Kentucky Counties 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]

Assessing Land-Cover Change Trends, Patterns, and Transitions in Coalfield Counties of Eastern Kentucky, USA

Surface coal mining and reclamation have greatly reshaped eastern Kentucky’s landscape affecting its socioeconomic, environmental and climatic aspects. This study examined the land-cover changes, trends and patterns in Floyd, Knott, Letcher, Magoffin, Martin, Perry, and Pike counties from 2004 to 2019. Using a random forest classifier, land cover was categorized into seven major classes, i.e., water, barren land, developed land, forest, shrubland, herbaceous, and planted/cultivated, majorly based on Landsat images. The Kappa accuracy ranged from 75 to 89%. The results showed a notable increase in forest area from 5052 sq km to 5305 sq km accompanied by a substantial decrease in barren land from 179 sq km to 91 sq km from 2004 to 2019. These findings demonstrated that reclamation activities positively impacted the forest expansion and reduced the barren land of the study area. Key land-cover transitions included barren land to shrubland/herbaceous, forest to shrubland, and shrubland to forest, indicating vegetation growth from 2004 to 2019. An autocorrelation analysis indicated similar land-cover types clustered together, showing effective forest restoration efforts. As surface coal mining and reclamation significantly influenced the landscapes of the coalfield counties in eastern Kentucky, this study provides a holistic perspective for understanding the repercussions of these transformations, including their effects on humans, society, and environmental health.

Rapid jail-based implementation of overdose education and naloxone distribution in response to the COVID-19 pandemic

BackgroundPeople incarcerated in jails are highly impacted by the opioid epidemic, and overdose education and naloxone distribution (OEND) is an effective strategy to reduce opioid overdose deaths. This study examines barriers and facilitators of fast-track OEND implementation within the jails in the Wave 1 Kentucky counties of the HEALing Communities Study during the COVID-19 pandemic.MethodsMeeting minutes with jail stakeholders were qualitatively coded using the Practical, Robust Implementation and Sustainability Model (PRISM) as the coding framework. The analysis highlighted the top barriers and facilitators to fast-track OEND implementation within the PRISM framework.ResultsSpace and staffing shortages related to the COVID-19 pandemic, disruptions in interorganizational programming from pandemic-related service suspensions, and a lack of technological solutions (e.g., reliable Internet access) for socially distanced delivery were the top barriers to fast-track OEND implementation. In addition, there were limitations on non-jail staff access to jails during COVID-19. Top facilitators included jail leadership support, the option to prioritize high-risk groups, and the incorporation of OEND processes into existing communications and management software. While the COVID-19 pandemic strained jail infrastructure, jail and partner agency collaboration led to creative implementation strategies for the successful integration of OEND into jail operations. Urban jails were more likely than rural jails to be early adopters of OEND during the public health emergency.ConclusionsUnderstanding the barriers to and facilitators of OEND within jails will improve implementation efforts seeking to curb opioid overdose deaths. Jail leadership support and interorganizational efforts were key facilitators to implementation; therefore, it is recommended to increase buy-in with multiple agencies to promote success. Challenges brought on by COVID-19 have resulted in a need for innovative solutions for implementation.Clinical trial informationClinicalTrials.gov, NCT04111939, Submitted 30 September 2019, https://clinicaltrials.gov/study/NCT04111939?titles=HEALing%20Communities%20Study&rank=1.

Perceived Barriers to Pap Screening Influence Adherence to Screening Recommendations Among Black Women.

Objectives: The aim of this study was to determine the Health Belief Model (HBM) constructs associated with Pap screening adherence among a sample of African American and sub-Saharan African immigrant women in the United States. Methods: A descriptive cross-sectional study was conducted via an online survey. Participants were recruited from central Kentucky counties. Ninety-one eligible women participated (mean age 38 ± 12 years), 49.5% identified as African American. Twenty-nine percent indicated never being screened or not being up-to-date. Self-reported demographic data, HBM constructs for Pap screening, and Pap screening history were collected. Bivariate and logistic regressions were performed. Results: There was a significant negative association between perceived barriers and being up-to-date. For every one-point increase in perceived barriers, the odds of being up-to-date decreased by 81%, (p = 0.004; CI: 0.06-0.60), findings from further evaluation of the barrier construct showed that barriers significantly associated with screening include items related to lack of knowledge about where to get a Pap screening, lack of time to attend the screening, screening-associated shame and pain, negligence, and age. There were no other significant HBM constructs associated with up-to-date Pap screening status. There was no difference in perceived barriers between African American and sub-Saharan African women. Conclusions: Despite public health efforts to decrease screening barriers, a perception of barriers exists among Black women. Continued efforts to address screening barriers as well as the perception of barriers are warranted among Black women.

