Introduction:Local health departments and healthcare organizations in rural areas face challenges, including workforce shortages and complex population health-related needs. While they share related roles in their communities, incentives to collaborate may be sparse. Methods:Using a 2-tiered qualitative approach, we describe the purpose, motivations, benefits, and barriers to collaborations between local health departments and healthcare delivery organizations serving rural communities, with a focus on workforce factors. Twenty-four semi-structured interviews were conducted, including 18 interviews with individuals from local organizations and 6 interviews with representatives of membership groups that support these organizations. Interviews were analyzed using a deductive rapid coding process. Results:We find that collaborations are necessary, common, and often driven by workforce or other capacity limitations. However, potential competition for staff, differing structures, and a lack of familiarity with the role of public health were identified as barriers to robust and sustained collaborations. Conclusions:There are potential benefits of collaborations between local health departments and healthcare organizations in rural areas, including for both the organizations and community. Developing and sustaining collaborations requires time, resources, and relationships. Inherent to collaborative work is a need for communication across professions, including the articulation of each organization's role, expertise, and value.

OBJECTIVE:To identify and characterize the motivations and perceived impacts of formal structural changes to local health departments (LHDs), with a specific focus on perceived impacts for the public health workforce. DESIGN:We conducted a systematic search of publicly available news articles, outreach to public health organizations, and 17 semistructured interviews with individuals involved in a formal LHD structural change between 2020 and 2025. SETTING:The exploratory study identified and examined structural changes in LHDs across the United States between 2020 and 2025. PARTICIPANTS:Participants were individuals associated with a restructured LHD, including past or present staff or board members. We identified participants through structured search queries and systematic state outreach, followed by a review of LHD websites to obtain contact information. RESULTS:We identified 16 structural changes covering 12 states and all Census regions of the United States. Across these changes, 153 news articles were identified, ranging from 0 to 50 articles per change. Change classifications included regional health district dissolutions and splits, mergers and consolidations, formations, and closures or transfers of authority. The changes varied widely, although almost all occurred rapidly and carried a substantial administrative burden. COVID-19, cost-effectiveness, efficiency, and population change were among the key drivers reported. Participants reported notable impacts, including job losses and gains, changes in administrative processes, increased employee stress, and greater innovation and productivity. CONCLUSIONS:Local public health restructuring occurs for many reasons and yields perceived benefits and challenges. Robust monitoring and guidance on restructuring may support LHDs during changes.

OBJECTIVES:Public health nurses (PHNs) are one of the largest public health occupation groups, bringing important expertise to the activities of public health; however, their roles and distribution differ across the country. The objective of this study was to estimate the relative need for, supply of, and priority areas for PHNs at the county level. METHODS:We used a cross-sectional design with national data sources available at the county level to measure the local need for, supply of, and priority areas for PHNs. We estimated need through a newly developed index based on 4 domains: demographic characteristics, economic characteristics, health care context, and health outcomes within the county. We estimated supply by using registered nurse staffing data from local health departments. We identified priority tiers of PHN deserts as counties with relatively high need and low supply. We conducted the study in 2024-2025. RESULTS:The need for and supply of PHNs varied across the country, with little correlation (+0.26). For example, average need was highest in the southeastern United States (mean need score, 68.3 of 100; median need score, 76.0 of 100) and lowest in the upper northeastern United States (mean need score, 19.8 of 100; median need score, 13.5 of 100). CONCLUSIONS:The combination of local-level PHN need and supply can be used to identify potential gaps in PHN availability and can inform investment, recruitment, training, or allocation of other resources to address the PHN workforce needs of local health departments.

The Centers for Disease Control and Prevention (CDC) produced two reports, in 2017 and 2021, highlighting rural inequities across the five leading causes of death. These reports were pivotal in bringing attention to geographic disparities in preventable deaths. The 2024 update provides similar focus and attention and shows concerning trends over time, given that inequities have increased significantly across four of the five leading causes of death. The purpose of this commentary is to highlight these ongoing health inequities and create dialogue among public health professionals as to how we regain trust and work collaboratively with rural communities to address these ongoing and growing challenges.

