Appalachian Area Research Articles

Status of uterine cervix cancer mortality and incidence disparities in Appalachian eastern Kentucky.

132 Background: Cervical cancer continues to affect the Appalachian population to a higher degree than the rest of the American population. Researchers believe the increased prevalence of cervical cancer in the Appalachian area is due to health disparities across the area. Methods: We queried the Kentucky Cancer Registries online public Cancer Incidence and Mortality Inquiry System to determine changes in age adjusted invasive cervical cancer incidence and mortality rates in Appalachian (AK) and Non-Appalachian Kentucky (NAK) counties over time. Incidence rate ratios were used to analyze the difference in cervical cancer incidence and mortality between Appalachian KY and non-Appalachian KY populations across several time periods. Results: In 1995-1999, there was a statistically significant difference in cervical cancer incidence between AK and NAK 14.8 vs. 12.7/100,000 people (p= 0.0035) and mortality 4.6 vs. 4.0/100,000 (p=0.0471). The cervical cancer incidence was 16.9% higher in AK versus NAK and mortality was 18.4% higher in AK versus NAK. In 2016-2020, there was a statistically significant difference in cervical cancer incidence between AK and NAK 12.1 vs. 8.9/100,000 people (p≤ 0.0001) and mortality between AK and NAK 3.6 vs. 2.3/100,000 people (p= 0.0001). The cervical cancer incidence was 36% higher in AK versus NAK and mortality was 55.7% higher in AK versus NAK. Conclusions: Disparities between in Appalachian Kentucky and Non-Appalachian Kentucky in cervical cancer incidence and mortality not only have persisted since the 1990’s, but they have widened proportionally over time as survival gains have lagged in Appalachia. The observed cervical cancer outcome disparities are likely contributed to by not only the lack of general health education in the region, but more importantly barriers to care access contributing to a lower use of Pap testing in the area. Higher rates of poverty, increased rates of smoking and HPV infection also likely play a role. Research has been conducted to observe identified opportunities for intervention and begin collaborative efforts in the region engineered towards a cervical cancer risk reduction program, but the need for improvement clearly remains. Cervical cancer mortality rates in Appalachian Kentucky vs. non-Appalachian Kentucky, 1995-2020. Appalachia Non-Appalachia Population at Risk Deaths Crude Rate/100,000 Age-Adjusted Rate 95% Confidence Interval Population at risk Deaths Crude Rate/100,000 Age-Adjusted Rate 95% Confidence Interval 1995-1999 2928468 145 5 4.6 [3.9-5.4] 7209127 301 4.2 4 [3.6-4.5] 2000-2004 2962204 102 3.4 3.2 [2.6-3.9] 7485965 214 2.9 2.7 [2.3-3.1] 2005-2009 2986284 117 3.9 3.5 [2.9-4.2] 7833348 225 2.9 2.6 [2.3-3.0] 2010-2015 3577269 141 3.9 3.4 [2.8-4.0] 9803897 277 2.8 2.5 [2.2-2.9] 2016-2020 2941022 121 4.1 3.6 [3.0-4.4] 8378683 221 2.6 2.3 [2.0-2.7]

Abstract C166: Overall survival and mutational landscape comparison between Appalachian and non-Appalachian patients with ovarian cancer - An Oncology Research Information Network (ORIEN) analysis

