Rural Appalachian Community Research Articles

Icelandic Prevention Model in Rural Appalachian Communities: Gauging Stakeholder Experience with the Core Processes Three Years into County-Level Implementation

Background: This study assessed stakeholder experience with the core processes of The Integrated Community Engagement (ICE) Collaborative, a primary prevention approach addressing adolescent substance use in rural West Virginia, after three years of county-level implementation. Objectives: Guided by the Icelandic Prevention Model (IPM), the ICE Collaborative aims to enhance cooperation between researchers, policy makers, local practitioners, and community members and facilitate a paradigm shift in youth and community substance use prevention. This shift involves moving away from strategies focused on the repeated allocation of short-term grants that fund time-limited programs to a long-term, holistic, and sustainable approach overseen by local practitioners and coalitions. Results: We conducted qualitative interviews and focus groups with 33 stakeholders during the fall of 2022. Data analyses generated six major themes: 1) It Takes a Village to Prevent Adolescent Substance Use, 2) Improving Understanding and Commitment to Prevention Through Outreach, 3) Enhancing Student Engagement and Program Accessibility, 4) Addressing the Chronic Underfunding of Prevention and Youth Development Programs, 5) Acknowledging Family Contexts and Family Member Substance Use as Risk Factors, and 6) ICE/IPM Inspiring Solution-based Conversations, Goal Setting, and Strategy Selection. Conclusions: Stakeholders reported multiple positive characteristics of ICE for their communities and applauded the long-term focus and access to local data. Several suggestions for improved strategies were also reported. Results are discussed in line with the theoretical underpinnings of the IPM and current discourse around community health promotion in rural areas.

EP.04A.12 Exploring Rural Appalachian Community Perceptions and Practices on Health and Lung Cancer to Inform Screening Interventions

EP.04A.12 Exploring Rural Appalachian Community Perceptions and Practices on Health and Lung Cancer to Inform Screening Interventions

Unmet Needs and Factors Impacting Home- and Community-Based Service Use Among Rural Appalachian Caregivers of People With Alzheimer's and Dementia.

Family caregivers of persons with Alzheimer's disease and related dementias (ADRD) living in rural areas face significant health and healthcare challenges. Limited research, however, has explored factors shaping their use of home- and community-based services (HCBS). This study identifies unmet needs among caregivers of people with ADRD in rural Western North Carolina and highlights contextual factors that facilitate HCBS use. Nineteen qualitative interviews were conducted with 21 family caregivers and 1 person with ADRD between 2021 and 2022. Thematic analyses revealed unmet needs among caregivers for information, service navigation, and caregiving support. HCBS use was shaped by multiple factors including illness needs, cultural beliefs, preferences for home-based care, and place-based resources. These findings suggest that culturally tailored HCBS are needed to support people with ADRD and their caregivers in rural Appalachian communities, especially those which facilitate access to paid caregiving, clearly communicate program eligibility requirements, and emphasize service availability.

The Impact of Rural Environments on Reproductive Autonomy Among Women in Appalachia: A Qualitative Analysis

Reproductive autonomy encompasses one’s ability to make decisions around contraceptive use, pregnancy, and childbirth. An individual’s geographic location affects access to a wide range of information and care related to reproductive choice. Individuals in rural areas face additional barriers to reproductive health and decision-making than those in urban areas. This phenomenological qualitative study examined the experiences with and perceptions of reproductive decision-making among women in rural Appalachian communities in the United States. Four themes emerged from the data: autonomy tied to choice, role of religion and church on autonomy and decision-making, navigating limited access to care, and shame. Women should be supported in making reproductive health decisions, and efforts are needed to increase autonomy within reproductive health care and decisions. Sexual health programming within school and other community settings should address shame that often occurs around reproductive health topics, particularly among religious communities.

Predictors of engagement in screening for a hepatitis C virus (HCV) treatment trial in a rural Appalachian community.

