Appalachian North Research Articles

Factors in rural community buprenorphine dispensing

BackgroundThere are pharmacy-related barriers to the dispensing of buprenorphine for the treatment of opioid use disorders. These include pharmacists' moral objections and mistrust of treatment regimens; the perception of a limit on the amount of buprenorphine able to be ordered and dispensed; stigma and concerns about diversion; and knowledge and communication gaps. ObjectivesTo document pharmacy stakeholders' awareness and interpretation of regulatory policies that may impact rural community pharmacists' willingness and ability to dispense buprenorphine. To identify factors that affect rural community pharmacists' willingness and ability to dispense buprenorphine in Appalachian North Carolina. MethodsQualitative analysis and thematic coding of phone interviews with eight pharmacists from several rural North Carolina counties where local health departments recently began prescribing MOUD and four pharmacy industry stakeholders representing knowledge of wholesale distributors and pharmacy education. ResultsThree major themes were identified: stigma and misinformation, provider-prescriber communication, and perceived and actual regulatory constraints. A number of respondents indicated a desire to better understand MOUD treatment plans and displayed a misunderstanding of evidence-based treatment guidelines. Stakeholders indicated the importance of pharmacists establishing a relationship with prescribers and described pharmacist preference for dispensing buprenorphine to established patients over new or out-of-area patients. Pharmacist stakeholders and industry/education stakeholders expressed concern over a perceived DEA ‘cap’ for buprenorphine ordering. ConclusionsThis study provides insight on possible approaches to address rural pharmacy-related barriers patients may face when filling buprenorphine prescriptions. There is a demonstrated need for further pharmacist training on evidence-based practices for treating opioid use disorders and ordering limits, as well as a need for increased communication between prescribers and pharmacists.

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

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). 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. 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. 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.

Substance Use Disorder Treatment Providers' Knowledge and Opinions Toward Testing and Treatment of Chronic Hepatitis C in Rural North Carolina.

Poor access to care has made western North Carolina vulnerable to an outbreak of hepatitis C viral infection (HCV), particularly among persons who inject drugs (PWID). As substance use disorder (SUD) treatment providers could potentially improve linkage to HCV testing and treatment, we sought to understand SUD providers, clinic and client characteristics; referral patterns; HCV knowledge; willingness to participate in additional trainings; and local linkage-to-care pathways for treatment of substance use and HCV. Online survey data were collected from 78 SUD providers serving PWID in eight western rural North Carolina counties. Providers' attitudes toward working with HCV+ clients were very positive. One-third of providers reported a low fund of knowledge regarding HCV, HCV treatment, and financial assistance opportunities. Non-prescribing providers rarely initiated discussions about HCV testing/treatment, but were receptive to training. Respondents indicated that HCV testing and treatment were best delivered at local health departments or primary care clinics but were open to other venues where PWID access care. The vast majority of prescribing and non-prescribing providers expressed interest in obtaining training in HCV treatments, how to obtain HCV medications and topics on advanced liver disease. Data from prescribing and non-prescribing SUD providers suggest opportunities to develop or expand integrated care models for HCV testing/treatment in PWID in rural Appalachian North Carolina.

Hepatitis C and HIV Screening, Testing, and Risk Perceptions among South-Central Appalachian County Health Department Staff.

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are significant public health concerns, especially given the risks for disease interactions. Rates of HCV and HIV are increasing, especially in rural areas. Local health departments (LHDs) play an important role in rural health care, offering screening, testing, and treatment for HCV and HIV. Gaps persist in LHD resources for meeting these demands, especially in Appalachia and the US South. To explore HCV/HIV screening, testing, and treatment approaches and perspectives in south-central Appalachian North Carolina, structured telephone questionnaires were administered to communicable disease nurses and other health department staff directly involved in screening and testing. Mixed-methods data analyses were conducted and triangulated with stakeholders. Eighteen participants representing 19 counties completed the questionnaire, achieving a saturation sample. Participants reported barriers to screening and testing, including housing insecurity, lack of transportation and insurance, unemployment, and the isolation of living in a rural area. Divergence in perceptions of barriers between public health regions emerged, as did perceptions of who is at risk and use of stigmatizing language about people at risk for HCV/HIV. This study highlights the impact of LHD behaviors and perceptions on screening and testing, and offers recommendations to improve HCV/HIV screening and testing accessibility in south-central Appalachia, a high-risk region.