Abstract Objectives: Few studies have examined the mutational landscape in ovarian cancers, and none have focused on the Appalachian region which has a higher incidence of ovarian cancer, higher rates of poverty, and limited access to care compared to non-Appalachian region. Women with ovarian cancer enrolled in the Total Cancer Care prospective cohort study were evaluated to compare overall survival, mutational landscape, and immune cell composition between subjects in Appalachian and Non-Appalachian regions. Methods: Clinical and genomic data are available for 627 ovarian cancer patients with varying histology, including 66 from Appalachian Kentucky. MutSigCV was used to identify significantly mutated genes. CIBERSORTx was used to estimate the immune cell composition based on RNA sequencing data. Fisher’s exact test was used to compare clinical and genomic characteristics, Cox regression analysis was used to compare survival, and Wilcoxon rank-sum was used to compare immune cell composition. Results: Appalachian women with ovarian cancer were more likely to be older at time of diagnosis (64 years vs 58 years, p= 0.003), have a higher BMI (28.8 vs 26.9 kg/m2, p= 0.045), and be diagnosed at the highest pathologic grade (Grade III, 90.3% vs 84.8%, p=0.023) than non-Appalachian residents. A higher proportion of Appalachian residents were diagnosed at advanced stage III/IV (85.9% vs 75.4%, p= 0.128). In univariate survival analysis, those residing in Appalachian areas had poorer survival than the non-Appalachian residents (HR1.92, 95% CI 1.25-2.94, p=0.0022). Appalachian status remained significantly associated with worse survival after adjusting for age, BMI and stage at diagnosis (HR 1.72, 95% CI 1.04-2.86, p=0.036). There was no significant difference between cohorts on histology of ovarian carcinomas. Multiple genes were significantly different between the two populations. The Appalachian cohort had more frequent PRF1 (8.3% vs 1.9%, p=0.013), MECOM (6.7% vs 1.3%, p=0.018), and ITGAV mutations (6.7% vs 1.5%, p=0.026). RECQL4, EZR, SRGAP3, USP6 were also significantly more frequent in Appalachian residents. LRP1B was the only gene significantly associated with non-Appalachian status (9.4% vs 1.7%, p= 0.047). When analyzing immune cell composition by Appalachian status, Appalachian residency was significantly associated with higher levels of activated dendritic cells. Non-Appalachian residents had non-significantly higher levels of M2 macrophages. Conclusion: Women with ovarian cancer residing in Appalachia are older at time of diagnosis, have a higher BMI, and are diagnosed at higher pathologic grade compared to non- Appalachian residents. Even after controlling for age, stage and BMI, Appalachian residence remained significantly associated with worse survival. Multiple mutations associated with oncogenesis were significantly over-represented in the Appalachian cohort, which may contribute to excess mortality in the region. Citation Format: Allison L. Swiecki-Sikora, Jinge Liu, Michelle Churchman, Jinpeng Liu, Dava Piecoro, Taylor A. Rives, Julia Nagle, Eugenia Girda, Aliza Leiser, Sheri Holmen, Jennifer Doherty, Jing-Yi Chern, Robert Wenham, Bodour Salhia, Marilyn Huang, Stephen Edge, Laura L. Holman, Abdul Rafeh Naqash, Bradley Corr, Bryan Schneider, Chi Wang, Charles S. Dietrich, Jill M. Kolesar. Overall survival and mutational landscape comparison between Appalachian and non-Appalachian patients with ovarian cancer - An Oncology Research Information Network (ORIEN) analysis [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C166.

Does gender moderate the relationship between protective factors and rule violating behavior?

This paper explores the role that gender plays in moderating the relationship between protective factors and rule violating behavior among adolescents and young adults. We explore the relationship between rule violating behavior, protective factors, and gender for regulatory strengths, meaning making strengths, and interpersonal strengths. The Resilience Portfolio Model is used to understand the process of resilience and how utilizing various types of strengths may decrease the prevalence of rule violating behavior. Participants were 860 adolescents and young adults (12–20 years old) within a rural, Appalachian area of the United States who self-reported behaviors based on survey data. Blockwise regression analyses and interaction analyses were conducted to identify gender differences. Findings indicate that overall, males are significantly more likely to report rule violating behaviors than females. Gender moderated the relationship between psychological endurance and moral meaning making with these strengths showing a stronger protective effect for male versus female youth. Several strengths were associated with less rule violating behavior and operated similarly for male and female youth, including emotion regulation, optimism, and community support. Findings suggest that more attention needs to focus on identifying and understanding gender-specific strengths as well as identifying strengths which may operate similarly for both males and females that contribute to reduced rule violating to improve developmental outcomes for adolescents and young adults. These findings are important especially as it relates to prevention of rule breaking among all adolescents and young adults.

The differential proteomic response to ischemic stroke in appalachian subjects treated with mechanical thrombectomy

