The paradox of high greenness and poor health in rural Central Appalachia

While many studies have found positive correlations between greenness and human health, rural Central Appalachia is an exception. The region has high greenness levels but poor health. The purpose of this commentary is to provide a possible explanation for this paradox: three sets of factors overwhelming or attenuating the health benefits of greenness. These include environmental (e.g., steep typography and limited access to green space used for outdoor recreation), social (e.g., chronic poverty, declining coal industry, and limited access to healthcare), and psychological and behavioral factors (e.g., perceptions about health behaviors, healthcare, and greenness). The influence of these factors on the expected health benefits of greenness should be considered as working hypotheses for future research. Policymakers and public health officials need to ensure that greenness-based interventions account for contextual factors and other determinants of health to ensure these interventions have the expected health benefits.

Kids SIPsmartER reduces sugar-sweetened beverages among Appalachian middle-school students and their caregivers: a cluster randomized controlled trial

BACKGROUND

High consumption of sugar-sweetened beverages (SSB) is a global health concern. Additionally, sugar-sweetened beverage (SSB) consumption is disproportionately high among adolescents and adults in rural Appalachia. The primary study objective is to determine the intervention effects of Kids SIPsmartER on students' SSB consumption. Secondary objectives focus on caregivers' SSB consumption and secondary student and caregiver outcomes [e.g, body mass index (BMI), quality of life (QOL)].

METHODS

This Type 1 hybrid, cluster randomized controlled trial includes 12 Appalachian middle schools (6 randomized to Kids SIPsmartER and 6 to control). Kids SIPsmartER is a 6-month, 12 lesson, multi-level, school-based, behavior and health literacy program aimed at reducing SSB among 7th grade middle school students. The program also incorporates a two-way text message strategy for caregivers. In this primary prevention intervention, all 7th grade students and their caregivers from participating schools were eligible to participate, regardless of baseline SSB consumption. Validated instruments were used to assess SSB behaviors and QOL. Height and weight were objectively measured in students and self-reported by caregivers. Analyses included modified two-part models with time fixed effects that controlled for relevant demographics and included school cluster robust standard errors.

RESULTS

Of the 526 students and 220 caregivers, mean (SD) ages were 12.7 (0.5) and 40.6 (6.7) years, respectively. Students were 55% female. Caregivers were mostly female (95%) and White (93%); 25% had a high school education or less and 33% had an annual household income less than $50,000. Regardless of SSB intake at baseline and relative to control participants, SSB significantly decreased among students [-7.2 ounces/day (95% CI = -10.7, -3.7); p < 0.001, effect size (ES) = 0.35] and caregivers [-6.3 ounces/day (95% CI = -11.3, -1.3); p = 0.014, ES = 0.33]. Among students (42%) and caregivers (28%) who consumed > 24 SSB ounces/day at baseline (i.e., high consumers), the ES increased to 0.45 and 0.95, respectively. There were no significant effects for student or caregiver QOL indicators or objectively measured student BMI; however, caregiver self-reported BMI significantly decreased in the intervention versus control schools (p = 0.001).

CONCLUSIONS

Kids SIPsmartER was effective at reducing SSB consumption among students and their caregivers in the rural, medically underserved Appalachian region. Importantly, SSB effects were even stronger among students and caregivers who were high consumers at baseline.

TRIAL REGISTRATION

Clincialtrials.gov: NCT03740113. Registered 14 November 2018- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03740113 .

The Breast-Imaging Operations, Practices and Systems Inventory: A framework to examine mammography facility effects on screening in rural communities

PURPOSE

Develop and test a measurement framework of mammogram facility resources, policies, and practices in Appalachia.

METHODS

Survey items describing 7 domains of imaging facility qualities were developed and tested in the Appalachian regions of Kentucky, Ohio, Pennsylvania, Virginia, and West Virginia. Medicare claims data (2016-2018) were obtained on catchment area mammogram services. Construct validity was examined from associations with facility affiliation, community characteristics, mammogram screening uptake, and market reach. Analyses were performed with t-tests and ANOVA.

RESULTS

A total of 192 (of 377) sites completed the survey. Five factors were initially selected in exploratory factor analysis (FA) and refined in confirmatory FA: capacity, outreach & marketing, operational support, radiology review (NNFI = .94, GFI = 0.93), and diagnostic services (NNFI = 1.00, GFI = 0.99). Imaging capacity and diagnostic services were associated with screening uptake, with capacity strongly associated with catchment area demographic and economic characteristics. Imaging facilities in economically affluent versus poorer areas belong to larger health systems and have significantly more resources (P < .001). Facilities in economically distressed locations in Appalachia rely more heavily on outreach activities (P < .001). Higher facility capacity was significantly associated (P < .05) with larger catchment area size (median split: 48.5 vs 51.6), mammogram market share (47.4 vs 52.7), and screening uptake (47.6 vs 52.4).

CONCLUSIONS

A set of 18 items assessing breast imaging services and facility characteristics was obtained, representing policies and practices related to a facility's catchment area size, market share, and mammogram screening uptake.

A Comparison of Hospice Care Utilization Between Rural and Urban Children in Appalachia: A Geographic Information Systems Analysis

Long driving times from hospice providers to patients lead to poor quality of care, which may exacerbate in rural and highly isolated areas of Appalachia. This study aimed to investigate geographic patterns of pediatric hospice care across Appalachia. Using person-level Medicaid claims of 1,788 pediatric hospice enrollees who resided in the Appalachian Region between 2011 and 2013. A database of boundaries of Appalachian counties, postal addresses of hospices, and population-weighted county centroids of residences of hospice enrollees driving times from the nearest hospices were calculated. A choropleth map was created to visualize rural/urban differences in receiving hospice care. The average driving time from hospice to child residence was 28 minutes (SD = 26). The longest driving time was in Eastern Kentucky-126 minutes (SD = 32), and the shortest was in South Carolina-11 min (SD = 9.1). The most significant differences in driving times between rural and urban counties were found in Virginia 28 (SD = 7.5) and 5 minutes (SD = 0), respectively, Tennessee-43 (SD = 28) and 8 minutes (SD = 7), respectively; and West Virginia-49 (SD = 30) and 12 minutes (SD = 4), respectively. Many pediatric hospice patients reside in isolated counties with long driving times from the nearest hospices. State-level policies should be developed to reduce driving times from hospice providers.

Kentucky Outreach Service Kiosk (KyOSK) Study protocol: a community-level, controlled quasi-experimental, type 1 hybrid effectiveness study to assess implementation, effectiveness and cost-effectiveness of a community-tailored harm reduction kiosk on HIV, HCV and overdose risk in rural Appalachia

INTRODUCTION

Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia.

METHODS AND ANALYSIS

KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness.

ETHICS AND DISSEMINATION

The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings.

TRIAL REGISTRATION NUMBER

NCT05657106.

Community-Academic Partnership: Intervention to Prepare Community Members for the End-of-Life Journey

Despite research findings that rural Appalachians prefer to die at home, few people access palliative and hospice care services, and many report limited knowledge about palliative/end-of-life care resources. A community-academic partnership was formed to address this need. Train-the-trainer workshop and materials were co-developed. This study tested the feasibility and cultural acceptability of the training intervention to increase community members' knowledge about palliative/end-of-life care resources for East Tennessee Appalachian people. Community-based participatory research design and culture care theory guided the project, intervention, and research. After engaging in end-of-life training, participants completed a retrospective pretest-posttest survey. Paired samples t tests were used to compare knowledge before and after training. Means and standard deviations were used to report training material usefulness and cultural acceptability. Short-answer qualitative data were analyzed using content analysis. Sixty-six adults completed the survey. Ratings for training materials and cultural/theological acceptability were high. Participant knowledge rankings showed significant improvement after training at the P <.001 level. Qualitative feedback was positive. The training intervention was feasible, culturally acceptable, and effective for increasing East Tennessee Appalachian persons' palliative/end-of-life care knowledge. Community member expertise/collaboration integrated into every stage of the project is the bedrock of cultural acceptability and feasibility.

