Appalachian Kentucky Research Articles

1077-P: Assessing the Relationship among Multimorbidity, Psychosocial Factors, and Clinical Outcomes in Older Adults Living in Rural Appalachia

Type 2 diabetes (T2DM) is a significant public health burden in rural Appalachian Kentucky, with an estimated one in four older adults diagnosed with T2DM. To determine factors associated with T2DM, we assessed the relationship between multimorbidity (MM) , psychosocial factors, and clinical outcomes among 148 older adults with T2DM along with one or more comorbid conditions, living in rural Appalachian Kentucky. A community-based sample of Appalachian residents provided data on diabetes knowledge, chronic conditions in addition to T2DM, demographics, and clinical measures (HbA1c, blood pressure) using point-of-care methods.The sample population (N=148) had an average age of 72.2 years (± 5.4) and were mostly women (66%) and White (98%) , reflecting the region’s demographics. The average HbA1c was 7.6 (±1.3) and systolic and diastolic blood pressure were 145.2 (±20.8) mmHg and 81.9 (±12.6) mmHg, respectively. Participants reported having 2.3 (±1) chronic conditions in addition to T2DM. As for psychosocial factors, participants reported average score stress 20.7 (±9.1) , distress 26.7 (±10.7) , and social support 115.0 (±15.9) . There was a significant relationship between MM and HbA1c (β=0.27, SE=0.13, p=0.04) and stress (β=0.23, SE=0.08, p=0.004) . However, distress, social support, disability, and depression did not have significant relationships with MM in this sample.These findings elucidate the burden of MM in older adults who are living with T2DM in a rural environment. Though MM is not unique to the aging population, understanding how MM effects clinical outcomes and T2DM related psychosocial factors is important. In most cases, properly managing T2DM could reduce (or prevent) severity and complications of comorbid conditions. Thus, identifying psychosocial factors that are associated with clinical outcomes provides a pathway for targeted interventions to improve health outcomes for this vulnerable population. Disclosure B.L.Smalls: None. A.Adegboyega: None. P.Simon-okube: None. P.Westgate: None. N.Schoenberg: n/a. Funding NIDDK RDK112136NIDDK K01DK116923

When Mamaw Becomes Mom: Social Capital and Kinship Family Formation amid the Rural Opioid Crisis

Amid the opioid crisis, the number of kinship families—or children living with relatives—has risen dramatically, particularly in rural communities. Using in-depth interviews with relative caregivers and local legal actors in Appalachian Kentucky, I consider how rural kinship families are formed. I demonstrate how relatives’ experiences depend on the social capital they hold with local legal actors who regulate kinship care. Whether a relative possesses positive, negative, or no social capital with these actors affects their ability to secure their ideal legal arrangement and the level of surveillance they must endure. These findings illuminate how seemingly rigid legal processes can reproduce inequalities in rural jurisdictions. In this case, the unequal distribution of legal-specific social capital precipitates different levels of stability and support afforded to rural kinship families.

Developing a Public Health Improvement Consortium in Appalachian Kentucky: Harnessing the Power of the Local Collective.

Many Appalachian counties in Kentucky are known for poor health and limited resources, however, by harnessing the power of relationships in the eight counties of the Kentucky River Area Development District, a team developed a public health improvement consortium to maximize power of the local collective.

Doing Place: A context specific framework for sustaining commitments in Appalachian Kentucky

ABSTRACT In the context of high outmigration, this study drew on the experiences of college educated young adults (N = 30) who made conscious commitments to live in Appalachian Kentucky and work on social, economic, and environmental changes in the region. Using Constructivist Grounded Theory methods, we present doing place as a context specific framework that highlights three dynamic and multi-directional strategies that guided participants’ decisions, commitments, and meaning making. Working out place emphasized how place is acquired and navigated. Keeping peace in place highlighted the strategies engaged to maintain relationships and well-being in place. Connecting to the big picture depicted how meaning making is infused throughout these experiences. These including working out place, keeping peace in place, and connecting to the big picture. We discuss theoretical contributions to place and practical implications in social work education and practice in and beyond the region.

