Compositional stability and diversity of vascular plant communities following logging disturbance in Appalachian forests

Human-caused changes in disturbance regimes and introductions of nonnative species have the potential to result in widespread, directional changes in forest community structure. The degree that plant community composition persists or changes following disturbances depends on the balance between local extirpation and colonization by new species, including nonnatives. In this study, we examined species losses and gains, and entry of native vs. exotic species to determine how oak forests in the Appalachian Mountains might shift in species composition following a gradient of pulse disturbances (timber harvesting). We asked (1) how compositional stability of the plant community (resistance and resilience) was influenced by disturbance intensity, (2) whether community responses were driven by extirpation or colonization of species, and (3) how disturbance intensity influenced total and functional group diversity, including the nonnative proportion of the flora through time. We collected data at three spatial scales and three times, including just before, one year post-disturbance, and 10 years post-disturbance. Resistance was estimated using community distance measures between pre- and one year post-disturbance, and resilience using community distance between pre- and 10-year post-disturbance conditions. The number of colonizing and extirpated species between sampling times was analyzed for all species combined and for six functional groups. Resistance and resilience decreased with increasing timber-harvesting disturbance; compositional stability was lower in the most disturbed plots, which was driven by colonization, but not extirpation, of species. Colonization of species also led to increases in diversity after disturbance that was typically maintained after 10 years following disturbance. Most of the community-level responses were driven by post-disturbance colonization of native forbs and graminoids. The nonnative proportion of plant species tended to increase following disturbance, especially at large spatial scales in the most disturbed treatments, but tended to decrease through time following disturbance due to canopy development. The results of this study are consistent with the theory that resources released by disturbance have strong influences on species colonization and community composition. The effects of management activities tested in this study, which span a gradient of timber-harvesting disturbance, shift species composition largely via an increase in species colonization and diversity.

The effects of mountaintop mines and valley fills on the physicochemical quality of stream ecosystems in the central Appalachians: a review

This review assesses the state of the science on the effects of mountaintop mines and valley fills (MTM-VF) on the physicochemical characteristics of streams in the central Appalachian coalfields of West Virginia, Kentucky, Virginia and Tennessee, USA. We focus on the impacts of mountaintop removal coal mining, which involves removing all - or some portion - of the top of a mountain or ridge to expose and mine one or more coal seams. Excess overburden is disposed in constructed fills in small valleys adjacent to the mining site. MTM-VF leachate persistently increases the downstream concentrations of major ions. Conductivity is a coarse measure of these ions, which are dominated by a distinct mixture of SO(4)(2-), HCO(3)(-), Ca(2+) and Mg(2+), that reflects their source, the oxidation of pyrite to form acid followed by neutralization of the acidity by carbonate minerals within the valley fills. This results in neutral to alkaline pHs, a range at which many metals are relatively insoluble. Other compounds within coal or overburden are solubilized and occur at elevated albeit lower concentrations, including K(+), Na(+), Cl(-), Se and Mn. In terms of physical characteristics, the valley fills act like headwater aquifers, baseflows increase in streams below valley fills and water temperatures exhibit reduced seasonal variation. Peak discharges may be increased in response to intense precipitation events, because of compaction of base surfaces of the MTM-VF areas, but newer approaches to reclamation reduce this compaction and may ameliorate these peak flows. Although the sedimentation pond is intended to capture fine particles that wash downstream from the valley fill, some studies found increased fine sediments in streams downstream from valley fills. However, a proportion of these fines may be eroded from stream banks rather than the valley fills. This is probably a result of the alterations in stream flows.

Ohio Appalachian residents' views on smoke-free laws and cigarette warning labels

INTRODUCTION

Smoke-free laws and the addition of graphic warning labels to cigarette packages represent public health policies that can potentially reduce smoking and smoking-related disease. The attitudes and beliefs relating to these policies were examined among residents of Ohio Appalachia, a mostly rural region with high smoking prevalence among its residents.

METHODS

Focus groups were conducted with participants from Ohio Appalachia during the summer of 2007. Groups included healthcare providers (n=37), community leaders (n=31), parents (n=19), and young adult women aged 18-26 years (n=27).