Addressing Geographical Inequities and Barriers in Access to Mental Health Care among Youth in a Rural Western Kentucky County.

A Community Health Assessment (CHA) was conducted among community members in a rural Western Kentucky county in 2022-2023 identified mental health as one of the top health issues in the county. The purpose of a CHA is to identify key health needs and issues through data and develop strategies for action. One of the objectives was to identify barriers to accessing mental health care, especially among youth. Secondary data analyses were performed from survey results conducted by the local health department and local public schools. Quantitative data were analyzed using SPSS software. Qualitative data were analyzed using a two-cycle coding process. Access to mental healthcare is an area of great need in this rural Western Kentucky county. Recommendations include working with healthcare providers, especially specialists, to accept Medicaid and it is recommended to cross-train other professionals to address mental health needs in this region.

Geospatial analysis of the distribution of uveal melanoma patients at a referral center in the United States.

e21566 Background: Approximately 2500 new uveal melanoma (UM) cases (5.2 cases per million population) are diagnosed yearly in the United States. We previously identified three unique geospatial accumulations of UM in North Carolina, Alabama, and New York based on our clinical experience. Such unexpected findings prompted us to conduct a more systematic evaluation of geospatial accumulations of UM patients at our institution. Methods: Through the electronic medical record system, we identified patients seen at our institution with a diagnosis of UM. Identified living patients and family of deceased patients were either sent an e-mail or paper letter with an internet link to a survey. The survey asked for the patient’s name, date of birth, sex, date of primary UM diagnosis, address at time of UM diagnosis and number of years at that address, and all previous addresses and dates of residence prior to the UM diagnosis. Using these addresses, ArcGIS and R software was used to analyze the geospatial distribution of our UM patients. The data was supplemented with 2020 American Community Survey census estimates at the state, county, and census tract level to estimate population-based rates of UM. Results: We identified 2718 UM patients in our clinical database, and a total of 726 participants completed the survey with a total of 2939 US addresses. The majority of addresses were precise to the street address level (77.9%). At the time of UM diagnosis, patients had lived at their current address for a median of 16 years. Pennsylvania and the neighboring states expectedly made up the majority (63.6%) of our patients, but about 1/3 of our patients resided in other states at the time of their UM diagnosis (total of 42 different states). Several counties presented elevated rates of UM with ≥5 case per 100,000 persons. We observed a group of counties in central Pennsylvania, at the border of Pennsylvania and New York, and in upper New York by the Finger Lakes with notably elevated rates of UM, which was consistent with our clinical observations at our institution. Several neighboring counties in Kentucky and Virginia also presented elevated rates. Conclusions: Through this pilot project, we have demonstrated that it is possible to collect lifetime residency information from UM patients in order to map their geospatial distribution in the US. Furthermore, although institutional bias toward referring physicians should be considered, our geospatial analysis identified accumulations of UM in areas similar to our clinical concerns. The results of our study warrant further investigations into environmental influences on UM development. Our future goal is to extend our approach through national and international collaborations to increase the number of participants in the analysis and to minimize institutional bias.

Isolates of Corynespora cassiicola, Causal Agent of Target Spot of Soybean, in Kentucky Contain the G143A Mutation Conferring Resistance to Quinone Outside Inhibitor Fungicides

Target spot, caused by Corynespora cassiicola, is a soybean disease of increasing importance in the southern United States. Recently, isolates of C. cassiicola with resistance to quinone outside inhibitor (QoI) fungicides have been confirmed with the G143A mutation in multiple southern states, including Alabama, Arkansas, Mississippi, and Tennessee. From 2017 to 2019, a total of 84 isolates of C. cassiicola were recovered from soybean field in 12 counties in Kentucky. DNA sequencing of the cytochrome b gene of these isolates revealed that 15.5% of the isolates had the G143A mutation that confers resistance to QoI fungicides and were in 50% of the counties in which isolates originated. This represents the first report of QoI fungicide resistance in C. cassiicola isolates from Kentucky soybean fields. Considering these findings, Kentucky soybean growers should adopt target spot management practices which include rotating to non-host crops, planting resistant soybean cultivars, and applying fungicides from different fungicide classes.

