State of Tennessee

Tennessee is a southern state well known for music, which is an integral part of its culture; less well known is the state’s agricultural history.

Before the Civil War, Tennessee was among the nation’s top 10 producers of tobacco, cotton, corn, wheat, and hogs. It remains among the nation’s top five tobacco-producing states. The Volunteer State, as it is commonly known, is primarily rural, with a higher proportion of white and Black residents, compared with national averages, and fewer Hispanics. The Hispanic population is growing, having nearly doubled in the last 10 years.

Tennessee’s two major cities, Memphis and Nashville, are home to 20 percent of the state’s residents. “Noncore” counties—those with cities or towns with populations of less than 10,000—are prevalent throughout the state. These counties are the most rural areas of Tennessee. The state is divided into three culturally and geographically distinct regions, called Grand Divisions—each one comprises approximately one-third of the state’s land area. Cultural, racial, and historical differences in the state’s Grand Divisions, and variations in income and education within each region, play a significant role in the health outcomes of its residents. For example, West Tennessee comprises 39 percent Black residents, compared with 13 percent for Middle Tennessee and 6 percent for East Tennessee. West Tennessee’s economy was historically more dependent on cotton production, with its associated history of slavery, than the other two Grand Divisions. This report provides a snapshot of health and well-being issues and initiatives across Tennessee and in selected areas within the Grand Divisions: Memphis/Shelby County (West Tennessee), Nashville/Davidson County (Middle Tennessee), and throughout East Tennessee.

Overview

Population and Demographics

Population: 6,499,615

SOURCES:
U.S. Census Bureau; photography courtesy Flickr user Thomas Hawk CC BY NC 2.0.

Context and Actions

Community Context and Challenges

Tennessee’s reliance on and long commitment to tobacco continues to affect the health and well-being of its residents; in 2015, 22% of Tennesseans smoked compared with 18% nationwide.
Tennessee ranks 43rd out of 50 states for overall health; while the state’s overall obesity rate (31%) is comparable to the national average (30%), obesity and chronic disease disproportionately affect Black and Hispanic residents.
Low educational attainment and high poverty rates are more prevalent in the state’s rural counties.
Only 25% of Tennesseans have a bachelor’s degree or higher, compared with 18% of Black residents and 13% of the Hispanic population.
Tennessee is home to some of the nation’s best health care systems, with 87% of the population covered by health insurance; however, health care is more accessible in urban areas, and a majority of counties are medically underserved.

SOURCES:
Centers for Disease Control and Prevention. (2013). Youth Risk Behavior Surveillance System.

U.S. Census Bureau. (2015).2011–2015 American Community Survey 5-Year Estimates.

Taking Action

Spurred by its most pressing health challenges, communities across Tennessee are investing in a wide variety of cross-sector initiatives.

Within the state and its three regions, leaders have formed innovative partnerships to address these and other issues and have mobilized a variety of stakeholders, including elected officials; public health departments; other government agencies, such as transportation and city planning departments; development districts; parks and recreation departments; law enforcement; departments of public works; advocates; nonprofit organizations; businesses and chambers of commerce; hospitals; universities; foundations; and schools. Those partnerships are working to address these issues at the state and local levels using a variety of strategies.

NOTE:
These baseline reports, created in 2016, reflect our initial observations on select community programs and initiatives to gauge ongoing, as well as newer, efforts to improve community health. Future reports will provide more in-depth insights and analysis into this community's activities.

CEO Culture of Health Initiative

The CEO Culture of Health initiative has the goal of promoting health in the workplace and improving the sense of community, morale and retention of employees. As of March 2016, 64 businesses in the Memphis area have joined the initiative. The Memphis Business Group on Health assists businesses with planning and implementation by providing a Worksite Health Assessment, a roadmap for establishing an evidence-based wellness program and technical assistance.

Coordinated School Health

Tennessee’s Coordinated School Health (CSH) program focuses on reducing childhood obesity rates. The effort includes private and public partners from hospitals, universities, foundations, community-based organizations and all 95 school districts to connect health with education through eight interrelated components (nutrition, health services, health education, healthy school environment, school counseling, student and family involvement and school staff wellness). The rate of overweight and obese students dropped from more than 41 percent during the 2007-2008 school year to less than 39 percent in 2014-2015, according to CSH’s annual report. Additionally, in 2013, 41 percent of students reported that they were physically active for at least 60 minutes per day during 5 or more of the previous 7 days, up from just 25 percent in 2005.