RESULTS

Most participants were female (94%), non-Hispanic White (94%), and married (65%). Participants believed that most non-smokers supported Ohio's enforced statewide comprehensive smoke-free law that began in 2007, while some smokers opposed the law due to a perceived infringement of their rights. They also reported that most residents and local businesses were abiding by and enforcing the law. Participants supported the addition of graphic warning labels to cigarette packages in the USA. They believed that such warning labels could help deter adolescents and adult non-smokers from smoking initiation, particularly if the negative aesthetic effects of smoking were emphasized. However, they felt the labels would be less effective among current smokers and older individuals living in their communities.

CONCLUSIONS

Participants generally held positive views about both the smoke-free law and the addition of graphic warning labels to cigarette packages in the USA. These tobacco-related public health policies are promising strategies for potentially reducing smoking and its associated diseases among residents living in Appalachia. Additional research is needed to further examine support for these policies among more diverse Appalachian populations.

Disparities in underserved white populations: the case of cancer-related disparities in Appalachia

There are meaningful cancer-related disparities in the Appalachian region of the U.S. To address these disparities, the Appalachia Community Cancer Network (ACCN), a collaboration of investigators and community partners in five states (Kentucky, Ohio, Pennsylvania, Virginia, and West Virginia), is involved in increasing cancer education and awareness, conducting community-based participatory research (CBPR), and creating mentorship and training opportunities. The primary objective of this paper is to describe cancer-related disparities in the Appalachian region of the U.S. as an example of the disparities experienced by underserved, predominantly white, rural populations, and to describe ACCN activities designed to intervene regarding these disparities. An ACCN overview/history and the diverse activities of ACCN-participating states are presented in an effort to suggest potential useful strategies for working to reduce health-related disparities in underserved white populations. Strengths that have emerged from the ACCN approach (e.g., innovative collaborations, long-standing established networks) and remaining challenges (e.g., difficulties with continually changing communities, scarce resources) are described. Important recommendations that have emerged from the ACCN are also presented, including the value of allowing communities to lead CBPR efforts. Characteristics of the community-based work of the ACCN provide a framework for reducing health-related disparities in Appalachia and in other underserved white and rural populations.

Formative research conducted in rural Appalachia to inform a community physical activity intervention

PURPOSE

Despite the well-established benefits of physical activity (PA), most Americans, especially those in rural, traditionally underserved areas, engage in considerably less PA than recommended. This study examines perceived barriers to and facilitators of PA and promising organized PA programs among rural Appalachians.

DESIGN

Eight focus groups and seven group key informant interviews were conducted.

SETTING

This study was conducted in eastern Kentucky, in central Appalachia.

SUBJECTS

One hundred and fourteen rural Appalachian residents (74% female, 91% white) participated.

MEASURES

Open-ended, semistructured, and structured questions regarding perceptions of, barriers to/facilitators of, and examples of successful/failed PA programs were asked.

ANALYSIS

Qualitative data analysis was conducted, including codebook development and steps taken to ensure rigor and transferability. Interrater reliability was over 94%.

RESULTS

In addition to barriers that are consistent with those found in other populations, rural Appalachian residents indicated that travel time, family commitments, and inadequate community resources undermine PA. Suggested avenues to increase PA include partnership with churches and the U.S. Department of Agriculture's Cooperative Extension Service; programs that include families, are well advertised, and focus on health rather than appearance; and, underlying all suggestions, culturally relevant yet nonstereotyping activities.

CONCLUSIONS

When developing PA interventions in rural Appalachia, it is important to employ community-based participatory approaches that leverage unique assets of the population and show potential in overcoming challenges to PA.

Trust and distrust among Appalachian women regarding cervical cancer screening: a qualitative study

OBJECTIVE

To explore Appalachian women's perceptions of trust and distrust of healthcare providers and the medical care system as they relate to views about cervical cancer and screening.

METHODS

Thirty-six Ohio Appalachia female residents participated in community focus groups conducted by trained facilitators. Discussion topics included factors related to cervical cancer, and the issues of trust and distrust in medical care. The tape-recorded focus groups were transcribed and analyzed to identify salient themes.

RESULTS

Five themes emerged related to trust in healthcare. Patient-centered communication and encouragement from a healthcare provider led women to trust their physicians and the medical care system. In contrast, lack of patient-centered communication by providers and perceptions of poor quality of care led to distrust. Physician gender concordance also contributed to trust as women reported trust of female physicians and distrust of male physicians; trust in male physicians was reported to be increased by the presence of a female nurse.