An HCV treatment trial was initiated in September 2019 to address the opioid/hepatitis C virus (HCV) syndemic in rural Kentucky. The focus of the current analysis is on participation in diagnostic screening for the trial. Initial eligibility (≥18 years of age, county resident) was established by phone followed by in-person HCV viremia testing. 900 rural residents met the inclusion criteria and comprised the analytic sample. Generalized linear models were specified to estimate the relative risk of non-attendance at the in-person visit determining HCV eligibility. Approximately one-quarter (22.1%) of scheduled participants were no-shows. People who inject drugs were no more likely than people not injecting drugs to be a no-show; however, participants ≤35 years of age were significantly less likely to attend. While the median time between phone screening and scheduled in-person screening was only 2 days, each additional day increased the odds of no-show by 3% (95% confidence interval: 2%-3%). Finally, unknown HCV status predicted no-show even after adjustment for age, gender, days between screenings and injection status. We found that drug injection did not predict no-show, further justifying expanded access to HCV treatment among people who inject drugs. Those 35 years and younger were more likely to no-show, suggesting that younger individuals may require targeted strategies for increasing testing and treatment uptake. Finally, streamlining the treatment cascade may also improve outcomes, as participants in the current study were more likely to attend if there were fewer days between phone screening and scheduled in-person screening.

Assessing Chronic Pain Among Adults Diagnosed with Diabetes Residing in Rural Appalachia.

Appalachian populations have some of the highest rates of overdose and comorbidity, all of which are considered risk factors for and contributors to chronic pain. The purpose of this study was to examine the associations of comorbidity, disability (physical limitations), and depression with chronic pain among a community-based sample of Appalachian adults living with diabetes. This study used baseline data to conduct a secondary analysis of cross-sectional data (n=356). Data included sociodemographic, disability (physical limitations), chronic pain, and depression measures. These data were collected and analyzed from 2017-2019. Multiple logistic regression was used to investigate the association between comorbidity, disability, depression, and chronic pain. Participants were predominantly non Hispanic white (98.0%), women (64.6%), and had a mean age of 64.2 years. Comorbidity (p=.044), physical limitations (pp. Chronic pain affects physical and psychosocial health among those diagnosed with diabetes who live in rural Appalachian communities. Alleviating chronic pain could have a synergistic benefit to healthy functioning.

Trauma-Informed Research-Practice Partnership Building to Support Early Childhood Educators in an Appalachian Community

Trauma-informed initiatives that prioritize educator well-being through equitable research-practice partnership (RPP) building are necessary to advance trauma-informed education and care for young children in rural Appalachian communities. Early stages of partnership building that consider dimensions identified by Henrick et al. (2017) foster trusting relationships, address the goals of partnering organizations, and work toward capacity building. Burnout, secondary traumatic stress, and compassion fatigue are common problems faced by early childhood professionals who may be exposed to high levels of stress and trauma in their work with young children. Thus, any initiatives with early childhood educators should include short- and long-term strategies to address the status of the workforce. Recognizing how trauma and social determinants of health impact the rural early childhood workforce and their ability to implement trauma-informed practices in the classroom is a first step toward holistic professional development. The purpose of this article is to highlight how the early stages of a partnership study with a rural Appalachian pre-kindergarten (pre-K) program and two universities provided a foundation for future research, practice, and partnership activities. Often, trauma-informed professional learning relies on classroom strategies and swift problem-solving techniques that do not consider the primary and secondary trauma faced by early childhood educators and how these traumas directly impact educators’ ability to improve classroom practices.

The Achieving Success Everyday (ASE) Group Counseling Model Applied in Rural Schools: Implications for Future School Counselor Training and Practice

ABSTRACTThere is a critical need for school counselors to understand and support the unique needs of students in rural settings. The school counseling literature around rural school counseling is underdeveloped. In this training article, we describe a partnership between school counselor educators at two different universities to improve school counseling group leadership practice in rural schools using a small group counseling intervention. We include strategies used to prepare school counselors to implement the Achieving Success Everyday (ASE) group counseling model with elementary students in a rural Appalachian community as a training framework. Implications for group leadership training and practice are provided.

Fish in a Dish: Using Zebrafish in Authentic Science Research Experiences for Under-represented High School Students from West Virginia.