Praying with One Eye Open: Mormons and Murder in Nineteenth-Century Appalachian Georgia

Praying with One Eye Open: Mormons and Murder in Nineteenth-Century Appalachian Georgia

Rural community pharmacist willingness to dispense Suboxone® - A secret shopper investigation in South-Central Appalachia

BackgroundBuprenorphine access is limited for patients with opioid use disorder, especially in rural areas. Telephone audits have identified pharmacist limitations to the dispensing of buprenorphine particularly in independent pharmacies in comparison to chain pharmacies and in rural areas. The objective of this study was to assess rural community pharmacists' stated willingness to dispense buprenorphine-naloxone, and document potential bias and or stigma that the shopper experiences when asking about buprenorphine- naloxone. MethodsTo assess pharmacist willingness, a telephone audit of 15 rural Appalachian North Carolina pharmacies was conducted. Three secret shopper scenarios were utilized including one shopper posing as a new patient, one shopper posing as an out of state patient, and one shopper first asking about buying syringes. Encounters were noted by willingness to dispense buprenorphine, and shoppers were to note any potential stigma and or bias that they experienced while asking for Suboxone®. ResultsOverall, 60% of pharmacies audited indicated willingness to dispense buprenorphine without reservation, and 31% indicated willingness to dispense only under certain circumstances. Pharmacies tended to add more conditions to dispensing to the out of state patient (46%), such as only dispensing if the practitioner was from in state in comparison to the other shopper scenarios. Potential stigma and bias were encountered in 40% of the 45 encounters. ConclusionAlthough pharmacies overall seemed willing to dispense, nuances regarding who pharmacies are most likely to dispense are felt in rural areas. Buprenorphine access limitations were more common in independent pharmacies and more often placed on patients from out of state. Pharmacy- directed education is necessary to reduce stigma and bias and increase patient access to buprenorphine.

Qualitative Analysis of Maternal Barriers and Perceptions to Participation in a Federal Supplemental Nutrition Program in Rural Appalachian North Carolina.

BackgroundLittle is known about barriers to and perceptions of participation in the in Women, Infants, and Children (WIC) program in rural Appalachia.PurposeTo gain a deeper understanding of maternal barriers and perceptions related to WIC participation in rural AppalachiaMethodsPregnant women and mothers were recruited in-person and via flyers from WIC offices in three counties in Appalachian North Carolina. Four semi-structured focus groups were conducted between May to July 2018. Each focus group was approximately 60 minutes long and included open-ended questions about the overall WIC experience in rural Appalachia. Focus groups were audio-recorded, transcribed verbatim, and content analysis of transcripts was performed by two trained researchers. Identified themes were discussed and consensus was reached by the researchers to generate final themes for four areas of interest: (1) most valued aspects of WIC program, (2) barriers to program participation and benefit redemption, (3) experiences during appointments, and (4) suggestions for improving experiences in program.ResultsThe most valued aspects of participation were financial benefits and support/resources provided by WIC staff. In contrast, lack of variety of WIC-approved foods and social stigma were perceived as major barriers to participation and redeeming benefits.ImplicationsThis study contributes to a better understanding of the barriers and perceptions related to WIC participation in this geographically and culturally unique area of rural Appalachia. Findings are valuable for informing WIC state-agencies and policymakers whose efforts focus on the identification and development of effective recruitment and retention strategies for WIC-eligible families in rural Appalachia.

Parental Impact on Child Physical Activity and Sedentary Time in Appalachian North Carolina.

IntroductionPhysical activity has positive health benefits across the lifespan including reduced rates of chronic disease. Despite having ample availability of outdoor space for physical activity in the Appalachian Mountain region, there are low rates of physical activity along with high rates of sedentary time and increased prevalence of overweight individuals across all age groups. Therefore, there is a need to understand the factors that influence family’s physical activity and sedentary time.PurposeTo assess whether parental attitudes and behaviors influence children’s physical activity and sedentary time.MethodsThe current study was a secondary analysis of the baseline data from a pilot study of a pediatrician prescription program for outdoor physical activity. Parents (N = 70) with children aged 5–13 years living in a county served by a single-pediatrician office completed surveys in the pediatrician’s office during a well-child visit. The survey included questions related to parental attitudes toward children’s physical activity and the physical activity and sedentary time performed by the parent and their child.ResultsParent sedentary time was the only factor that had an impact on child sedentary time, with 18% of the variance in children’s sedentary time being explained by parent sedentary time. No factors predicted children’s physical activity.ImplicationsTo decrease child sedentary time, interventions should focus on reducing parental and joint parent–child sedentary time.

