Women in Central Appalachia represent a significant proportion of those engaging in problematic patterns of opioid use, which is concerning given the limited available services in the region and gender specific treatment barriers. This investigation seeks to understand the role of mental health and substance use symptoms among incarcerated Central Appalachian women and build on the conceptual model of substance use treatment utilization purposed by Leukefeld and colleagues (1998). Data for this study was drawn from a larger longitudinal investigation (NIDA 1R01-DA033866) and baseline data collected during initial interviews was analyzed. The sample included 400 women incarcerated at one of three central Appalachian jails. Bivariate analyses determined significant relationships between symptoms of depression, anxiety, trauma and substance use. Binary logistic regression was used to assess the factors influencing treatment utilization. The overall multivariate model of treatment utilization with eight factors (income, overdose history, injection drug use, entered detox, attended self-help groups, substance use problems, number of children, and no way to get to their provider) significantly improved the prediction of treatment utilization. Implications of this study highlight the importance of continued interventions at the individual, community, and policy level.

During the past several decades, globalization forces in general and mechanization of coal mining jobs more specifically have sharply changed the economic and social conditions of many of the coal towns in the Central Appalachian region of the United States. Efforts to identify and seek alternatives to replace the ongoing decline of their traditional way of life are deeply entangled with community identity and culture due to the historical hegemonic role and power of coal mining and other extractive industries and their critical role in forming residents' identities. Many of the small communities in this region are pursuing initiatives to highlight their natural and cultural assets in efforts to develop tourism as a new foundation for their economies. However, to avoid tourism simply becoming another extractive industry, researchers and practitioners have suggested that these communities must develop capacity to participate in and take ownership of tourism-related decision-making processes. In an effort to examine the dynamics of one such effort in detail this study drew on Community Capacity theory as interpreted by Chaskin (2001a) to explore the relationships between Community Cultural Development (CCD) and the sustainability of tourism in a small town located in Central Appalachia seeking to transition to a visitor-based economy. This dissertation explored whether and in what ways engaging in CCD projects and community capacity are related and identified ways such interactions influence the sustainability of tourism. Along with personal observation and a review of relevant archival data, I conducted 10 semi-structured interviews with a sample of individuals from a community cultural development organization regarding their efforts to build possibilities for sustainable tourism in their rural jurisdiction. This study's findings contribute to the existing literature by suggesting Chaskin's framework of community capacity as an apt model for charting progress towards sustainable community-based tourism. Moreover, this research found that employing CCD methods can enhance community capacity by encouraging a sense of shared identity among the group's members and through them among a broader cross-section of residents. Lastly, this inquiry suggested that CCD contributed to the sustainability of tourism in the case study community by increasing residents' effective participation in decision-making processes concerning such efforts, encouraging locals' partnership and ownership of tourism development projects and providing space for negotiating the tourist gaze in guest-host relationships. / Doctor of Philosophy / Since at least the late 1960s and the advent of the ongoing decline of mining, the populations of many small coal-dependent towns in Central Appalachia have fallen into economic hardship (e.g., high rates of poverty, too few and/or inadequate jobs and public services), now confront a range of social issues arising from that harsh reality (e.g., youth out-migration, rapidly aging populations, the current opioid epidemic). In response to those conditions, many affected communities are investing in their wealth of natural resources and unique cultural assets to promote tourism as a palliative, if not replacement, for their previous economies. Tourism has the potential to reduce poverty and to boost shared prosperity among host communities, but it also, if poorly managed, could become another extractive industry. This study focused on the ways that residents in one Central Appalachian community have individually and as groups sought to assume ownership of their area's tourism-related efforts. I specifically analyzed participation in that jurisdiction's cultural activities (e.g., community theatre and story circles) to understand whether and how involvement in them affected participants' awareness of their capability to address the conditions in their community. My interviews with 10 active participants in my sample community's collective cultural projects revealed that residents did come to perceive themselves as possessing capacity as individuals and as groups to address the challenges that have arisen in their community as its traditional economy has declined. This study also found that participants in culture-based group activities were better prepared to participate effectively in tourism-related decision-making processes in their community. Indeed, many of those I interviewed have become owners and/or partners in tourism development projects because of the information and networks they developed during their participation in cultural activities. Finally, this analysis found that community cultural activities created a space for residents to interact regardless of their socio-economic status, ideological predisposition or other characteristics; an outcome that interviewees indicated they had come to cherish.