IntroductionThe Appalachia region of North America is known to have significant health disparities, specifically, worse risk factors and outcomes for stroke. Appalachians are more likely to have comorbidities related to stroke, such as diabetes, obesity, and tobacco use, and are often less likely to have stroke interventions, such as mechanical thrombectomy (MT), for emergent large vessel occlusion (ELVO). As our Comprehensive Stroke Center directly serves stroke subjects from both Appalachian and non-Appalachian areas, inflammatory proteomic biomarkers were identified associated with stroke outcomes specific to subjects residing in Appalachia.MethodsThere were 81 subjects that met inclusion criteria for this study. These subjects underwent MT for ELVO, and carotid arterial blood samples acquired at time of intervention were sent for proteomic analysis. Samples were processed in accordance with the Blood And Clot Thrombectomy Registry And Collaboration (BACTRAC; clinicaltrials.gov; NCT 03153683). Statistical analyses were utilized to examine whether relationships between protein expression and outcomes differed by Appalachian status for functional (NIH Stroke Scale; NIHSS and Modified Rankin Score; mRS), and cognitive outcomes (Montreal Cognitive Assessment; MoCA).ResultsNo significant differences were found in demographic data or co-morbidities when comparing Appalachian to non-Appalachian subjects. However, time from stroke onset to treatment (last known normal) was significantly longer and edema volume significantly higher in patients from Appalachia. Further, when comparing Appalachian to non-Appalachian subjects, there were significant unadjusted differences in the NIHSS functional outcome. A comprehensive analysis of 184 proteins from Olink proteomic (92 Cardiometabolic and 92 Inflammation panels) showed that the association between protein expression outcomes significantly differed by Appalachian status for seven proteins for the NIHSS, two proteins for the MoCA, and three for the mRS.ConclusionOur study utilizes an ELVO tissue bank and registry to investigate the intracranial/intravascular proteomic environment occurring at the time of thrombectomy. We found that patients presenting from Appalachian areas have different levels of proteomic expression at the time of MT when compared to patients presenting from non-Appalachian areas. These proteins differentially relate to stroke outcome and could be used as prognostic biomarkers, or as targets for novel therapies. The identification of a disparate proteomic response in Appalachian patients provides initial insight to the biological basis for health disparity. Nevertheless, further investigations through community-based studies are imperative to elucidate the underlying causes of this differential response.

Implementing Self-Measured Blood Pressure Monitoring With Clinical Support: A Qualitative Study of Federally Qualified Health Centers.

Self-measured blood pressure monitoring (SMBP) with clinical support is effective at reducing blood pressure for people with hypertension. Although strengths and challenges around SMBP are well-documented, few studies describe the complexities of real-world implementation of SMBP with clinical support in the Federally Qualified Health Center (FQHC) setting. Between 2019 and 2023, the Ohio Department of Health funded the Ohio Association of Community Health Centers to manage a multiyear quality improvement (QI) project with 21 FQHCs. The project aimed to improve the identification and management of patients with hypertension, diabetes, and prediabetes. This study focuses on the activities implemented to provide SMBP support to patients with hypertension. FQHCs implemented clinical SMBP support using multiple roles, approaches, and resources. FQHCs established a process to identify patients eligible for SMBP support, provide blood pressure monitors, train patients on SMBP, track blood pressure readings, follow up with patients, and connect patients to resources. External evaluators interviewed 13 staff members within seven FQHCs from the QI project. Interviewed FQHCs were located across Ohio and represented urban, rural, suburban, and Appalachian areas. Clinical activities to support SMBP, facilitators, and barriers were identified with thematic analysis. The National Association of Community Health Centers SMBP Implementation Toolkit was used as a framework to assess SMBP activities. Facilitators included team-based care, health information technology capacity, funding for blood pressure monitors and staff time, leadership and staff support, and external support. Barriers included technology challenges, staffing shortages, low patient engagement, sustainability, and the COVID-19 pandemic. This study demonstrates how FQHCs can use a variety of staff, processes, and resources to implement clinical SMBP support across a range of geographic regions. To facilitate this, FQHCs and patients may need more comprehensive insurance coverage of blood pressure monitors, reimbursement for staff time, and technology support.

Unveiling rural and Appalachian disparities in cigarette smoking through the social vulnerability index and other county-level characteristics.

Mitigating tobacco-related disparities in the Appalachian region and rural areas is crucial. This study seeks to gauge cigarette smoking prevalence in Virginia counties, uncover rurality and Appalachian-linked disparities, and explore local drivers of these gaps. A 2011-2019 Virginia BRFSS data were used to estimate county-level cigarette smoking rates in adults aged 18 or older. Counties were categorized as urban/rural and Appalachian/non-Appalachian, with a focus on rural-Appalachian. Disparities in cigarette smoking rates and associated factors were analyzed via the Blinder-Oaxaca decomposition method. The study assessed 4 dimensions of the Centers for Disease Control and Prevention's social vulnerability index (SVI): socioeconomic, minority status, household composition, and housing. Additionally, county-specific factors such as tobacco agriculture, physician availability, coal mining, and tobacco retailer density were examined. Rural areas exhibited a 6.18% higher cigarette smoking prevalence compared to urban areas (P<.001). SVI dimensions accounted for 53.2% of the disparity, county features explained 16.4%, and 30.4% remained unexplained. Appalachian areas had a 6.79% higher cigarette smoking prevalence than non-Appalachian areas (P<.001). SVI dimensions explained 51.4% of the disparity, county features accounted for 21.8%, leaving 26.8% unexplained. Rural-Appalachian areas showed a 7.8% higher cigarette smoking prevalence (P<.001). SVI dimensions contributed to 51.7% of the disparity, county features explained 9.6%, and 38.7% remained unexplained. Substantial disparities in cigarette smoking prevalence exist in underserved areas of Virginia, including rural, Appalachian, and rural-Appalachian regions. While SVI dimensions, physician availability, tobacco agriculture, and coal mining contribute, yet notable gaps remain unexplained. Targeted interventions must tackle unique challenges in disadvantaged areas to reduce smoking and promote health equity.