OBJECTIVES:Block grant funding provides federal financial support to states, with increased flexibility as to how those funds can be allocated at the community level. At the state level, block grant amounts and distributions are often based on outdated formulas that consider population measures and funding environments at the time of their creation. We describe variation in state-level funding allocations for 5 federal block grant programs and the extent to which funding aligns with the current needs of state populations. METHODS:We conducted an analysis in 2022 of state block grant allocations as a function of state-level characteristics for 2015-2019 for all 50 states. We provide descriptive statistics of state block grant allocations and multivariate regression models for each program. Models include base characteristics relevant across programs plus supplemental characteristics based on program-specific goals and state population needs. RESULTS:Mean state block grant allocations per 1000 population by program ranged from $618 to $21 528 during 2015-2019. Characteristics associated with state allocations varied across block grants. For example, for every 1-percentage-point increase in the percentage of the population living in nonmetropolitan areas, Preventive Health and Health Services Block Grant funding was approximately $7 per 1000 population higher and Community Services Block Grant funding was approximately $40 per 1000 population higher. Few supplemental characteristics were associated with allocations. CONCLUSIONS:Current block grant funding does not align with state characteristics and needs. Future research should consider how funds are used at the state level or allocated to local agencies or organizations and compare state block grant allocations with other types of funding mechanisms, such as categorical funding.

The public health workforce continues to atrophy due to mass and early retirement, under-funding, slow hiring processes, lack of advancement opportunities, and shifting policies. Organizational research into workforce sustainability is crucial for ensuring a robust, diverse staff capable of delivering essential public health services. We examined career ladders, a potential solution to workforce challenges, through interviews with 10 health departments (HDs) across seven states. Interview participants were recruited from HDs using or planning career ladders held administrative positions, and had a role in the hiring process.Many health department positions have traditionally included steps within certain job classifications that promote pay adjustments with increasing years of service. Career ladder approaches, however, specifically focus on providing opportunities for health continuing education, leadership development, or movement into formal leadership roles.Findings indicate that HDs have begun utilizing career ladders for professional development and critical role maintenance. Career ladders have been applied mostly for retention with limited impact on recruitment and increasing staff diversity. Challenges include civil service requirements, funding limitations, and complex recruitment that might exclude diverse candidates.This study emphasizes the importance of transparent development, engaging front-line staff, offering advancement pathways, and providing insights to enhance workforce recruitment and retention. The public health workforce plays a critical role in ensuring positive health outcomes for patients; however, workforce atrophy is a problem the field faces. Lack of viable advancement opportunities limits both recruitment and retention opportunities in public health systems. This study examined career ladders as a potential solution for recruitment and retention issues within public health agencies. Findings emphasize the challenges facing the public health workforce as well as opportunities for mitigation strategies in public health settings. The American public health workforce faces a crisis in both recruitment and retention of health workers, ranging from clinic staff and health care providers to billing and coding professionals and leadership executives. However, ensuring an efficient and sustainable workforce is a key factor in ensuring optimum public health outcomes For this study, we interviewed staff members in public health settings to assess challenges and opportunities for addressing recruitment and retention barriers. Findings from this study shed light on the ways in which public health systems are using career ladders for recruitment and retention.