Many ecosystems are losing biodiversity, raising concern for the services they provide. However, the extent of loss is uncertain, especially for insects that use freshwater during their life. Further study is needed to assess freshwater insect abundances and diversity. In Central Appalachian streams, macroinvertebrate diversity declines in response to mining-induced salinization and resulting changes to ecosystem processes remain largely unknown, such as how the availability and movement of macroinvertebrate biomass is altered in stream food webs. However, taxa observed are dependent upon sampling effort that could bias diversity-process interpretation. Taxon sampling curves can be used to estimate sampling effort that maximizes the probability of complete community characterization. We sampled six streams in the Central Appalachian region for benthic macroinvertebrates and explored the number of samples needed to capture taxonomic richness in salinized streams. Sampling effort did not differ between reference and salinized streams, though more uneven distributions of macroinvertebrates in salinized streams seemed to necessitate greater sampling effort relative to reference streams. We also used taxon and trait-based sampling curves to expand our understanding of biodiversity and functional responses to environmental change. Because macroinvertebrate biomass and emergence can assess the movement and changes in organic material and energy in response to a salinization gradient, we added them as additional metrics. Macroinvertebrates may have varied responses to a stressor dependent upon life stage, suggesting that assessments relying only on immatures may not fully characterize the effects of salinization. We sampled benthic macroinvertebrate biomass and emergent insect biomass from six streams in the Central Appalachian region to be representative of a salinization gradient. We predicted benthic biomass would either decrease, be maintained by greater density and biomass of salt-tolerant taxa, or increase from a salt subsidy effect, while emergent biomass would decrease disproportionately relative to benthic biomass due to late instar and pupae succumbing to stress. Our results suggest that total benthic macroinvertebrate biomass is maintained along a salinization gradient despite the loss of salt-sensitive mayflies due to compensation by salt-tolerant taxa that experience a subsidizing effect. Emergent biomass was variable among streams with peak emergence occurring in spring, with no apparent negative response to increasing conductivity. The present study can help to further develop metrics of stream ecosystem processes in response to a disturbance gradient. / Master of Science in Life Sciences / Freshwater salinization is a growing, global concern. Pollution and accelerated weathering of rock, caused by human activities, introduce salts to streams and other freshwaters. Surface coal mining is a common land use in the Central Appalachian region and increases leaching of sulfate and other major ions that increase stream salinity, leading to losses of aquatic insect species. Aquatic insects are important to stream processes, such as providing food to other animals, and they can serve as the bioassessments when impacts are suspected. For example, the impacts of salinization on streams are not fully understood despite bioassessments. We sampled aquatic insects from six Appalachian streams with varying levels of salinity. We estimated the sampling effort needed to characterize aquatic larval insect communities in streams with low salinity compared to streams with high salinity. We found that about six samples captured 80 percent of estimated total taxa and that insect communities with greater unevenness required more sampling effort. Such comparisons will allow us to make more informed decisions when sampling aquatic insects and assessing the effects of salts on streams. We also estimated insect biomass in streams using two life stages, larvae and adults, to determine if these life stages would respond differently to salinization. As we expected, total larval biomass slightly increased as the concentration of salt increased, but mayfly biomass decreased. Mayflies are an important and diverse group of insects in Appalachian streams and decreases in their biomass can have consequences for insect communities and stream food webs. Even though emergent insect biomass was found to represent only a small proportion of the larval biomass observed in streams, they represent critical food for terrestrial animals. Estimates of benthic and emergent biomass could be considered to refine bioassessments that support future management and policy regarding surface mining and the rising issue of freshwater salinization.