CONCLUSIONS

Important factors associated with trust and distrust of providers and the medical care system may impact health-seeking behaviors among underserved women.

PRACTICE IMPLICATIONS

Opportunities to improve patient-centered communication around the issues of prevention and cervical cancer screening (such as providing patient-focused information about access to appropriate screening tests) could be used to improve patient care and build patients' trust.

Impact of a community-based intervention on serving and intake of vegetables among low-income, rural Appalachian families

OBJECTIVE

To evaluate the effectiveness of a community-based intervention promoting the serving and eating of deep-orange, cruciferous, and dark-green leafy vegetables.

DESIGN

Randomized, parallel-group, community-based intervention with a baseline/postintervention/3-month follow-up design.

SETTING AND PARTICIPANTS

Low-income food preparers (n = 50) and their partners (n = 50) in rural Appalachia Pennsylvania.

INTERVENTION

Experimental food preparers attended 8 weekly interactive lessons; control food preparers received 8 weekly mailings that included similar recipes and handouts.

MAIN OUTCOME MEASURES

Target vegetable intake and frequency of serving by experimental and control treatment groups and by high and low meal diary scores, a measure of recipe acceptability.

ANALYSIS

Linear mixed-model analysis with repeated measures.

RESULTS

No significant differences resulted between the original experimental and control treatment groups. When grouped by high and low meal diary scores, more experimental families had high scores than in controls. High scores were associated with significant changes in frequency of serving and intake of the target vegetables.

CONCLUSIONS AND IMPLICATIONS

Meal diary use may foster food preparer negotiation with partners and children to become involved in vegetable dish evaluation. Tools to help the trained food preparer draw family members into recipe evaluation, such as the meal diary, are useful and needed.

Effectiveness of community health workers in providing outreach and education for colorectal cancer screening in Appalachian Kentucky

The purpose of this study was to examine the effectiveness of a community health worker (CHW)-delivered cancer education program designed to increase knowledge and awareness of colorectal cancer screening options. The study population was an extremely vulnerable and medically underserved geographic region in Appalachian Kentucky. CHWs enrolled participants in face-to-face visits, obtained informed consent, and administered a baseline assessment of knowledge of colorectal cancer risks and the benefits of screening and screening history. An educational intervention was then provided and participants were re-contacted 6 months later when a posttest was administered. The mean score of the 637 participants increased from 4.27 at baseline to 4.57 at follow-up (p < .001). Participants who reported asking their health care provider about colorectal cancer screening increased from 27.6% at baseline to 34.1% at follow-up (p = .013). Results suggest that CHWs were very effective at maintaining the study population; no loss to follow-up occurred. The results also showed increased knowledge and awareness about colorectal cancer screening education. Implications for social work practice, policy and research are discussed.

Sexually related behaviors as predictors of HPV vaccination among young rural women

PURPOSE

To explore whether sexually related behaviors predict refusal of the human papillomavirus (HPV) vaccine among a sample of women aged 18-26 in Appalachian Kentucky.

METHODS

Using a convenience sample, young women attending health clinics and a community college in southeastern Kentucky were recruited to participate in a Women's Health Study. After completing a questionnaire, women received a free voucher for the three-dose HPV vaccine series. Completion of dose one served as the outcome variable.

RESULTS

Women with a history of an abnormal Pap test were almost two times more likely to decline the HPV vaccine (adjusted odds ratio [AOR] 1.91, 95% confidence interval [CI] 1.14-3.20, p=0.015), and women who reported they had never had a Pap test were four times more likely to decline the vaccine (AOR 4.02, 95% CI 1.13-14.32, p=0.032). Women engaging in mutual masturbation were nearly two times more likely to decline the free vaccine (AOR 1.91, 95% CI 1.17-3.10, p=0.009). Use of hormonal birth control showed a protective effect against refusal of the free HPV vaccine (AOR 0.593, 95% CI 0.44-0.80, p=0.001).

CONCLUSIONS

Among this sample of Appalachian women, those engaging in behaviors that increase their risk for HPV infection were more likely to refuse the vaccine. Conversely, those women engaging in protective health behaviors were more likely to accept the vaccine. These findings suggest that those women not being vaccinated may be the very group most likely to benefit from vaccination. Cervical cancer prevention programs need to be creative in efforts to reach young women most in need of the vaccine based on a higher profile of sexually related behaviors and the proxy measure of this risk (having an abnormal Pap test result).