Tobacco Quitline utilization compared with cigarette smoking prevalence in Virginia across rurality and Appalachian Status, 2011–2019

IntroductionWhile cigarette smoking rates have declined, rural and Appalachian populations in the United States have not seen similar decreases. Quitline programs are promising strategies in reducing disparities in these areas, but research on their usage is limited. MethodsWe employed Small Area Estimation on the Virginia Behavioral Risk Factor Surveillance System (2011–2019) to estimate county-level smoking prevalence and utilized The Quit Now Virginia Quitline data (2011–2019) to estimate Quitline users. We analyzed differences in Quitline utilization by rurality and Appalachian status using statistical t-tests. Stepwise regression assessed the absolute estimate of county features, including poverty rate, tobacco retailer density, physician availability, coal mining industry, and tobacco agriculture, on Quitline usage. ResultsWhile the average smoking rate overall was 15.3 %, only 7.4 % of smokers accessed Quitline services from 2011 to 2019. Appalachian regions exhibited higher smoking rates (20.9 %) and lower quitline usage (4.8 %) compared to non-Appalachian areas (14 % smoking prevalence, 8 % quitline usage). Rural regions had higher smoking prevalence (19.0 %) than urban areas (12.9 %), but no significant difference in Quitline utilization (7.6 % vs. 7.2 %, p = 0.7). Stepwise regression revealed counties with more tobacco agriculture had 3.2 % (p = 0.04) lower Quitline utilization. Also, more physicians availability in the county was associated with 3.9 % higher Quitline usage (p = 0.03) and Appalachian counties exhibited a 3.6 % lower Quitline usage rate compared to non-Appalachian counties. ConclusionA significant gap exists between cigarette smoking prevalence and Quitline utilization, particularly in underserved rural and Appalachian areas, despite no clear barriers to accessing this remote cessation resource. ImplicationThe study underscores persistent disparities in smoking rates, with rural and Appalachian regions in the United States facing higher smoking prevalence and limited utilization of Quitline services. Despite no clear barriers to access, the gap between smoking prevalence and Quitline usage remains significant, particularly in underserved areas. Tailoring interventions to address regional disparities and factors like tobacco agriculture and physician availability is essential to reduce smoking rates and improve Quitline utilization in these communities.

Adverse Childhood Experiences and Co-Occurring Disorders: Is There a Relationship Among ACEs, Mental Health Issues, and Substance Use Among Inmates?

Previous literature has shown that adverse childhood experiences (ACEs) are a factor in future criminal behavior, victimization, and overall health. Research has also found that co-occurring disorders (CODs) are prevalent among inmates with approximately half of inmates meeting the criteria of mental health and substance use disorders in previous studies. Exposure to ACEs and drug use may also be higher in rural, Appalachian areas with the opioid crisis impacting adults and children alike. Moreover, research has indicated that some relationships, such as parenthood, may serve as protective factors for those involved in the justice system. The current study explores the relationship between ACEs and CODs, specifically in the areas of substance use and mental health among a rural jail sample. This study utilizes an Inmate History and Needs interview survey completed by 166 inmates (59 females, 107 males) from three different rural jails in a southern state to examine the relationship between ACEs and CODs among inmates, if CODs differ among male and female inmates, and the relationship between parents, CODs, and living with their children prior to arrest. We found that inmates in our study report high rates of ACEs, mental health issues, and drug use, and there is a significant relationship between exposure to ACEs and CODs.