Fitness and Diet Initiatives

In 2010, Nashville/Davidson County received a Communities Putting Prevention to Work grant, which it has used to improve fitness in diet through a variety of efforts. Through this initiative the county formalized a Complete Streets plan to ensure safer streets and active transportation options for pedestrians, bicyclists and transit users. And it launched NashVitality, a citywide initiative to encourage physical activity and healthier eating. As part of NashVitality the community created a cross-sector School Nutrition Advisory Committee with members ranging from parents to local growers to improve healthy food options for 76,000 students; passed new policies promoting healthy foods in Metropolitan Public Health Department meetings and vending machines; and challenged the mayor and others to walk 100 miles over six weeks.

Mobile Clinics

To address a lack of care, many counties rely on mobile clinics and telemedicine. St. Mary’s Legacy Clinic offers a mobile health clinic that provides free care to East Tennessee residents. Wallace Mobile Healthcare was created to provide basic health services to the uninsured and underprivileged living in Knox and nearby counties. In addition, East Tennessee State University received a $191,000 grant from the U.S. Department of Agriculture to establish a telemedicine system to provide care to residents in five counties in Tennessee, Kentucky and Virginia.

Going Forward

Initial analyses point to numerous health challenges facing Tennessee, many of which are directly tied to disparities by income, education, region, and race/ethnicity. State, regional, and local agencies, along with private-sector partners, have taken steps to address their priority health concerns of obesity and tobacco use. The state is making progress in tackling childhood obesity by decreasing the percentage of students who are overweight or obese and increasing the percentage of students who are engaging in physical activity. The state has implemented some tobacco reduction efforts, but these are not always evidence-based or implemented with sufficient intensity or reach.

The demographic, cultural, and geographic features of each region present unique challenges relating to the health and well-being of residents, which require varied approaches to developing and implementing local initiatives. Urban counties, such as Shelby and Davidson, have developed several large-scale initiatives involving multiple sectors, which include approaches such as policy change, integration of treatment and prevention, and changes to the built environment. Leaders in many urban counties have also been able to take advantage of resources and partnerships available to them through local universities. Rural counties, on the other hand, appear to be more dependent on regional, statewide, and national programs.

Additional surveillance, data and information gathering, analysis, and reporting will examine the extent to which Tennessee’s initiatives are addressing the state’s priority health concerns, particularly among racial/ethnic minorities and populations with low incomes and low educational attainment. Future reports will also delve into the interaction between race/ethnicity, urban setting, and regional outcomes.

Ongoing questions for the state and each region include the following:

State

What factors contribute to the rural/urban disparities in socioeconomic and health outcomes? How does urban setting and race/ethnicity affect differences in outcomes by Grand Division? To what extent do approaches to advancing community health and well-being vary across Grand Divisions, and how are these being tailored to address population characteristics within each region?
To what extent do Tennessee stakeholders and residents share a common understanding of health inequities and how to address them, and to what extent does this differ across regions of the state? What efforts, if any, are being made to engage Tennessee’s underserved residents in the process of planning and implementing initiatives to address inequities?
What cross-sector collaborations are in place to reduce inequities in the urban and rural regions of the state? What collaborations exist in each region and what types of cross-regional collaborations exist (e.g., partnerships among rural counties across the state)? Who is involved and how?
How is Tennessee working to improve access to health care in underserved areas of the state?
To what extent have the state’s health priorities been integrated into the missions, goals, and actions of non-health-related organizations or sectors? In what ways are organizations in non-health sectors working to address health inequities? Are there specific efforts that are aimed to improve the health and well-being of certain groups experiencing disparities?
What initiatives exist across the state to improve infrastructure and modify the built environment to improve health and well-being?

Grand Divisions

West Tennessee (Memphis/Shelby County)

In what ways are the voices of the large Black population of this county incorporated into local decision-making processes about health and well-being? What is the status of leadership for this traditionally marginalized group?
What cross-sector collaborations are in place to meet the health care needs of the large proportion of uninsured residents in Memphis/Shelby County?

Middle Tennessee (Nashville/Davidson County)

In what ways is Middle Tennessee addressing the built environment as a part of its effort to build a Culture of Health and how have these efforts affected the health and well-being of residents? What changes to the built environment are planned in the near future?
How has leadership from the mayor’s office influenced Nashville’s path toward a Culture of Health?
In what ways has the presence of several major universities facilitated cross-sector collaboration in the Nashville area? What other influential partnerships, coalitions, or initiatives involve the universities?

East Tennessee (Knox, Hamilton, Washington, and Noncore Counties)

How is East Tennessee working to improve access to health care in medically underserved Appalachia? To what extent are mobile health clinics reaching the noncore counties with the greatest provider shortages in Appalachia?
What factors contribute to the rural/urban disparities in educational attainment? What is Tennessee doing to improve educational attainment in rural Appalachia?