Target loads of atmospheric sulfur deposition for the protection and recovery of acid-sensitive streams in the Southern Blue Ridge Province

An important tool in the evaluation of acidification damage to aquatic and terrestrial ecosystems is the critical load (CL), which represents the steady-state level of acidic deposition below which ecological damage would not be expected to occur, according to current scientific understanding. A deposition load intended to be protective of a specified resource condition at a particular point in time is generally called a target load (TL). The CL or TL for protection of aquatic biota is generally based on maintaining surface water acid neutralizing capacity (ANC) at an acceptable level. This study included calibration and application of the watershed model MAGIC (Model of Acidification of Groundwater in Catchments) to estimate the target sulfur (S) deposition load for the protection of aquatic resources at several future points in time in 66 generally acid-sensitive watersheds in the southern Blue Ridge province of North Carolina and two adjoining states. Potential future change in nitrogen leaching is not considered. Estimated TLs for S deposition ranged from zero (ecological objective not attainable by the specified point in time) to values many times greater than current S deposition depending on the selected site, ANC endpoint, and evaluation year. For some sites, one or more of the selected target ANC critical levels (0, 20, 50, 100μeq/L) could not be achieved by the year 2100 even if S deposition was reduced to zero and maintained at that level throughout the simulation. Many of these highly sensitive streams were simulated by the model to have had preindustrial ANC below some of these target values. For other sites, the watershed soils contained sufficiently large buffering capacity that even very high sustained levels of atmospheric S deposition would not reduce stream ANC below common damage thresholds.

Adapting and implementing evidence-based cancer education interventions in rural Appalachia: real world experiences and challenges

INTRODUCTION

There is recognition among public health scholars and community practitioners that translating cancer prevention and control research into practice is challenging. This circumstance is particularly germane to medically underserved communities, such as rural Appalachia, where few evidence-based interventions originate and cancer incidence and mortality are elevated.

METHODS

A case study approach was selected to examine the collective experience of 13 West Virginia community organizations awarded mini-grants requiring the use of an evidence-based cancer control intervention. Methods included a systematic review of grant applications and final programmatic reports, a faxed survey, and qualitative, in-depth interviews with key stakeholders.

RESULTS

Appalachian grantees reported notable challenges with selecting, adapting, and implementing evidence-based cancer education interventions. Evidence-based programming was viewed as a barrier. Grantees made a range of adaptations to meet constituent needs, thereby jeopardizing intervention fidelity. However, programs were perceived as successful due to community participation and engagement, some element of behavioral change, dissemination of the health message, and establishment of collaborative partnerships.

CONCLUSIONS

A descriptive examination provides insights into the challenges of translating research to practice. This Appalachian cancer education grant program also highlights areas of compromise that are important for researchers and practitioners to understand.

Can forest management be used to sustain water-based ecosystem services in the face of climate change?

Forested watersheds, an important provider of ecosystems services related to water supply, can have their structure, function, and resulting streamflow substantially altered by land use and land cover. Using a retrospective analysis and synthesis of long-term climate and streamfiow data (75 years) from six watersheds differing in management histories we explored whether streamflow responded differently to variation in annual temperature and extreme precipitation than unmanaged watersheds. We show significant increases in temperature and the frequency of extreme wet and dry years since the 1980s. Response models explained almost all streamflow variability (adjusted R2 > 0.99). In all cases, changing land use altered streamflow. Observed watershed responses differed significantly in wet and dry extreme years in all but a stand managed as a coppice forest. Converting deciduous stands to pine altered the streamflow response to extreme annual precipitation the most; the apparent frequency of observed extreme wet years decreased on average by sevenfold. This increased soil water storage may reduce flood risk in wet years, but create conditions that could exacerbate drought. Forest management can potentially mitigate extreme annual precipitation associated with climate change; however, offsetting effects suggest the need for spatially explicit analyses of risk and vulnerability.