The Ordovician System of Canada: an extensive stratigraphic record of Laurentian shallow water platforms and deep marine basins

Abstract Ordovician rocks extensively border and cover Laurentia or the North American Craton in Canada. These rocks represent diverse and significant successions spread across a variety of depositional and palaeogeographic settings in the Canadian Arctic Islands, Eastern Canada, Western Canada and the Canadian Interior. During much of the Ordovician, Laurentia straddled the palaeoequator and was flooded by extensive epicontinental seas, experiencing high temperatures and high faunal diversity. The central and western parts of the Laurentian Craton remained relatively stable during the Ordovician, but there was substantial tectonic activity with the Taconic Orogeny affecting the Appalachian area and the Pearya composite terrane affecting the Franklinian Margin along its eastern and northern margins, respectively. The large Hudson Bay and Williston basins and smaller satellite basins cover the cratonic interior in Canada. These shallow intracratonic basins, dominated by marine carbonates with some evaporites, are the erosional remnant of a more extensive sea episodically connected with the adjacent platformal areas during the Ordovician. The Global Boundary Stratotype Section and Point (GSSP) for the base of the Ordovician System is exposed in Green Point, western Newfoundland while the Ordovician–Silurian boundary interval is well exposed on Anticosti Island, Québec but is also present in Ontario, Manitoba, Yukon and Arctic Canada.

Prevalence and Factors of Self-medication with Antibiotics in Claiborne County, Tennessee.

Antimicrobial resistance (AMR) is a serious concern to public health, causing an estimated 35,000 deaths annually in the U.S. Misuse of antimicrobials increases the rate of AMR. Self-medication with antibiotics (SMA) is a primary contributor to AMR that can be addressed through education. SMA has been reported at rates of 3% to 66% in the U.S. but has not been evaluated in Appalachia.1 Low health literacy and barriers to accessing care have been correlated with SMA and are common in many areas of Appalachia. This study aims to assess factors associated with SMA, demographic differences in knowledge of / beliefs about SMA, and describe practices and beliefs of those who self-medicate in the Cumberland Gap region. Structured interviews were conducted in a rural health clinic and in a dental office to ascertain demographic information, knowledge of appropriate antibiotic use, and behaviors associated with self-medication. Inferential statistics (chi-squared, Fisher's exact, and ANOVA tests) were conducted. In the last 3 years, 41% of the 78 respondents had practiced SMA. A higher percentage of those who believed that antibiotics are used to treat viral infections have self-treated compared to those who did not hold that belief. Of those who SMA, convenience was the most common reason, while the common symptoms treated were congestion and fever. The current study provides a first estimate of SMA in the Central Appalachian Region and finds the prevalence to be higher than previously reported in other regions of the U.S. Future studies could include larger, more representative samples and longitudinal study designs to confirm these findings.

Over the Hills and Through the Hollers: How One Program is Assisting Residents of Appalachian with Opioid Use Recovery.

The consequences of increasing opioid misuse in the U.S. over the last two decades have been severe, contributing to hundreds of thousands of lives lost and heavy tolls on individuals, families, and society. The Appalachian Region has been hit particularly hard, with its predominantly rural landscape seeing disproportionate increases in opioid misuse and overdoses. These cases have been difficult to address due to poor treatment access and capacity constraints in many areas of Appalachia. The current study focuses on evaluating The Kentucky Access to Recovery Program (KATR), which provides services to individuals recovering from opioid addiction residing in several counties in Eastern Kentucky. Its purpose is to understand the impact of KATR on service recipients' access to recovery services and supports. Semi-structured interviews were conducted with 12 service recipients, three service providers, and four vendors of support services related to housing, transportation, medical/dental care, employment, and childcare. Qualitative data were analyzed using thematic analysis. Themes related to individual-level impacts were identified and discussed, including behavioral changes related to recovery, physical and mental health improvements, relationship repair, regaining custody of children, provision of needed supports, and ability to gain employment and improve finances. Study findings showed that KATR had meaningful impacts on the lives of service recipients by helping meet needs and reducing barriers to their ongoing recovery. Through its use of vouchers for support services and basic-needs provision, KATR demonstrates a potentially effective strategy for increasing access to health-related social services for persons in recovery in predominantly rural areas.

Disparities in spatial access to neurological care in Appalachia: a cross-sectional health services analysis

