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Obesity risk factors for women living in the Appalachian region: an integrative review.

INTRODUCTION

Obesity is a contributing factor in many chronic illnesses that lead not only to poorer health outcomes, but also to higher health care costs. In 2000, the estimated medical cost of obesity was $117 billion. Obesity has both direct medical costs (prevention, diagnosis, treatment services) and indirect costs (mortality and morbidity) (Center for Disease Control and Prevention, 2009). Obesity is a complex epidemic rooted in biological, social, and economic factors. The Social Determinants of Health framework (Wilkinson &Marmot, 2008) suggest that individuals who live in poverty experience shorter life expectancy and poorer health than the more affluent. The Appalachian region is largely rural and characterized as having high poverty rates, low educational attainment, aging population and high rate of chronic illness (Tessaro & Smith, 2005).

Life expectancy for women living in the Appalachian region has seen a decline in recent years, and obesity and obesity-related illnesses have been cited as major contributors. The prevalence of obesity among white women in the Appalachian region is estimated at 6.9% to 25%; among black women it is estimated at 11.3% to 47.1% (Halverson et al, 2004). Five

Appalachian states (AL, MS, SC, TN, and WV) have overall obesity prevalence rates equal to or greater than 30% (Centers for Disease Control and Prevention, 2009; Halverson et al., 2004; Ezzatil et al., 2008). Race seems to be a risk factor in obesity, with prevalence for white women in the Appalachian region estimated at 6.9% to 25%, while among black women prevalence is estimated at 11.3% to 47.1%. Many biological, socio-cultural and economic factors play a role in the development of obesity among women, including weight gain associated with pregnancy, menopause, estrogen metabolism, a sedentary lifestyle, and socio-economic status. The health consequences of obesity include coronary heart disease, type 2 diabetes, cancers (including breast and colon), respiratory problems, hypertension, and stroke, all contribute to the disparities in life expectancy for Appalachian women (Halverson et al., 2004; Centers for Disease Control and Prevention, 2009).

The Appalachian region is mostly white, with some representation of blacks and Native Americans (Denham, Meyer, Toborg, & Mande, 2004). The region includes 420 counties that follow the spine of the Appalachian Mountains, which spread across parts of 12 states and all of West Virginia. Eighty- two of these 420 Appalachian counties are considered distressed counties (Appalachian Regional Commission, 2010). Forty-two percent of the people living in the Appalachian Region are in rural areas, as compared with 20% of people in the US as a whole (Appalachian Regional Commission, 2010a). Poverty rates in the region range between 13 and 27%. The number of residents with at least 12 years or more of education ranges from 68 to 77%, (Appalachian Regional Commission, 2009) and most people are employed in blue-collar jobs. Unemployment is high, with many families dependent on public assistance and Supplemental Security Income (SSI) for disability. Residents have limited access to health care. This is the nation's most economically depressed and medically underserved area, with proportionately more counties considered distressed than in the rest of the nation (Bagi, Reeder, & Calhoun, 2002).

From this perspective, the lives of Appalachian women are shaped by the distribution of money, power and resources, and these forces are responsible for health inequities in this population, including obesity. This review presents what is currently known about factors that contribute to the high obesity levels among Appalachian women, identifies best practice interventions, and recommends areas for future research.

METHODS

A comprehensive literature search was conducted for the years 1989 to 2009 using four electronic databases: CINAHL, ERIC, Medline, and Academic Search Premier. We used the keywords (mesh terms): "Appalachian region" AND "women" OR "female" AND "obesity", OR "female" AND "mortality", with and without and "obesity".

The following criteria were used for inclusion in the review: (a) adult population (19+ years old); (b) randomized controlled trial, observational study, epidemiological study, qualitative study, or secondary analysis of data from the Appalachian region; (c) original report, not a review or meta-analysis; and, (d) findings reported separately for women. The search returned a total of 926 hits; however, only 8 studies met the inclusion requirements. They are summarized in Table 1.