Early research experiences positively affect students' interest in STEM careers, and develop practical science and critical thinking skills. However, outreach opportunities are not equally accessible for all students. In states like West Virginia, where many students live in rural Appalachian communities, opportunities for engaging in STEM experiences are limited. In addition, rural teachers may not be equipped to provide authentic research experiences for students due to lack of resources or support. For many students in West Virginia, the Health Sciences and Technology Academy (HSTA) is a major opportunity for STEM engagement. Since its inception in 1998, HSTA has spread to 26 of 55 counties in West Virginia. The program recruits first-generation, low-socioeconomic status, rurally living, and African American high school students who are under-represented in STEM fields. Our research laboratory partnered with HSTA to implement an innovative, hands-on research camp using zebrafish for students participating in their annual junior-level biomedical sciences summer camp. Our camp was held in-person and adapted to an online format during the Covid-19 pandemic. We used pre-post surveys in both camps to assess impacts on science confidence and to collect information about general perceptions of zebrafish, research, and STEM fields. We found that students participating in the in-person and online camps experienced similar overall gains in science confidence. We also identified strong interest in zebrafish, research, and STEM degrees among online students. Online students did not prefer virtual learning experiences; however, they still enjoyed our camp. We also surveyed high school teachers volunteering for HSTA to identify factors that would encourage use of zebrafish in classrooms. The most prominent needs include classroom supplies, experience, and funding. Our successful science-education partnership demonstrates that zebrafish research experiences foster positive outcomes for under-represented students, and can inform future outreach efforts and collaborations with teachers.

Negotiating the Gemeinschaft/Gesellschaft Dichotomy: Appalachian Medical Student Perceptions of Practice☆

AbstractThis study investigated motivations for Appalachian medical students to stay or leave the region weighing postgraduation options. Semi‐structured interviews were employed with final year medical students. Transcripts were open‐coded and analyzed using the theoretical concept of Gemeinschaft/Gesellschaft. Participants were in continuous negotiation between notions of Gemeinschaft and Gesellschaft in their decisions to stay or leave rural Appalachian communities. Students navigated multiple tensions in their decisions to stay or leave, including: (1) geographic isolation versus place identity and (2) community responsibility versus individual opportunity. Utilization of Gemeinschaft/Gesellschaft provides a novel contribution to the literature on decisions to stay or leave as the majority of participants hedged in their decision‐making regarding future practice location. These students tended to employ a Gesellschaft rationale to stay and a Gemeinschaft rationale to leave, expressing complicated ideas about community and individual opportunity.

Impact of community-driven interventions on dietary and physical activity outcomes among a cohort of adults in a rural Appalachian county in Eastern Kentucky, 2019-2022.

Several environmental level factors exacerbate poor health outcomes in rural populations in the United States, such as lack of access to healthy food and locations to be physically active, which support healthy choices at the individual level. Thus, utilizing innovative place-based approaches in rural locations is essential to improve health outcomes. Leveraging community assets, like Cooperative Extension, is a novel strategy for implementing community-driven interventions. This prospective cohort study (n = 152), recruited in 2019 and surveyed again in 2020 and 2021, examined individual level changes in diet and physical activity in one rural Appalachian county. During this time, multiple community-driven interventions were implemented alongside Cooperative Extension and several community partners. Across the three-year study, the cohort indicated increases in other vegetables and water and reductions in fruits and legumes. There were also reductions in less healthy items such as French fries and sugar-sweetened beverages. The cohort also reported being less likely to engage in physical activity. Our findings suggest that key community-driven programs may have indirect effects on dietary and physical activity choices over time. Outcomes from this study are relevant for public health practitioners and community organizations working within rural Appalachian communities to address health-related behaviors.

Facilitating factors and barriers for use of medications to treat opioid use disorder (MOUD) among justice-involved individuals in rural Appalachia.

The purpose of this qualitative study is to assess facilitating factors and barriers for medications to treat opioid use disorder (MOUD) initiation among justice-involved individuals in one rural Appalachian community, as well as how those factors may differ across the three types of Food and Drug Administration (FDA) approved medications. Qualitative interviews were conducted with rural justice-involved individuals (N = 10) with a history of opioid use in the target community. Overall, participants demonstrated knowledge of the different types of MOUD and their pharmacological properties, but limited overall health literacy around opioid use disorder and MOUD treatment. Treatment access was hampered by transportation, time burdens, and costs. Findings call for research into improving health literacy education, training, and resources to decrease stigma and increase access to MOUD, particularly in light of the ongoing opioid crisis. State policies also need to increase access to all FDA medications among justice-involved individuals, as well as supporting a care continuum from facility entry, release, and community re-entry.

Assessing the availability of trusted health information in a rural Appalachia community using social network analysis

The purpose of this study was to investigate how trusted health information is transmitted within a rural Appalachian community. Egocentric social network methods were used to identify and characterize influential community members (“alters”) that participants (“egos”) go to for trusted health advice. Friends and “other health professionals” were named most frequently as health advice alters, and health advice was described as frequent and helpful. Participants could count on their health advice network for multiple forms of social support. Understanding trusted sources of health advice will allow us to identify community members to serve as change agents for rural T2DM interventions.