Forest restoration potentials of coal-mined lands in the eastern United States

The Appalachian region in the eastern United Sates is home to the Earth's most extensive temperate deciduous forests, but coal mining has caused forest loss and fragmentation. More than 6000 km in Appalachia have been mined for coal since 1980 under the Surface Mining Control and Reclamation Act (SMCRA). We assessed Appalachian areas mined under SMCRA for forest restoration potentials. Our objectives were to characterize soils and vegetation, to compare soil properties with those of pre-SMCRA mined lands that were reforested successfully, and to determine the effects of site age on measured properties. Soils were sampled and dominant vegetation characterized at up to 10 points on each of 25 post-SMCRA mines. Herbaceous species were dominant on 56%, native trees on 24%, and invasive exotics on 16% of assessed areas. Mean values for soil pH (5.8), electrical conductivity (0.07 dS m(-1)), base saturation (89%), and coarse fragment content (50% by mass) were not significantly different from measured levels on the pre-SMCRA forested sites, but silt+clay soil fraction (61%) was higher, bicarbonate-extractable P (4 mg kg(-1)) was lower, and bulk density (1.20 g cm(-1)) was more variable and often unfavorable. Pedogenic N and bicarbonate-extractable P in surface soils increased with site age and with the presence of weathered rocks among coarse fragments. Our results indicate a potential for many of these soils to support productive forest vegetation if replanted and if cultural practices, including temporary control of existing vegetation, soil density mitigation, and fertilization, are applied to mitigate limitations and aid forest tree reestablishment and growth.

Geotechnical characterization of mined clay from Appalachian Ohio: challenges and implications for the clay mining industry

Clayey soil found in coal mines in Appalachian Ohio is often sold to landfills for constructing Recompacted Soil Liners (RSL) in landfills. Since clayey soils possess low hydraulic conductivity, the suitability of mined clay for RSL in Ohio is first assessed by determining its clay content. When soil samples are tested in a laboratory, the same engineering properties are typically expected for the soils originated from the same source, provided that the testing techniques applied are standard, but mined clay from Appalachian Ohio has shown drastic differences in particle size distribution depending on the sampling and/or laboratory processing methods. Sometimes more than a 10 percent decrease in the clay content is observed in the samples collected at the stockpiles, compared to those collected through reverse circulation drilling. This discrepancy poses a challenge to geotechnical engineers who work on the prequalification process of RSL material as it can result in misleading estimates of the hydraulic conductivity of the samples. This paper describes a laboratory investigation conducted on mined clay from Appalachian Ohio to determine how and why the standard sampling and/or processing methods can affect the grain-size distributions. The variation in the clay content was determined to be due to heavy concentrations of shale fragments in the clayey soils. It was also concluded that, in order to obtain reliable grain size distributions from the samples collected at a stockpile of mined clay, the material needs to be processed using a soil grinder. Otherwise, the samples should be collected through drilling.

Neighborhood disparities in stroke and myocardial infarction mortality: a GIS and spatial scan statistics approach

BACKGROUND

Stroke and myocardial infarction (MI) are serious public health burdens in the US. These burdens vary by geographic location with the highest mortality risks reported in the southeastern US. While these disparities have been investigated at state and county levels, little is known regarding disparities in risk at lower levels of geography, such as neighborhoods. Therefore, the objective of this study was to investigate spatial patterns of stroke and MI mortality risks in the East Tennessee Appalachian Region so as to identify neighborhoods with the highest risks.

METHODS

Stroke and MI mortality data for the period 1999-2007, obtained free of charge upon request from the Tennessee Department of Health, were aggregated to the census tract (neighborhood) level. Mortality risks were age-standardized by the direct method. To adjust for spatial autocorrelation, population heterogeneity, and variance instability, standardized risks were smoothed using Spatial Empirical Bayesian technique. Spatial clusters of high risks were identified using spatial scan statistics, with a discrete Poisson model adjusted for age and using a 5% scanning window. Significance testing was performed using 999 Monte Carlo permutations. Logistic models were used to investigate neighborhood level socioeconomic and demographic predictors of the identified spatial clusters.

RESULTS

There were 3,824 stroke deaths and 5,018 MI deaths. Neighborhoods with significantly high mortality risks were identified. Annual stroke mortality risks ranged from 0 to 182 per 100,000 population (median: 55.6), while annual MI mortality risks ranged from 0 to 243 per 100,000 population (median: 65.5). Stroke and MI mortality risks exceeded the state risks of 67.5 and 85.5 in 28% and 32% of the neighborhoods, respectively. Six and ten significant (p < 0.001) spatial clusters of high risk of stroke and MI mortality were identified, respectively. Neighborhoods belonging to high risk clusters of stroke and MI mortality tended to have high proportions of the population with low education attainment.