142 A Community Mini-Grant Program: Community Leaders and Academic Partners Work Together to Improve Health in Appalachian Kentucky

OBJECTIVES/GOALS: Through the Community Mini-Grant program, the University of Kentucky Center for Clinical and Translational Science Community Engagement and Research Core (CERC) provides a unique funding mechanism designed to empower community response by supporting local solutions to complex health issues facing central Appalachian Kentucky communities. METHODS/STUDY POPULATION: Four $2500 grants are awarded annually to Appalachian organizations to implement evidence-based programs responsive to community-identified priority health needs. The CERC also supports program implementation and evaluation by facilitating collaborations between the organizations, community practitioners, and academic researchers. RESULTS/ANTICIPATED RESULTS: Since inception, grants have been awarded to 20 community organizations in 14 Appalachian counties. Health issues addressed have ranged from Alzheimers disease, cancer treatment and prevention, obesity, healthy lifestyle, and chronic disease management and prevention. Evidence-based programs have focused on improving health outcomes among older adults, caregivers, youth, children, women and infants, and families. Program outcomes have included immediate health benefits and long-term benefits resulting from community adoption of and ongoing financial support for programs. As example, results of an evidence-based educational program to improve diabetic foot assessment among clinicians in a large Appalachian healthcare network resulted in establishment of a traveling podiatrist program. DISCUSSION/SIGNIFICANCE: Community mini-grant recipients have successfully implemented projects that address the most significant health disparities in the region. Also of benefit are expanded partnerships that are foundational to the creation of new academic-community collaborations to address the challenging health issues of Appalachian populations in Kentucky.

Using Culturally Focused Storytelling to Empower Appalachian Kentucky Youth to Understand and Address Cancer Disparities in Their Communities.

Kentucky has the highest cancer incidence and mortality rates in the nation with the Appalachian region of the state being most affected. These rates are driven by health behaviors and inequities in social determinants of health. Herein, Appalachian Kentucky students with the University of Kentucky's Appalachian Career Training in Oncology (ACTION) program were engaged in a storytelling exercise by writing culturally framed essays. Students discussed their personal experiences with cancer and their thoughts on the causes of and potential solutions to Appalachian Kentucky's cancer disparities. Content analysis was used to identify common themes, subthemes, and subtopics in the essays regarding cancer types, causes of cancer in Appalachia, and solutions to the high cancer rates. Common cancer types experienced by the students included breast, lung, and prostate. The most frequently identified themes that drive cancer rates in Appalachian Kentucky were identified as geography, environmental factors, tobacco use, education, poverty, prevention, and mistrust. Common proposed solutions to decrease cancer rates were to increase education and awareness, screening, and tobacco cessation. Overall, through storytelling, youth gained a better understanding of cancer in their communities and envisioned culturally tailored, community-based intervention strategies that can aid in reducing the cancer burden in Appalachian Kentucky.

Capacity for sustainment of recently established syringe service programs in Appalachian Kentucky: The central role of staff champions.

Ensuring adequate harm reduction infrastructure in rural areas is imperative, as drug-related epidemics expand into them. Here, we explore the capacity for sustainment of syringe service programs (SSP) in Appalachian Kentucky. We interviewed all staff (n= 16) of all SSPs (n= 7) in two Kentucky health districts in 2018-2019 using semi-structured one-on-one qualitative interviews; local departments of health (DOH) operated the SSPs. Interview domains encompassed: (i) SSP establishment; (ii) day-to-day operations, participation and health impacts; (iii) perceived prospects for sustainment; and (iv) perceived influences on #i-#iii. We analysed verbatim transcripts using thematic analytic methods; Schell's 'capacity for sustainment' constructs were treated as sensitising concepts during the analysis. Most community members, law enforcement and DOH staff opposed SSPs before they opened, because of stigma and concerns about enabling and needlestick injuries; DOH staff also opposed SSPs because they believed they lacked the capacity to operate them. Training, technical assistance, visible evidence of the programs' public health impact and contact with SSP participants transformed DOH staff into program champions. As champions, SSP staff developed programs that had strong capacity for sustainment, as defined by Schell (e.g. visible public health impact, stable funding, political support). Staff reported that the SSPs had high prospects for sustainment. As in SSPs that opened in cities decades ago, staff in emerging SSPs in these rural areas appear to have become crucial champions for these controversial programs, and may serve as vital resources for expanding harm reduction programming more broadly in these underserved areas.