The Importance of Justice and Health Care Partnerships in MOUD Feasibility Trials

ABSTRACT This paper overviews the importance of justice and health-care partnerships in a MOUD feasibility trial in a rural Appalachian community. Research partners included a local jail, a local community supervision office, and a local community federally qualified health center. This paper describes the pilot feasibility study participants and methodology, as well as lessons learned including the challenges encountered and needed changes to address feasibility as the environment changes over time. Implications for social work research, practice, and policy advocacy focused on delivery of extended-release naltrexone and other MOUDs are discussed.

High-risk Individuals and Naloxone Use: Implications for THN Programs in Rural Appalachian Communities.

Take-home naloxone (THN) is being made available across rural Appalachia to curb opioid overdose fatalities. Despite this initiative, some opioid users do not possess naloxone, and if they do, do not administer it to others. Research findings on risk factors that contribute to opioid overdose are presented. These factors, identified in a sample of 16 overdose cases, are (1) early onset age of opioid use; (2) progressive opioid use; (3) a transition from pain medication to heroin and fentanyl; (4) fears of being arrested at a naloxone intervention if first responders are contacted, and (5) limited knowledge of Good Samaritan Laws. The findings are based on a subsample 16 overdose victims who were identified during a one-year (2018) qualitative study on the decline of overdose fatalities in four rural counties in Western Pennsylvania. They were recruited from a larger sample of 50 current and former substance users and were interviewed a second time using a semi-structured interview guide about their overdose experiences. All interview data were analyzed using thematic analysis via NVivo. Findings reveal that risk factors contribute to a severe opioid dependence that interferes with naloxone use. These factors also hinder adherence to proper naloxone protocol, designed to place overdose victims in contact with treatment providers. Recommendations are made for additional research and for pursuing measures to increase efficacy of naloxone interventions. They include developing naloxone campaigns aimed at high-risk individuals, improving their knowledge of Good Samaritan Laws, increasing adherence to THN protocols that improve the possibility of treatment, and using community harm reduction specialists for community outreach.

Association Between Insurer Connectivity in Appalachian Population Health Networks and Preventable Hospitalizations: Evidence from Kentucky.

Addressing complex health and social needs requires cross-sector collaboration to deliver medical, social, and population health services at the community level. Capacity in community health and social services networks may be constrained in regions like Appalachia due to the combined effects of rurality and persistently poor health and social outcomes. One way that cross-sector networks serving low-resource communities can expand their capacity is by engaging partners, like health insurers, who can leverage resources from outside the local area. This study examines insurer connectivity in cross-sector networks across Kentucky's geographic regions and the association between connectivity and the probability of an individual experiencing a preventable hospitalization. A cross-sectional design was used that linked data from the National Longitudinal Survey of Public Health Systems (NALSYS) with 2018 patient-level Kentucky hospital discharge data to examine the association between insurer connectivity in community networks and preventable hospitalizations across urban, rural non-Appalachian, and Appalachian regions. Analysis of the data shows substantial geographic variation in the association between insurer connectivity in community networks and preventable hospitalization. Insurer connectivity in rural Appalachian communities was associated with lower likelihood that an individual was admitted for a preventable hospitalization ( p < 0.01). Findings suggest insurer connectivity in cross-sector community health and social services networks has the potential to strengthen network capacity to address preventable hospitalizations and improve health outcomes and well-being for the people of Appalachia.

Differences in Distress Between Rural and Non-rural Appalachian Breast Cancer Patient/Caregiver Dyads During the First Year of Treatment.

Breast cancer patients and their caregivers living in rural Appalachia face substantial health disparities compared to their non-rural Appalachian counterparts. However, there is limited research on how these specific health disparities in rural Appalachian communities may impact patient psychological distress and caregiver strain during the first year of breast cancer treatment. The purpose of the current study was to assess differences in patient psychological distress (depression and anxiety) and caregiver strain between rural non-rural Appalachian breast-cancer-affected dyads (patients and their caregivers) during the first year of treatment. A total of 48 Appalachian breast cancer patients (with a Stage I through Stage III diagnosis) and their identified caregiver (together, 'dyads') were identified from The University of Tennessee Medical Center across 2019 to 2020. Dyads completed follow-up surveys throughout the first year of treatment. In this prospective pilot study, measures on anxiety, depression and caregiver strain were self-reported and then analyzed using RM-ANOVA. There was a statistically significant higher number of reports of patient depression and caregiver strain in rural-residing dyads compared to non-rural-residing dyads. However, there was not a statistically significant difference between rural and non-rural Appalachian dyads for patient-reported anxiety during the first year of treatment. The higher reported patient depression and caregiver strain among rural-residing Appalachian patients may indicate the need for implementing remote (e.g., telehealth) Cognitive Behavioral Therapy (CBT) to address the psychological needs of rural-residing dyads. Additionally, greater education from physicians to rural dyads on what to expect during treatment could alleviate caregiver strain.