Prevalence and domains of disability within and outside Appalachian North Carolina: 2013–2016 Behavioral Risk Factor Surveillance System

BackgroundThe health and social conditions of the Appalachian region generally are poorer than in the US overall, and this gap is widening, suggesting disability may be higher in Appalachia. ObjectiveTo describe the prevalence of disability overall and by domain in Appalachian and non-Appalachian regions in North Carolina (NC) and describe the characteristics of people with and without disability in each region. MethodsWe conducted a cross-sectional study using data from the NC Behavioral Risk Factor Surveillance System from 2013 to 2016 which assessed disability in five domains: vision, cognitive, mobility, self-care, and independent living. We calculated weighted proportions and age- and sex-adjusted prevalence using direct standardization to the 2010 Census. ResultsThe prevalence of disability in Appalachian NC was significantly higher than in non-Appalachian NC after standardizing by age and sex (26.6% in Appalachia, 24.1% outside Appalachia, p < 0.001). In both regions, mobility disability was most common and self-care disability was least common. People within Appalachia more frequently reported disability in all domains compared to people outside Appalachia. ConclusionsMore than one in four adults in Appalachian North Carolina experience disability in at least one domain and one in eight experiences disability in multiple domains. The high prevalence of disability should be considered when planning programs and services across the spectrum of public health. Understanding common disability domains present in populations can inform public health agencies and service providers and help them develop programs and messaging that meet the needs of residents in Appalachia and are accessible to people with disabilities.

Adult Food Security and the Relationship with Adverse Childhood Experiences Among Residents of Appalachian North Carolina.

IntroductionThe Appalachian region has worse health outcomes than the remainder of the United States. These disparities are often linked to the underlying social and environmental determinants of health. Adverse childhood experiences (ACEs) are associated with poor health outcomes across the lifespan and have a significant impact on future social determinants as an adult, including food security status.PurposeTo explore the relationships between ACEs and food security among adults in the Appalachian counties of North Carolina and make comparisons with the rest of the state.MethodsResearchers used North Carolina’s 2012 Behavioral Risk Factor Surveillance System data; namely, the ACEs optional module which includes 11 items related to experiences respondents had before the age of 18 and a single item from the Social Context optional module to classify food security status. The sample was divided into three age categories (18–44, 45–64, and 65 and older) for statistical comparisons as well as by the indicator for Appalachian county. Using Stata 15, weighted logistic regression was utilized for examining relationships between variables.ResultsACEs were a statistically significant predictor of food insecurity across all respondents; each additional ACE was associated with a 13–21% increase in the odds of food insecurity, depending on age group. However, living in an Appalachian county was only a predictor for those age 45–64.ImplicationsThese findings highlight the long-term effects of childhood experiences on food security generally, and in Appalachia particularly for middle-aged adults. Reducing ACEs could reduce food insecurity and improve health in the region.

Song and Silence at the Gallows: Cultural Representations of Violence, Region, and Race in State v. McTaggart Slaves and State v. Frances Silver

This article analyzes cultural representations of two 19th century North Carolina cases, State v. McTaggart Slaves and State v. Frances Silver. Cultural memory of Silver thrives in Appalachian North Carolina, whereas McTaggart Slaves has been largely forgotten. Both cases involve women who faced execution for resistance to abuse, and who both lacked full personhood under the law. I argue that in both cases, cultural representations served to reinforce the legal power of white men over women in the home and justify legal punishment for their resistance. These representations also reflect and strengthen understandings of deviant whiteness in the Appalachian South.

The Motivations for Food Exchanges in the Lives of Rural Older Adults

AbstractGrowing older in rural areas can be challenging since access to support from others can be difficult. I conducted an exploratory descriptive study, framed by exchange theory, in rural Appalachian North Carolina in the United States over the course of a year with 16 rural elders with physical limitations and 8 of their supporters to determine how and why they constructed their networks of support. I conducted a total of 50 interviews. Through the analysis of interview data a theme regarding the important role of the exchange of food emerged. For this group of rural elders, food is both given to and received from others. The giving of food to others helps to rebalance exchanges where elders are receiving a good deal of support. In addition, food is exchanged for reasons that move well beyond nutritional needs. Food is used to initiate and support social exchanges, as expressions of kindness and neighborliness, and as a way to share abundance. Results expand on our understanding of the role of food exchanges in the lives of rural elders and expand exchange theory to include the motivations behind exchanges as an additional component of the theory.