RESULTS

The eight studies were conducted in the Appalachian region between the years of 2002 and 2009. Five studies used a combination sample from both rural and urban settings in the region(Armstrong, et al., 2004; Denham, et al., 2004; Ezzatil, Friedman, Kulkarni, & Murray, 2008; Halverson, Barnett, & Casper, 2002; Ramsey & Glenn, 2002). Three studies were conducted only in rural settings (Schoenberg, Hatcher, & Dignan, 2008; Tessaro, et al., 2007; Tessaro & Smith, 2005). One study was conducted in West Virginia and did not state whether the sample was from a rural or urban setting; however, the majority of the counties in West Virginia are rural(Rye, Rye, Tessaro, & Coffindaffer, 2009). Five studies were quantitative, using secondary analysis descriptive designs (Armstrong, et al., 2004; Ezzatil, et al., 2008; Halverson, et al., 2002; Ramsey & Glenn, 2002; Rye, et al., 2009). Two studies were qualitative and used ethnographic designs (Denham, et al., 2004; Schoenberg, et al., 2008). Only one study was an intervention study (Tessaro, et al., 2007). Four studies reported on biological factors that were associated with obesity in Appalachian women, (Ezzatil, et al., 2008; Ramsey & Glenn, 2002; Rye, et al., 2009; Schoenberg, et al., 2008) and four studies reported on socio-cultural factors associated with obesity in these women (Armstrong, et al., 2004; Denham, et al., 2004; Halverson, et al., 2002; Tessaro, et al., 2007). Two studies obtained samples from the National Center for Health Statistics (Armstrong, et al., 2004; Ezzatil, et al., 2008).

Adult Appalachian women were included in all eight studies, and the range of participants' reported ages in the studies was 40-64 years. The highest level of education reported in three studies was high school (Ezzatil, et al., 2008; Rye, et al., 2009; Schoenberg, et al., 2008). Four studies did not report the level of education of participants (Armstrong, et al., 2004; Denham, et al., 2004; Halverson, et al., 2002; Tessaro, et al., 2007). Only two studies compared Black and White women, and in both of these studies the majority of participants were white women (Ramsey & Glenn, 2002; Schoenberg, et al., 2008). Two studies did not report the race of participants (Ezzatil, et al., 2008; Tessaro, et al., 2007). In three studies the majority of women earned an annual income less than $20,000 (Ramsey & Glenn, 2002; Schoenberg, et al., 2008; Tessaro et al, 2007).

Four studies found a decrease in life expectancy for Appalachian women and an increase in chronic illnesses related to obesity (Armstrong, et al., 2004; Ezzatil, et al., 2008; Halverson, et al., 2002; Schoenberg, et al., 2008). One study found that women living in rural regions had the highest rate of obesity (Ramsey & Glenn, 2002).

Socio-cultural Factors Related to Obesity in Appalachian Women

Physical Activity. Many Appalachian residents do report engaging in some type of physical activity. According to the Behavioral Risk Factor Surveillance System, when residents of Appalachian states were asked if they participated in any form of exercise in the past month, an average of 27.33% reported "no"(CDC, 2008). When examining women, the Appalachian Regional Commission (2004) reported 19.6% to 58% of white Appalachian women are physical inactivity, as compared to 12.9% to 54% of white women in the nation. Also, 35.8% to 67.2% of Appalachian black women reported physical inactivity, as compared to 25.4% to 58.1% black women in the nation. Some studies have found relationships between the lack of physical activity and long work hours, low motivation or will power, and lack of resources to participate in regular exercise, such as fitness centers, walking paths or bike paths (Rye, et al., 2009; Schoenberg, et al., 2008).

Using a cross sectional survey design, Rye and colleagues examined barriers to physical activity among low-income Appalachian women aged 40 to 60 years (n=733). Lack of support and lack of willpower were the greatest barriers to physical activity. Interestingly, among these women, lack of time was not perceived as a major barrier to physical activity.

Schoenberg and colleagues interviewed 52 middle-aged rural Appalachian women in focus groups. Women perceived that lack of character or intelligence contributed to low physical activity. Further, they said cable TV and the Internet had replaced walks to visit neighbors. Long work schedules and insufficient resources such as fitness centers also contributed to sedentary lifestyle.