Objective Lens

During the first 30 years of the 20th Century, many scholars agree that Cora Wilson Stewart was the most widely known authority of adult literacy in the world. By establishing the Moonlight Schools in Rowan County Kentucky in 1911, she rose to prominence as a well-regarded advocate for promoting literacy and adult education. Stewart frequently held viewpoints which ran counter to the mindset of educators in the 1920s and 1930s. Wilson was ahead of her time in many aspects of promoting literacy in an era largely before adult education was widely recognized.

Incidence Rates and Outcomes of Nodular and Superficial Spreading Melanoma along the Rural-Urban Continuum in Kentucky and Their Relationship to Provider Care Access.

This study compared incidence rates, stage at presentation, and cause-specific mortality of nodular and superficial spreading melanoma along the rural-urban continuum in Kentucky. We compared resulting patterns in our data with sample demographic and other potential factors, including population by county and primary care provider rate. Retrospective patient data were extracted from the Surveillance, Epidemiology, and End Results database from 2010 through 2017. These data were supplemented by environmental, demographic, and socioeconomic data derived from publicly accessible databases. Correlation and χ2 analyses were used to test for significant differences in outcome variables by US Department of Agriculture Rural-Urban Continuum Code (RUCC) categories and other potential predictor variables. Incidence rates by Kentucky county were not associated with RUCC or population; likewise, there was no relationship between stage at presentation and RUCC category. There was, however, a highly significant association between cause-specific mortality and RUCC; patients from rural areas were significantly more likely to die from melanoma than those in urban areas. This overall difference was due to differences in mortality for superficial spreading melanoma. Our results suggest that a disparity in patients' ability or tendency to access primary care and/or specialist providers postdiagnosis may be critical factors in determining the ultimate outcome of a melanoma diagnosis. Further studies should explore the availability of dermatologists and/or treatment options for melanoma in rural areas. Our data also provide additional support for inclusion of melanoma subtype in the American Joint Committee on Cancer guidelines.

Tobacco use disparities in rural communities

This exploratory study described facilitators and barriers to reducing tobacco disparities in 2 small rural communities and identified ways to reduce tobacco use. This was a descriptive design using qualitative methods. We created a resource database for 2 rural Kentucky counties, using a Culture of Health Framework. We recruited 16 organizational stakeholders serving low-socioeconomic populations and conducted focus groups and key informant interviews. We also completed key informant interviews with 7 tobacco users. Lastly, we tailored Community Action Plans for each county based on the data and then solicited feedback from the key stakeholders. The 2 counties were similar in population size, but County A had fewer resources than County B, and the stakeholders expressed differences toward tobacco use and quitting. County A stakeholders talked most about the protobacco culture and that tobacco users accept the risks of smoking outweighing the benefits of quitting; they also expressed concerns about youth use and the influences of family, society, and industry. County B stakeholders described ambivalence about the health effects of use and quitting. County A's Action Plan identified an opportunity to build Community Health Worker-delivered tobacco treatment into a new school-based health center. County B's Action Plan focused on reaching tobacco users by providing incentives for participation and tailoring messages to different audiences. Tobacco control resources and stakeholder perspectives vary in small rural communities, implying a need for tailored approaches. Tobacco users in rural areas are a critical population to target with cessation resources.

The variation in preventable hospitalization in patients with type 2 diabetes in Kentucky before and after the Medicaid expansion.