CONCLUSIONS

These methods for identifying disparities in mortality risks across neighborhoods are useful for identifying high risk communities and for guiding population health programs aimed at addressing health disparities and improving population health.

Identifying unique neighborhood characteristics to guide health planning for stroke and heart attack: fuzzy cluster and discriminant analyses approaches

BACKGROUND

Socioeconomic, demographic, and geographic factors are known determinants of stroke and myocardial infarction (MI) risk. Clustering of these factors in neighborhoods needs to be taken into consideration during planning, prioritization and implementation of health programs intended to reduce disparities. Given the complex and multidimensional nature of these factors, multivariate methods are needed to identify neighborhood clusters of these determinants so as to better understand the unique neighborhood profiles. This information is critical for evidence-based health planning and service provision. Therefore, this study used a robust multivariate approach to classify neighborhoods and identify their socio-demographic characteristics so as to provide information for evidence-based neighborhood health planning for stroke and MI.

METHODS AND FINDINGS

The study was performed in East Tennessee Appalachia, an area with one of the highest stroke and MI risks in USA. Robust principal component analysis was performed on neighborhood (census tract) socioeconomic and demographic characteristics, obtained from the US Census, to reduce the dimensionality and influence of outliers in the data. Fuzzy cluster analysis was used to classify neighborhoods into Peer Neighborhoods (PNs) based on their socioeconomic and demographic characteristics. Nearest neighbor discriminant analysis and decision trees were used to validate PNs and determine the characteristics important for discrimination. Stroke and MI mortality risks were compared across PNs. Four distinct PNs were identified and their unique characteristics and potential health needs described. The highest risk of stroke and MI mortality tended to occur in less affluent PNs located in urban areas, while the suburban most affluent PNs had the lowest risk.

CONCLUSIONS

Implementation of this multivariate strategy provides health planners useful information to better understand and effectively plan for the unique neighborhood health needs and is important in guiding resource allocation, service provision, and policy decisions to address neighborhood health disparities and improve population health.

Deconstructing fatalism: ethnographic perspectives on women's decision making about cancer prevention and treatment

Researchers have long held that fatalism (the belief in a lack of personal power or control over destiny or fate) constitutes a major barrier to participation in positive health behaviors and, subsequently, adversely affects health outcomes. In this article, we present two in-depth, ethnographic studies of rural women's health decisions surrounding cancer treatments to illustrate the complexity and contestability of the long-established fatalism construct. Narrative analyses suggest that for these women, numerous and complex factors--including inadequate access to health services, a legacy of self-reliance, insufficient privacy, combined with a culturally acceptable idiom of fatalism--foster the use of, but not necessarily a rigid conviction in, the notion of fatalism.

Health disparities between Appalachian and non-Appalachian counties in Virginia USA

The examination of health disparities among people within Appalachian counties compared to people living in other counties is needed to find ways to strategically target improvements in community health in the United States of America (USA).

METHODS

A telephone survey of a random sample of adults living in households within communities of all counties of the state of Virginia (VA) in the USA was conducted.

FINDINGS

Health status was poorer among those in communities within Appalachian counties in VA and health insurance did not make a difference. Health perception was significantly worse in residents within communities in Appalachian counties compared to non-Appalachian community residents (30.5 vs. 17.4% rated their health status as poor/fair), and was worse even among those with no chronic diseases. Within communities in Appalachian counties, black residents report significantly better health perception than do white residents.

CONCLUSION

Residents living in communities in Appalachian counties in VA are not receiving adequate health care, even among those with health insurance. More research with a larger ethnic minority sample is needed to investigate the racial/ethnic disparities in self-reported health and health care utilization within communities.

