Rural Southern Appalachia Research Articles

Mystery of the Talking Skull: Family Secrets in Southern Appalachia

Abstract: When an out-of-town merchandiser goes missing in 1930s rural Southern Appalachia, whiskey and foul play are suspected. The small town of Woodbury, Tennessee, soon forgets and moves on, until the man's skeletal remains are uncovered three years later by two boys digging for mayapple root. Two men are immediately charged with the murder, though only one would be convicted. The trial would attract newspapers from across the state and beyond through the end of the decade. The story was lost to time and largely unknown to the descendants of those involved. The tale might have stayed buried in the past if not for a pulp fiction magazine that made its way back to the family some seventy years later.

Impact of Concurrent Hospice Care on Primary Care Visits Among Children in Rural Southern Appalachia.

The purpose of the study was to test the effect of receiving pediatric concurrent hospice care on primary care visits. This retrospective study was limited to pediatric decedents younger than 21 years with a hospice service claim from 2011 to 2013. Our outcome of interest concerned whether concurrent hospice care impacted primary care visits. Of the 460 pediatric decedents in rural Southern Appalachia, 42% continued to visit their primary care provider during hospice enrollment, whereas 51% received concurrent hospice care. Concurrent hospice care was significantly related to pediatric primary care visits (β=2.31; p < .001). Findings revealed that receipt of concurrent hospice care impacted primary care. Children in concurrent care were twice as likely to continue to receive care from their primary care provider. This finding is consistent with our hypothesis; however, the magnitude of the finding was unexpected given their residence in medically underserved areas.

Religious and spiritual journeys of LGBT older adults in rural Southern Appalachia

ABSTRACT This article reports on religious and spiritual experiences of 11 lesbian, gay, bisexual, and/or trans*-identified (LGBT) older adults in rural southern Appalachia. Template analysis of interview data yielded themes including: harmful experiences with Christianity in childhood and adulthood, religion and spirituality as sources of support, current participation in supportive Christian churches, and personalized approaches to spirituality and religion. Despite prior harmful experiences in some cases, religion and spirituality now provided meaning, strength, and support for most of the participants. The article concludes with implications for theory, research, and professional practice for clergy, social workers and other helping professionals.

Social Support and Social Networks among LGBT Older Adults in Rural Southern Appalachia

ABSTRACT While research has begun to examine social networks and social support among LGBT older adults living in rural contexts, no research to date has examined these issues within the unique context of rural southern Appalachia. Thus, the purpose of this qualitative study was to extend this emerging area of research by exploring the perspectives of LGBT older adults on their social networks and social support while living in rural southern Appalachia. In this study, 11 LGBT-identifying older adults were interviewed regarding their social networks and social support within the cultural context of rural Southern Appalachia. Participants generally described having rich informal social support networks that seemed to buffer and mitigate the deleterious effects of the wider culture of homophobia and transphobia. These networks, while varying from person to person, included families of choice (spouse / partner, close friends), neighbors, pets, biological family / families of origin, religious and spiritual communities, women’s or men’s social groups, and current or former coworkers. While six of the participants voiced that their support system was adequate for their needs, there were reports of mixed, tenuous, or insufficient support systems for five participants. After reviewing main findings, implications for research, practice, and policy are discussed.

Social Support for Physical Activity for High Schoolers in Rural Southern Appalachia.

Social support for physical activity (PA) has been shown to enhance PA levels in adolescents. Although social support has been examined extensively in the literature, less is known about the role of social support for PA for high school adolescents in rural southern Appalachia. PA is important because adolescent obesity is greater in Appalachia than in the rest of the United States. This was a qualitative secondary analysis of focus groups conducted in 2013-2014 among parents, teachers, and high school students (N = 77) in 6 counties across rural southern Appalachia. Beets' typology of social support was used to categorize themes. Participants discussed instrumental supports, including providing transportation and paying fees, enrolling child in recreation/sports, and providing PA equipment at home. Performing PA with adolescents and modeling, watching/supervising, and prioritizing PA were identified as conditional supports. Several motivational supports were identified: encouragement, force, and the admiration of people who are active. Participants also identified key informational supports, including discussing the importance/health benefits of PA, how to be physically active, and general advice/information. Barriers to PA engagement (eg, body image issues, bullying, competitive nature of PA opportunities) and the role of referent groups (eg, family, peers, teachers) emerged as important concepts in the discussion. This study identifies opportunities and practical ways for families and schools to provide, build, and strengthen supports for PA among adolescents in rural Appalachia.