Hospitalizations are more resource intensive and expensive than outpatient care. Therefore, type 2 diabetes-related preventable hospitalization are a major topic of research efficiency in the healthcare system. Analyze county level variation in type 2 diabetes-related preventable hospitalization rates in Kentucky before the Medicaid expansion (2010-2013) and after the Medicaid expansion (2014-2017). Geographic mapping and cluster analysis. Data for a state of the United States of America. We used the KID data to generate geographic mapping for type 2 diabetes-related preventable hospitalizations to visualize rates. We included all Kentucky discharges of age 18 years and older with the ICD9/10 principal diagnosis code for type 2 diabetes. Then, we conducted cluster analysis techniques to compare county-level variation in type 2 diabetes-related preventable hospitalization rates across Kentucky counties pre- and post-Medicaid expansion. County type 2 diabetes-related preventable hospitalization pre- and post-Medicaid expansion. From 2010-2017, type 2 diabetes-related preventable hospitalization discharge rates reduced significantly in the period of the post-Medicaid expansion (P=.001). The spatial statistics analysis revealed a significant spatial clustering of counties with similar rates of type 2 diabetes-related preventable hospitalization in the south, east, and southeastern Kentucky pre- and post-Medicaid expansion (positive z-score and positive Moran's Index value (P>.05). Also, there was a significant clustering of counties with low type 2 diabetes-related preventable hospitalization rates in the north, west, and central regions of the state pre-Medicaid expansion and post-Medicaid expansion (positive z-score and positive Moran's Index value (P>.05). Kentucky counties in the southeast have experienced a significant clustering of highly avoidable hospitalization rates during both periods. Focusing on the vulnerable counties and the economic inequality in Kentucky could lead to efforts to lowering future type 2 diabetes-related preventable hospitalization rates. We used de-identified data which does not provide insights into the frequency of hospitalizations per patient. An individual patient may be hospitalized several times and counted as several individuals.

Geographic variation of HPV-associated cancer incidence in Kentucky using spatial scan statistics.

Populations with high cancer risk that are targeted for screening, education, and vaccination have been shown to increase rates of screening, which ultimately may improve timing of diagnosis and overall outcome for certain cancers. Spatial scan analysis provides a visual representation of areas with higher rates of disease. Limited research has used this methodology to assess HPV-associated cancers. Using, spatial scan statistics, our goal was to identify regions within Kentucky having significantly higher rates of HPV-associated tumors. These regions can be targeted for public health efforts in the form of education, vaccination, screening, and physician recruitment. The Kentucky Cancer Registry data from 1995 to 2016 and spatial scan statistics were used to identify county-level clusters with high-incidence of HPV-associated cancers after adjustment for age and sex. Anatomic sites included in this analysis were oropharynx, cervix, anus, penis, and vulva. There was one high-rate cluster of oropharyngeal cancer, which was observed in the Louisville metropolitan region (Relative Risk [RR] = 1.24, p < 0.001). One high-rate cluster of anal and penile cancer incidence in men was identified that partially overlapped with the oropharyngeal cluster. There were five clusters of higher cervical, vulvar, and anal cancer incidence in females, one of which overlapped with the oropharyngeal cluster. Overlapping clusters of HPV-associated cancers were identified at the county-level and included both urban and rural counties of Kentucky. Findings can assist in the design of public health interventions to increase screenings, promote vaccination, and recruit physicians in these regions to improve prevention, diagnosis, and early treatment of HPV-associated cancers.

Equity of overdose education and naloxone distribution provided in the Kentucky HEALing Communities Study

BackgroundOpioid overdoses differentially affect demographic groups. Strategies to reduce overdose deaths, specifically overdose education and naloxone distribution (OEND), are not consistently delivered equitably. MethodsThe HEALing Communities StudySM (HCS) is a cluster-randomized trial designed to implement evidence-based practices, including OEND, to reduce overdose deaths across communities. Individuals receiving OEND in eight Kentucky counties between January 2020 and June 2022 provided demographics and overdose history. Recipient characteristics were compared to opioid overdose decedent characteristics to evaluate whether OEND was equitably delivered to the target population. Recipient characteristics were also analyzed based on whether OEND was delivered in criminal justice, behavioral health, or health care facilities. ResultsA total of 26,273 demographic records were analyzed from 137 partner agencies. Most agencies were in behavioral health (85.6 %) or criminal justice sectors (10.4 %). About half of OEND recipients were male (50.6 %), which was significantly lower than the 70.3 % of overdose decedents who were male, (p<0.001). OEND recipients tended to be younger than overdose decedents, but there were not significant differences in race/ethnicity between OEND recipients and overdose decedents. Over 40 % of OEND recipients had overdosed, and 68.9 % had witnessed a prior overdose. There were notable differences across facility types, as males and Black individuals accounted for fewer OEND recipients in addiction treatment facilities compared to jails. ConclusionAlthough OEND recipients’ demographics resembled those of decedents, specific attention should be paid to ensuring equitable OEND access. Variation in OEND uptake by facility type may reflect biases and barriers to care.