Academic detailing to increase colorectal cancer screening by primary care practices in Appalachian Pennsylvania

BACKGROUND

In the United States, colorectal cancer (CRC) is the third most frequently diagnosed cancer and second leading cause of cancer death. Screening is a primary method to prevent CRC, yet screening remains low in the U.S. and particularly in Appalachian Pennsylvania, a largely rural area with high rates of poverty, limited health care access, and increased CRC incidence and mortality rates. Receiving a physician recommendation for CRC screening is a primary predictor for patient adherence with screening guidelines. One strategy to disseminate practice-oriented interventions is academic detailing (AD), a method that transfers knowledge or methods to physicians, nurses or office staff through the visit(s) of a trained educator. The objective of this study was to determine acceptability and feasibility of AD among primary care practices in rural Appalachian Pennsylvania to increase CRC screening.

METHODS

A multi-site, practice-based, intervention study with pre- and 6-month post-intervention review of randomly selected medical records, pre- and post-intervention surveys, as well as a post-intervention key informant interview was conducted. The primary outcome was the proportion of patients current with CRC screening recommendations and having received a CRC screening within the past year. Four practices received three separate AD visits to review four different learning modules.

RESULTS

We reviewed 323 records pre-intervention and 301 post-intervention. The prevalence of being current with screening recommendation was 56% in the pre-intervention, and 60% in the post-intervention (p=0.29), while the prevalence of having been screened in the past year increased from 17% to 35% (p<0.001). Colonoscopies were the most frequently performed screening test. Provider knowledge was improved and AD was reported to be an acceptable intervention for CRC performance improvement by the practices.

CONCLUSIONS

AD appears to be acceptable and feasible for primary care providers in rural Appalachia. A ceiling effect for CRC screening may have been a factor in no change in overall screening rates. While the study was not designed to test the efficacy of AD on CRC screening rates, our evidence suggests that AD is acceptable and may be efficacious in increasing recent CRC screening rates in Appalachian practices which could be tested through a randomized controlled study.

Appalachian residents' experiences with and management of multiple morbidity

Approximately three fourths of middle-aged and older adults have at least two simultaneously occurring chronic conditions ("multiple morbidity," or MM), a trend expected to increase dramatically throughout the world. Rural residents, who tend to have fewer personal and health resources, are more likely to experience MM. To improve our understanding of the ways in which vulnerable, rural residents in the United States experience and manage MM, we interviewed 20 rural Appalachian residents with MM. We identified the following themes: (a) MM has multifaceted challenges and is viewed as more than the sum of its parts; (b) numerous challenges exist to optimal MM self-management, particularly in a rural, underresourced context; however, (c) participants described strategic methods of managing MM, including prioritizing certain conditions and management strategies and drawing heavily on assistance from informal and formal sources.

Restoring forests and associated ecosystem services on appalachian coal surface mines

Surface coal mining in Appalachia has caused extensive replacement of forest with non-forested land cover, much of which is unmanaged and unproductive. Although forested ecosystems are valued by society for both marketable products and ecosystem services, forests have not been restored on most Appalachian mined lands because traditional reclamation practices, encouraged by regulatory policies, created conditions poorly suited for reforestation. Reclamation scientists have studied productive forests growing on older mine sites, established forest vegetation experimentally on recent mines, and identified mine reclamation practices that encourage forest vegetation re-establishment. Based on these findings, they developed a Forestry Reclamation Approach (FRA) that can be employed by coal mining firms to restore forest vegetation. Scientists and mine regulators, working collaboratively, have communicated the FRA to the coal industry and to regulatory enforcement personnel. Today, the FRA is used routinely by many coal mining firms, and thousands of mined hectares have been reclaimed to restore productive mine soils and planted with native forest trees. Reclamation of coal mines using the FRA is expected to restore these lands' capabilities to provide forest-based ecosystem services, such as wood production, atmospheric carbon sequestration, wildlife habitat, watershed protection, and water quality protection to a greater extent than conventional reclamation practices.

Factors associated with participation in cancer prevention and control studies among rural Appalachian women

Rural Appalachian women bear a disproportionate burden from many types of cancer yet often are underrepresented in cancer research. This article uses 2 case studies to illustrate barriers faced and strategies used when recruiting hard-to-reach rural participants. Recruitment barriers include the population's competing demands and lack of trust of outsiders. Strategies employed include involving insider advocates, highlighting the positive experiences of early participants, spending extensive time in the community, and emphasizing potential community benefits of the study. We suggest recruitment strategies to better involve rural women and others who, by virtue of being "hard-to-reach," often are overlooked.