BACKGROUND:Communities with robust recovery ecosystems could reduce negative outcomes associated with substance use disorders (SUDs) and facilitate the recovery process. This cross-sectional study examined the relationship between drug overdose mortality rates in the United States and the strength of county-level recovery ecosystems, as measured by the Recovery Ecosystem Index (REI). METHODS:The REI assesses the strength of county-level recovery ecosystems in the United States. Comprised of 14 indicators across 3 component classes, overall and component scores ranging from "one" (strongest) to "five" (weakest) were calculated for each county using standardized values of the indicators. County-level analyses included: (1) correlational analyses between drug overdose mortality rates (n = 2076) and REI scores (overall score and by component); and (2) quadrant analysis (n = 2076), dividing counties based on their drug overdose mortality rates and overall REI scores. RESULTS:Drug overdose mortality rates were inversely related to REI overall, SUD treatment component, and continuum of SUD support component scores, indicating that lower (stronger) scores corresponded to higher rates. Conversely, REI infrastructure and social component scores were positively related to rates. Counties were relatively evenly distributed across quadrants, with 26% (n = 537) with a strong REI score and high overdose mortality rate, 24% (n = 489) with a strong REI score and low overdose mortality rate, 20% (n = 409) with a weak REI and high overdose mortality rate, and 31% (n = 641) with a weak REI and low overdose mortality rate. CONCLUSIONS:REI scores were generally inversely associated with drug overdose mortality rates in US counties, suggesting that communities have stronger recovery systems and services as the burden of SUD increases. Given relative variation in the scale of drug overdose mortality and strength of recovery ecosystems among counties, results could guide the identification of communities where the need for expanded recovery systems and services may be particularly critical.

The sampling and analysis of sewage for pathogens and other biomarkers offers a powerful tool for monitoring and understanding community health trends and potentially predicting disease outbreaks. Since the early months of the COVID-19 pandemic, the use of wastewater-based testing for public health surveillance has increased markedly. However, these efforts have focused on urban and peri-urban areas. In most rural regions of the world, healthcare service access is more limited than in urban areas, and rural public health agencies typically have less disease outcome surveillance data than their urban counterparts. The potential public health benefits of wastewater-based surveillance for rural communities are therefore substantial - though so too are the methodological and ethical challenges. For many rural communities, population dynamics and insufficient, aging, and inadequately maintained wastewater collection and treatment infrastructure present obstacles to the reliable and responsible implementation of wastewater-based surveillance. Practitioner observations and research findings indicate that for many rural systems, typical implementation approaches for wastewater-based surveillance will not yield sufficiently reliable or actionable results. We discuss key challenges and potential strategies to address them. However, to support and expand the implementation of responsible, reliable, and ethical wastewater-based surveillance for rural communities, best practice guidelines and standards are needed.

ObjectiveTo assess the association of drug overdose mortality with grandparents serving as caregivers of children in Appalachia and non-Appalachia in the U.S.MethodsThis study used a cross-sectional design, with percent of grandparents as caregivers and overdose mortality rates being of primary interest. County-level data were combined, and descriptive, bivariate, and multivariable statistics were applied. Multiple sociodemographic and geographic variables were included: median age of the population, percent of the population that is uninsured, percent of the population that is non-Hispanic white, teen birth rate, percent of high school dropouts, and rurality.ResultsThe percent of grandparents as caregivers increased as the overdose mortality rate increased (p < 0.01). For every 1% increase in the overdose mortality rate, the percent of grandparents as caregivers increased by 56% in Appalachian counties compared to 24% in non-Appalachian counties. After adjusting for sociodemographic characteristics, the interaction between overdose mortality and Appalachian vs. non-Appalachian counties was no longer significant (p = 0.3).ConclusionsCounties with higher overdose mortality rates had greater rates of grandparents as caregivers, with Appalachian counties experiencing greater rates of grandparents as caregivers than non-Appalachian counties. Sociodemographic characteristics that are often more prevalent in Appalachia may be driving the observed differences.Policy implicationsPolicies and programs are needed to support grandparents providing caregiving for children impacted by substance use disorders including reform to federal child welfare financing to support children, parents, and grandparent caregivers such as kinship navigation, substance use treatment and prevention services, mental health services and in-home supports.