Climate Change and Apple Diversity: Local Perceptions from Appalachian North Carolina

Research to date on the relationship between climate change and agriculture has focused primarily on annual crops. Long-term perennial crops such as apple trees give researchers the opportunity to study a more longitudinal record of human-climate interactions. In Appalachia, one of the earliest orchard areas in the United States, many orchards have been run by single families for multiple generations, and oral histories contain climate information stretching back several decades or longer. We investigated folk crop varietal diversity in southern Appalachian orchards, grower observations and perceptions of environmental change, and the potential effects of climate change on apple diversity. Twenty-two orchardists were consulted in Appalachian North Carolina, using a combination of participant observation, free-listing exercises, in-depth semi-structured interviews, and benchmark socioeconomic surveys. We documented 450 apple ethnotaxa in 22 orchards. Our results show that although a majority of growers recognize increased climate variation and variability in annual and seasonal weather patterns, only a minority attribute those changes to human activity. The major environmental change of concern to orchardists in the study region is warmer winters and earlier springs, which can cause devastating losses to apple production. Current consumer and market trends are selecting away from diverse and potentially disease- and weather-resistant heirloom apple varieties toward modern commercial varieties that are highly susceptible to environmental change. Apple diversity is threatened in southern Appalachia as a result of multiple factors, yet maintaining high diversity levels may be a key adaptive strategy in the face of global climate change.

The Effects of Geography and Spatial Behavior on Health Care Utilization among the Residents of a Rural Region

This analysis determines the importance of geography and spatial behavior as predisposing and enabling factors in rural health care utilization, controlling for demographic, social, cultural, and health status factors. A survey of 1,059 adults in 12 rural Appalachian North Carolina counties. This cross-sectional study used a three-stage sampling design stratified by county and ethnicity. Preliminary analysis of health services utilization compared weighted proportions of number of health care visits in the previous 12 months for regular check-up care, chronic care, and acute care across geographic, sociodemographic, cultural, and health variables. Multivariable logistic models identified independent correlates of health services utilization. Respondents answered standard survey questions. They located places in which they engaged health related and normal day-to-day activities; these data were entered into a geographic information system for analysis. Several geographic and spatial behavior factors, including having a driver's license, use of provided rides, and distance for regular care, were significantly related to health care utilization for regular check-up and chronic care in the bivariate analysis. In the multivariate model, having a driver's license and distance for regular care remained significant, as did several predisposing (age, gender, ethnicity), enabling (household income), and need (physical and mental health measures, number of conditions). Geographic measures, as predisposing and enabling factors, were related to regular check-up and chronic care, but not to acute care visits. These results show the importance of geographic and spatial behavior factors in rural health care utilization. They also indicate continuing inequity in rural health care utilization that must be addressed in public policy.

Complementary and Alternative Medicine Use Among Rural Residents in Western North Carolina

This analysis examines prevalence and identifies the predictors of complementary and alternative medicine (CAM) use among adults living in a rural region and analyzes the general health concerns for which rural adults use CAM remedies. Data are from a cross-sectional survey of 1,059 adults residing in 12 nonmetropolitan counties in Appalachian North Carolina conducted in 1999. “Home remedies” is the most extensively used CAM category in this population, with “honey-lemon-vinegar-whiskey and herbs” being the most widely used. The use of specific home remedies is associated with age, gender, and education. Chiropractors are the only widely used alternative therapist. Home remedies are differentially used to treat health conditions.

North Carolina Yeoman. The Diary of Basil Armstrong Thomasson, 1853-1862 (review)