Diet/Nutrition. Residents of the Appalachian region are often older, with higher poverty rates, and more limited access to healthcare than their non-Appalachian counterparts (Armstrong, et al., 2004; Ezzatil, et al., 2008; Halverson, et al., 2002; Ramsey & Glenn, 2002). The association between poverty and obesity may be related to the low cost of energy dense foods. Many Appalachian women report eating fewer fruits and vegetables, more red meat, and more foods high in saturated fats than their non-Appalachian counterparts (Schoenberg, et al., 2008; Wewers, Katz, Paskett, & Fickle, 2006). People with lower incomes are more likely to be able to afford these non-nutrient energy dense foods, including refined grains and foods containing high fat and sugar. They are less likely to be able to afford lean meats, fish, fresh vegetables, and fruits. In the studies, Appalachian residents said that overeating, defined as frequently consuming high calorie foods, was often a problem (Schoenberg, et al., 2008; Wewers, et al., 2006). Moreover, many women reported being taught to prepare traditional Appalachian foods, with recipes handed down through generations for cornbread, fried potatoes, biscuits and gravy, stack cakes, chicken "n' dumplings, and grilled cheese sandwiches, all dense with calories to sustain those performing heavy manual labor (Ramsey & Glenn, 2002; Schoenberg, et al., 2008; Tessaro, et al., 2007).

Education and Socioeconomic Status. The women living in the Appalachian region received less primary education as compared to other parts of the nation (Ramsey & Glenn, 2002; Rye, Rye, Tessaro, & Coffindaffer, 2009). Ramsey & Glenn, 2002, found that obese women often had less primary education. Often women living in urban and suburban areas with higher income level have more education and report better health than women living in rural areas. As noted earlier, the Appalachian region has high poverty and low education levels (Ramsey & Glenn, 2002).

Cultural Norms. The Appalachian community also holds values that are related to obesity; cultural heritage influences food choices. Two studies reviewed here concluded that the Appalachian family is the central unit for making decisions about food selection and preparation. The mother plays the dominant role in the family, and other members of family learn from the mother's choices (Denham, et al., 2004; Schoenberg, et al., 2008), which tend to be high calorie.

Effects on Mortality and Economic Burden. The health consequences of obesity include elevated mortality rates and economic burden. Living in the Appalachian region is linked to health disparities, more chronic illnesses and higher mortality rates for women. Over the past few decades, average life expectancy has increased for most Americans; however, for women in this region life expectancy has decreased (Armstrong, et al., 2004; Ezzatil, et al., 2008). Mortality rates are higher for white, older Appalachian women than for women in the rest of the nation, and mortality is most often due to heart disease and stroke (Armstrong, et al., 2004; Ezzatil, et al., 2008; Halverson, et al., 2002). Biological Factors Related to Obesity in Appalachian Women

Genetic risk factors influence energy metabolism and makes some individuals susceptible to weight gain and obesity. Even with genetic susceptibility, however, a nutritious diet and regular physical activity enable maintenance of a healthy weight. None of these studies described caloric intake or energy expenditure or genetic variations in the metabolism of women living in the Appalachian region. Future research should examine associations between caloric intake and energy expenditure of women living in this region.

DISCUSSION

Appalachian women are an understudied population in the US. Life expectancy in these women declined in recent years, with obesity and obesity-related illnesses cited as contributing factors (Halverson, et al, 2004). Biological factors in obesity include gender, age, and genetic variations in metabolism. Socio-cultural factors include socioeconomic levels, educational levels, and cultural norms. This review summarizes what is known about biological, socio-cultural and economic factors that contribute to the high levels of obesity among Appalachian women. These women clearly experience high rates of obesity, which is a multifaceted problem and is associated with both biological and environmental factors.

The per capita income of people living in the Appalachian region is approximately $4,000 less than the national average, and 15.3% of households are at the poverty level (Armstrong, et al., 2004). Only 68% to 77% of people living in the Appalachian region have at least 12 years of education (Wewers, et al., 2006). They also have low health literacy skills, which compounds the problem of obesity. Finally, the Appalachian region has many barriers to healthy lifestyles, including limited access to health care and limited facilities for recreational activity (Tessaro, et al., 2007).

These studies did not include body mass indices (BMI's) or caloric intake of participants. Further, the majority of the studies were cross sectional or qualitative; few obesity intervention studies have been conducted with Appalachian women, making it impossible to draw causal associations. Future investigations should test interventions for women in Appalachia and other regions with high obesity rates.

IMPLICATIONS FOR NURSING

Despite their limitations, the studies reviewed provide evidence that awareness of barriers to physical activity can assist nurses in developing approaches to increase activity in Appalachian women. In addition, exploring cultural influences on food selection and preparation can suggest strategies for decreasing high calorie diets and overeating. Decreasing obesity in rural Appalachian women can in turn assist in decreasing chronic illness related mortality.