Human risk to tick encounters in the southeastern United States estimated with spatial distribution modeling

Expanding geographic distribution and increased populations of ticks has resulted in an upsurge of human-tick encounters in the United States (US), leading to an increase in tickborne disease reporting. Limited knowledge of the broadscale spatial range of tick species is heightened by a rapidly changing environment. Therefore, we partnered with the Forest Inventory and Analysis (FIA) program of the Forest Service, U.S. Department of Agriculture and used passive tick surveillance to better understand spatiotemporal variables associated with foresters encountering three tick species (Amblyomma americanum L., Dermacentor variabilis Say, and Ixodes scapularis L.) in the southeastern US. Eight years (2014-2021) of tick encounter data were used to fit environmental niche and generalized linear models to predict where and when ticks are likely to be encountered. Our results indicate temporal and environmental partitioning of the three species. Ixodes scapularis were more likely to be encountered in the autumn and winter seasons and associated with soil organic matter, vegetation indices, evapotranspiration, temperature, and gross primary productivity. By contrast, A. americanum and D. variabilis were more likely to be encountered in spring and summer seasons and associated with elevation, landcover, temperature, dead belowground biomass, vapor pressure, and precipitation. Regions in the southeast least suitable for encountering ticks included the Blue Ridge, Mississippi Alluvial Plain, and the Southern Florida Coastal Plain, whereas suitable regions included the Interior Plateau, Central Appalachians, Ozark Highlands, Boston Mountains, and the Ouachita Mountains. Spatial and temporal patterns of different tick species can inform outdoorsmen and the public on tick avoidance measures, reduce tick populations by managing suitable tick habitats, and monitoring areas with unsuitable tick habitat for potential missed encounters.

The semantics, sociolinguistics, and origins of double modals in American English: New insights from social media

In this paper, we analyze double modal use in American English based on a multi-billion-word corpus of geolocated posts from the social media platform Twitter. We identify and map 76 distinct double modals totaling 5,349 examples, many more types and tokens of double modals than have ever been observed. These descriptive results show that double modal structure and use in American English is far more complex than has generally been assumed. We then consider the relevance of these results to three current theoretical debates. First, we demonstrate that although there are various semantic tendencies in the types of modals that most often combine, there are no absolute constraints on double modal formation in American English. Most surprisingly, our results suggest that double modals are used productively across the US. Second, we argue that there is considerable dialect variation in double modal use in the southern US, with double modals generally being most strongly associated with African American Language, especially in the Deep South. This result challenges previous sociolinguistic research, which has often highlighted double modal use in White Southern English, especially in Appalachia. Third, we consider how these results can help us better understand the origins of double modals in America English: although it has generally been assumed that double modals were introduced by Scots-Irish settlers, we believe our results are more consistent with the hypothesis that double modals are an innovation of African American Language.

Developing, implementing, and evaluating the visiting Neighbors' program in rural Appalachia: A quality improvement protocol

INTRODUCTION

Older adults living alone in rural areas frequently experience health declines, social isolation, and limited access to services. To address these challenges, our medical academic university supported a quality improvement project for developing and evaluating the Visiting Neighbors program in two rural Appalachian counties. Our Visiting Neighbors program trained local volunteers to visit and guide rural older adults in healthy activities. These age-appropriate activities (Mingle, Manage, and Move- 3M's) were designed to improve the functional health of older adults. The program includes four in-home visits and four follow-up telephone calls across three months.

PURPOSE

The purpose of this paper was to describe the 3M's Visiting Neighbors protocol steps guiding the quality improvement procedures relating to program development, implementation, and evaluation.

METHODS AND MATERIALS

This Visiting Neighbors study used a single-group exploratory quality improvement design. This program was tested using quality improvement standards, including collecting participant questionnaires and visit observations.

RESULTS

Older adults (> 65 years) living alone (N = 30) participants were female (79%) with a mean age of 82.96 (SD = 7.87) years. Volunteer visitor participants (N = 10) were older adult females. Two volunteer visitors implemented each visit, guided by the 3M's activities manual. All visits were verified as being consistently delivered (fidelity). Enrollment and retention data found the program was feasible to conduct. The older adult participants' total program helpfulness ratings (1 to 5) were high (M = 51.27, SD = 3.77). All volunteer visitor's program helpfulness ratings were also high (M = 51.78, SD = 3.73).

DISCUSSION

The Visiting Neighbors program consistently engaged older Appalachian adults living alone in the 3M's activities. The feasibility and fidelity of the 3M's home visits were verified. The quality improvement processes included engaging the expert advisory committee and rural county stakeholders to ensure the quality of the program development, implementation, and evaluation.

Health Disparities in Appalachian and Other Rural Communities

Rural areas are home to a larger proportion of older adults and populations who age within these locales and suffer disproportionately from health, mental health, and economic disparities compared to their urban counterparts. This article will explore the disparities faced by persons that reside in rural communities across the lifespan. It will briefly discuss what is meant by rural. As a rural region at specific risk, the issues confronting those aging in Appalachia will be examined. Finally, best practices and future directions to combat health disparities among rural residents and elders will be discussed. This includes the Appalachian Gerontology Experiences: Advancing Diversity in Aging Research training program which recruits and trains minority and first-generation undergraduate students in aging and health disparity research.

State-Level Hypertension Prevalence and Control Among Adults in the U.S

INTRODUCTION

Improving hypertension control is a national priority. Electronic health record data have the potential to augment traditional surveillance systems. This study aimed to assess hypertension prevalence and control at the state level using a previously established electronic health record-based phenotype for hypertension.

METHODS

Adult patients (N=11,031,368) were included from the IQVIA ambulatory electronic medical record-U.S. 2019 data set. IQVIA ambulatory electronic medical record comprises electronic health records from >100,000 providers and includes patients from every U.S. state and Washington DC. Authors compared hypertension prevalence and control estimates against those from the Behavioral Risk Factor Surveillance System 2019. Results were age-standardized and stratified by state and sociodemographic characteristics. Statistical analyses were conducted in 2022-2023.

RESULTS

IQVIA ambulatory electronic medical record-U.S. patients had a median age of 55 years, and 56.7% were women. Overall age-standardized hypertension prevalence was higher in IQVIA ambulatory electronic medical record-U.S. (35.0%) than in the Behavioral Risk Factor Surveillance System (29.7%), however, state-level geographic patterns were similar, with the highest burden in the South and Appalachia. Similar patterns were also observed by sociodemographic characteristics in both data sets: hypertension prevalence was higher in older age groups (than younger), men (than women), and Black patients (than other races). Hypertension control varied widely across states: among states with >1% data coverage, control rates were lowest in Nevada (51.1%), Washington DC (52.0%), and Mississippi (55.2%); highest in Kansas (73.4%), New Jersey (72.3%), and Iowa (71.9%).

CONCLUSIONS

This study provided the first-ever estimates of hypertension control for all states and Washington DC. Electronic health record-based surveillance could support hypertension prevention and control efforts at the state level.

Conventional Fossil Fuel Extraction, Associated Biogeochemical Processes, and Topography Influence Methane Groundwater Concentrations in Appalachia

The production of fossil fuels, including oil, gas, and coal, retains a dominant share in US energy production and serves as a major anthropogenic source of methane, a greenhouse gas with a high warming potential. In addition to directly emitting methane into the air, fossil fuel production can release methane into groundwater, and that methane may eventually reach the atmosphere. In this study, we collected 311 water samples from an unconventional oil and gas (UOG) production region in Pennsylvania and an oil and gas (O&G) and coal production region across Ohio and West Virginia. Methane concentration was negatively correlated to distance to the nearest O&G well in the second region, but such a correlation was shown to be driven by topography as a confounding variable. Furthermore, sulfate concentration was negatively correlated with methane concentration and with distance to coal mining in the second region, and these correlations were robust even when considering topography. We hypothesized that coal mining enriched sulfate in groundwater, which in turn inhibited methanogenesis and enhanced microbial methane oxidation. Thus, this study highlights the complex interplay of multiple factors in shaping groundwater methane concentrations, including biogeochemical conversion, topography, and conventional fossil extraction.