Background:Adolescent births are associated with numerous challenges. While adolescent birth rates have declined across the U.S., disparities persist, and little is known about the extent to which broader declines are seen within Appalachia.Purpose:The purpose of this study was to examine the extent to which adolescent birth rates have declined across the subregions of Appalachia relative to non-Appalachia.Methods:We conducted a retrospective study of adolescent birth rates between 2012 and 2018 using county-level vital records data. Differences were examined across the subregions of Appalachia and among non-Appalachian counties. Multiple regression models were used to examine changes in the rate of decline over time, adjusting for additional covariates of relevance.Results:About 13.4% of all counties in the U.S. are within the Appalachian region. The rate of adolescent births decreased by 12.6 adolescent births per 1,000 females between 2012 and 2018 across the U.S. While all regions experienced declines in the rate of adolescent births, Central Appalachia had the largest reduction in adolescent births (18.5 per 1,000 females), which was also noted in the adjusted models when compared to the counties of non-Appalachia (b= -5.78, CI: -9.58, -1.97). Rates of adolescent birth were markedly higher in counties considered among the most socially and economically vulnerable.Implications:This study demonstrates that the rates of adolescent births vary across the subregions of Appalachia but have declined proportional to rates in non-Appalachia. While adolescent birth rates remain higher in select subregions of Appalachia compared to non-Appalachia, the gap has narrowed considerably.