Age and Medicare Insurance are Barriers to Telemedicine Access-A Quality Improvement Project.

Telehealth use has had widespread expansion and adoption over the past two years. This study aims to evaluate access to telehealth essentials (TE) using a novel metric. This single institute study surveyed outpatient surgical patients to determine their access to TE. Generalized linear mixed models were used to determine the relationship of demographic and county-level variables on access to four TE. 138 patients were surveyed. Sixty-six (47.8%) were from Appalachian Kentucky. In the survey cohort, 122 (88.4%) had smart phones, 109 (80.7%) had devices with video messaging capabilities, 106 (80.9%) had cellular reception, and 112 (82.4%) had access to WiFi. Increasing age and Medicare insurance were the most consistent predictors of lack of access to TE. Rural Appalachian Kentucky has access to TE. Telehealth has the potential to decrease the healthcare inequity in rural populations, but incompletely address this inequity for the aging population.

Recent Increase in Methamphetamine Use in a Cohort of Rural People Who Use Drugs: Further Evidence for the Emergence of Twin Epidemics.

Appalachian Kentucky was at the epicenter of the prescription opioid epidemic in the early 2000's. As we enter the third decade of the epidemic, patterns have begun to emerge as people who use drugs (PWUD) transition from use of opioids to other drugs. The purpose of this analysis was to examine longitudinal changes in methamphetamine use in an ongoing cohort of rural people who use drugs (PWUD) in Appalachian Kentucky. All but five of the cohort participants (N = 503) reported nonmedical prescription opioid use (NMPOU) at baseline and those 498 are included in this longitudinal analysis encompassing eight waves of data (2008–2020). Past 6-month use of methamphetamine was the dependent variable. Given the correlated nature of the data, mixed effects logistic regression was utilized to examine changes in methamphetamine use over time. Significant increases in methamphetamine use were observed over the past decade in this cohort of PWUD, especially in recent years (2017–2020). Prevalence of recent use at baseline and each of the follow-up visits was as follows: 9.4, 5.6, 5.0, 5.4, 8.1, 6.8, 6.9, and 33.1%, respectively (p < 0.001). On the contrary, significant reductions in NMPO and heroin use were observed in the same time period. The odds of methamphetamine use at the most recent visit were 25.8 times greater than at baseline (95% CI: 14.9, 44.6) and 52.6% of those reporting methamphetamine use reported injecting the drug. These results provide further evidence of “twin epidemics” of methamphetamine use among NMPOU. While problematic on several fronts, of particular concern is the lack of effective treatment options for methamphetamine use disorder. As policies around the opioid epidemic continue to evolve, particular attention should be paid to the surge in stimulant use in opioid-endemic areas.

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.

COVID-19 Pandemic Impact on Essential Public Health Services and Online Health Communication-Appalachian Kentucky, March-December 2020.

The COVID-19 pandemic posed many challenges for local health departments (LHDs). This study examines how stay-at-home orders impacted the provision of essential public health services and subsequent increased use of online health communication by LHDs for rural populations in Appalachian Kentucky during the first year of the COVID-19 pandemic. A survey to gather information about provision of essential public health services was administered to five LHDs representing 13 counties between June 2020 and December 2020. Additionally, demographic and health-outcome data from LHD, state health department, and CDC websites were reviewed, alongside health communications posted on LHD social media pages. Using these data, the authors conducted descriptive analyses to assess how essential public health services and health communications were impacted by the COVID-19 pandemic. In Appalachian Kentucky, limited internet access was identified by all LHDs as the most common barrier for clients of essential public health services. During stay-at-home orders, the use of telehealth increased participation rates for programs that support parents for optimal growth and development of children. Additionally, social media was the most preferred media source by all LHDs to communicate with the local population to promote health education. By using publicly available data and conducting interviews with LHDs, alongside examination of the health information they posted online, the study is able to characterize the impacts of the COVID-19 pandemic on providing essential public health services-successes and challenges. Expanding use of telehealth for essential public health services and increased access to online health communication improves access to care and information for rural populations in Appalachian Kentucky.