Appalachia is rural and socioeconomically deprived with a heavy burden of neurological disorders and poor access to healthcare providers. Rates of neurological disorders are increasing over time without equal increases in providers, indicating that Appalachian disparities are likely to worsen. Spatial access to neurological care has not been robustly explored for U.S. areas, so we aimed to examine disparities in the vulnerable Appalachian region. Using 2022 CMS Care Compare physician data, we conducted a cross-sectional health services analysis, where we computed spatial accessibility of neurologists for all census tracts in the 13 states with Appalachian counties. We stratified access ratios by state, area deprivation, and rural-urban commuting area (RUCA) codes then utilized Welch two-sample t-tests to compare Appalachian tracts with non-Appalachian tracts. Using stratified results, we identified Appalachian areas where interventions would have the largest impact. Appalachian tracts (n=6169) had neurologist spatial access ratios between 25% and 35% lower than non-Appalachian tracts (n=18,441; p<0.001). When stratified by rurality and deprivation, three-step floating catchment area spatial access ratios for Appalachian tracts remained significantly lower in the most urban (RUCA=1 [p<0.0001) and most rural tracts (RUCA=9 [p=0.0093]; RUCA=10 [p=0.0227]). We identified 937 Appalachian census tracts where interventions can be targeted. After stratifying by rural status and deprivation, significant disparities in spatial access to neurologists remained for Appalachian areas, indicating both poorer access in Appalachia and that neurologist accessibility cannot be determined solely by remoteness and socioeconomic status. These findings and our identified disparity areas have broad implications for policymaking and intervention targeting in Appalachia. R.B.B. was supported by NIH Award Number T32CA094186. M.P.M. was supported by NIH-NCATS Award Number KL2TR002547.

Geographic Differences in JUUL Use and Risk Perceptions

Purpose The aim of this study was to compare prevalence of JUUL use and JUUL risk perceptions between adolescents living in an urban area versus Appalachian areas of the U.S. Methods Data were drawn from a prospective cohort study of adolescent males (the Buckeye Teen Health Study, or BTHS); our cross-sectional analysis used data from one timepoint, collected between January and December 2019 (N = 873). Chi-square tests and multivariable logistic regression compared JUUL use prevalence and risk perceptions between participants in an urban Ohio county and nine predominantly rural Appalachian Ohio counties. Results Over a quarter of the sample (29.2%) had ever used JUUL. In the unadjusted model, prevalence of JUUL use was similar between regions but Appalachian participants perceived JUUL as more harmful (p < .001) and more addictive (p = .04) than urban participants. In the adjusted model, region was not significantly related to current JUUL use (OR: 1.20, 95% CI: 0.77, 1.87) or ever JUUL use (OR: 1.15, 95% CI: 0.83, 1.60). Conclusions JUUL use was similar between urban and Appalachian participants despite regional differences in risk perceptions. Interventions that only target risk perceptions may not be sufficient to prevent adolescent e-cigarette use, particularly in rural communities.

921-P: Diabetes Preventive Care for Medicare Beneficiaries: Comparing Efficiency between the Diabetes Belt and Surrounding Areas

Objective: Evidence-based preventive care services are crucial for people with diabetes to improve their health outcomes, but the utilization of the services among older adults is suboptimal. Our objective is to compare relative performance of the Diabetes Belt and surrounding counties in the uptake of preventive services among Medicare beneficiaries with diabetes given available health care resources in the counties. The Diabetes Belt includes 644 counties in the Appalachian and deep south areas of the US that have high diabetes prevalence. Methods: We used data envelopment analysis (DEA) to compute technical efficiency of counties for 2009-2015. Technical efficiency measures how many outputs a decision-making unit produces given a set of inputs. Inputs included the number of physicians and nurses per 1000 adults in the counties, and outputs included the number of foot exams, a1c tests, and microalbumin tests per 1000 Medicare beneficiaries with diabetes. The Diabetes Belt includes counties in the Appalachian and deep south areas of the US that have high diabetes prevalence. We performed t-tests to compare efficiency between the Diabetes Belt and surrounding counties. We excluded counties with 0 doctors or 0 nurses for &amp;gt;1 year in 2009-2015. Results: Of 1057 counties, 861 (496 in the Belt and 365 in surrounding areas) were included. During the study period, the average technical efficiency of the counties ranged from 79% to 83%, with only 2.- 3.4% of counties achieving 100% technical efficiency. Diabetes Belt counties had consistently lower efficiency than surrounding counties during the study period (p &amp;lt;0.05) . The mean efficiency was 78-81% in the Diabetes Belt and 81-85% in the surrounding counties. Discussion: Our results suggest that the degree of inefficiencies was higher in the Diabetes Belt compared to surrounding counties. Given relatively low available resources in these areas, more attention to improve diabetes preventive care is needed. Disclosure H.Kang: None. S.Kim: None. J.M.Lobo: n/a. M.Sohn: None. Funding National Institutes of Health (1R01DK113295-01A1)

122-OR: Association between Annual Wellness Visits and Major Amputations among Medicare Beneficiaries in the Diabetes Belt