The ongoing SARS-CoV-2 (COVID-19) pandemic has taken a considerable toll on the health and well-being of populations globally and in the United States. While much of the early spread concentrated in high population-density urban centers, individuals and communities historically at higher risk of experiencing adverse health, social, and economic outcomes are now disproportionately affected by COVID-19—including rural communities.1-3 Evidence suggests that the overall rate of infection and subsequent mortality in rural communities is higher than what is observed among their urban counterparts.1, 4 On average, rural populations tend to be older and experience more chronic conditions than urban populations, both of which are associated with an increased risk of severe COVID-19 illness and death.2, 5, 6 Furthermore, well-documented historical barriers in accessing preventive and treatment-related health care services, which contribute to higher overall mortality and decreased life expectancy in rural communities, remains a salient issue during the ongoing pandemic.2, 7, 8 While the ongoing focus remains largely on controlling viral spread, vaccination efforts, and minimizing the loss of life—the potential for longer-term effects of COVID-19 infection is emerging as an important sequalae. Many individuals experiencing COVID-19 go on to experience what has been termed as post-acute sequelae of SARS-CoV-2 infection or long COVID. While a formal definition and inclusion criteria has evolved, long COVID is generally characterized a "post-COVID-19 condition that occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset, with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis."9 The list of symptoms associated with long COVID is extensive and can range in severity and duration but may include shortness of breath, chronic fatigue, tachycardia, exercise intolerance, and cognitive dysfunction.9, 10 While symptoms may persist following initial infection, they can also be newly onset among individuals with no prior history of a given symptom profile.9-11 The underlying pathophysiology triggering long COVID remains an important, unsettled area of investigation; however, early indications suggest that long COVID exhibits many characteristics of autoimmune disease and often draws parallels with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).12, 13 Estimating the prevalence of long COVID is very difficult given wide variation in case definitions, methods of ascertainment, study populations (hospitalized or nonhospitalized), and time frames considered. However, US-based studies suggest that approximately 10%-30% of those with COVID-19 may go on to experience long-term symptoms.14, 15 A study using private health insurance claims in the United States puts the estimate at 23.2% with higher rates among those with severe cases/hospitalization.16 The duration of symptoms can vary widely. For some, long COVID symptoms resolve over time; however, for others, symptoms can persist for an extended period of time and be quite severe to the point of disability.15 With current COVID infections in the United States at 76 million, it is estimated that 7 to 22 million individuals may experience long COVID.17 This potential impact is a particularly salient issue for those infected in rural America. First and foremost, long COVID places the health and well-being of rural populations at risk. Higher rates of infection coupled with lagging vaccination uptake suggest that long COVID will likely affect individuals living in rural communities disproportionately relative to urban.18 While symptoms and severity of long COVID can range from mild to severe, the potential impact on mental health, social function, and the ability to continue working can be substantial.10 Significant proportions of individuals with long COVID report difficulty returning to a previous level of health and functioning, even those who were previously healthy with no underlying medical conditions.19, 20 While research on long-term functioning and returning to work is in their infancy, early findings suggest that many individuals with long COVID simply do not return to work or reduce work hours significantly.19 This is consistent with previous longitudinal research focused on the other SARS-CoV outbreaks21-23 and parallels previous research findings specific to ME/CFS.24 While estimates of those who do not return to work can vary widely, recent projections from the Bookings Institution bear this out further, suggesting that long COVID is also a key contributor to existing labor shortages nationally, with long COVID accounting for about 15% of unfilled jobs.25 Potential gaps in employment are particularly problematic for rural communities given the economic impact of COVID-19 on employment in rural communities has already been substantial.26 The inability to work and subsequent reduced income also has implications for health insurance and the affordability of the care needed to manage long COVID. Lower rates of health insurance are a persistent disparity within rural communities.7 As employment and insurance are often linked, individuals residing in rural communities with long COVID are particularly vulnerable to crippling health care expenses. Even with health insurance, the battery of diagnostic testing and subsequent treatment plans likely pose a significant financial barrier for rural populations. Furthermore, news media coverage suggests that health insurance companies are also struggling to keep up with the novelty of long COVID and denied claims for long COVID care are becoming an issue when seeking care.27 Fortunately, individuals experiencing long COVID to the point of interfering with 1 more daily activities may qualify for disability under the Americans with Disabilities Act.28 However, proving a long COVID diagnosis and actually qualifying for benefits may an entirely different issue.27, 29 The health and economic impact of long COVID has important implications for individuals, families, and society as a whole that must be considered.10 Rural health care providers and health care delivery systems are also in a difficult position. Most states have long COVID clinics; however, these typically require multidisciplinary teams of specialist health care providers primarily located in urban centers.10 The availability of the multidisciplinary specialty care needed to diagnose and treat long COVID is sparse in rural communities that already face longstanding structural barriers in accessing medical care.30 Information and clinical best practices related to long COVID is a moving target.10, 31, 32 Among clinics actively treating long COVID patients, most (73%) report experiencing obstacles in treating patients.33 The need for more established protocols and more clinical resources top the list of barriers reported.33 These challenges are most certainly exacerbated in rural communities. As is stands, individuals seeking care for long COVID may find few answers, which is frustrating for both individuals and providers. Rural patients and providers already struggling with limited clinical capacity, now have their challenges compounded by a lack of resources to manage this complex and novel condition. Health literacy, or the ability to assess, understand, and use health information for decision making, also poses an additional challenge. Previous research suggests that rural populations typically have lower rates of health literacy than their urban counterparts.34 As with other chronic conditions, long COVID may require ongoing communication and care management between individuals, lay caregivers, and their medical team.35 This may be particularly difficult for individuals and providers when managing a novel condition and further increase the burden of long COVID in rural communities. There are many unknowns that providers, researchers, and individuals are trying to better understand to develop treatment protocols for long COVID. The potential economic impact of long COVID on rural health delivery systems parallels that of individuals experiencing long COVID. Rural delivery systems provide care for a disproportionate number of uninsured individuals and payer mix is slanted toward government sources. This has put a significant financial strain on an already strained primary care and health delivery system in rural communities. In addition, nurses and other allied health workers in rural areas are just as susceptible to the impact of COVID infection and long COVID. The loss of these front-line caregivers is felt more acutely in rural areas without the population concentrations to draw upon as seen in urban areas. At this point with long COVID, there are more questions than answers. The ultimate impact of long COVID on rural populations remains unknown. The emergence of new variants and subsequent long COVID sequelae provides an additional wrinkle. The extent to which new variants trigger long COVID symptoms remains unknown. The extent to which current/future vaccines protect against long as breakthrough infections occur remains unknown. Early evidence from pre-Omicron breakthrough infections suggests that receiving both vaccine doses reduced the risk of long COVID (symptoms 28 days or more) by half.36 These findings underscore the importance of vaccine uptake in rural communities, which remains a challenge. Taken collectively, rural communities have higher rates of infection and increased susceptibility for more severe disease. Given historical barriers in accessing care and less rural engagement in mitigation strategies—long COVID will have a disproportionate effect on rural communities, much like acute COVID.37, 38 As significant investments in long COVID research emerge,39 ensuring that rural areas are represented in ongoing research efforts is critical for confirming that rural communities are not left behind as diagnosis, treatment, and rehabilitation programs and policies are developed.