LGBT OLDER ADULTS IN RURAL SOUTHERN APPALACHIA: PERCEPTIONS OF CURRENT AND FUTURE FORMAL SERVICE NEEDS

Older sexual and gender minority adults in rural communities face challenges in accessing formal health, mental health, and long-term care services (Butler, 2017; Koch & Knutson, 2016; Stein et al., 2010). Formal service providers in rural Southern Appalachia are more likely to have conservative values that are closely linked to their religious beliefs (Keefe, 2005). Some may be opposed to gender non-conformity and same-sex relationships or marriage, making it wise for LGBT older adults in rural contexts to carefully select formal service providers and settings (Willging et al., 2006). Barriers to accessing formal services for LGBT older adults residing in rural contexts include few LGBT-inclusive service providers and facilities, transportation, cost, and health insurance (Butler, 2017). When faced with the prospect of long-term care, older LGBT adults are more likely to conceal their sexual or gender identity due to fears of being mistreated (Brotman et al., 2003). This session will present results of a qualitative study examining experiences, concerns, and recommendations regarding formal services among 11 LGBT older adults residing in rural southern Appalachia. Several of the participants described experiencing discrimination from local service providers. A number of participants were fearful about the perceived lack of LGBT-inclusive services in the area and expressed that they would consider leaving the area if their own or their partner’s health declined. Many participants expressed the need for local provider education about the needs of LGBT older adults. The presenters will discuss the implications for research and for health, social, and long-term care services.

INTEREST GROUP SESSION—HUMAN-ANIMAL INTERACTION: PETS IN OLDER ADULTS’ SOCIAL NETWORKS: HUMAN-ANIMAL INTERACTION, INTERPERSONAL CONNECTIONS, AND HEALTHY AGING

Empirical evidence supports positive associations between social support, interpersonal connections, and health as people age. This symposium addresses how human-animal interaction may facilitate connection throughout later life. Each talk presents unique ways pets: fit into social networks; expand interpersonal connections; and thereby, impact health and wellbeing. The first talk presents longitudinal associations of a history of pet ownership and marital status on health, in particular cognitive functioning, over time. The second talk presents qualitative evidence for how pets fit into older adults’ social network and quantitative evidence for the impact of animal and interpersonal companionship on overall and functional health. The third talk builds upon the literature linking dog walking with older adults’ physical health, by providing evidence for the positive impact of dog walking improving interpersonal connections with neighbors. The fourth talk discusses the influence of a unique intergenerational human-animal interaction service-learning course on university students’ attitudes towards older adults and those with disabilities. Enrolled students provide pet care (e.g., brushing, dog walking, delivering pet food and supplies) to low-income pet owners ages 60 and older and disabled adults. Students reported decreased biases towards older adults and those with disabilities after completing the course. The final talk is the first study to focus on the influence of pets in LGBTQ older adults living in rural southern Appalachia. Identifying as a LGBTQ person and living in a rural environment can present unique challenges and these qualitative results provide insight into pets’ influence on aging in this understudied population.

Barriers to Healthy Eating Among High School Youth in Rural Southern Appalachia.