Objective: Annual Wellness Visits (AWVs) are yearly visits for Medicare beneficiaries that include discussing preventive care needs and scheduling future preventive care services. Our prior work found that AWVs are associated with increased utilization of preventive care for diabetes patients, including uptake of foot exams. Our objective is to determine whether AWVs are associated with a reduced risk of major lower-extremity amputations (MLEAs) for patients in the Diabetes Belt. Methods: Our analysis used a sample of approximately 900,000 Medicare Fee-for-Service beneficiaries from 2015 that lived in the Diabetes Belt and surrounding areas. The Diabetes Belt is a region of 644 counties in the Appalachian and deep south areas of the US identified by the CDC in 20 that continues to have a high prevalence. We used multivariable logistic regression to examine the association between AWVs and MLEAs in 2015, adjusting for demographic factors, comorbidities, major risk factors including diabetic foot ulcers, neuropathy, peripheral vascular disease, and access to care factors. Results: The rate of MLEAs was significantly lower among patients in the Diabetes Belt who had an AWV in the last year. The odds of MLEAs were 36% lower in patients who used AWVs in the same year compared to those who did not, adjusting for all covariates. We also found that patients in the Diabetes Belt had about 27% higher odds of having an MLEA compared to those residing in the surrounding areas. Discussion: Patients who used AWVs may have had their diabetic foot examined sooner to prevent a major adverse outcome than those who did not. Policy makers should prioritize incentives for having patients participate in AWVs to help reduce MLEAs. Disclosure J.M.Lobo: n/a. S.Kim: None. H.Kang: None. M.Sohn: None. Funding NIH/NIDDK R01DK113295

Timing and evolution of the Mississippian sedimentary system on southeastern Laurussia: Evidence from the Appalachian area, U.S.A.

This paper is a synthesis of Mississippian sedimentation on the southeastern, Appalachian margin of Laurussia. The Mississippian stratigraphic framework in the Appalachian area shows a large-scale, three-part, wedge-like, clastic‑carbonate-clastic sequence, which has been interpreted to be a likely flexural response to coeval Neoacadian Orogeny. Using an already established flexural framework and biostratigraphy, we have interpreted the approximate timing of flexural events based on biostratigraphy. These flexural events begin with active deformational loading that initiated rapid subsidence in the Appalachian foreland basin, during which the deeper-water, black Sunbury Shale and equivalents were deposited throughout the basin. Subsequent relaxational loading contributed to basin infilling through the deposition of a deeper-water, clastic succession, manifest as the extensive Cuyahoga-Logan-Borden-Grainger-Price-Rockwell-Pocono deltaic clastic wedge. By the time this clastic wedge had filled the foreland basin, clastic source areas in the orogen had apparently been lowered to the point that shallow seas migrated far eastward across former source areas. This brief period of equilibrium between the basin and source areas resulted in reduced clastic influx at a time when the basin entered subtropical latitudes, setting the stage for widespread carbonate deposition, represented by units like the Newman, Greenbrier, and Slade Limestones. Ensuing, rebound-related uplift, perhaps abetted by incipient, subsurface, Alleghanian thrusting, generated new sediment source areas and accompanying wedges of prograding marginal-marine and terrestrial sediment represented by the Pennington, Mauch Chunk and equivalent units. Marginal-marine sedimentation continued into Early Pennsylvanian time, when a combination of Alleghanian uplift and LPIA lowstand conditions generated a period of widespread, deep erosion that in many places across the Appalachian Basin destroyed substantial parts of the underlying Mississippian succession along the sub-Absaroka or “Mississippian-Pennsylvanian” unconformity. Although the basic Mississippian stratigraphic framework described above for the Appalachian Basin largely appears to be a consequence of Neoacadian flexural responses, major details regarding processes, timing and lithology were apparently controlled by concomitant interactions involving paleoclimate, eustasy, coeval Ouachita tectonism, and possibly early Alleghanian tectonism.

The Appalachian area as a tectonostratigraphic analogue for the Barents Sea shelf

AbstractThe US Appalachian Basin and the Arctic Norwegian and Russian Barents Sea shelf (BSS) areas are two strategic provinces for the energy industry. The Appalachian Basin is a well‐studied, mature, onshore basin, whereas the offshore BSS is still considered a frontier area. This study suggests that the Appalachian Basin may be an appropriate analogue for understanding the BSS and contribute to development of a tectonostratigraphic framework for the area. Although the Appalachian and BSS areas reflect different times and settings, both areas began as passive margins that were subsequently subjected to subduction and continent collision associated with the closure of an adjacent ocean basin. As a result, both areas exhibited multi‐phase subduction‐type orogenies, a rising hinterland that sourced sediments, and a foreland‐basin sedimentary system that periodically overflowed onto an adjacent intracratonic area of basins and platforms with underlying basement structures. Foreland‐basin sedimentary systems in the Mid‐to‐Late Palaeozoic Appalachian Basin are composed of unconformity‐bound cycles related to specific orogenic pulses called tectophases. Each tectophase gave rise to a distinct sequence of lithologies related to flexural events in the orogen. In this study, similar sequences are recognised in both BSS foreland‐basin and adjacent intracratonic sedimentary sequences that formed in response to the Late Palaeozoic–Mesozoic Uralian–Pai–Khoi–Novaya Zemlya Orogeny, suggesting that the processes generating the sequences are analogous to the tectophase cycles in the Appalachian Basin. Hence, this pioneering use of the Appalachian area and its succession as large‐scale tectonostratigraphic analogues for the BSS may further enhance understanding of Upper Palaeozoic to Middle Jurassic stratigraphy across the BSS.