Best practice strategies for addressing the increasing obesity rates in Appalachian women include emphasis on education about health promotion and better access to preventive health care in low-income, medically underserved communities. Given the documented increase in mortality among Appalachian women and its relationship to obesity, interventions should be tailored to women. Best practice interventions take into account Appalachian cultural and socioeconomic features, such as income and health literacy needs. Nurses can re-educate Appalachian women about healthy food choices using educational material that are culturally diverse and written at a low literacy level. Also, interventions directed at providing women with motivational and support training helps them make better healthcare decisions. Exploring obesity interventions using information technology systems or Telehealth will allow education to be delivered in remote rural regions.

Health care policies need to focus on ways to improve living environments and make healthier communities, especially communities with high obesity rates and few resources. Health care services to low-income households, including nutrition education, and health screenings to manage weight, need to be a priority. Community coalitions and neighborhood associations promoting active lifestyles for Appalachian women can provide health interventions which focus on reducing obesity, and improving health outcomes for people living in rural regions.

REFERENCES

Appalachian Regional Commission.(2009). Economic overview. Retrieved August 5, 2009, from http://www.arc.gov/index.do?nodeId=26

Appalachian Regional Commission. (2010a). The Appalachian region. Retrieved January 29, 2010, from http://www.arc.gov/appalachian_region/TheAppalachianRegion.asp

Appalachian Regional Commission. (2010b). ARC-Designated distressed counties, fiscal year 2010. Retrieved February 1, 2010, from http://www.arc.gov/appalachian_region/ ARCDesignatedDistressedCountiesFiscalYear2010.asp

Armstrong, L., Thompson, T., Hall, I., Coughlin, S., Steele, B., & Rogers, J. (2004). Colorectal carcinoma mortality among Appalachian men and women 1969-1999. Cancer, 101(2), 2851-2858. [MEDLINE]

Bagi, S., Reeder, J., & Calhoun, D. (2002). Federal funding in Appalachia and its three subregions. Rural America, 17(4), 31-37.

Centers for Disease Control and Prevention. (2008). Behavioral risk factor surveillance system. Retrieved from http://apps.nccd.cdc.gov/brfss/list.asp?cat=EX&yr=2008&qkey=4347 &state=All

Centers for Disease Control and Prevention. (2009). U.S obesity rates and trends. Retrieved July 31, 2009, from http://www.cdc.gov/obesity/data/trends.html

Denham, S., Meyer, M., Toborg, M., & Mande, M. (2004). Providing health education to Appalachia populations. Holistic Nursing Practice, 18(6), 293-301. [MEDLINE]

Ezzatil, M., Friedman, A., Kulkarni, S., & Murray, C. (2008). The reversal of fortunes: trends in county mortality and cross county mortality disparities in the United States. Plos Medicine, 5(4), 557-568. [MEDLINE]

Halverson, J.A., Byrd, R.C., Ma, L., & Harner E.J. (2004) An analysis of disparities in health status and access to health care in the Appalachian Region. Office of Social Environment and Health Research (OSEAHR)/Prevention Research Center, West Virginia University.

Halverson, J., Barnett, E., & Casper, M. (2002). Geographic disparities in heart disease and stroke mortality among black and white populations in the Appalachian region. Ethnicity & Disease, 12 (4), 82-91. [MEDLNE]

Ramsey, P., & Glenn, L. (2002). Obesity and health status in rural, urban, and suburban southern women. Southern Medical Journal, 95(7), 666-671. [MEDLINE]

Rye, J., Rye, S., Tessaro, I., & Coffindaffer, J. (2009). Perceived barriers to physical activity according to stage and body mass index in West Virginia wisewoman population. Women Health Issues, 19 (2), 126-134. [MEDLINE]

Schoenberg, N., Hatcher, J., & Dignan, M. (2008). Appalachian women's perceptions of their community's health threats. Journal of Rural Health, 24(1), 75-83. [MEDLINE]

Tessaro, I., Rye, S., Parker, L., Mangone, C., & McCrone, S. (2007). Effectiveness of a nutrition intervention with rural low income women. American Journal of Health Behavior, 31(1), 35-43. [MEDLINE]

Tessaro, I., Smith, S.L & Rye, S. (2005). Knowledge and perceptions of diabetes in an Appalachian population. Preventing Chronic Disease: Public Health Research, Practice, and Policy, 2(2), 1-9. [MEDLINE]

Wewers, M., Katz, M., Paskett, E., & Fickle, D. (2006). Risky behavior among Ohio Appalachian adults. Preventing Chronic Disease, 3(4), 1-8. [MEDLINE]

Wilkinson, R., & Marmot, M. (2008) The social determinants of health: The solid facts. Geneva, SW: World Health Organization.