Dollar General has seen massive growth, opening almost 1,000 stores per year for ten years. Executives attribute the company's success to their attention to the expanding poverty class in low-food-access urban and rural areas. Central Appalachia in particular -- which has one of the highest rates of low food access and poverty in the nation -- has been a growth center for Dollar General stores. Has the growth in Dollar General stores in Central Appalachia affected residents' food procurement patterns? Through an analysis of USDA data on food access and by conducting interviews with 11 people living in Central Appalachia, I find that Dollar General stores are most frequently found in low-income and low-food-access counties and that Central Appalachian people perceive the chain as a necessary evil. I argue that the complicated relationship between Dollar General and Central Appalachian people is an example of David Harvey's theory of accumulation by dispossession. Neoliberal globalization created the conditions that allow Dollar General to thrive in the region – in particular, the corporate enclosure of the commons, the decline of the coal industry, and the new economy which has forced many people to travel hours a day for work. / Master of Science / Dollar General has seen massive growth, opening almost 1,000 stores per year for ten years. Executives attribute the company's success to their attention to the expanding poverty class in low-food-access urban and rural areas. Central Appalachia in particular -- which has one of the highest rates of low food access and poverty in the nation -- has been a growth center for Dollar General stores. Has the growth in Dollar General stores in Central Appalachia affected residents' food procurement patterns? Through an analysis of USDA data on food access and by conducting interviews with 11 people living in Central Appalachia, I find that Dollar General stores are most frequently found in low-income and low-food-access counties and that Central Appalachian people perceive the chain as a necessary evil. I argue that the complicated relationship between Dollar General and Central Appalachian people is an example of David Harvey's theory of accumulation by dispossession. Neoliberal globalization created the conditions that allow Dollar General to thrive in the region – in particular, the corporate enclosure of the commons, the decline of the coal industry, and the new economy which has forced many people to travel hours a day for work.

In a multiphasic study, the stories of 29 female Appalachian cancer survivors were collected through either a day-long modified story circle event (n=26) or an in-depth interview (n=3). Qualitative content analysis was used to identify emergent themes in the data. The analysis revealed 5 types of family cancer communication including both pre-diagnosis and postdiagnosis cancer communication strategies

Objective: To examine the association between subclinical atherosclerosis (ascertained as coronary artery calcium; CAC) in asymptomatic individuals in the Central Appalachian region of the United States and individual- and geographic-level factors. Methods: Data were obtained from participants in CAC screening during 2012 and 2016. CAC score was assessed as CAC=0 (no plaque), 1≤CAC≤99 (mild plaque), 100≤CAC≤399 (moderate plaque), and CAC≥400 (severe plaque). Additionally, data on demographics (age, sex, and race), medical conditions, lifestyle factors, and family history of coronary artery disease (CAD) were obtained. Further, zip codes of place of residence for participants were used to generate geographic-level data. Descriptive statistics were used to estimate the prevalence of CAC, and multinomial logistic regression models were used to delineate significant factors. Results: Of 1512 participants, 57.6% had CAC>0. The prevalence of mild, moderate, and severe plaques was 31.6%, 16.3%, and 9.7%, respectively. Demographic, medical conditions, lifestyle factors, and family history of CAD were associated with increased risk for subclinical atherosclerosis. Further, the proportion of minority residents significantly increased the risk for severe plaque [RRR=1.06; p-value=0.04] and the proportion of residents on government assistance significantly decreased the risk for mild plaque [RRR=0.93; p-value=0.03]. Conclusion: The results imply that the proportion of minority residents in a geographic area is associated with increased relative risk for subclinical atherosclerosis, while the proportion of residents on government assistance decreased such risk. However, future geographic or neighborhood-level studies with larger sample size are needed to delineate further the consistency of these results in the Central Appalachian population.