Primary Care Providers' Experiences Treating Opioid Use Disorder Using Telehealth in the Height of the COVID-19 Pandemic.

The COVID-19 pandemic catalyzed a rapid shift in healthcare delivery towards telehealth services, impacting patient care, including opioid use disorder (OUD) treatment. Regulatory changes eliminated the in-person evaluation requirement for buprenorphine treatment, encouraging adoption of telehealth. This study focused on understanding experiences of primary care providers in predominantly rural areas who used telehealth for OUD treatment during the pandemic. Semi-structured interviews were conducted with 22 primary care providers. Participants practiced in 13 rural and 9 urban counties in Kentucky and Arkansas. Data were analyzed using conventional content analysis. The pandemic significantly impacted healthcare delivery. While telehealth was integrated for behavioral health counseling, in-person visits remained crucial, especially for urine drug screenings. Telehealth experiences varied, with some facing technology issues, while others found it efficient. Telehealth proved valuable for behavioral health counseling and sustaining relationships with established patients. Patients with OUD faced unique challenges, including housing, internet, transportation, and counseling needs. Stigma surrounding OUD affected clinical relationships. Building strong patient-provider relationships emerged as a central theme, emphasizing the value of face-to-face interactions. Regarding buprenorphine training, most found waiver training helpful but lacked formal education. This research offers vital guidance for improving OUD treatment services, especially in rural areas during crises like the COVID-19 pandemic. It highlights telehealth's value as a tool while acknowledging its limitations. The study underscores the significance of strong patient-provider relationships, the importance of reducing stigma, and the potential for training programs to elevate quality of care in OUD treatment.

Comparing the Demographic Characteristics of Victims of Sexual Assault in Rural Versus Urban Areas.

In 2019, over 459,000 persons in the United States survived sexual assault, and 21%-26% sought medical treatment. Ideally, trained medical professionals who understand the unique physical and mental health needs of this patient population, such as forensic nurses, would provide care. Yet, the care that forensic nurses and other healthcare providers can offer to sexual violence/abuse survivors is hindered by the lack of understanding of the demographics of those who seek care. With the delineation of highly affected demographic groups, barriers to care can be addressed. This study compared rates, demographic characteristics, acuity, and codes for sexual violence/abuse encounters experienced by those patients residing in rural versus urban counties of Kentucky (KY). This included encounters before and after SARS-CoV-2. Deidentified claims data were extracted for patient encounters billed with the International Classification of Diseases, 10th Revision, Clinical Modification for sexual violence/abuse seen at a university healthcare center serving the Northeastern, Southeastern, and Central regions of KY from October 2015 to February 2021. Analysis comprised descriptive statistics, independent samples t tests, and chi-square tests of association. Significant demographic differences were identified between the two groups. The mean age of those residing in rural areas was significantly younger than those living in urban areas. Similarly, the percentage of male survivors was significantly higher in the rural population. The racial composition also differed, with higher percentages of survivors being Black and Hispanic in the urban population, relative to rural dwellers. Findings suggest that rural youth (especially boys aged 10 years and younger) and urban minorities are at a higher risk for sexual violence/abuse in KY when compared with their counterparts (i.e., urban youth and rural minorities).