Tara O'Brien MSN, RN (1) Laura A. Talbot EdD, PhD, RN, GCNS-BC (2)

(1) School of Nursing, University of North Carolina at Charlotte, obrien8@uncc.edu

(2) Director, HSR PhD Program, Dean Colvard Distinguished Professor in Nursing, University of North Carolina at Charlotte, ltalbot@uncc.edu
Table 1. Appalachian Women & Obesity

First Author Purpose Sample Design

Armstrong To determine Residents of Quantitative
 the extent to all Secondary
 which death Appalachian data analysis
 rates from counties in
 colorectal 13 states
 cancer by
 age, race, & Sample group
 gender was provided
 subgroups of from the
 Appalachians Multiple
 differ from Cause of
 rates of the Death Public
 same sub File; Death
 groups Certificate,
 elsewhere in which was
 the US provided by
 the National
 Center for
 Health
 Statistics
 (NCHS).Sample
 size was not
 provided Age
 50-80 Men &
 women were
 analyzed
 separately
 for the study

Denham To determine Sample group Qualitative
 if behavioral was provided Study
 health from the
 interventions Multiple
 could be more Cause of
 successful if Death Public
 culturally File; Death
 sensitive Certificate,
 which was
 provided by
 the NCHS

 Age 50-80 Focus groups,
 (Mean age common themes
 3645 for the were analyzed
 adult women's
 group) Gender
 analyzed
 separately
 for the study
 Sample size
 52 focus
 groups
 included 469
 persons
 Adolescents n
 =16, adult
 men n= 30
 adult women =
 273

Ezzati To compare Sample group Quantitative
 average life was provided Secondary
 expectancies by the US data analysis
 in various Census
 regions of population
 the US from 1961 to
 1999 which
 was provided
 by the NCHS

 Men & women
 were analyzed
 separately
 for the study
 Sample size
 was not
 provided

Halverson To examine Residents of Quantitative
 geographical, all Secondary
 racial/ Appalachian data analysis
 ethnic counties in
 differences 13
 in heart Appalachian
 disease & states
 stroke
 mortality. Sample group
 was provided
 National
 Vital
 Statistics
 System by the
 NCHS

 White men 35-64
 White men 65& older
 White women 35-64
 White women 65& older
 Black men 35-64
 Black men 65& older
 Black women 35-64
 Black women 65 & older
 Sample size was
 not provided

Ramsey To 4,391 women Quantitative
 investigate living in the Descriptive
 the southern study
 differences region of the
 between US
 rural, urban,
 & suburban Urban n= Data from
 southern 1,042 National
 women based Suburban Health Survey
 on n=1,977 Rural
 socioeconomi n= 1,372 ages
 c factors 40-64

Rye To 733 women Quantitative
 investigate living in Descriptive
 the West Virginia
 prevalence of Health Risk/
 lack of time 244-aged 40-64 Behavioral
 & motivation 489-aged 50-60 Survey
 as barriers
 to physical
 activity
 among low
 income women

Tessaro To evaluate a 262 Women Quantitative
 computer living in Intervention
 based rural West
 interactive Virginia 131
 nutrition Intervention
 intervention 131 Control
 Mean age
 50.25

Schoenberg To determine Snowball Qualitative
 what sample from Focus groups
 Appalachian four rural using open
 women Appalachian ended
 consider the Kentucky questions
 most pressing counties n =
 threat to 52 65% women
 their Mean age 52
 communities

First Author Setting Contributing Outcome
 Rural/Urban Factors

Armstrong 13Appalachia Socio- Death rates
 counties in cultural among obese
 both rural factors white men &
 and urban related to women were
 settings of the lack of significantly
 the education & higher for
 Appalachian geographic colorectal
 region isolation cancer in the
 (access to Appalachian
 care) region than
 in the rest
 of the
 country

Denham 24 Socio- Appalachian
 Appalachian cultural mothers play
 counties in factors a major role
 ten states in related to in the health
 both rural sensitivity of their
 and urban of the family
 settings of delivery of members and
 the education play a major
 Appalachian methods role for
 region promoting
 positive
 health
 behaviors for
 the family.

