “people around here are willing to help their neighbors” and only up to 10% of people disagreeing that people share the same values. (Table 3).

Table 3.

Neighborhood Characteristics

Statement	Strongly Agree/Agree (%)	Neutral (%)	Strongly Disagree/Disagree (%)
Walking Environment
My community offers many opportunities to be physically active.	65.00	5.00	30.00
Local sports clubs and other facilities in my community offer many opportunities to get exercise.	75.00	0.00	25.00
It is pleasant to walk in my community.	80.00	10.00	10.00
The trees in my community provide enough shade.	80.00	15.00	5.00
In my community it is easy to walk places.	30.00	20.00	50.00
Physical Activity Opportunities
I often see other people walking in my community.	65.00	5.00	30.00
I often see other people exercise (for example, jog, bicycle, play sports) in my community.	55.00	5.00	40.00
Availability of Healthy Foods
A large selection of fresh fruits and vegetables is available in my community.	60.00	15.00	25.00
The fresh fruits and vegetables in my community are of high quality.	55.00	25.00	20.00
A large selection of low fat products is available in my community.	50.00	25.00	25.00
Safety
I feel safe walking in my community day or night.	70.00	5.00	25.00
Violence is not a problem in my community.	35.00	35.00	30.00
My community is safe from crime.	42.00	21.00	37.00
Social Cohesion
People around here are willing to help their neighbors.	100.00	0.00	0.00
People in my community can be trusted.	85.00	10.00	5.00
People in my community share the same values.	40.00	50.00	10.00

A strong and significant correlation was observed between Pollution Sensitivity and Community Environmental Action (r= 0.808, p=0.0001, Table 4), which indicates those noticing environmental hazards tend to take community action. As well, Pollution Sensitivity was also strongly correlated with the Pollution Causes-Illness scale (r= 0.686, p=0.001), which suggests an association between noticing environmental hazards and having concerns about the health effects. Strong correlations between Community Environmental Action and Pollution Causes-Illness (r=0.661, p=0.002) indicates that those having concerns about the health effects of pollution tend to take community action, and lastly, a moderate correlation emerged between Personal Environmental Action and Fruit and Vegetable Intake (r=0.479, p=0.03) demonstrating that those consuming more fruits and vegetables are more likely to take personal environmental action. The data also demonstrated that each community characteristic category was moderately to strongly, negatively and significantly correlated to the number of self-reported health conditions. Community characteristics, however were not correlated to pollution categories, fruit and vegetable intake or BMI (data not shown).

Table 4.

Correlations Among Pollution Categories, Fruit and Vegetable Consumption, BMI and Self-Reported Health^*

	Pollution Sensitivity Scale	Pollution-Causes-Illness Scale	Pollution Acceptance Scale	Personal Environmental Action Scale	Community Environmental Action Scale	Fruit & Vegetable Score	BMI	Self-reported Health
Pollution Sensitivity Scale	M=5.67 SEM=0.32	0.686 0.001	0.24084 0.306	0.25001 0.2877	0.80778 0.0001	0.13320 0.5756	0.21634 0.3596	0.04744 0.8426
Pollution-Causes-Illness Scale		M=6.27 SEM=0.37	0.18117 0.4446	0.03137 0.8955	0.66136 0.0015	0.07620 0.7495	0.04516 0.8501	0.18391 0.437
Pollution Acceptance Scale			M=2.32 SEM=0.40	0.31627 0.5492	−0.26129 0.7508	−0.23012 0.3920	0.04113 0.8633	−0.37550 0.1028
Personal Environmental Action Scale				M=6.35 SEM=0.32	0.31627 0.1743	0.47419 0.0347	−0.26129 0.2658	0.06995 0.7695
Community Environmental Action Scale					M=6.84 SEM=0.38	0.33358 0.1506	0.06763 0.7770	−0.13686 0.5650
Fruit & Vegetable Score						M= 5.0 SEM= 0.50	−0.09978 0.6756	−0.07038 0.7681
BMI							M= 29.5 SEM= 1.33	0.04113 0.8633
Self-reported Health								M= 0.80 SEM= 0.26

^*The indicators for each pollution category were averaged to generate the mean for each pollution category; the fruit and vegetable categories were averaged and divided by 7 days; and the sum of the self-reported health conditions were averaged. M= mean for each category and SEM = standard error of the mean for each category.

Significant correlations, p ≤ 0.05 are in bold text.

Discussion

The UK-CEC sought to understand the health concerns and ongoing efforts by Appalachian community leaders to address their concerns, and to identify collaboration opportunities between the CEC and community leaders to promote healthy lifestyle behaviors. To do this the UK-CEC participated in the planning, execution and evaluation of the Appalachian Health & Well-Being Community Forum, which encouraged communication between the public and an assembled panel of experts. The forum audience was primarily composed of community leaders as evidenced by their organization affiliations. Their position as community leaders explains the high percentage of attendees have college degrees, which is uncharacteristic of eastern Kentucky (United State Census Bureau, 2017). The top concerns of forum attendees were the high prevalence of obesity and obesity-related chronic diseases, the underlying role of poverty and environmental pollution.