Reports of bacterial sexually transmitted infections are at the highest levels ever reported in the United States, and state and local budgetary issues are placing specialized sexually transmitted disease (STD) care at risk. This study collected information from 4138 patients seeking care at 26 STD clinics in large metropolitan areas across the United States with high levels of reported STDs to determine patient needs and clinic capabilities. Surveys were provided to patients attending these STD clinics to assess their demographic information as well as reasons for coming to the clinic and surveys were also provided to clinic administrators to determine their operational capacities and services provided by the clinic. For this initial study, we conducted univariate analyses to report all data collected from these surveys. Patients attending STD clinics across the country indicated that they do so because of the relative ease of getting an appointment; including walk-in and same-day appointments as well as the welcoming environment and expertise of the staff at the clinic. Additionally, STD clinics provide specialized care to patients; including HIV testing and counseling as well as on-site, injectable medications for the treatment of gonorrhea and syphilis in an environment that helps to reduce the role of stigma in seeking this kind of care. Sexually transmitted disease clinics continue to play an important role in helping to curb the rising epidemic of sexually transmitted infections.

ABSTRACT:Introduction: This study provides an update on mortality due to diseases of despair within the Appalachian Region, comparing 2015 to 2018.Methods: Diseases of despair include: alcohol, prescription drug and illegal drug overdose, suicide, and alcoholic liver disease/cirrhosis of the liver. Analyses are based on National Vital Statistics System (NVSS) mortality data for individuals aged 15–64.Results: Between 2015 and 2017, the diseases of despair mortality rate increased in both Appalachia and the non-Appalachian U.S., and the disparity grew between Appalachia and the rest of the county. In 2018, the disease of despair mortality rate declined by 8 percent in Appalachia, marking the first decline for the Region since 2012. Diseases of despair continue to impact the working-age population, and while males experience a higher burden of mortality due to diseases of despair, the disparity between Appalachia and the rest of the United States is greater for females. Overdose mortality rates in Appalachia increased between 2015 and 2017, followed by a decline in 2018. During this same time frame, suicide also increased notably within the Appalachian region, and the disparity between Appalachia and the non-Appalachian U.S. increased by 50 percent.Implications: These findings document that the diseases of despair continue to have a greater impact in the Appalachian Region than in the rest of the United States. While the declining trends between 2017 and 2018 are promising, data has shown that these rates are likely to increase again, particularly as a result of the COVID-19 pandemic.

Public health in the rural United States is a complex and underfunded enterprise. While urbanrural disparities have been a focus for researchers and policy-makers alike for decades, inequalities continue to grow. Life expectancy at birth is now 1 to 2 years greater between wealthier urban and rural counties, and is as much as 5 years, on average, between wealthy and poor counties. This article explores the growth in these disparities over the past 40 years, with roots in structural, economic, and social spending differentials that have emerged or persisted over the same time period. Importantly, a focus on place-based disparities recognizes that the rural United States is not a monolith, with important geographic and cultural differences present regionally. We also focus on the challenges the rural governmental public health enterprise faces, the so-called "double disparity" of worse health outcomes and behaviors alongside modest investment in health departments compared with their nonrural peers. Finally, we offer 5 population-based "prescriptions" for supporting rural public health in the United States. These relate to greater investment and supporting rural advocacy to better address the needs of the rural United States in this new decade.

