Patient-centered contraceptive care is key for ensuring that individuals achieve their personal reproductive goals. Despite public health efforts, preventing undesired pregnancies and improving maternal and child health outcomes remains unresolved in the United States (US). In Tennessee (TN), the rate of unintended pregnancies remains higher than the national rate (32.4% vs. 30.3%). Long-acting reversible contraceptives (LARCs) are 99% effective in preventing undesired pregnancies; however, uptake remains low in rural and underserved communities. Previous research has provided some insight into women’s perceptions of LARCs; however, those guided by conceptual frameworks to understand the multiple influences that impact perceptions towards LARCs, especially among rural regions, are scarce. This multimethod qualitative study explored multiple influences that impact northeast Tennessee women’s perceptions and attitudes toward LARCs using the Socio-ecological Model (SEM) as a guiding framework. The qualitative study comprised six focus groups and seven individual interviews of women aged 18-44, not pregnant, and current residents of five Counties in Northeast TN. Participants’ demographics were captured through an anonymous survey administered through REDCap. Qualitative data from these sessions were recorded via Zoom, an online audio/video conferencing platform. Each interview and focus group lasted 60 to 90 minutes. Focus group and interview data were combined, transcribed, and uploaded into NVivo for thematic analysis. A priori list of codes identified from the constructs of the SEM was initially used to deductively code the data. Subsequently, the data were analyzed inductively for new codes and themes that did not apply to the a priori categories. Quotations that were representative of or inconsistent with the codes of interest were identified. Fifteen themes and 20 sub-themes were identified using the SEM; On the intrapersonal level of the SEM, participants’ attitudes towards a method, perception of method features, and perceived side effects were identified as themes that delineate influences on their LARC utilization. On the interpersonal level, perception of partner support, perceived support from peer/social networks, and provider trust were themes that describe influences on participants’ LARC utilization. On the community level, the cost of the method, access to information, perceived accessibility to a method, social services, and cultural norms themes were identified as influences on participants’ use of LARCs. On the organizational level, the availability of preferred methods in a clinic, the need for multiple clinic visits to enable the use of a method, and provider counseling practices were salient themes impacting LARC utilization. On the policy level, insurance, and billing policies, sex education policies were identified as impacting LARC utilization. The study presents multi-layered influences on LARC utilization among Northeast TN women, highlighting the utility of the SEM in understanding factors that influence contraceptive use. Findings are critical for programming as they highlight the areas of influence that can be addressed to increase LARC uptake and enable women in rural and underserved regions of the US to achieve personal reproductive goals.

Abstract Introduction: Tobacco use continues to be the leading preventable cause of morbidity and mortality in the Appalachian Tennessee despite the nationwide decline in tobacco use. The main reason contributing to this nationwide decline in tobacco use is tobacco control applied to prevention, cessation and protection efforts. Evidence indicates that regions with comprehensive tobacco control policies and programs have lower tobacco use prevalence than those with fewer policies and less comprehensive programs, which is characteristic of Tennessee. Therefore, this study examines the current capacity that exists around the tobacco control protection in Appalachian Tennessee. Methods: During 2015-2016, a Population Health Improvement Plan (PHIP) study involving 222 community stakeholders and 91 organizations was conducted in Appalachian Tennessee to assess the capacity of the region in addressing the high burden of tobacco use. First, twenty (20) key informant interviews were conducted with tobacco control professionals within the eight counties in Northeast Tennessee. Afterwards, two community meetings were held in the northern and southern areas of the region with additionally identified stakeholders (n = 36) to gather input on current efforts and methods to increase community capacity for tobacco control in the region. The interviews and discussions were audio-recorded, transcribed, and analyzed using a multifaceted framework approach to tobacco control that focuses on prevention, protection and cessation. This study focuses on important themes identified related to tobacco protection for the Northeast region of Tennessee. Results: The PHIP assessment process found that most current activities around protection for tobacco control were related to national tobacco control policies such as the Non-Smokers Protection Act (NSPA). Also, differences were found between rural and urban areas in the extent of policy efforts, with better enforcement of existing policies found in more metro areas. Rural counties expressed the need for better education and awareness of current policies to help with enforcement efforts. Assessment of findings for barriers to protection/policy for tobacco control resulted in two themes; the existence of state preemption on tobacco control policies, which limits what policies local governments can enact, and the need for higher tobacco taxes. An overall barrier found for tobacco protection was a cultural tolerance of tobacco use including an intergenerational culture of use in Appalachian Tennessee. Conclusion: The Appalachian region of the US suffers disproportionately in health risks and adverse health outcomes, including tobacco-related diseases. For this reason, there is the need for comprehensive culturally-tailored and region-specific protection policies that address existing urban-rural disparities including the removal of the state preemption and increase of tax for tobacco products to effectively address the high burden of tobacco use in Appalachian Tennessee.

Objective. To examine alternative tobacco product (ATP) use and associated factors among middle school students in Appalachian Tennessee. Method. Data (2015– 2016; N=573) from school-based tobacco surveys in 11 middle schools in Appalachian Tennessee were analyzed. Multiple logistic regression model described factors associated with ATP use. Results. More than one-tenth (13.2%) of participants have ever used ATPs. Approximately 9%, 7%, 6%, and 2% of participants have ever used e-cigarettes, cigarettes, smokeless tobacco, and little cigars or cigarillos, respectively. The following were significantly associated with ever use of ATPs: believing tobacco users have more friends, owning tobacco-branded item(s), living with a tobacco user, having ever smoked cigarettes, and living in homes where smoking is allowed. Conclusion. More than one in 10 of participants have ever used at least one ATP, and association with desirable objects and situations may promote ATP use. Interventions should seek to reduce these positive images and make all tobacco products unappealing.