The community forum audience emerged as a critical audience for UK-CEC to target their engagement activities, not only because of their great concern about the health impacts of environmental pollution, but because they are the influential gatekeepers to the other citizens of the community (Pavlova, 1993). During the forum discussion community members named better nutrition as part of the solution to decrease and manage chronic diseases. A starting point with these stakeholders would be to reinforce their beliefs of healthy lifestyle choices being necessary to prevent and manage chronic diseases and to build upon the belief that environmental pollution has damaging health consequences while adding the concept that good nutrition helps negate these negative health effects of environmental pollution. The strong and significant correlations between the Awareness of Pollution category and taking Personal and Community Action supports the notion that community forum attendees are motivated to implement behavior change strategies at the individual and community levels. Therefore, educating the gatekeepers of the community about the relationship between good nutrition protecting health against environmental pollution is a necessary first-step in order to reach other pockets of citizens within their community.

Beyond the discussion during the forum, the results of the EHEP questionnaire (Table 2) provided additional information (from questionnaire respondents) about environmental health engagement, or the way and extent of concern people have regarding environmental hazards (Jones et al., 2016) including the motivation to adopt appropriate protective dietary strategies that improve health and mitigate the effects of environmental insults (Jones et al., 2016). The middle to high rankings for each pollution category observed in the current study indicates this Appalachian community to have substantial awareness of environmental hazards, their health risks, and have greater inclination to take personal and community environmental action. This is not surprising as the majority of audience members had college/professional degrees, were affiliated with environment-focused programs or organizations, and were residents of a coal-producing area of Appalachian Kentucky. Previous studies have found a positive correlation between education level and environmental concern (Fransson & Garling, 1999) as well as when residing in the vicinity of environmental hazards (Fransson & Garling, 1999; Jones et al., 2016) and having certain political-ideology (Maloney, Ward, & Braucht, 1975). An identified strength of this group was their strong social cohesion, as evidenced by 100% of questionnaire respondents strongly agreeing that people in their community were willing to help their neighbors and 85% strongly agreed/agreed that people in their community can be trusted. Social capital, in which social cohesion is a subset, provides a platform to enforce and/or reinforce group or social norms for positive health behaviors (Lindstrom, 2008). Previous studies have shown social capital to be associated with positive health behaviors, in particular fruit and vegetable consumption (Kawachi, Kim, & Subramanian, 2008; Lindstrom, 2008; Poortinga, 2006). In addition, the community characteristics portion of the questionnaire showed strong and significant negative correlations between each community characteristic and self-reported health. Therefore, those with fewer health conditions reported higher community attribute scores in the dimensions of walking environment, availability of healthy foods, safety and social cohesion. This finding is similar to Mujahid MS who reported lower incidence of hypertension among residents that reported better neighborhood characteristics (Mujahid et al., 2008). These results indicate that community leaders should highlight the positive attributes of their communities to citizens while encouraging social participation as this can lead to increased social cohesion. A study by Lindstrom suggested that a high level of social participation can establish a platform in which healthy lifestyle choices is the social norm thereby making it easier for people within the social network to opt for healthy choices even if they are of low socioeconomic status (Lindstrom, Hanson, Wirfalt, & Ostergren, 2001). Interestingly, in this study, respondents reported an average intake of 5 servings of fruits and vegetables per day, which falls short of the current Dietary Guidelines for Americans recommendation of 9 – 11 servings/day (U.S. Department of Health and Human U.S. Department of Health and Human Services, 2015), but is much higher than state (1 serving of fruit/day and 1.5 servings of vegetables/day) and national levels (1.1 servings of fruit/day and 1.6 servings of vegetables/day) (Centers for Disease Control and Prevention, 2013). Their moderate consumption could be attributed in part to this group’s high level of social participation, which is assumed to be high because of their presence at the forum and their reported elevated Community Environmental Action scores.

The Pollution-Causes-Illness portion of the questionnaire showed strong concerns with contaminated water. Correspondingly, the Personal Action portion of the questionnaire showed respondents are mindful in seeking safe drinking water sources and avoiding other sources of environmental pollution. In addition, Table 1 summarizes forum discussion about water noting that as a recreational resource, water use has been lost to the community due to environmental pollution. Lastly, the Pollution Acceptance portion of the questionnaire indicates that respondents are unwilling to accept pollution in their community, which suggests UK-CEC can consider ways to support the community in achieving their goals to eliminate pollution.

Limitations of the current study include a small sample of questionnaire respondents, few average citizens attended the forum, and limited attendance by stakeholders from surrounding counties. Despite these limitations, the results of the current study clearly demonstrate the opportunities for the UK-SRC to continue engaging with these community stakeholders in Eastern Kentucky to foster social cohesion and bring to the forefront the connection among good nutrition, environmental pollution, and health.

Conclusion

The Appalachian Health & Well-Being Community Forum and the associated EHEP questionnaire provided bi-directional feedback about the informational needs and interests of community members. Community leaders in the Appalachian Region of Eastern Kentucky have substantial awareness and concern regarding the health effects associated with environmental pollution, particularly air and water pollution. Furthermore, community leaders recognized the role of nutrition and physical activity as being key components to preventing and managing chronic conditions. As such, these results indicate that UK-CEC’s mission to meet the needs and interests of individuals and communities by providing educational support about nutrition, environmental issues, and other perceived areas of concern of community members is well-suited for communities in Letcher and surrounding counties.