Caring for Appalachians With Intravenous Drug Use-Associated Infective Endocarditis at End of Life: A Phenomenological Secondary Data Analysis

The purpose of this study was to describe the experiences of nurses caring for patients with intravenous drug use-associated infective endocarditis at the end of life in Appalachia. This study was a secondary analysis of 9 phenomenological unstructured interviews conducted by the author with nurses as part of a study exploring their lived experiences caring for this population. Data were analyzed using van Manen's 6-step approach. The analysis revealed 5 themes: (1) care at the end of life as a resolve to care for lost causes, (2) care at the end of life as an act of courageous communication, (3) care at the end of life as a resolve to endure chaos, (4) care at the end of life as a resolve to protect self and others, and (5) care at the end of life as a resolve to carry on and let go. Nurses perceived patients who use injection drugs as being at the end of life with eventual death. Patients with recurrent infective endocarditis from drug use are viewed as lost causes. To empower nurses, they need to be at the table of surgical decision making. Communication being one of a nurse's greatest tools, end-of-life communication education is needed. Administrative support should be a standard to safeguard nurses when dealing with emotionally challenging situations.

Mistreatment in health care among women in Appalachia

Good quality patient care requires health care providers to respect the humanity and autonomy of their patients. However, this is not achieved in all settings. This study used cross-sectional survey data including open-ended text responses to explore negative experiences with health care providers among women in Appalachia. We used the Heath Stigma & Discrimination Framework (HSDF) to identify how stigma is created and perpetuated through interactions with health care providers. Survey data from 628 women collected through purposive sampling identified that two out of three participants had had a bad encounter with a provider that made them not want to return for care. One in six participants had a negative experience specifically while seeking contraception. Using the domains of the HSDF framework, qualitative answers to open-ended questions illuminated how health care providers, influenced by social and cultural norms related to religiosity, patriarchal views, poverty, poor health infrastructure, and the opioid crisis, created and perpetuated stigma through dehumanising treatment, low-quality care, and health care misogyny. Because stigma is a driver of health inequity, these findings highlight the important and sometimes problematic role that health care providers can play when they create a barrier to future care through poor treatment of patients.

The importance of family relationships for the health of underserved Appalachians: An application and extension of the biobehavioral family model

INTRODUCTION

Appalachia is characterized by many contextual stressors, including geographic, economic, and cultural barriers to healthcare. Guided by the biobehavioral family model (BBFM), an understanding of the influence of interpersonal relationships (i.e., marital and nonmarital relationships) on health outcomes could be critical to mitigating the region's contextual stressors.

METHOD

Data were collected from 2018 to 2019 among 243 participants across seven pop-up medical clinics in central and southern Appalachia 59% from rural Appalachian counties (rural Mage = 41, 66% women, 90% White; urban Mage = 36, 74% women, 82% White). A series of multivariate regression models were conducted for outcome measures (i.e., depression, pain, physical symptoms, number of conditions, and perceived health).

RESULTS

The results suggest that family quality was significantly related to all outcome measures except for perceived health, whereas marital satisfaction was only significantly linked to physical symptoms. Rurality was not significantly associated with any outcome measures and only moderated the association between family quality and a number of conditions.

DISCUSSION

These findings demonstrate the importance of nonmarital family relationships on health outcomes for people in Appalachia. Given the limited direct impact rurality in this sample, close relationships may be important for the health and well-being of all economically marginalized Appalachians regarding where they live. Given the cultural tendency for Appalachians to rely on family and kinship networks for healthcare support and the findings in this study, medical professionals should develop innovative programs to incorporate family into healthcare visits, and disease management interventions for people living in Appalachia. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Trace Elements and Consequent Ecological Risks in Mining-Influenced Streams of Appalachia

Appalachian (eastern USA) coal surface mines fracture geologic materials, causing release of both major ions and trace elements to water via accelerated weathering. When elevated above natural background, trace elements in streams may produce adverse effects on biota via direct exposure from water and sediment and via dietary exposure in food sources. Other studies have found elevated water concentrations of multiple trace elements in Appalachia's mining-influenced streams. Except for Se, trace-element concentrations in abiotic and biotic media of Appalachian mining-influenced streams are less well known. We analyzed environmental media of headwater streams receiving alkaline waters from Appalachian coal mines for eight trace elements (Al, As, Cd, Cu, Ni, Sr, V, and Zn) and assessed the potential consequent ecological risks. Streamwater, particulate media (sediment, biofilm, leaf detritus), and benthic macroinvertebrates (primary consumers, secondary consumers, crayfish) were sampled from six mining-influenced and three reference streams during low-flow conditions in two seasons. Dissolved Cu, Ni, and Sr were higher in mining-influenced streams than in reference streams; Ni, Sr, and Zn in fine sediments and Ni in macroinvertebrates were also elevated relative to reference-stream levels in samples from mining-influenced streams. Seasonal ratios of mining-influenced stream concentrations to maximum concentrations in reference streams also demonstrated mining-influenced increases for several elements in multiple media. In most media, concentrations of several elements including Ni were correlated positively. All water-column dissolved concentrations were below protective levels, but fine-sediment concentrations of Ni approached or exceeded threshold-effect concentrations in several streams. Further study is warranted for several elements (Cd, Ni, and Zn in biofilms, and V in macroinvertebrates) that approached or exceeded previously established dietary-risk levels. Environ Toxicol Chem 2023;42:2651-2665. © 2023 SETAC.

Establishing a Rural General Surgery Residency Program: Identifying Community Stakeholder Perception and Obstacles of a de Novo Residency in Rural Appalachia

BACKGROUND

Rural healthcare has become more challenging over the past several years with increasingly limited access to surgical care in the rural setting. The Accreditation Council for Graduate Medical Education (ACGME) has recently introduced the Rural Track Program (RTP) initiative to combat physician shortage in rural areas. We intend to start the first Rural General Surgery Residency program under the RTP designation in rural Appalachia.

STUDY DESIGN

430 community stakeholders were surveyed regarding the anticipated impact of a new training program. Questions focused on the understanding of a Residency Program, the care provided by residents, impact on availability of local care, current geographical limitation of surgical care, and potential benefits/obstacles of the training program.

RESULTS

Over 90% of all surveyed approved of training surgeons locally, with the local government believing that the program would be a good investment for the community. Several locals had been treated by resident physicians at other facilities and the majority were satisfied with the care they received. Several families frequently travel to larger cities for surgical care, with 96% of all respondents believing that the program would provide better access to care locally.

CONCLUSION

Our study demonstrated that the community is familiar with healthcare in a training facility and welcoming to a local training program, while believing that trainees will have a positive impact on local surgical care in rural Appalachia. We will continue to work with the local community and healthcare personnel while developing the program and tailor our Residency to the rural setting as able.

Covid and the coalfield: Covid-19 vaccine hesitance in Wales and Appalachia

BACKGROUND

Vaccine hesitancy is a barrier to Covid-19 vaccine uptake and displays a social gradient, compounding health disparities. While social gradients are a vital concept in health, they flatten distinctions between types of disadvantaged community. This paper focuses on vaccine hesitance in post-industrial and de-industrialising coalfields. The social consequences of the decline of coal mining may present barriers to vaccine uptake.

METHODS

We ran parallel surveys in Wales (N = 4187) and US states overlapping with central Appalachia (N = 4864), to examine whether vaccine attitudes and uptake varied between areas with different coal mining histories. These surveys were accompanied by qualitative interviews of 36 residents of these coalfields to explore vaccination decisions and triangulate with survey data.

RESULTS

Factor analysis identified four axes of attitudes in the survey data: vaccine confidence, covid scepticism, vaccine individualism, and concerned confusion. These themes were echoed in the interviews. Vaccine confidence was lower; and covid scepticism, vaccine individualism, and concerned confusion higher, in residents of areas of Wales with greater mining extent and where pits closed during certain periods. Residents of former US coal counties had lower vaccine confidence and higher covid scepticism, while those in current coal counties had greater vaccine individualism and concerned confusion. In former US coal counties and Welsh areas where pits closed since 1980, vaccine uptake was lower. Differences could not be explained by respondents' income and education. In the interviews, norms of social solidarity were often invoked by vaccinated respondents, while unvaccinated respondents did not frame decisions in the context of the industrial history of their areas.

DISCUSSION

The legacy of coal-mining's decline presents barriers to public health campaigns. We show evidence of this across two historically significant coalfields. Attention is needed to avert negative public health consequences of global energy transition.