IntroductionDiet and nutrition play an important role in a child’s health and reduce the risk of numerous health problems including obesity. Dietary habits can be difficult to modify in children, particularly in Appalachia, where access to affordable, healthy foods is limited.PurposeTo examine barriers to healthy eating among Appalachian youth.MethodsIn 2013–2014, data were gathered via focus groups and interviews from parents, school personnel, and adolescents (N=99) in six counties across southern Appalachia. Data were analyzed using thematic network analysis. Analysis was completed in 2015.ResultsParticipants identified multiple barriers to healthy eating among adolescents. Barriers comprised three global themes: cultural norms, school-based nutrition policy and programming, and rurality. Within the individual and home environment, beliefs and practices, time management, and preference for unhealthy foods affected adolescents’ dietary behaviors. Schools faced challenges in terms of translating nutrition policy into practice, providing nutrition education, and engaging stakeholders. Limited socioeconomics and food deserts/swamps were community-level impacts.ImplicationsParticipants discussed how adolescents’ eating behaviors were shaped by social, physical, and environmental factors (e.g., cultural norms, school-based nutrition policy/programming, and rurality). These findings provide important insights into barriers to healthy eating in this population and point to future directions for research and practice. For example, the findings can be used by school personnel to develop ecologic approaches to school-based nutrition programming in Appalachia. Student associations can also use these findings to actively participate in efforts to improve school food offerings.

Dialect and Influences on the Academic Experiences of College Students

The dialects that college students speak represent a type of diversity that can influence many elements of their experiences in college, including academic experiences. In this study, we examined the influence of speaking a stigmatized dialect on academic experiences for White and African American students (both male and female) from rural Southern Appalachia attending a large research institution in the urban South. This qualitative study was aided by quantitative sociolinguistic methods used to identify and describe students' speech patterns in order to better understand the influence that students perceived their dialect to have on academic experiences. Findings suggest that for more vernacular students, dialect can influence participation in class, degree of comfort in course, perceived academic challenges, and for some, their beliefs about whether or not others perceive them as intelligent or scholarly based on their speech. This study has implications for the consideration of language diversity in fostering welcoming academic environments and in the role of language discrimination and stereotype threat/stereotype management.

Promoting Healthy Eating Among High School Youth in Rural Southern Appalachia: Barriers, Facilitators and the Role of Parents and Schools

Promoting Healthy Eating Among High School Youth in Rural Southern Appalachia: Barriers, Facilitators and the Role of Parents and Schools

Dialect and Influences on the Academic Experiences of College Students

The dialects that college students speak represent a type of diversity that can influence many elements of their experiences in college, including academic experiences. In this study, we examined the influence of speaking a stigmatized dialect on academic experiences for White and African American students (both male and female) from rural Southern Appalachia attending a large research institution in the urban South. This qualitative study was aided by quantitative sociolinguistic methods used to identify and describe students’ speech patterns in order to better understand the influence that students perceived their dialect to have on academic experiences. Findings suggest that for more vernacular students, dialect can influence participation in class, degree of comfort in course, perceived academic challenges, and for some, their beliefs about whether or not others perceive them as intelligent or scholarly based on their speech. This study has implications for the consideration of language diversity in fostering welcoming academic environments and in the role of language discrimination and stereotype threat/stereotype management.

Burden of elective early-term births in rural Appalachia.

Infants delivered at ≥ 37 weeks' gestation are considered full term, but research has demonstrated those born at 37 to 38 weeks (early term) have a higher risk for poor birth outcomes than deliveries at 39 to 41 weeks (full term). Despite this, many deliveries occur electively (scheduled, no medical indication) before 39 weeks. This study examined the risks of elective early-term delivery in a disadvantaged, rural sample and compared these results with national findings. Data were available for 638 rural women, recruited prenatally from three counties in rural southern Appalachia, who delivered electively at ≥ 37 weeks. Compared with electively delivered full-term infants, those delivered electively at early term were 7.7 times more likely to be low birth weight, 4.4 times more likely to have a neonatal intensive care unit admission, and 2.5 times more likely to develop jaundice. Those living furthest from the hospital were most likely to deliver electively at <39 weeks. Although rates of elective deliveries <39 weeks were no higher than national rates, adjusted odds ratios (aOR) of associated admission to a neonatal intensive care unit doubled (aOR 4.4 vs aOR 2.2). Results demonstrate that initiatives targeting early-term elective deliveries are needed in rural, disadvantaged regions.