BOOK REVIEWS173 of the Union decision to conduct the campaign and the way the campaign was fought; otherwise his conclusions are similar to Johnson's. Johnson offers a fuller recounting of the background of the campaign. Surprisingly, the military events are covered at a similar level of detail as in the Johnson book, in spite of Brooksher's military background. Brooksher, of course, does use more recently published articles and theses about the campaign. Brooksher's book is a survey for readers with an interest in the Red River campaign. The work is written in a lively fashion and includes a number of quotes from participants. Readers' though, should be aware that no new or startling conclusions have been reached—the basic outline is the same as the Johnson book. In spite of the book jacket's claim, this monograph does not fill a gap. M. Jane Johansson Pryor, Oklahoma North Carolina Yeoman. The Diary ofBasilArmstrong Thomasson, 1853-1862. Edited by Paul D. Escott. (Athens: University of Georgia Press, 1996. Pp. lxvi, 355. $50.00.) Basil Armstrong Thomasson (1829-1862), called Strong by his family, was a small farmer and part-time schoolteacher in the Piedmont North Carolina counties of Yadkin and Iredell. A seemingly otherwise unremarkable exemplar of the antebellum South's yeomanry, Thomasson left a remarkable diary covering the years from 1853 to his death. As Paul Escott notes in his lucid, contextualizing introduction, Thomasson's diary is one of only six such documents that have been recovered from the yeomanry, and as such it provides rare first-person testimony from a class of Southerners whose history remains largely unknown in both its details and in its wider relationships with the world the slaveholders made. It is uncertain, however, whether the example ofThomasson's diary will inspire the widening of Southern social history for which its editor hopes. This widening has been a desideratum of southern historiography for at least the last quarter century, but despite sterling work by people like Steven Hahn, Stephanie McCurry, and Vernon Burton, it remains a goal still wished for, not achieved. Part of the problem is the very paucity of sources to which the richness of the Thomasson diary negatively attests. No diary orjournal can ever be called typical, and Thomasson may have been an exceptionally atypical member of his class; he was a temperance man, for instance, and this caused him some difficulty in successfully navigating the social rituals—local politics and barn raisings—of his community. If anything, Thomasson seems to be out of place as a kind of Ben Franklin Yankee on a Southern farm: frugal, religious, given to self-moralizing lists, and an autodidact ofthe most attractive sort. Thomasson's diary entries are frequentlyjust a record of the weather ("Clear and warm.") and work ("Hauled my hay from Pardue's meadow."), but there are also literary effects such as the following, which rises 174CIVIL WAR HISTORY to a rustic pastoralism: "Just after the 'bright orb of day' had gone down behind the western hills, I heisted the head of three of my beestands, two of which was, I think, as rich as I ever saw. . . . The comb was white, and the honey beautiful. I guess from its appearance, that most it was collected from the bloom of the sowerwood." Thomasson belies our notion of the Southern yeomanry in other ways as well perhaps because he lived in the hermetic world of Appalachian North Carolina but also perhaps because we so little know Thomasson's class that we are surprised to hear it speak in ways that have escaped the historian's paradigms. For instance, if Thomasson did not seem to participate in or even notice the vaunted Southern conception of honor perhaps that concept needs some revision or moderation of its totalitizing aspects. Indeed the very hermeticism of the mountain hollows and Thomasson's hardscrabble day-to-day existence must be counterpoised to his subscriptions to many national and regional newspapers andjournals; he courted his wife, in part, by taking out a newspaper subscription for her. And on women's issues generally, Thomasson was remarkably progressive, taking the Northern feminist line that linked slavery with the state of...

Chapter 16 Devonian history

Svalbard is part of the Old Red Sandstone province with affinities in East Greenland, Norway, Appalachian North America and, of course, the British Isles where the Devonian Period was defined. This allows Devonian history in this region, controlled by Caledonian events, to form a neat and natural chapter, though not necessarily a global one. Old Red Sandstone environments in each area were already becoming established in Late Silurian time. Olaf Holtedahl was the prime author of both Caledonian tectogenesis in Svalbard and the Old Red Sandstone aftermath. Of the many and varied biotas of Svalbard the fossil fish have made remarkable and classic contributions to Spitsbergen geology. The earliest 'Old Red Sandstone' Spitsbergen strata have yet to yield evidence of age and so may be latest Silurian (Siktefjellet Group). But the earliest Devonian strata to be identified biostratigraphically begin with the Red Bay Group. Similarly the (major) Ny Friesland Orogeny and the various late orogenic granite emplacements, while initially Silurian, continued at least to cool in Devonian time. For convenience the orogenic events that may continue as early Devonian are treated in the Silurian chapter and the sedimentary events that may be Silurian are treated here. Devonian successions in Svalbard are known only from terranes which are postulated to have originated from the North East Greenland Province. No record has yet been established for Devonian strata in Svalbard either from the eastern terranes (East Greenland Province) or from the western terranes (North Greenland-Pearya Province). Moreover, the East Greenland succession lacks

Enhancing participatory research with the community oriented primary care model: A case study in community mobilization

Refining Participatory Research with the methodology of Community Oriented Primary Care (COPC), sociologists, medical providers and other “professionals” were able to assist the people of a small, rural county in western Appalachian North Carolina create a “community health consortium.” The consortium grew out of a research process funded by the W.K. Kellogg Foundation, which included some 40 interviews with community groups that articulated health problems and barriers to health care. The consortium then undertook action projects, which in turn enhanced networking between community groups and agencies while reducing mistrust between them. The consortium empowered people to articulate their realities, needs and became a force for change able to make demands on political office holders and decision makers. Despite its democratic origins and ideology, the consortium needs to do more to extend its outreach to include the marginal and disenfranchised.