Molecular phylogeography and historical demography of a widespread herbaceous species from eastern North America, Podophyllum peltatum

PREMISE

Glacial/interglacial cycles and topographic complexity are both considered to have shaped today's diverse phylogeographic patterns of taxa from unglaciated eastern North America (ENA). However, few studies have focused on the phylogeography and population dynamics of wide-ranging ENA herbaceous species occurring in forest understory habitat. We examined the phylogeographic pattern and evolutionary history of Podophyllum peltatum L., a widely distributed herb inhabiting deciduous forests of ENA.

METHODS

Using chloroplast DNA (cpDNA) sequences and nuclear microsatellite loci, we investigated the population structure and genetic diversity of the species. Molecular dating, demographic history analyses, and ecological niche modeling were also performed to illustrate the phylogeographic patterns.

RESULTS

Our cpDNA results identified three main groups that are largely congruent with boundaries along the Appalachian Mountains and the Mississippi River, two major geographic barriers in ENA. Populations located to the east of the Appalachians and along the central Appalachians exhibited relatively higher levels of genetic diversity. Extant lineages may have diverged during the late Miocene, and range expansions of different groups may have happened during the Pleistocene glacial/interglacial cycles.

CONCLUSIONS

Our findings indicate that geographic barriers may have started to facilitate the population divergence in P. peltatum before the Pleistocene. Persistence in multiple refugia, including areas around the central Appalachians during the Quaternary glacial period, and subsequent expansions under hospitable climatic condition, especially westward expansion, are likely responsible for the species' contemporary genetic structure and phylogeographic pattern.

Perceptions of oral nicotine pouches & their marketing among Ohio Appalachia smokers and smokeless tobacco users

BACKGROUND

Oral nicotine pouches (ONPs) are novel products, gaining popularity and marketed as "tobacco-free" alternatives to cigarettes and smokeless tobacco (SLT), but their public health impact is unknown. This study qualitatively examined ONP appeal and perceptions among cigarette smokers and SLT users from Ohio Appalachia.

METHODS

In 2022, we conducted 10 virtual focus groups with smokers (n = 19) and smokeless tobacco users (n = 18) from Appalachia Ohio aged ≥21 to examine perceptions of risks and benefits, substitutability for cigarettes and SLT, and ONP marketing. We transcribed focus groups verbatim, thematically coded transcripts, and analyzed coded data for prominent themes.

RESULTS

Participants perceived ONPs to have similar or less risk than cigarettes/SLT but prominently discussed gastrointestinal and cardiovascular risks. Addiction risk was thought to be comparable to cigarettes/SLT, citing "nicotine is nicotine." Participants viewed ONPs to be situational rather than complete substitutes for cigarettes/SLT, viewing them as "cleaner," more socially acceptable, and discrete. Despite appealing features of ONP marketing, participants surmised ads would appeal to youth, new users, tobacco users seeking to cut down/quit, or to "high class," "white-collar" demographics.

CONCLUSIONS

Participants' perceptions of ONPs and their marketing suggest ONPs are more likely to be used as situational versus complete substitutes for cigarettes and SLT. While situational substitution could exacerbate disparities in Appalachia by facilitating more frequent tobacco/nicotine use, complete substitution could reduce disparities. Research is needed to understand how perceptions, the appeal of ONP marketing, and novel product features translate to patterns of use to understand ONPs' potential impact.

System Failure: The Geographic Distribution of Sepsis-Associated Death in the USA and Factors Contributing to the Mortality Burden of Black Communities

Sepsis is deadly and costly to health care systems, but these costs are disproportionately born by Black patients. Little empirical work has established the geographic patterning of sepsis or its area-level correlates. This study illustrates the geography of sepsis-associated death and racial composition of US counties with area socioeconomic indicators, health care access, and population health. Cartographic and spatially explicit analyses utilize mortality data from the National Cancer Institute and county data from the American Community Survey, Area Health Resource File, and County Health Rankings. Death rates are highest in the South, Southeast, and Appalachia. Counties disproportionately populated by Black people have higher death rates and associated risk indicators including poor air quality and vaccination coverage, socioeconomic distress, and impaired access to high-quality health care. Spatial Durbin error models suggest that conditions in nearby counties may also influence death rates within focal counties. Racial disparities in sepsis-associated death can be narrowed with improved health care equity-including immunization coverage-and by reducing socioeconomic distress in Black communities. Policy options for achieving these ends are discussed.

Contraceptive Behavior in Appalachia: Exploring Use, Nonuse, and Contraceptive Attitudes

Very little is known about contraceptive behavior in Appalachia, a large geographic region in the eastern United States where even basic prevalence estimates of contraceptive use/nonuse are lacking. This study characterizes contraceptive behavior among Appalachians, including contraceptive use, reasons for use, and methods used; contraceptive nonuse and reasons for nonuse; and attitudes about contraception, including acceptability. This is a secondary analysis of a subsample of survey data collected on sexual and reproductive health attitudes, behaviors, and needs among reproductive-age women (18-49 years) living in the Appalachian region (n = 332). Results identify rates of contraceptive use (66.6%) and nonuse (33.1%) among Appalachian residents. Methods used most frequently included those that did not require prescription (i.e., external condoms and natural family planning methods) though many reported the use of intrauterine devices (IUDs). Among nonusers, fear of side effects from contraception and ambivalence towards pregnancy were most commonly selected as the most important reason for not using contraception. Contraception was considered acceptable by this sample overall, and these acceptability attitudes were significantly associated with contraceptive behavior.

Biogeography and the evolution of acoustic communication in the polyploid North American grey treefrog complex

After polyploid species are formed, interactions between diploid and polyploid lineages may generate additional diversity in novel cytotypes and phenotypes. In anurans, mate choice by acoustic communication is the primary method by which individuals identify their own species and assess suitable mates. As such, the evolution of acoustic signals is an important mechanism for contributing to reproductive isolation and diversification in this group. Here, we estimate the biogeographical history of the North American grey treefrog complex, consisting of the diploid Hyla chrysoscelis and the tetraploid Hyla versicolor, focusing specifically on the geographical origin of whole genome duplication and the expansion of lineages out of glacial refugia. We then test for lineage-specific differences in mating signals by applying comparative methods to a large acoustic data set collected over 52 years that includes >1500 individual frogs. Along with describing the overall biogeographical history and call diversity, we found evidence that the geographical origin of H. versicolor and the formation of the midwestern polyploid lineage are both associated with glacial limits, and that the southwestern polyploid lineage is associated with a shift in acoustic phenotype relative to the diploid lineage with which they share a mitochondrial lineage. In H. chrysoscelis, we see that acoustic signals are largely split by Eastern and Western lineages, but that northward expansion along either side of the Appalachian Mountains is associated with further acoustic diversification. Overall, results of this study provide substantial clarity on the evolution of grey treefrogs as it relates to their biogeography and acoustic communication.

State-Level History of Overdose Deaths Involving Stimulants in the United States, 1999‒2020

Objectives. To examine the state-level history of US overdose deaths involving stimulants with and without opioids from 1999 to 2020. Methods. We used death certificate data from the National Center for Health Statistics to categorize deaths into 4 groups of interest: cocaine with and without opioids, and psychostimulants with and without opioids. We used a Bayesian multiple change point model to describe the timing and magnitude of changes in overdose death rates involving stimulants for each state and year. Results. There was little change in the death rates of cocaine without opioids. Death rates involving cocaine and opioids sharply increased around 2015, particularly in the Northeast and Mid-Atlantic. We also observed steady increases in deaths involving psychostimulants without opioids just before 2010, particularly in states in the West and South. Deaths involving psychostimulants with opioids increased around 2015 with largest increases concentrated in Appalachian states. Conclusions. There is significant geographic heterogeneity in the co-involvement of stimulants in the US overdose crisis. Results can inform public health efforts to inform state-level overdose efforts such as naloxone distribution. (Am J Public Health. 2023;113(9):991-999. https://doi.org/10.2105/AJPH.2023.307337).

