Mid-Life Health Inequalities in the Rural South: Risk and Resilience

Abstract
This application builds on the Great Smoky Mountains Study (GSMS) and leverages its recently funded
extension, Great Smoky Mountains Study of Rural Aging (GSMS-RA) to improve our understanding of the
determinants of health inequalities in rural America. This new study, the Mid-Life Health Inequalities in the
Rural South: Risk and Resilience, augments data being collected (and already funded) for two GSMS-RA
samples in western North Carolina, one of Native Americans and the other of non-Hispanic Whites, that are in
their early 40s and currently reside in rural regions of Appalachia, with two new samples from the northeastern
part of the State, one of African Americans and the other of non-African Americans, ages of 30 and 55, that will
be recruited from rural Census tracts of the “Black Belt” region of the state. The Black Belt samples will be
recruited, consented and surveyed using the same 120-minute in-home assessment utilized in the GSMS-RA to
collect demographic and socioeconomic and attitudinal information, neurocognitive tasks (IQ, memory, attention,
and executive function), and biomeasure collection (i.e., height, weight, waist, blood pressure, pulmonary
function, bloodspots) (Aim 1). The Black Belt sample will also participate in the same 6-month Ecological
Momentary Assessment (EMA) every other week (13 times total), using protocols to measure within-person day-
to-day or week-to-week fluctuations in one's financial and social situations and/or mood, as these measurements
may affect individuals' risk/resilience related to mid-life health outcomes, and track geospatial movement using
GPS monitoring to assess activity space (Aim 2). For each of these 2 rural regions (Appalachia and Black Belt),
we will assemble contextual data from several existing data bases to construct measures of the health, economic
and social contexts of the localities in which participants in our 4 samples reside. The data from Aims 1 and 2
for these 4-sample/2 region samples will be used to analyze the causal linkages between person-specific and
contextual measures of risk and resilience factors for those health conditions (e.g., suicide, alcohol abuse,
cardiometabolic diseases) most associated with mid-life mortality (Aim 3). Multiple statistical methods, including
fixed effect, structural equation and multilevel models as well as instrumental variables methods will be used to
identify these causal linkages and their racial/ethnic and region differences. A distinctive feature of this analysis
will be to employ the within-person data collected under the EMA protocol to examine the role of instability of
socio-emotional, economic and social support as a unique contributor to those health conditions that result in
midlife mortality. Finally, this project will harmonize measures collected in this rural-based study with measures
in existing health/aging studies, disseminate the data collected through the National Archive of Computerized
Data on Aging and conduct interdisciplinary user workshops on these data to facilitate urban/rural national
comparisons of the study of health inequalities at midlife (Aim 4).