Portrait of Dr. Ervin Fox
Dr. Ervin Fox, professor of medicine, is principal investigator for the Mississippi site of the Risk Underlying Rural Areas Longitudinal Study.
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Study seeks to understand RURAL residents' health challenges

Published on Thursday, May 30, 2019

By: Karen Bascom

In an effort to understand why people born in rural communities in the South live shorter and less healthy lives than their counterparts elsewhere in the same counties as well as across the country, researchers from the University of Mississippi Medical Center and partner institutions announced May 22 the launch of a new longitudinal cohort study aimed at combating this issue.

The Risk Underlying Rural Areas Longitudinal Study, or RURAL, will allow researchers to learn what causes the high burden of heart, lung, blood and sleep, HLBS for short, disorders in Kentucky, Alabama, Mississippi and Louisiana and offer clues regarding how to alleviate them.

With funding from the National Heart, Lung, and Blood Institute and led by Boston University, the six-year, $21.4 million multi-site prospective cohort study will include 50 investigators from 16 institutions.

To better understand why certain factors amplify risk in some rural counties and what renders some communities more resilient, the researchers plan to recruit and study 4,000 multi-ethnic participants from 10 of the most economically challenged rural counties in the Southern Appalachia and Mississippi Delta regions, or AMD.

“We are going to look at a rural population cohort – a cohort that’s never been successfully studied at this scale,” said Dr. Ervin Fox, UMMC professor of medicine and principal investigator for the Mississippi sites. “We plan to draw participants from throughout these communities and be able to identify solutions for a group of people who have been overlooked by previous research efforts because of their geography.”

RURAL logo
The RURAL study is a collaboration between 16 research institutions, including UMMC, with the goal of better understanding why people who live in rural areas of Appalachia and the Mississippi Delta have increased risk of heart, lung, blood and sleep-related diseases.

After finalizing protocols and securing Institutional Review Board approval, the transdisciplinary RURAL team hopes to start the study by first conducting a four-hour detailed baseline exam of the study participants. They plan to use a combination of tools, such as a mobile examination unit, wearable activity monitors and smart phones to assess familial, lifestyle, behavior and medical histories including risk for HLBS disorders. In addition to considering environmental and economic factors, they will also study standard and novel risk factors for HLBS disorders.

Fox said “RURAL has the potential for national impact.” Locally, the study plans to recruit its Mississippi cohort from Oktibbeha and Panola counties in the northern part of the state. Fox, who grew up in north Mississippi, visited the two counties May 15 for initial outreach.

“I wanted trusted community figures to know about RURAL before its launch so that if community members hear about it in the new, they have someone trusted they can speak to,” Fox said. He said there was good turnout in both counties, including elected officials, business leaders, community advocates, local agencies, health care providers and others.

“We had some pastors who couldn’t attend the meeting because it was at the same time as Wednesday evening Bible study and services, but they let us know they were interested as well,” Fox said. “Our goal is to build a network of supporters who can help us with community engagement and recruitment.”

Additional RURAL investigators in Mississippi include Dr. Frances Henderson, former Jackson Heart Study deputy director and dean emeritus of the Alcorn State University School of Nursing; Dr. Sandra Carr-Melvin, chief operating officer of Open Arms Healthcare Center in Jackson; Dr. Bettina Beech, dean of the John D. Bower School of Population Health at UMMC; and Abril Grant, research specialist for the Division of Cardiology at UMMC.

While the specific visits and routes for the mobile units are not planned yet, Fox said RURAL will reach beyond the larger towns Batesville and Starkville.

“We hope to visit people in Como, Crenshaw, Pope, Maben, Sturgis and all throughout Panola and Oktibbeha counties. We want this study to be representative of these communities,” Fox said.

The main hypothesis of RURAL is that exposure to adverse social and environmental factors creates greater wear and tear of the body, affects psychosocial well-being and impacts lifestyle choices that influence HLBS risk. Furthermore, increased genetic predisposition, greater economic challenges, and non-white status may all exacerbate HLBS risk in the South.

Portrait of Vasan Ramachandran

The result is a “rural health penalty,” said Dr. Vasan Ramachandran of Boston University, RURAL’s principal investigator.

 “The rural health penalty in the South does not spare any race or ethnicity. These high risk and economically challenged rural communities are vulnerable to clusters of multiple health problems,” Ramachandran said. “We aim to understand the rural health penalty in the AMD and share our findings with and offer health education to these rural communities.”

Dr. Javed Butler, professor and chair of the Department of Medicine and Patrick Lehan Chair of Cardiovascular Research at UMMC, is excited that the Medical Center will participate in RURAL.

Portrait of Javed Butler

"The NIH has guided many of the pivotal cohort studies over the last decades, that led to better understanding of diseases and ushered an era of improvement in patient treatment and outcomes. Rural communities may face unique challenges with respect to environment, health care infrastructure, health habits, and disease risks and characteristics,” Butler said. “The recently NIH-funded RURAL study holds promise in understanding these unique aspects of drivers of disease and outcomes in the diverse rural communities in the United States. Dr. Ervin Fox is to be congratulated for his leadership and the Department of Medicine looks forward to being part of this very important study."

Dr. Richard Summers, associate vice chancellor for research at UMMC, said this kind of research study is much needed in Mississippi.

Portrait of Dr. Richard Summers

“Frequently in the Delta and other rural areas of our state, it is more difficult for patients to get to a health care provider, particularly ones in urban centers that can provide a higher quality of care, and we do not know enough about how that environment can impact their health,” Summers said. He says that some characteristics of these communities, such as long distances to full-service grocery stores, may contribute to the health disparity, and RURAL may help elucidate those effects.

Summers noted that RURAL has some similarities in scope and design to other population-level studies that UMMC conducts, such as Atherosclerosis Risk in Communities Study and the Jackson Heart Study. The difference is that RURAL’s emphasis is on geography, not race.

In addition to UMMC, investigators from the University of Louisville, Louisiana State University Pennington Biomedical Research Center and University of Alabama at Birmingham will play a central role in participant recruitment, retention, follow-up, data return, return of results, community engagement and education. The study coordinating center is Boston University School of Medicine.

The other 11 institutions participating in RURAL are Duke University; Emory University; Johns Hopkins University; University of California, Los Angeles BioMedical Research Institute; University of California, Berkeley; University of Massachusetts Medical School; University of North Carolina at Chapel Hill; Perelman School of Medicine at the University of Pennsylvania; University of Vermont; University of Virginia at Charlottesville and the Wake Forest School of Medicine.