STIGMA IN THE CONTEXT OF ALZHEIMER’S DISEASE AND RELATED DEMENTIAS (ADRD) WITHIN RURAL AND UNDERSERVED POPULATIONS

Abstract Stigma in the context of Alzheimer’s disease and related dementias (ADRD) is associated with a higher prevalence of depression, anxiety, social isolation, and poorer caregiver health. This is particularly true for underserved and rural communities; however, little is known about the sources of stigma and implications of stigma within these communities. This symposium explores sources of stigma along with implications of stigma in rural and/or underserved communities and introduces novel interventional considerations for addressing stigma. The first presentation by Rhodus and colleagues highlights implications of stigma in rural Appalachian communities as it relates to ADRD healthcare service and research participation. Next, Sabat and colleagues present findings of a recent intervention program, “Respite for All,” specifically, implications of this program for caregivers’ perception of stigma, as well as the person living with ADRD. This symposium also includes presentations focused on Alaska Native (AN) experiences with stigma and ADRD. Kim discusses findings of a community-based participatory research project using mixed-method to explore structural stigma in rural communities and needed initiatives for familial care partners. To conclude the program, Crouch and Rosich present results of a grounded theory, exploratory study aimed to understand the cultural practices and values that compose AN Elder beliefs and perceptions of ADRD, including stigmas. This symposium will conclude with a discussion on how researchers may begin to integrate approaches to address stigma in rural and underserved communities in order to enhance care utilization and quality of life for older adults caring for and living with ADRD.

Designing for Shared Values: Exploring Ethical Dilemmas of Conducting Values Inclusive Design Research

Recent prevalence of values-inclusive design research introduces the potential of conducting research with those whose values conflict with researchers' own values. This is the scenario we have found ourselves in as we conduct values-inclusive participatory design to develop and deploy critical digital literacy education in a rural Appalachian community. We present provocations which outline the ethical concerns we have grappled with in pursuit of conducting fair and responsible research for our participants, indirect stakeholders, and ourselves. Through consideration of these provocations, we have developed a preliminary approach for managing a research relationship with those with whom we disagree which we call Designing for Shared Values. This approach is a conflict-avoidant method for negotiating values in values-inclusive design. It centers around reflexivity as a mechanism to account for one's own values and potential impacts of design research outcomes on indirect stakeholders, while maintaining responsibility to prioritize beneficial outcomes to research participants.

Evaluating the feasibility of pharmacist-facilitated tobacco cessation interventions in independent community pharmacies in rural Appalachia

BackgroundSmoking rates in the United States are the highest in underserved rural regions. Thus, more points of contact are needed to link smokers to evidence-based cessation programs. ObjectivesThe purpose of this study was to conduct an evaluation to determine the feasibility, acceptability, and interest among rural pharmacists in implementing a pharmacist-facilitated smoking cessation program in independent community pharmacies in rural Appalachian communities in Virginia, North Carolina, Tennessee, and West Virginia. MethodsThis study utilized a complementary sequential mixed-methods approach to explore independent community pharmacists and technicians’ experiences and beliefs about implementing a tobacco cessation program in their pharmacy. ResultsThere were 49 pharmacists or technicians who completed the survey and 7 pharmacists who participated in the interviews. Four main findings emerged from the data: 1) pharmacies can help fill the gap in tobacco cessation services in rural communities, 2) under current practice, tobacco cessation resources when offered by independent community pharmacies are not always formalized, 3) there are known barriers, such as reimbursing for services, that need to be addressed to provide tobacco cessation in an independent pharmacy setting, and 4) the Ask-Advise-Connect model is a feasible tobacco cessation approach in a pharmacy. ConclusionAlthough pharmacists may be ideally situated to build capacity for smoking cessation in rural areas, smoking cessation interventions need to use existing approaches that compensate pharmacists for their time spent counseling patients. Furthermore, simple documentation and billing systems are needed to maximize utilization of tobacco cessation products and services provided in the pharmacy.