Blackwelder and Cross collaborate in family medicine clinic

When Brian Cross, PharmD, first went to work for the Indian Health Service (IHS) on the San Carlos Apache Reservation in eastern Arizona in 1991, he believed that the physician-pharmacist collaboration that he encountered there—a model pioneered by the IHS and a handful of other federal agencies and private health care systems—as common across the country.

Forgiveness and Health: Assessing the Mediating Effect of Health Behavior, Social Support, and Interpersonal Functioning

ABSTRACT Religiousness and spirituality are important to most Americans and while beneficial associations between forgiveness and health are consistently observed, little is known regarding the mechanism of association. Cross-sectional multiple mediation-based analyses of associations between dimensions of forgiveness and physical and mental health were conducted using a sample of 363 undergraduate students from rural Southern Appalachia. Controlling for demographic variables (i.e., gender, age, education, ethnicity, and marital status) and lifetime religiousness, multivariable analyses reflected associations of forgiveness of self and forgiveness of others, but not feeling forgiven by God, with physical health status, somatic symptoms, mental health status, and psychological distress. All such associations operated through health behavior and/or social support; however, only in the context of forgiveness of self did such associations also operate through interpersonal functioning (problems). While forgiveness of self and forgiveness of others each appear to have a robust indirect relationship with health, mediation-based associations involving forgiveness of self were nearly twice as frequent. It may be that forgiveness of self is relatively more important to health-related outcomes.

Educating Nursing Students on Issues Related to Smoking during Pregnancy to Improve Regional Intervention Efforts

Objective To implement and evaluate training session related to smoking during pregnancy for baccalaureate nursing students in rural Southern Appalachia. Design Nursing students attended training on dangers and intervention techniques related to smoking during pregnancy. Sample Third year students beginning clinical rotations in obstetrics. Methods One and one half hour training including pre‐ and post tests. Implementation Strategies Four months later, a follow‐up survey assessed gains in knowledge, skill, comfort, and willingness to address smoking during pregnancy. Results During seven semesters, 659 nursing students were trained. Substantial gains in knowledge of issues related to smoking during pregnancy were seen from pre‐ to post testing, and knowledge was retained at 4‐month follow‐up. The percentage of students who felt they lacked skills to intervene with pregnant smokers dropped from 39% at pretest to 6% at same day post test. In addition, the percentage who reported they would be uncomfortable talking with pregnant women about smoking dropped from 10% to 1%; the percentage who indicated they would always make time to address smoking with pregnant women increased from 54% to 87%. While most students did address smoking with multiple pregnant patients during clinicals, and more than half felt the patients benefited from their actions, only 58% were confident in their intervention skills at 4‐month follow‐up. Finally, 83% felt the training had been beneficial, and more than 90% committed to addressing smoking with pregnant patients once they graduated. Conclusion/Implications for Nursing Practice Rates of smoking during pregnancy in the rural South are twice as great as national averages and contribute to poor birth and long‐term outcomes for affected women and children. Efforts to intervene during prenatal care with pregnant women have been hampered by lack of knowledge, skill, comfort, and commitment from prenatal providers and their nursing staff. Regional community providers and staff have been reluctant to participate in available trainings, and even those who do seldom exhibit attitude and practice change long term. Therefore, efforts to educate healthcare professionals on the dangers of smoking during pregnancy and to provide necessary skills for intervention efforts may need to occur before students enter practice, and ongoing education may be needed to promote skills and confidence long term. In the rural South, where smoking rates are high and provider efforts to address pregnancy smoking are inconsistent, educating future nurses could have substantial impact on rates of smoking during pregnancy and birth outcomes into the future. To implement and evaluate training session related to smoking during pregnancy for baccalaureate nursing students in rural Southern Appalachia. Nursing students attended training on dangers and intervention techniques related to smoking during pregnancy. Third year students beginning clinical rotations in obstetrics. One and one half hour training including pre‐ and post tests. Four months later, a follow‐up survey assessed gains in knowledge, skill, comfort, and willingness to address smoking during pregnancy. During seven semesters, 659 nursing students were trained. Substantial gains in knowledge of issues related to smoking during pregnancy were seen from pre‐ to post testing, and knowledge was retained at 4‐month follow‐up. The percentage of students who felt they lacked skills to intervene with pregnant smokers dropped from 39% at pretest to 6% at same day post test. In addition, the percentage who reported they would be uncomfortable talking with pregnant women about smoking dropped from 10% to 1%; the percentage who indicated they would always make time to address smoking with pregnant women increased from 54% to 87%. While most students did address smoking with multiple pregnant patients during clinicals, and more than half felt the patients benefited from their actions, only 58% were confident in their intervention skills at 4‐month follow‐up. Finally, 83% felt the training had been beneficial, and more than 90% committed to addressing smoking with pregnant patients once they graduated. Rates of smoking during pregnancy in the rural South are twice as great as national averages and contribute to poor birth and long‐term outcomes for affected women and children. Efforts to intervene during prenatal care with pregnant women have been hampered by lack of knowledge, skill, comfort, and commitment from prenatal providers and their nursing staff. Regional community providers and staff have been reluctant to participate in available trainings, and even those who do seldom exhibit attitude and practice change long term. Therefore, efforts to educate healthcare professionals on the dangers of smoking during pregnancy and to provide necessary skills for intervention efforts may need to occur before students enter practice, and ongoing education may be needed to promote skills and confidence long term. In the rural South, where smoking rates are high and provider efforts to address pregnancy smoking are inconsistent, educating future nurses could have substantial impact on rates of smoking during pregnancy and birth outcomes into the future.