White-tailed deer (Odocoileus virginianus) fawn survival and the influence of landscape characteristics on fawn predation risk in the Southern Appalachian Mountains, USA

In the Southern Appalachian region of the United States, harvest data has indicated the occurrence of low deer densities while exposing a trend of declining white-tailed deer (Odocoileus virginianus) populations over the past several decades in northern Georgia. A triumvirate of increasing fawn predator populations reside in the Southern Appalachian Mountains including coyotes (Canis latrans), black bears (Ursus americanus) and bobcats (Lynx rufus). This region is also characterized by a homogenous landscape composed of mature forests and sparse understory vegetation, likely lacking adequate cover to offer fawns refugia from predators. Our objectives were to estimate survival and cause-specific mortality rates of fawns while assessing a possible link between mortality risk, intrinsic fawn characteristics (i.e., birth mass, Julian birth date, sibling status), and landscape features within fawn usage areas. During 2018-2020, we radio-collared 71 fawns within the Chattahoochee National Forest of northern Georgia, USA and monitored survival to 12 weeks of age. We observed low fawn survival (cumulative = 0.157, 95% CI = 0.091-0.273; vaginal implant transmitter = 0.196, 95% CI = 0.096-0.403) with predation as the leading cause of all known mortalities (45 of 55 mortalities; 82%) due primarily to coyotes (n = 22), black bears (n = 12), and bobcats (n = 7). Relationships between landscape features and fawn predation risk were minimal with only one informative covariate. Increasing amounts of early successional land cover within fawn usage areas decreased fawn mortality risk within the first 20 days of life, but elevated mortality risk thereafter. All fawns with any amount of early successional land cover in their usage areas died of predation (n = 13) at various time intervals, suggesting limited areas of potential fawning cover may be targeted by predators. However, fawn predation risk seemed to be high regardless of landscape covariates due to the limited number of surviving fawns. Coyote-caused mortality occurred over a longer period at a consistently higher magnitude than all other forms of mortality, indicating possible delayed prey-switching behavior and coyote predation as an important factor of fawn survival. The low recruitment of fawns influenced by high predation rates and homogenous habitat conditions is likely the cause of deer population declines in the region.

Progress in reducing cancer mortality in the United States by congressional district, 1996-2003 to 2012-2020

BACKGROUND

United States cancer death rates have been steadily declining since the early 1990s, but information on disparities in progress against cancer mortality across congressional districts is lacking. This study examined trends in cancer death rates, overall and for lung, colorectal, female breast, and prostate cancer by congressional district.

METHODS

County level cancer death counts and population data from the National Center for Health Statistics were used to estimate relative change in age-standardized cancer death rates from 1996-2003 to 2012-2020 by sex and congressional district.

RESULTS

From 1996-2003 to 2012-2020, overall cancer death rates declined in every congressional district, with most congressional districts showing a 20%-45% decline among males and a 10%-40% decline among females. In general, the smallest percent of relative declines were found in the Midwest and Appalachia, whereas the largest declines were found in the South along the East Coast and the southern border. As a result, the highest cancer death rates generally shifted from congressional districts across the South in 1996-2003 to districts in the Midwest and central divisions of the South (including Appalachia) in 2012-2020. Death rates for lung, colorectal, female breast, and prostate cancers also declined in almost all congressional districts, although with some variation in relative changes and geographical patterns.

CONCLUSIONS

Progress in reducing cancer death rates during the past 25 years considerably vary by congressional district, underscoring the need for strengthening existing and implementing new public health policies for broad and equitable application of proven interventions such as raising tax on tobacco and Medicaid expansion.

Vaccination intention and uptake within the Black community in Appalachia

OBJECTIVE

Black communities have disproportionately experienced adverse health effects from the COVID-19 pandemic while simultaneously having less vaccination access and decreased vaccine utilization. As such, predictors of vaccination uptake within Black communities are a public health imperative. Black Americans from socio-geographic regions associated with health inequities (e.g., Appalachia), including vaccination disparities, represent an intersection of racial, economic, and ethnic social identities. To better understand the preventive health needs of Black communities in Appalachia and elsewhere, this study examined psychosocial predictors of vaccination intention or behavior.

METHOD

Adults (n = 336) identifying as Black or African American from West Virginia indicated demographics, reported COVID-19 vaccination intention, flu vaccination uptake, and human papillomavirus (HPV) vaccination uptake, and completed assessments of vaccine hesitancy, medical mistrust, and racial discrimination. Hierarchical logistic regression modeling examined potential associations between psychosocial predictors and each vaccine type.

RESULTS

Results showed variation in significant predictors across the vaccines of focus. Racial discrimination (OR = 0.64) and medical mistrust (OR = 0.93) were negatively associated with COVID-19 vaccination intention. Vaccine confidence was positively associated with COVID-19 vaccination intention (OR = 2.17) and HPV vaccination uptake (OR = 1.77). Total household income was the only predictor associated with flu vaccination uptake (OR = 1.12).

CONCLUSIONS

These findings suggest that social interventions targeting racial discrimination in healthcare may significantly help address vaccination disparities in rural Black communities. Moreover, results emphasize unique aspects of vaccination behavior in the Black community within Appalachia that may generalize to other Black communities living in rural regions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Barriers to Service Use Among Dementia Family Caregivers in Rural Appalachia: Implications for Reducing Caregiver Overload

Although the benefits of home- and community-based services (HCBS) to support the needs of older adults are well-established, researchers have persistently reported service underutilization by dementia caregivers to assist them with their caregiving responsibilities. Using the Health Behavior Model and Conservation of Resources Theory, the aim of the current study was to understand what barriers prevent caregivers from using HCBS and the toll it takes on them. Utilizing a sample of 122 rural family caregivers (74% female, 87% white, Mage = 64.86 years) of persons living with dementia (PLwD), simultaneous ordinary least square regressions were employed to understand the association between barriers to service use and the current use of support services and personal services, and concurrently on caregiver role overload. Financial barriers, caregiver's reluctance to use services, and their capability of seeking services were associated with lower use of support services. After controlling for need and enabling factors, caregivers who used more support services, and those who reported system complexities to using support services experienced higher role overload. Financial barriers, system complexities, and caregivers' reluctance also affected the use of personal care services. Despite the use of personal services, caregivers of PLwD with greater needs and fewer enabling factors experienced higher role overload. Study findings suggest that reducing system complexities of HCBS and improving prevention and intervention efforts to facilitate caregivers' awareness of HCBS are needed to address lack of service use and reduce caregiver overload.

Medical Mistrust Among Food Insecure Individuals in Appalachia

This study focused on the relationship between food insecurity and medical mistrust within Appalachia. Food insecurity has negative consequences on health, while medical mistrust can lead to a decrease in health care use, creating additive consequences to already vulnerable populations. Medical mistrust has been defined in various ways, with measures addressing health care organizations and individual health care providers. To determine whether food insecurity has an additive impact on medical mistrust, a cross-sectional survey was completed by 248 residents in Appalachia Ohio while attending community or mobile clinics, food banks, or the county health department. More than one-quarter of the respondents had high levels of mistrust toward health care organizations. Those with high food insecurity levels were more likely to have higher levels of medical mistrust than those with lower levels of food insecurity. Individuals with higher self-identified health issues and older participants had higher medical mistrust scores. Screening for food insecurity in primary care can reduce the impact of mistrust on patient adherence and health care access by increasing patient-centered communication. These findings present a unique perspective on how to identify and mitigate medical mistrust within Appalachia and call attention to the need for further research on the root causes among food insecure residents.

Reproductive Autonomy in Appalachia: An Investigation into Perceived Contraceptive Pressure

The reproductive autonomy of persons who can give birth can be impeded through forms of interpersonal violence and coercion. Moreover, macro-level factors (e.g., poverty, discrimination, community violence, legislative policies) may impede the reproductive autonomy of entire communities. This study investigates a form of violence we term perceived contraceptive pressure in Appalachia, an understudied region of the Eastern U.S., regarding reproductive health and decision-making. Through targeted Meta advertising, participants (N = 632) residing in Appalachian zip codes completed an online survey on reproductive health. The focus of this study was to investigate the prevalence of perceived contraceptive pressure, who was at increased risk of experiencing pressure, and the source(s) of perceived pressure. Binomial regressions were conducted on three different dependent variables: perceived pressure to be sterilized, perceived pressure to use birth control, and perceived pressure not to use birth control. Approximately half of all respondents (49.5%) reported experiencing at least one type of pressure targeting contraceptive decision-making. The most prevalent source of perceived pressure to use birth control was from the healthcare provider (67.4%), and the most prevalent source of perceived pressure not to use birth control was the respondent's partner (51.1%). Recommendations for providers serving clients in the Appalachian region include pursuing education regarding contraceptive pressure at the individual level and macro-level. In addition, Appalachian residents may benefit from educational programming on reproductive autonomy, healthy relationships, and how to navigate pressure in relationships.