Ezzati All US states Biological Life
 both rural factors expectancy
 and urban related to decline for
 settings of chronic women living
 the US diseases in the deep
 south of the
 U.S.
 extending
 into the
 Appalachian
 region.
 Patterns of
 female
 mortality
 rise are
 consistent
 with smoking,
 high blood
 pressure &
 obesity

Halverson 403 Socio- Nearly 35% of
 Appalachian cultural the US
 counties in factors counties with
 13 included low the highest
 Appalachian education rates of
 states both attainment, heart disease
 rural and low per mortality for
 urban capita white men &
 settings of income, women are in
 the limited Appalachia
 Appalachian access to 25% of
 region medical care counties with
 were the highest
 associated rates for
 with higher Black men &
 rates of women are the
 morbidity & Appalachian
 mortality region

Ramsey Women living Biological Participants
 in urban, factors for with higher
 suburban, and white women incomes &
 Rural regions associated educational
 analyzed with levels had
 separately morbidity & better health
 for the study mortality outcomes
 rates
 Women living
 in rural
 regions had
 the highest
 rate of
 obesity &
 reported the
 poorest
 health.
 Obesity &
 poor health
 related

Rye Rural and Biological A lack of
 urban areas factors time &
 of West associated support was
 Virginia with lack of the greatest
 motivation & barrier
 time reported by
 contributed participants
 to higher
 rates of
 obesity for
 women

Tessaro Two rural Socio- The computer
 counties of cultural based
 West Virginia factors interactive
 included to nutrition
 low income intervention
 and rural showed
 region with a potential
 history of change in the
 chronic diets for the
 disease women in the
 intervention
 group

Schoenberg Four rural Biological Participants
 Appalachian factors of identified
 counties in poor diet & the greatest
 Kentucky exercise threats to
 contribute to their
 obesity communities
 as substance
 abuse,
 cancer, heart
 disease &
 diabetes,
 poor diet,
 lack of
 exercise, &
 obesity

 Several
 Appalachian
 areas have
 the highest
 rates of
 obesity &
 physical
 inactivity in
 the country

First Author Suggested
 Future
 Strategy

Armstrong Appalachian
 region may
 benefit from
 targeted
 obesity
 prevention to
 eliminate
 health
 disparities.

Denham In
 Appalachian
 families
 women most
 often have
 the power to
 influence the
 family health
 needs
 (including
 chronic
 conditions
 such as
 obesity), but
 often need
 support to
 make
 effective use
 of this role.

Ezzati Programs need
 to be
 established
 that increase
 insurance
 coverage for
 interventions
 for chronic
 disease.

Halverson Distressed
 counties need
 to use direct
 money &
 resources to
 make policy
 decisions at
 the local
 level to
 improve
 health
 outcomes for
 people living
 in the
 region. These
 policy
 changes would
 include
 various
 approaches to
 promote a
 healthy
 lifestyle for
 people living
 in the
 Appalachian

Ramsey Community
 health care
 providers
 should use
 community
 based health
 strategies to
 manage weight
 through new
 or existing
 programs.

 Programs need
 to be
 sensitive to
 income &
 educational
 factors that
 characterize
 rural regions

Rye Motivational
 counseling is
 a critical
 intervention
 to increase
 motivation &
 social
 support for
 physical
 activity,
 which will
 assist in
 decreasing
 the
 prevalence of
 obesity.

Tessaro Personal
 delivery of
 information
 may not
 always be
 available in
 rural
 regions.
 Technology
 may be one
 way to bridge
 the gap
 between
 education and
 behavior
 change.

Schoenberg Lifestyle-
 related
 choices
 comprise the
 core risk
 factors for
 developing
 chronic
 disease. The
 best approach
 for
 addressing
 these threats
 is to develop
 coalitions to
 target
 troublesome
 community
 health
 problems.

 Community
 health
 promotion can
 best be
 implemented
 by respecting
 existing
 community
 knowledge,
 priorities, &
 capacities
 through
 community
 research
 partnerships
 that point to
 proven
 interventions.
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Author:O'Brien, Tara; Talbot, Laura A.
Publication:Online Journal of Rural Nursing & Health Care
Date:Mar 22, 2011
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