Willingness to utilize a mobile treatment unit in five counties at the epicenter of the US rural opioid epidemic

IntroductionUS federal policies are evolving to expand the provision of mobile treatment units (MTUs) offering medications for opioid use disorder (MOUD). Mobile MOUD services are critical for rural areas with poor geographic access to fixed-site treatment providers. This study explored willingness to utilize an MTU among a sample of people who use opioids in rural Eastern Kentucky counties at the epicenter of the US opioid epidemic. MethodsThe study analyzed Cross-sectional survey data from the Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic (CARE2HOPE) study covering five rural counties in the state. Logistic regression models investigated the association between willingness to utilize an MTU providing buprenorphine and naltrexone and potential correlates of willingness, identified using the Behavioral Model for Vulnerable Populations. ResultsThe analytic sample comprised 174 people who used opioids within the past six months. Willingness to utilize an MTU was high; 76.5 % of participants endorsed being willing. Those who had recently received MOUD treatment, compared to those who had not received any form of treatment or recovery support services, had six-fold higher odds of willingness to use an MTU. However, odds of being willing to utilize an MTU were 73 % lower among those who were under community supervision (e.g., parole, probation) and 81 % lower among participants who experienced an overdose within the past six months. ConclusionsThere was high acceptability of MTUs offering buprenorphine and naltrexone within this sample, highlighting the potential for MTUs to alleviate opioid-related harms in underserved rural areas. However, the finding that people who were recently under community supervision or had overdosed were significantly less willing to seek mobile MOUD treatment suggest barriers (e.g., stigma) to mobile MOUD at individual and systemic levels, which may prevent improving opioid-related outcomes in these rural communities given their high rates of criminal-legal involvement and overdose.

Abstract C099: Take CARE: An implementation science initiative to reduce the cervical cancer burden in Appalachia

Abstract Appalachia has a higher burden of cervical cancer than other regions of the United States. Cervical cancer risk factors and causes are largely known, so evidence-based interventions in health systems addressing those factors and causes can improve cervical cancer incidence and mortality rates. Take CARE (Clinical Avenues to Reach Health Equity) is designed to address three factors strongly associated with cervical cancer and is made up of three evidence-based complementary initiatives focused on HPV vaccination, smoking cessation, and cervical cancer screening: I Vaccinate, Break Free, and The HOME Initiative, respectively. The overall goal is to use implementation science designs to provide an integrated approach to reduce cervical cancer risk among patients of 39 health centers from ten participating systems. The project was implemented in two phases: formative and trial. In the formative phase, community profiles were developed to better understand the cancer burden and resources available. Community members and clinic staff were interviewed about barriers to cervical cancer screening and HPV vaccination and norms about screening, vaccination, and tobacco cessation. Findings informed study materials. Clinic champions were identified, and implementation teams were formed to support the champion role. Details were gathered about facility processes, staffing, patient load, and existing cervical cancer-related activities. Waiting room seating, availability of digital displays, number of exam rooms, and locations for promotional materials and staff trainings were documented through environmental scans. The trial phase was introduced as a delayed group implementation design in ten health systems located in Appalachian counties of Kentucky, Ohio, Virginia, and West Virginia from October 2020 to June 2022. Five systems were assigned to an Early Group and five to a Late Group that would receive the intervention 12 months after Early systems. I Vaccinate was first to be implemented, promoting HPV vaccination in 9–45-year-olds. Health systems receive education materials and providers select strategies and set goals to improve vaccination rates. Break Free was introduced six to eight weeks later and identifies eligible smokers who want to quit in the next six months, providing free smoking cessation counseling and medication to patients. Systems received education on the Ask, Advise, Refer model and could select staff to be trained as Tobacco Treatment Specialists. HOME was the final initiative introduced and focuses on improving cervical cancer screening in underscreened female patients via a mail-based HPV self-sampling program. One year after the first initiative launched, health systems were taught to bundle the initiatives as one program, Take CARE. After this, the Early systems entered a sustainability phase for two years. The process will occur similarly for Delayed health systems but with only one year of sustainability. Analyses will focus on changes in HPV vaccination, smoking cessation, and cervical cancer screening over time. Citation Format: Ryan D. Baltic, Roger Anderson, Mark B. Dignan, Amy K. Ferketich, Mira L. Katz, Stephenie Kennedy, Paul L. Reiter, Electra D. Paskett. Take CARE: An implementation science initiative to reduce the cervical cancer burden in Appalachia [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C099.