Objectives: The central Appalachian region of the United States is disproportionately burdened with cardiovascular diseases (CVD) and associated risk factors; however, research to inform clinical practice and policies and programs is sparse. This study aimed to examine the association between multiple modifiable risk factors for CVD and hypertension in asymptomatic patients in central Appalachia. Methods: Between January 2011 and December 2012, 1629 asymptomatic individuals from central Appalachia participated in screening for subclinical atherosclerosis. Participants were asked to report their hypertension status (yes/no). In addition, data on two nonmodifiable risk factors (sex, age) and five modifiable risk factors (obesity, diabetes mellitus, hypercholesterolemia, smoking, and sedentary lifestyle) were collected. Multivariable logistic regression analyses were conducted to assess association between hypertension and risk factors. Results: Of the 1629 participants, approximately half (49.8%) had hypertension. Among people with hypertension, 31.4% were obese and 62.3% had hypercholesterolemia. After adjusting for sex and age, obesity and diabetes mellitus were associated with a more than twofold increased odds of having hypertension (odds ratio [OR] 2.02, confidence interval [CI] 1.57–2.60 and OR 2.30, CI 1.66–3.18, respectively). Hypercholesterolemia and sedentary lifestyle were associated with higher odds for hypertension (OR 1.26, CI 1.02–1.56 and OR 1.38, CI 1.12–1.70, respectively), compared with referent groups. Having two, three, and four to five modifiable risk factors was associated with increased odds of having hypertension by about twofold (OR 1.72, CI 1.21–2.44), 2.5-fold (OR 2.55, CI 1.74–3.74), and sixfold (OR 5.96, CI 3.42–10.41), respectively. Conclusions: This study suggests that the odds of having hypertension increases with a higher number of modifiable risk factors for CVD. As such, implementing an integrated CVD program for treating and controlling modifiable risk factors for hypertension would likely decrease the future risk of CVD.

Land Use Land Cover (LULC) changes can take place at the expense of degrading environmental conditions and undermining ecosystem’s capacity to deliver benefits to people. In the Appalachian region, surface mining for coal is a major driver of LULC change. The Surface Mining Control and Reclamation Act (SMCRA) of 1977 requires mine site reclamation but typical reclamation practices often result in land cover dominated by grass and shrubs. The Forestry Reclamation Approach (FRA) is a promising reclamation strategy but not in widespread use by industry. Assessing ecosystem services that can be obtained from a forest landscape may help policy-makers and other stakeholders fully understand the benefits of forestry based reclamation. The objectives of this study are to 1) identify how surface mining and reclamation changed the LULC of a watershed encompassing the north fork of the Kentucky River 2) assess the biophysical value of four major ecosystem services under the contemporary LULC condition and 3) assess the benefits of the FRA scenario in the provision of ecosystem services. Geographic Information System (GIS) was used to study the LULC change and InVEST software models for ecosystem services assessment. The results indicate that watershed’s forest area has decreased by 7,751 hectares from 2001 to 2011 and mining activity may have contributed 75% of the change in LULC. Barren and grassland land covers provide less carbon storage, yield more water, and export more sediments and nutrients than forests. At the watershed level, the FRA modeled scenario increased carbon storage (13%) and reduced water yield (5%), sediment export (40%) and nutrient export (7%). This study provides critical information regarding the ecological benefits of Forestry Reclamation Approach to assist policy and decision making in this region even considering the modeling and data limitations.