Assessing the Intention, Attitudes, and Social Influences on COVID-19 Preventive Behaviors Among Non-rural Black and Rural Appalachian White Populations: A Faith-Based Community Study.

The COVID-19 pandemic has had detrimental impacts in non-rural Black and rural Appalachian populations. Yet despite the pandemic's magnitude, there is a scarcity of research exploring potential influences of attitudes and social influences within these populations on their adherence to COVID-19 public health preventive behaviors. This study examines the intention, attitudes, and social influences to adhere to COVID-19 preventive behaviors among non-rural Black and rural Appalachian congregants in Kentucky by integrating the Theory of Planned Behavior (TPB). Secondary analysis of cross-sectional data was used to assess the association between the TPB constructs and four key public health behaviors: obeying a stay-at-home order, social distancing, good hygiene practices, and wearing a mask in public. Generalized estimating equation-type logistic regression models were fit for all binary outcomes. A total of 942 respondents completed the survey. Eighty-nine per cent were older than 36 years, and 73% were female. Of the respondents who were White, 97.7% lived in rural Appalachia Kentucky, and of those who were Black, 93.5% lived in non-rural Kentucky. Attitude towards the behavior was negatively associated with the stay-at-home order ( p=0.003). Both attitude toward the behavior ( p<0.001) and the subjective norm ( p=0.025) were negatively associated with mask wearing. Perceived behavioral control was positively associated with mask wearing ( p=0.023) with non-rural respondents more likely to wear a mask than rural ones ( p<0.001). None of the TPB constructs showed significant association with hygiene practices or with social distancing. This study provides further insight into the cultural and societal influences that intersect during a global pandemic. The intention to comply with public health recommendations may vary at favorable and unfavorable levels. The results lend support to the importance of designing effective, culturally tailored communication for future public health preparedness.

Through the Lens: Youth Experiences with Cancer in Rural Appalachian Kentucky Using Photovoice.

Rural Appalachian Kentucky experiences disproportionately high cancer incidence and mortality rates. This cancer burden is due to social determinants of health and cultural factors prominent in the region. The firsthand experiences of community members—especially young people—can highlight these factors and identify areas for improvement. The purpose of this study was to encourage Appalachian Kentucky youth to consider determinants of cancer and visualize the effects that cancer has on their families or communities by asking them to take photographs of cancer-related objects around them. Content analysis was performed on 238 photographs submitted by 25 students, and photographs were organized into themes, subthemes, and subtopics. The six themes that emerged were risk factors and exposures, marketing, awareness and support, health care, experiences, and metaphorical representations. Many of the submitted photographs aligned with cultural, environmental and/or situational factors prevalent in Appalachian Kentucky. Of the submitted photographs, 54 were displayed as an installment in two Kentucky art galleries. Viewer comments at the exhibitions demonstrated that young community members can educate and motivate change in those around them. Ultimately, this project demonstrates that young community members can recognize cancer-related issues around them and connect personal experiences back to the larger Appalachian Kentucky cancer disparity while also having an impact on other community members.

The Appalachian Career Training in Oncology (ACTION) Program: Preparing Appalachian Kentucky High School and Undergraduate Students for Cancer Careers.

The Appalachian Career Training In ONcology or ACTION Program is a National Cancer Institute (NCI) Youth Enjoy Science (YES) research education grant program that recruits and trains early-career undergraduate and high school students from underrepresented, socioeconomically distressed areas of Appalachian Kentucky in cancer research and outreach. The two-year program is a multifaceted experience that includes participation in cross-disciplinary, mentored cancer research projects. In addition to research projects, participants also shadow faculty mentors in clinical medical settings, engage in multiple types of educational activities, and participate in cancer-focused outreach projects within their communities. Participants also engage in peer-to-peer networking and receive career mentorship, training, and coaching. Highlights of program activities include a student-led photovoice project to promote cancer awareness and participant publications including a book featuring participant essays focused on their experiences and thoughts on cancer. Initial impact data show high school participants have a higher than state and county average four-year college-going rate and all undergraduate participants are gaining positive outcomes related to educational and career attainment. This article provides an overview of the significant benefits of the ACTION Program, the program's activities, and highlights from program implementation. Potential impacts of the program and barriers to implementation are also shared.