Influence of Spiritual Engagement on Appalachian Older Adults' Health: A Systematic Review

Appalachia leads the country in mortality related to chronic comorbidities, such as heart disease, cancer, depression, and suicide. Appalachian older adults experience disproportionate risks for poor health outcomes. Spirituality is integral to Appalachian culture, and many older adults use spiritual engagement (SE) to cope with health challenges. Despite these connections, there is limited evidence about SE and well-being in this population. Therefore, the current systematic review addresses the literature gap of how SE influences health of Appalachian older adults. Using thematic synthesis, we analyzed 11 qualitative and three mixed methods studies. Major findings indicate that SE positively impacts holistic health through adaptive coping, guided partnerships with God, decreased loneliness, and enhanced sense of purpose. Future studies could examine SE practices among diverse populations, SE virtual experiences, and SE nursing assessments. Understanding how SE influences health of Appalachian older adults could prepare nurses to reduce disparities and improve health outcomes for this vulnerable population. [Journal of Psychosocial Nursing and Mental Health Services, 61(5), 45-52.].

Outcomes of a Caregiver-Focused Short Message Service (SMS) Intervention to Reduce Intake of Sugar-Sweetened Beverages in Rural Caregivers and Adolescents

This study examined enrollment, retention, engagement, and behavior changes from a caregiver short message service (SMS) component of a larger school-based sugar-sweetened beverage (SSB) reduction intervention. Over 22 weeks, caregivers of seventh graders in 10 Appalachian middle schools received a two-way SMS Baseline Assessment and four monthly follow-up assessments to report their and their child's SSB intake and select a personalized strategy topic. Between assessments, caregivers received two weekly one-way messages: one information or infographic message and one strategy message. Of 1873 caregivers, 542 (29%) enrolled by completing the SMS Baseline Assessment. Three-quarters completed Assessments 2-5, with 84% retained at Assessment 5. Reminders, used to encourage adherence, improved completion by 19-40%, with 18-33% completing after the first two reminders. Most caregivers (72-93%) selected a personalized strategy and an average of 28% viewed infographic messages. Between Baseline and Assessment 5, daily SSB intake frequency significantly (p < 0.01) declined for caregivers (-0.32 (0.03), effect size (ES) = 0.51) and children (-0.26 (0.01), ES = 0.53). Effect sizes increased when limited to participants who consumed SSB twice or more per week (caregivers ES = 0.65, children ES = 0.67). Findings indicate that an SMS-delivered intervention is promising for engaging rural caregivers of middle school students and improving SSB behaviors.

Four decades of regional wet deposition, local bulk deposition, and stream-water chemistry show the influence of nearby land use on forested streams in Central Appalachia

Hydrologic monitoring began on two headwater streams (<1 km²) on the University of Kentucky's Robinson Forest in 1971. We evaluated stream-water (1974-2013) and bulk-deposition (wet + dust) (1984-2013) chemistry in the context of regional wet-deposition patterns that showed decreases in both sulfate and nitrate concentrations as well as proximal surface-mine expansion. Decadal time steps (1974-83, 1984-93, 1994-2003, 2004-2013) were used to quantify change. Comparison of the first two decades showed similarly decreased sulfate (minimum flow-adjusted annual-mean concentration of ≈13.5 mg/L in 1982 to 8.8 mg/L in 1992) and increased pH (6.6-6.8) in both streams, reflecting contemporaneous changes in both bulk and wet deposition. In contrast, concentrations of nitrate (0.14 to >0.25 mg/L) and base cations increased between these two decades, coinciding with expansion of surface mining between 1985 and 1995. In 2004, stream-water pH (6.7 in 2004), sulfate (9.2 mg/L), and nitrate (>0.11 mg/L) were similar to 1982, despite wet-deposition concentrations being lower. Base-cation concentrations were higher in the stream adjacent to ongoing surface mining relative to the stream situated near the middle of the experimental forest. However, pH decreased to approximately 5.7 by 2013 for both streams, which, combined with a shift in dominant cations from calcium to magnesium and potassium, indicates that the soil-buffering capacity of this landscape has been exceeded. Ratios of bulk deposition and stream-water concentrations indicate enrichment of sulfate (1.7-25.2) and cations (0.5-64.8), but not nitrogen (0.1-5.6), indicating that the Forest is not nitrogen saturated and that ongoing changes in water-quality are sulfate driven. When concentrations were adjusted to account for changes in streamflow (climate) over the 4 decades, external influences (land management/regulation) explained most change. The amount and direction of change differed among constituents, both between consecutive decades and between the first and last decades, reflecting the influence of localized surface mining even as regional wet deposition continued to improve due to the Clean Air Act. The implication is that localized stressors have the potential to out-pace the benefits of national environmental policies for communities that depend on local water-resources in similar environments.

Impact of the Appalachian Career Training in Oncology (ACTION) Program on Undergraduate Participants

Kentucky ranks first in the nation in cancer incidence and mortality. The Appalachian region of the state experiences the highest cancer disparities due to inequities in many social determinants of health. As a strategy for addressing cancer and education disparities in the region, the Appalachian Career Training in Oncology (ACTION) Program at the University of Kentucky Markey Cancer Center engaged 16 Appalachian-native undergraduate student participants annually in cancer-related activities. Students were recruited on an annual basis for the 2-year ACTION program. Entry, mid-point, and exit surveys were administered to participants. Classical test theory and exploratory factor analysis were used to examine the instruments used for program evaluation, whereas repeated measures ANOVA, paired t-tests, chi-squared, and post hoc analyses were used to analyze 6 years of survey data. There was a significant increase in participants' understanding of cancer-related topics among the entry, midpoint, and exit surveys (p < .001) and a significant increase in comfort with research, clinical, and outreach activities between entry and midpoint and entry and exit (p < .001), but not between midpoint and exit. With respect to research skills and perceptions of the program, increases in mean scores were observed between midpoint and exit, but these increases were not statistically significant (p = .167, p = 223, respectively). ACTION increased participants' understanding of cancer-related topics; comfort with research, clinical, and outreach activities; and research skills. These data suggest that ACTION has a significant impact on participants.

Biofluorescent sexual dimorphism revealed in a southern Appalachian endemic salamander, Plethodon metcalfi

Biofluorescence occurs when a living organism absorbs high energy light and reemits it at longer wavelengths. Many species within clades of vertebrates are known to fluoresce including mammals, reptiles, birds, and fish. Most, if not all, amphibians exhibit biofluorescence when exposed to either blue (440-460 nm) or ultra-violet (360-380 nm) wavelengths of light. Salamanders (Lissamphibia: Caudata) appear to consistently fluoresce in green wavelengths (520-560 nm) when excited by blue light. Biofluorescence is theorized to have many ecological functions including mate signaling, camouflage, and mimicry. Despite the discovery of their biofluorescence, its role in salamander ecology and behavior remains unresolved. In this study we present the first case of biofluorescent sexual dimorphism within Amphibia and the first documentation of the biofluorescent pattern of a salamander within the Plethodon jordani species complex. This sexually dimorphic trait was discovered in the southern Appalachian endemic species, Southern Gray-Cheeked Salamander (Plethodon metcalfi, Brimley in Proc Biol Soc Wash 25:135-140, 1912), and may extend into other species within the Plethodon jordani and Plethodon glutinosus species complexes. We propose that this sexually dimorphic trait could be related to fluorescence of ventral modified granular glands used in plethodontid chemosensory communication.