Scaling up overdose education and naloxone distribution in Kentucky: adoption and reach achieved through a “hub with many spokes” model

BackgroundScaling up overdose education and naloxone distribution (OEND), an evidence-based practice for reducing opioid overdose mortality, in communities remains a challenge. Novel models and intentional implementation strategies are needed. Drawing upon the EPIS model’s phases of Exploration, Preparation, Implementation, and Sustainment (Aarons et al. in Adm Policy Ment Health 38:4–23, 2011), this paper describes the development of the University of Kentucky’s unique centralized “Naloxone Hub with Many Spokes” approach to implementing OEND as part of the HEALing Communities Study (HCS-KY).MethodsTo scale up OEND in eight Kentucky counties, implementation strategies were utilized at two levels: a centralized university-based naloxone dispensing unit (“Naloxone Hub”) and adopting organizations (“Many Spokes”). Implementation strategies varied across the EPIS phases, but heavily emphasized implementation facilitation. The Naloxone Hub provided technical assistance, overdose education resources, and no-cost naloxone to partner organizations. Implementation outcomes across the EPIS phases were measured using data from internal study management trackers and naloxone distribution data submitted by partner organizations.ResultsOf 209 organizations identified as potential partners, 84.7% (n = 177) engaged in the Exploration/Preparation phase by participating in an initial meeting with an Implementation Facilitator about the HCS-KY OEND program. Adoption of the HCS-KY OEND program, defined as receipt of at least one shipment of naloxone, was achieved with 69.4% (n = 145) of all organizations contacted. During the Implementation phase, partner organizations distributed 40,822 units of naloxone, with partner organizations distributing a mean of 281.5 units of naloxone (SD = 806.2). The mean number of units distributed per county was 5102.8 (SD = 3653.3; range = 1057 − 11,053) and the mean county level distribution rate was 8396.5 units per 100,000 residents (SD = 8103.1; range = 1709.5–25,296.3). Of the partner organizations that adopted the HCS-KY OEND program, 87.6% (n = 127) attended a sustainability meeting with an Implementation Facilitator and agreed to transition to the state-funded naloxone program.ConclusionsThese data demonstrate the feasibility of this “Hub with Many Spokes” model for scaling up OEND in communities highly affected by the opioid epidemic.Trial registration ClinicalTrials.gov, NCT04111939. Registered 30 September 2019, https://clinicaltrials.gov/ct2/show/NCT04111939.

County-Level Trends in Cervical Cancer Incidence, Stage at Diagnosis, and Mortality in Kentucky

This cross-sectional study evaluates recent trends in rates of cervical cancer incidence and incidence-based mortality among women in Appalachian and non-Appalachian Kentucky counties.

Residence in urban or rural counties in relation to opioid overdose mortality among Kentucky hospitalizations before and during the COVID-19 pandemic.

At the beginning of the opioid overdose epidemic, overdose mortality rates were higher in urban than in rural areas. We examined the association between residence in an urban or rural county and subsequent opioid overdose mortality in Kentucky, a state highly impacted by the opioid epidemic, and whether this was modified by the COVID-19 pandemic. We captured hospitalizations in Kentucky from 2016 to 2020, involving an opioid using ICD-10-CM codes T40.0-T40.4 and T40.6. Patient's county was classified as urban or rural based on the NCHS Urban-Rural Classification Scheme. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of opioid overdose mortality, adjusted for demographics, hospitalization severity, and zip code SES. We assessed effect modification by the COVID-19 pandemic. Overall, patients living in urban counties had 46% higher odds of opioid overdose death than patients residing in rural counties (adjusted OR=1.46; 95% CI=1.22, 1.74). Before the pandemic, patients in urban counties had 63% increased odds of opioid overdose death (adjusted OR=1.63; 95% CI=1.34, 1.97); however, during the COVID-19 pandemic, patients in urban and rural counties became more similar in regard to opioid overdose mortality (adjusted OR=0.72; 95% CI=0.45, 1.16; p-value for interaction =0.02). Before the pandemic, living in urban counties was associated with higher opioid overdose mortality among Kentucky hospitalizations; however, during the COVID-19 pandemic, opioid overdose mortality in rural areas increased, approaching rates in urban areas. COVID-19 posed social, economic, and healthcare challenges that may be contributing to worsening mortality trends affecting both urban and rural patients.