Integration of behavioral health services in a primary care clinic serving rural Appalachia: Reflections on a clinical experience.

In the past few decades, there has been a move toward integrating behavioral health and medical services. This can be particularly beneficial for rural residents, as integration can increase access to mental healthcare in areas where there are shortages of mental health providers. Southern Appalachia is characterized by isolated areas that have shortages of both mental health and medical providers. This article discusses the experiences of a clinical psychology doctoral student integrating behavioral health services in a primary care clinic within rural Southern Appalachia. The role of the behavioral health consultant is described, including representative services and development and implementation of a clinic-wide depression protocol. Additionally, barriers to integration and recommendations for future training and practice are provided.

Eating Habits among Adolescents in Rural Southern Appalachia

A survey of 274 adolescents aged 14–16 years in rural Appalachia showed that unhealthy eating habits were prevalent. A few adolescents were teased about weight whereas 20.1% witnessed weight teasing almost everyday. Perception of parents’ healthy eating and better social support for healthy eating were associated with healthier eating habits.

Development of substance use and psychiatric comorbidity in an epidemiologic study of white and American Indian young adolescents the Great Smoky Mountains Study

The progression of substance use and the patterns of comorbidity of substance use and psychiatric disorders are explored prospectively in young adolescents enrolled in the Great Smoky Mountains Study. This study is an epidemiologic study of white and American Indian youths living in rural Southern Appalachia. Results from this study indicate that alcohol use without permission predicts subsequent use of illicit drugs and regular tobacco use. Use of tobacco was not associated with either later alcohol or drug use. Patterns of comorbidity showed strong cross-sectional relationships between substance use and behavioral disorders, but not emotional disorders. Use of alcohol was also associated with psychiatric diagnosis at a later interview. There were some differences between white and American Indian youths in the pattern of comorbidity of tobacco use and psychiatric disorder and the relationship between prior psychiatric disorder and later alcohol use. These findings suggest that alcohol use without permission may be an important marker for youths who are at risk for illicit drug use and/or psychiatric diagnoses.