Characterization of Uterine Cervix Cancers in Women from Appalachian Kentucky.

Uterine cervix cancer (UCCx) is clinically and socioeconomically diverse among women in the United States (US), which obscures the discovery of effective radiochemotherapy approaches for this disease. UCCx afflicts 7.5 per 100,000 American women nationally but 11.7 per 100,000 women in Appalachian Kentucky (AppKY), when age-adjusted to the 2000 US standard population. Epidemiological chart review was performed on 212 women with UCCx treated at the University of Kentucky (UKY) between January 2001 and July 2021. Demographics, tumor characteristics, and relative radiochemotherapy dose and schedule intensity were compared among AppKY and non-AppKY cohorts as well as Surveillance, Epidemiology, and End Results (SEER) data. One hundred thirty-eight (65%) of 212 women seeking radiochemotherapy treatment for UCCx resided in AppKY. Most (80%) sought external-beam radiochemotherapy close to their AppKY residence. Brachytherapy was then most frequently (96%) conducted at UKY. Cancer stage at diagnosis was significantly more advanced in AppKY residents. Women residing in AppKY had a median 10-week radiochemotherapy course, longer than an 8-week guideline. Estimated survival in women residing in AppKY was 8% lower than US national averages. In summary, this study identified an increased percentage of advanced-stage UCCx cancer at diagnosis arising in AppKY residents, with a confounding population-specific delay in radiochemotherapy schedule intensity lowering survival.

Using conjoint analysis to study health policy changes: An example from a cohort of persons who use drugs.

Historically, persons who use drugs (PWUDs) in the United States have often lacked health insurance, as Medicaid did not cover low-income adults. The Affordable Care Act of 2010 (ACA) increased access to insurance in states, such as Kentucky, that expanded their Medicaid programs. A cohort study of PWUDs in Kentucky found the prevalence of being insured increased from 34% pre-ACA to 87% post-ACA. However, changes to Medicaid were proposed that intended to restrict access to this program. This manuscript describes the feasibility and utility of conjoint analysis, an innovative method for studying decision-making, to identify potential impacts of health policy changes on PWUDs. IBM SPSS's "orthogonal design" command was used to construct 12 policy profiles that presented varying combinations of the proposed policy changes to Kentucky's Medicaid plan. Each policy profile presented information on (1) monthly premium costs, (2) penalties for not paying monthly premiums, (3) weekly work requirements, and (4) if their preferred physician accepted the plan for payment. Readability of the policy profiles was analyzed using the Readable.io application. The policy profiles were included in a recent follow-up of a longitudinal cohort of PWUDs in Appalachian Kentucky (n = 355). Participants rated the likelihood of enrolling in each policy profile's Medicaid plan, using a scale ranging from 0=not at all likely to 10=extremely likely. Data were analyzed using SPSS's conjoint analysis commands. Readability results indicated the policy profiles required a 3rd grade education. Nearly all participants responded to each of the 12 policy profiles. Across the policy profiles, the mean response for willingness to enroll was 3.43 (SD = 3.61), indicating relatively low willingness to enroll. Conjoint analysis revealed the two most influential factors on willingness to enroll were work requirements (importance score, IS = 77.63) and monthly premium costs (IS = 17.76). Penalties for nonpayment (IS = 0.43) and physician acceptance (IS = 4.13) had minimal influence. This research demonstrates the feasibility of using conjoint analysis to study the impacts of potential policy changes on PWUDs.