Land cover and community water system characteristics as predictors of Safe Drinking Water Act violations in Central Appalachia, USA

Upstream anthropogenic land cover can degrade source drinking water quality and thereby inhibit the ability of a community water system to provide safe drinking water. This study aimed to predict differences in Safe Drinking Water Act (SDWA) compliance between water systems based on upstream land cover in Central Appalachia and to examine whether national trends correlating violations with system size and source type were relevant for this region. Multiple generalized linear mixed models assessed relationships between SDWA violations and the distance weighted land cover proportions associated with the water system's contributing source watershed, as well as county economic status, system size, and water source. Results indicate that rates of monitoring and reporting violations were significantly higher for smaller water systems in more economically distressed counties. Interestingly, increases in surface mining landuse and high density development decreased monitoring and reporting violations, which may reflect impacts of associated economic development. Increases in low intensity development increased the likelihood of health-based violations. To protect public health, community managers should consider source water protection and/or upgrading drinking water system treatment capacity prior to developing previously undeveloped areas and further motivate compliance with monitoring and reporting requirements.

Examining Psychological and Knowledge Barriers to Colorectal Cancer Screening in Rural Appalachian Kentucky

While recent rates of colorectal cancer (CRC) screening have improved in Appalachian Kentucky due to public health efforts, they remain lower compared to both KY as a whole, and the USA. Suboptimal screening rates represent a missed opportunity to engage in early detection and prevention. The purpose of this study is to determine the impact that lack of knowledge has on psychological barriers (e.g., fear and embarrassment) to CRC screening as well as the potential effect of a psychosocial intervention to reduce these barriers. Participants were recruited through faith-based organizations and other community sites. After randomizing participants to either an early or delayed group, a faith-based group education and motivational interviewing intervention was administered. Existing and pilot tested instruments were used to assess knowledge and potential psychological barriers. Data were analyzed using paired t tests and linear regression. We hypothesized that (1) psychological barriers are associated with inadequate knowledge and (2) the intervention, by improving knowledge, could reduce these barriers and increase screening rates. There was a small but significant reduction in psychological barriers (-0.11, p value = 0.015) and moderate increases in CRC knowledge scores (+0.17, p value = 0.06). There was no evidence that the intervention affected these measures (+0.10, p value = 0.58). The relationship between lower barrier scores and increased knowledge was significant at follow up (-0.05, 95% CI (-0.09, -0.00)). An increase in CRC knowledge was correlated with a small but significant decrease in psychological barriers, although there was no evidence that these changes were associated with one another. Future cognitive-based interventions may be effective in increasing CRC knowledge and reducing barriers, but new intervention approaches should be considered.

Factors associated with perceived ease of access to syringes in Appalachian North Carolina

PURPOSE

To examine associations between perceived ease of syringe access, syringe sources, injection behaviors, and law enforcement (LE) interactions among people who inject drugs (PWID) in rural Appalachian North Carolina (NC).

METHODS

Using respondent-driven sampling, a diverse sample of 309 self-reported PWID were recruited from rural Appalachian NC. Data were collected via audio computer-assisted self-interview technology from February 2019 through March 2020. Respondents reported demographics, sources of syringes, LE interactions, and injection behaviors. Univariate, bivariate, and linear regression analyses were performed.

FINDINGS

Respondents most often obtained syringes from pharmacies and syringe service programs (SSPs). Twenty-one percent disagreed that it was easy to obtain sterile syringes, with 28% reporting low or no access to an SSP. PWID who reported longer physical distances to an SSP had greater difficulty accessing syringes (P<.001). PWID who reported greater ease of access to syringes reported engaging in receptive syringe sharing less often (P<.01). PWID who were stopped and searched by LE more often reported injecting drugs somebody else prepared with nonsterile supplies more often (P<.01). Participants shared used injection supplies more than twice as often than they shared used syringes.

CONCLUSIONS

These results underscore the importance of SSPs to mitigate the spread of human immunodeficiency virus and viral hepatitis in rural areas. Supporting mobile SSP services in rural areas could increase access to sterile syringes and injection supplies. SSPs should educate PWID about the importance of not sharing injection supplies. Pharmacies could increase syringe access in areas where SSPs do not operate.

Implementing the Better Starts For All Pilot Mobile and Telehealth Intervention in Ohio Appalachia: Improving Access to Maternal Healthcare

INTRODUCTION

Women in Ohio Appalachia experience greater maternal health disparities relative to the general U.S. population, resulting in poorer health outcomes. This paper describes the Ohio Better Starts for All (BSFA) program that provides mobile maternal health services in rural Ohio.

METHODS

This three-year intervention was delivered through a community-clinical partnership in Ohio Appalachia. The program's preliminary evaluation and opportunities were informed by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

RESULTS

Over six months, 86 patients were referred to the BSFA program, 54 (62.8 %) were seen by the maternal care team, and 14 out of 19 scheduled clinic days were held. Five clinics were canceled due to inclement weather, mobile unit breakdown, or provider COVID-19 infection.

DISCUSSION

Maternal care providers must provide equitable care to patients, with particular attention to those who face substantial challenges accessing obstetric services. The BSFA program offers one promising solution to help women overcome barriers to accessing care.

"That Was the Happiest Time of My Life": Understanding Childhood Eco-Connections in Appalachian Communities

The goal of this study was to explore facets of childhood eco-connections, using retrospective qualitative data from adults. One hundred and forty-five adults from predominantly rural and small-town communities in southern Appalachia (71.7% female), average age 36.23 years (SD = 12.08) participated in semi-structured qualitative interviews on key life experiences and the places they grew up. Mentions about place-related childhood memories or interactions were grouped into four themes based on exploratory thematic content analysis: nature nostalgia (positive reminiscences about nature experiences); nature immersion (extensive contact with the natural world during childhood); formative experiences with nature (nature interactions that taught a skill or life lesson); and rhythms of nature (appreciation of seasonal or cyclical patterns). Childhood eco-connections are multifaceted and often emerge from early impactful or intense experiences. Pro-environmentalism messages to youth may benefit from more references to childhood eco-connections.

Land Cover Change Associated with Unconventional Oil and Gas Development in the Appalachian Region

Unconventional oil and gas (UOG) wells from the Marcellus and Utica shale plays have expanded greatly across the Appalachian region of the United States (US) since the early 2000s. This region is now the single largest natural gas producing area of the US. The local and regional impacts of this industry on the landscape make it critical to understand for future planning efforts. This study investigated land cover change associated with over 21,000 unconventional wells representing 4,240 well pads permitted from 2007 to 2017 in Pennsylvania, West Virginia, and Ohio. The goal was to characterize UOG disturbance to document development patterns and extents in the region. Supervised classification was used to map land use and land-cover changes within a 25-ha buffer of well pads identified in the region. On average, disturbance related to unconventional development impacted 6.2 ha in Pennsylvania, 4.7 ha in Ohio and 4.4 ha in West Virginia and 5.6 ha over the region. Forest and grassland were found to be the most impacted cover types, with increases in impervious surface areas being a significant contributor to land-use classification change. These conversions can contribute to increased forest fragmentation and edge, which can in turn adversely impact biodiversity indicators at the regional level. Additionally, increases in impervious surface in small headwater watersheds can lead to increased sediment and runoff loads in receiving streams. Local and regional land use planning should be implemented during the well pad permit review process to help minimize environmental impacts over larger geographic scales.

Large-bodied ornithomimosaurs inhabited Appalachia during the Late Cretaceous of North America

Reconstructing the evolution, diversity, and paleobiogeography of North America’s Late Cretaceous dinosaur assemblages require spatiotemporally contiguous data; however, there remains a spatial and temporal disparity in dinosaur data on the continent. The rarity of vertebrate-bearing sedimentary deposits representing Turonian–Santonian ecosystems, and the relatively sparse record of dinosaurs from the eastern portion of the continent, present persistent challenges for studies of North American dinosaur evolution. Here we describe an assemblage of ornithomimosaurian materials from the Santonian Eutaw Formation of Mississippi. Morphological data coupled with osteohistological growth markers suggest the presence of two taxa of different body sizes, including one of the largest ornithomimosaurians known worldwide. The regression predicts a femoral circumference and a body mass of the Eutaw individuals similar to or greater than that of large-bodied ornithomimosaurs, Beishanlong grandis, and Gallimimus bullatus. The paleoosteohistology of MMNS VP-6332 demonstrates that the individual was at least ten years of age (similar to B. grandis [~375 kg, 13–14 years old at death]). Additional pedal elements share some intriguing features with ornithomimosaurs, yet suggest a larger-body size closer to Deinocheirus mirificus. The presence of a large-bodied ornithomimosaur in this region during this time is consistent with the relatively recent discoveries of early-diverging, large-bodied ornithomimosaurs from mid-Cretaceous strata of Laurasia (Arkansaurus fridayi and B. grandis). The smaller Eutaw taxon is represented by a tibia preserving seven growth cycles, with osteohistological indicators of decreasing growth, yet belongs to an individual approaching somatic maturity, suggesting the co-existence of medium- and large-bodied ornithomimosaur taxa during the Late Cretaceous Santonian of North America. The Eutaw ornithomimosaur materials provide key information on the diversity and distribution of North American ornithomimosaurs and Appalachian dinosaurs and fit with broader evidence of multiple cohabiting species of ornithomimosaurian dinosaurs in Late Cretaceous ecosystems of Laurasia.