Caregiver Feeding Practices as Predictors for Child Dietary Intake in Low-Income, Appalachian Communities.

The Appalachian region of the U.S. is disproportionately impacted by poverty, obesity, and nutrition-related chronic diseases. Evidence suggests that caregiver feeding practices may promote healthful eating behaviors among children; however, this has not been examined in low-income, rural, Appalachian populations. This study examines caregiver feeding practices as predictors for child diet in low-income Appalachian families, using a cross-sectional analysis of 178 caregivers of young children (ages 2–10 years old), that were recruited from low-income, rural communities in East Tennessee, from November 2017 to June 2018. Caregivers self-reported measures of demographics, feeding practices, and child dietary intake. Multiple linear regression analyses were run, and found that higher use of caregiver modeling positively predicted child vegetable consumption (Beta = 1.02; p = 0.04). Higher caregiver intake of fruits and vegetables positively predicted child fruit consumption (Beta = 0.29; p = 0.02) and vegetable consumption (Beta = 1.56; p < 0.001), respectively. Higher home availability of healthier foods positively predicted child fruit consumption (Beta = 0.06; p = 0.002) and vegetable consumption (Beta = 0.09; p = 0.05). Higher home availability of less healthy foods positively predicted child consumption of high-sugar/high-fat snack foods (Beta = 0.59; p = 0.003). The findings of this study indicate that caregiver modeling, healthy caregiver dietary intake, and healthful home food availability are associated with healthier child dietary intake among young children in low-income, rural, Appalachian areas. Promoting these practices among caregivers may be an important strategy to enhancing dietary intake of children in this hard-to-reach, underserved population.

Assessing Colorectal Cancer Screening Barriers in Rural Appalachia

The age-appropriate colorectal cancer (CRC) screening rate in the rural Appalachian area is low compared with the national rate, which may account for the overall higher incidence of CRC in this area. The purpose of this study was to explore potential barriers to CRC screening in the West Virginia Appalachian area. A cross-sectional survey was designed to identify patient-reported barriers to CRC screening using the health belief model to assess their attitudes and behaviors. Autonomous paper-based surveys were randomly handed to individuals older than 50 years at various locations, including healthcare and nonhealthcare facilities. All of the responses were then categorized into two groups: the screened group and the unscreened group. Differences among both groups were statistically analyzed. There were three main areas that significantly accounted for the discrepancies between the screened and unscreened groups: perceptions of discomfort from screening tests, psychological and behavior deterrents in CRC screening and diagnosis, and limited resources for accessing care, especially transportation. In particular, psychological and behavioral deterrents in CRC screening appeared to play a role in promoting aversion to CRC screening. Lack of CRC screening awareness and knowledge may be responsible for fatalism regarding CRC and aversion to screening. Thus, multidisciplinary interventions that provide education about CRC screening, early intervention prognosis, and treatment options, as well as addressing systemic barriers to screening, such as assistance with scheduling, prep instructions, and transportation, can improve the screening rate in Appalachia and eventually lead to better outcomes through the early diagnosis of CRC.

This Ain’t What I’m Used to: Reflections of a Black Educator in Rural Black America an Autoethnography

This autoethnography highlights reflections of a Black woman social studies educator, from a predominantly White, southern Appalachian area, teaching in a Southern, predominantly Black, rural area. The study reflects on practices utilized while teaching in southern Appalachia and the pedagogical transformation undergone as a result of migrating and teaching in a Southern, predominantly Black, rural area. Using Critical Race Theory, this autoethnography explores the impact of race in the development of pedagogical practices of a Black woman teacher. The author asserts Black teachers need to learn about and utilize culturally relevant pedagogical practices in their preservice programs and that teachers should engage in self-reflection as a means to navigate personal biases and confront the perpetuation of hegemonic culture in their classroom practices.