A qualitative examination of recent increases in methamphetamine use in a cohort of rural people who use drugs

IntroductionRising rates of methamphetamine use among populations using opioids is an escalating public health concern. The purpose of this manuscript is to identify socioecologic factors driving increases in methamphetamine use among Appalachian Kentucky adults with a history of opioid use. MethodsSemi-structured qualitative interviews were conducted among 20 Appalachian Kentuckians in the Social Network of Appalachian Peoples (SNAP) cohort who reported lifetime opioid use and past 30-day methamphetamine use. Interviews focused on initiation of methamphetamine use, factors that influence methamphetamine use at the individual, interpersonal, community and society levels. ResultsParticipants reported using methamphetamine to self-treat underlying issues, including withdrawal from opioids, chronic pain, and emotional distress. Initiation of use was most often facilitated through their drug networks. Participants reported that methamphetamine was widely available and affordable in their community. Several participants with extensive histories of non-medical prescription opioid (NMPO) use described transitioning to methamphetamine as their drug of choice as opioids became less available in their community. Participants also reported economic distress and lack of recreational opportunities as drivers of increased methamphetamine use. DiscussionRecent increases in methamphetamine use among those with a history of opioid use is facilitated by methamphetamine’s relative availability and affordability. Methamphetamine use was also highly influenced by societal factors such as economic deprivation and policies that decreased availability of NMPOs. Surging methamphetamine use exacerbates inequities in addiction care brought to light by the opioid epidemic. Interventions aimed at addressing the socioecological drivers of methamphetamine use among people who use opioids are warranted.

Trends in Incidence and Mortality Rates of Uterine Cancer in Kentucky.

The objective of this analysis was to gauge how the incidence and mortality of uterine cancer in Kentucky have changed from 1995 through 2017. An assessment of the trends in incidence and mortality across different geographic areas and between different races was also performed. Age-adjusted annual incidence and mortality rates for uterine cancer were obtained from the Kentucky Cancer Registry. A meta-regression framework was used to assess changes in incidence and mortality rates during the time frame and to determine differences in these rates between rural versus urban counties, Appalachian versus non-Appalachian counties, and Black versus White women. The incidence of uterine cancer has significantly increased throughout the state of Kentucky since 1995. Uterine cancer incidence was 10% and 22% higher in rural and Appalachian counties, respectively, compared with urban and non-Appalachian counties (P < 0.0001) from 1995 through 2017. In contrast, urban and non-Appalachian women had higher or equivalent age-adjusted mortality from uterine cancer, compared with rural and Appalachian women, respectively. The incidence of uterine cancer was significantly higher in White women compared with Black women from 1995 through 2006, but since 2007, there has been no significant difference in uterine cancer incidence based on race. Black women had higher age-adjusted mortality than White women throughout the entire time period examined. The incidence of uterine cancer is higher in rural and Appalachian Kentucky, without a corresponding geographic trend in mortality. Uterine cancer mortality is significantly higher in Black women.

Leveraging Community Resources to Provide a Box of Fruits and Vegetables to Low-Income Kentucky Appalachians Living in a Food Desert

Describe the results of distributing free fruits and vegetables to low income Appalachian Kentuckians. Low-income Appalachian Kentuckians often lack regular access to fresh food, especially fruits and vegetables (F/V). Compared to 23.4% of Americans, only 21.1% of Kentuckians and 19.0% of Appalachians meet the recommended daily F/V intake recommendations. Past studies have shown that low-income individuals did not tend to increase their F/V intake when they could choose where to spend their money when supermarket discounts and farmer’s market voucher programs were available to them. The current study explored if and how low-income Appalachian Kentuckians living in a food desert utilized a box of free fresh produce. The box included 20 pounds of culturally acceptable F/V that was distributed with a box of non-perishable foods provided by a local emergency food program. In October 2020, a pre-survey collected demographic information from 55 consented participants who received one food box. In November 2020, participants completed a follow-up food use survey. Most participants self-identified as white (92.6%) and female (85.2%). Almost all (98.0%) ate some of the F/V fresh and over half (61%) shared the F/V with others. One third preserved some and less than 10% threw some of the F/V away. The outcomes of this study suggest that distribution of fresh F/V through local food programs in low-income Appalachian Kentucky communities with food deserts may effectively increase F/V consumption. Collaborations between wholesale produce distributors and community outreach programs to provide fresh F/V could support healthier dietary intake in communities with limited accessibility to F/V.

“Everybody has Tried to Go on All Kinds of Diets”: Disordered Eating and Attempted Weight Loss in Rural Appalachian Kentucky

“Everybody has Tried to Go on All Kinds of Diets”: Disordered Eating and Attempted Weight Loss in Rural Appalachian Kentucky