Objectives. To investigate differences in funding and service delivery between rural and urban local health departments (LHDs) in the United States.Methods. In this repeated cross-sectional study, we examined rural-urban differences in funding and service provision among LHDs over time using 2010 and 2016 National Association of County and City Health Officials data.Results. Local revenue among urban LHDs (41.2%) was higher than that in large rural (31.3%) and small rural LHDs (31.2%; P < .05). Small (20.9%) and large rural LHDs (19.8%) reported greater reliance on revenue from Center for Medicare and Medicaid Services than urban LHDs (11.5%; P < .05). All experienced decreases in clinical revenue between 2010 and 2016. Urban LHDs provided less primary care services in 2016; rural LHDs provided more mental health and substance abuse services (P < .05).Conclusions. Urban LHDs generated more revenues from local sources, and rural LHDs generated more from the Center for Medicare and Medicaid Services and clinical services. Rural LHDs tended to provide more clinical services. Given rural LHDs' reliance on clinical revenue, decreases in clinical services could have disproportionate effects on them.Public Health Implications. Differences in financing and service delivery by rurality have an impact on the communities. Rural LHDs rely more heavily on state and federal dollars, which are vulnerable to changes in state and national health policy.

Leveraging Rural Strengths to Overcome Population Health Challenges Michael Meit MA, MPH, and Alana Knudson PhD Affiliation Michael Meit and Alana Knudson are with the Walsh Center for Rural Health Analysis, NORC at the University of Chicago, Bethesda, MD.CopyRightCorrespondence should be sent to Michael Meit, Codirector, Walsh Center for Rural Health Analysis, NORC at the University of Chicago, 4350 East West Hwy, Ste 800, Bethesda, MD 20814 (e-mail: meit-michael@norc.org). Reprints can be ordered at http://www.ajph.org by clicking the "Reprints" link.CONTRIBUTORSThe authors contributed equally to this editorial. https://doi.org/10.2105/AJPH.2020.305641 Accepted: February 26, 2020 Published Online: August 12, 2020

During the COVID-19 pandemic, rural Appalachia is at great risk of unforeseen side effects including increased mortality from substance use disorders (SUDs). People living with SUDs are at increased risk for both exposure to and poor outcomes from COVID infection. The economic impacts of COVID-19 must also be considered. As rural Appalachia combats the substance use crisis amidst the COVID-19 pandemic, the geographic economic, health and social inequities within our region must be considered. As a national recovery is sought, we should reimagine federal policies that center the economic and public health of rural Appalachia addressing the two crises.

Context: There is limited research on what factors are most salient to implementation of evidence-based practices (EBPs) among public health agencies in public health emergency preparedness and response (PHPR) and under what conditions EBP implementation will occur. Objective: This study assessed the conditions, barriers, and enablers affecting EBP implementation among the PHPR practice community and identified opportunities to support EBP implementation. Design: A Web-based survey gathered information from public health agencies. Data obtained from 228 participating agencies were analyzed. Setting: State, local, and territorial public health agencies across the United States. Participants: Preparedness program officials from 228 public health agencies in the United States, including Public Health Emergency Preparedness (PHEP) cooperative agreement awardees (PHEP awardees) and a random sample of local health departments (LHDs). Results: Respondents indicated that EBP is necessary and improves PHPR functions and tasks and that staff are interested in improving skills for EBP implementation. Top system-level barriers to EBP implementation were insufficient funding, lack of EBP, and lack of clarity regarding which practices are evidence based. PHEP awardees were significantly more likely to report a lack of EBP in the field, whereas LHDs were significantly more likely to report a lack of incentives. The top organizational-level barrier was insufficient staff. Most respondents indicated their agency culture supports EBP; however, LHDs were significantly more likely to report a lack of support from supervisors and leadership. Few respondents reported individual barriers to EBP implementation. Conclusions: Findings indicate an opportunity to improve dissemination strategies, communication efforts, and incentives to support EBP implementation in PHPR. Potential strategies include improving awareness of and accessibility to EBPs through targeted dissemination efforts; building organizational capacity to support EBP implementation, particularly staff capacity, knowledge, and skills; and identifying funding and incentives to promote EBP uptake and sustainment.