Road salting and natural brine migration revealed as major sources of groundwater contamination across regions of northern Appalachia with and without unconventional oil and gas development

High methane and salt levels in groundwater have been the most widely cited unconventional oil and gas development (UOGD) related water impairments. The attribution of these contaminants to UOGD is usually complex, especially in regions with mixed land uses. Here, we compiled a large hydrogeochemistry dataset containing 13 geochemical analytes for 17,794 groundwater samples from rural northern Appalachia, i.e., 19 counties located on the boundary between Pennsylvania (PA; UOGD is permitted) and New York (NY; UOGD is banned). With this dataset, we explored if statistical and geospatial tools can help shed light on the sources of inorganic solutes and methane in groundwater in regions with mixed land uses. The traditional Principal Component Analysis (PCA) indicates salts in NY and PA groundwater are mainly from the Appalachian Basin Brine (ABB). In contrast, the machine learning tool - Non-negative Matrix Factorization (NMF) highlights that road salts (in addition to ABB) account for 36%-48% of total chloride in NY and PA groundwaters. The PCA fails to identify road salts as one water/salt source, likely due to its geochemical similarity with ABB. Neither PCA nor NMF detects a regional impact of UOGD on groundwater quality. Our geospatial analyses further corroborate (1) road salting is the major salt source in groundwater, and its impact is enhanced in proximity to highways; (2) UOGD-related groundwater quality deterioration is only limited to a few localities in PA.

Disentangling the "who" and "when" of parents' depressive symptoms: A daily diary study analysis

Parents' depressive symptoms vary across days, but factors predicting this fluctuation are not well understood. The present study utilized ecological momentary assessments to capture 1620 days of parents' lived experience in a diverse sample of 146 mothers and fathers from Appalachia who reported on daily fluctuation in family chaos, family financial hardship, and lack of social support, as well as depressive symptoms every day for 14 consecutive days. Data were analyzed using a multilevel modeling framework. Results reveal that on days when parents experience higher family chaos, higher family financial hardship, and lower social support than they typically do, they also experience greater depressive symptoms. Daily linkages between low social support and depressive symptoms were uniform across families. In contrast, daily linkages between depressive symptoms and family financial hardship and chaos were strongest among families who experienced chronic levels of adversity. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Barriers to Providing Lactation Services and Support to Families in Appalachia: A Mixed-Methods Study With Lactation Professionals and Supporters

Objectives. To understand the barriers and facilitators that lactation professionals and supporters (LPSs) in the Appalachian region of the United States experience when providing services and support to families. Methods. We used a mixed-methods explanatory sequential design with a survey of LPSs in Appalachia (March‒July 2019), followed by semistructured interviews with LPSs (January‒April 2020). We summarized survey responses descriptively and analyzed interview transcripts thematically. Results. The survey was completed by 89 LPSs in Appalachia. We conducted semistructured interviews with 20 LPSs. Survey participants most commonly identified challenges with other health care providers, hospital practices, and non‒medically indicated supplementation as barriers. Interview participants described challenges with clients' families not supporting breastfeeding, difficulty reaching clients, limited numbers of LPSs, and lack of racial/ethnic diversity among LPSs. LPSs identified the need for training in lactation and substance use, mental health, and birth trauma, and supporting lesbian, gay, bisexual, transgender, queer or questioning, plus (LGBTQ+) families. LPSs described social media and telehealth as both facilitators and barriers. Social support from other LPSs was a facilitator. Conclusions. LPSs in Appalachia face various challenges. Addressing these challenges has the potential to improve the lactation support and services families in Appalachia receive. (Am J Public Health. 2022;112(S8):S797-S806. https://doi.org/10.2105/AJPH.2022.307025).

Factors Influencing the Sugar-Sweetened Beverage Intake of Caregivers of Adolescents in Appalachia

OBJECTIVE

To identify factors that influence the sugar-sweetened beverage (SSB) intake of caregivers of middle school-aged adolescents.

DESIGN

Cross-sectional.

SETTING

Southwestern Virginia, US, part of Central Appalachia.

PARTICIPANTS

Caregivers (n = 362) of adolescents enrolled in the Kids SIPsmartER trial. Participants were mostly female (91%) and non-Hispanic White (96%), and 21% received Supplemental Nutrition Assistance Program (SNAP) benefits.

MAIN OUTCOME MEASURES

Caregiver daily SSB intake and demographics, personal-level, interpersonal-level, and environmental-level determinants.

ANALYSIS

Descriptive statistics, 1-way ANOVA, and stepwise regression.

RESULTS

On average, caregivers consumed 25.7 (SD, 33.2) fluid ounces of SSB per day. In the final model, which included all variables, age (β = -0.41; P < 0.05), receiving SNAP benefits (β = 14.19; P ≤ 0.01), behavioral intentions (β = -5.48; P ≤ 0.001), affective attitudes (β = -2.15, P < 0.05), perceptions of whether their adolescent frequently consumes high amounts of SSB (β = 1.92; P ≤ 0.001), and home availability (β = 7.43; P ≤ 0.01) were significantly associated with SSB intake.

CONCLUSIONS AND IMPLICATIONS

Caregivers of Appalachian middle school students are high SSB consumers. Findings highlight the importance of implementing behavioral interventions for caregivers of adolescents that target multiple levels of influence, including demographic, personal-level, interpersonal-level, and environmental-level factors. Interventions may be particularly important for communities and groups with higher SSB intakes, such as those in Appalachia and who receive SNAP benefits.

Assessing Unconventional Oil and Gas Exposure in the Appalachian Basin: Comparison of Exposure Surrogates and Residential Drinking Water Measurements

Health studies report associations between metrics of residential proximity to unconventional oil and gas (UOG) development and adverse health endpoints. We investigated whether exposure through household groundwater is captured by existing metrics and a newly developed metric incorporating groundwater flow paths. We compared metrics with detection frequencies/concentrations of 64 organic and inorganic UOG-related chemicals/groups in residential groundwater from 255 homes (Pennsylvania n = 94 and Ohio n = 161). Twenty-seven chemicals were detected in ≥20% of water samples at concentrations generally below U.S. Environmental Protection Agency standards. In Pennsylvania, two organic chemicals/groups had reduced odds of detection with increasing distance to the nearest well: 1,2-dichloroethene and benzene (Odds Ratio [OR]: 0.46, 95% confidence interval [CI]: 0.23-0.93) and m- and p-xylene (OR: 0.28, 95% CI: 0.10-0.80); results were consistent across metrics. In Ohio, the odds of detecting toluene increased with increasing distance to the nearest well (OR: 1.48, 95% CI: 1.12-1.95), also consistent across metrics. Correlations between inorganic chemicals and metrics were limited (all |ρ| ≤ 0.28). Limited associations between metrics and chemicals may indicate that UOG-related water contamination occurs rarely/episodically, more complex metrics may be needed to capture drinking water exposure, and/or spatial metrics in health studies may better reflect exposure to other stressors.

Environmental Change in Southern Appalachia: Local Ecological Knowledge across Residential Groups

This paper examines how residents of Southern Appalachia observe changes in their natural environment, the values that they assign to plants and animals in that environment, and their understandings and explanations of environmental change. We use semi-structured interviews and participant observation to determine that multigenerational residents and newcomers to the region are observing and noting change in different components of the environment and that they have different determinations of both the causes and likely consequences of that change. While multigenerational residents focus their observation and commentary on staple crops and culturally-important species, newcomers to the area concentrate on species related to recreational pursuits, giving each group insights into different aspects of environmental change. These findings are translated into recommendations for more inclusive and effective environmental and conservation planning.