Introduction Hypertension occurs when there is persistent increase in the pressure of blood vessels in the body; this condition affects about 75 million people in the United States (U.S.). Hypertension is a major risk factor for Peripheral Artery Disease (PAD). PAD is a narrowing of the peripheral arteries in legs, stomach, arms and head regions of the body except the heart. Research has shown that hypertension can be life-threatening for patients with PAD. Moreover, research supports an evidence of a low threshold for blood pressure treatment in patients with PAD. Additionally, current American Heart Association guidelines recommend treating hypertension in patients with PAD to reduce the risk of other cardiovascular disease (CVD) comorbidities. In Central Appalachia, the rate of hypertension and the corresponding risk factors is higher than the national average. As such, this study examined the multiple risk factors of hypertension in patients with PAD within the Central Appalachian region. Method The study population consists of patients diagnosed with PAD in a large health system in Central Appalachia from 2008 to 2018. We extracted 13,455 patients with PAD from Electronic Medical Records (EMR) system using ICD- 9 and ICD-10 codes. The outcome variable of the study was hypertension in PAD patients. Explanatory variables included gender, age, and cardiovascular risk factors (myocardial infarction (MI), Body Mass Index (BMI), diabetes mellitus, smoking status, low-density lipoprotein, high-density lipoprotein, triglycerides, and hypercholesterolemia). Multivariable logistic regression was performed to assess the association between risk factors of hypertension in male and female PAD patients. All analyses were performed using SPSS version 24. RESULTS Of the total PAD patients in the study, 45.8% were females and 54.2% were males. Of these patients, 79.1%, 45.7% and 22.6% had hypertension, diabetes and a history of MI, respectively. Upon stratifying based on gender, the odds of hypertension in PAD female patients with a history of MI was approximately 5.4 times (OR: 5.4, CI : 1.80-16.21) and 2.6 times higher with diabetes (OR: 2.6, CI: 1.43-4.83). Whereas in PAD male patients, the odds of hypertension was 3.9 (OR: 2.6, CI: 1.61-9.21) and 2.6 times (OR: 2.6, CI: 1.43-4.83) higher in those with a history of MI and diabetes, respectively. Stratifying by MI, the odds of hypertension in PAD increased by 2.8 times in patients with diabetes (OR: 2.6, CI: 1.75-4.49). Stratifying by diabetes showed that the odds of hypertension in PAD increased by 4.7 times in patients with MI (OR: 4.7, CI: 1.32-17.07). CONCLUSION The study showed that odds of hypertension in PAD patients is increased in the presence of diabetes and history of MI in both genders. Therefore, controlling diabetes and myocardial infarction will have the greatest impact in reducing the likelihood of hypertension leading to decreased morbidity and mortality in patients with PAD.

This dissertation focuses on how rural community college students make decisions regarding their post-secondary plans. To understand these decision processes, I interviewed students, faculty and administrators at Southeast Community and Technical College in Harlan County, Kentucky. The literature informing my research reflects on rural college going patterns. Most studies connect place and post-secondary plans. Central Appalachia has among the lowest population percentages with Bachelor degrees in the country. Studies argue this is because of limited application for such degrees in the region. Matching their education and training to local job market requirements, people hesitate to complete advanced degrees when little if any local application requires such additional education. This study discusses how place informs and shapes students’ decisions around college and degree selection. Unlike those who connect advanced education with outmigration patterns, my research highlights students who pursue post-secondary training in hopes of applying these degrees locally to build their communities and families’ quality of life in a rural place. From the twenty-eight student and fifteen faculty and administrator interviews conducted, rationales regarding the purpose of post-secondary degrees and training surfaced. Through selected follow up oral histories, students further described the application of their degrees towards terminal, transfer and/or transformative ends. Their articulated positions regarding the purpose and application of higher education in Central Appalachia adds to the continuing studies on how advanced degrees informs students’ decisions to stay or leave rural areas. From the Southeast interview data, I provide a critique of policy directives related to advanced education and economic development. Given many of the urban assumptions embedded in development theory, my study was interested in how these rural students, in a place considered underdeveloped partly because of low college attendance rates, attain and then apply their degrees and the rationale they articulate in doing so. As US policy makers continue to require advanced education for more and more of their citizens, my research shows the complications and complexities such rhetoric evokes when people, committed to rural places and ways of life, apply them in their local contexts.