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Purpose: Prescription and illicit opioid abuse have disproportionately impacted the Central Appalachian Region. Centers for Disease Control and Prevention (CDC) data indicate the region is home to many of the 220 counties most vulnerable to rapid dissemination of Hepatitis C Virus (HCV) and HIV related to injection drug use. Growing evidence supports the role of community pharmacies in HCV/HIV prevention by providing access to non-prescription sterile syringes; however, research has largely been confined to major metropolitan areas. The objective of this study is to evaluate the feasibility of community pharmacies in Central Appalachia serving as access points for sterile syringes. Methods: This study was approved by the Institutional Review Board. Using state directories of health professionals, community pharmacists from Northeast Tennessee, Western North Carolina, and Southwest Virginia were randomly selected to participate in key informant interviews to inform understanding of the impact of attitudes, beliefs, and state-level policies on pharmacists’ syringe dispensing behaviors (N=15). Informed consent was obtained prior to initiating the interviews and participants were provided modest compensation for their time. The semi-structured interviews were guided by Theory of Planned Behavior constructs to focus the interview on evidence-based predictors of behaviors. Interviews were audio-recorded, de-identified, transcribed, and are currently being thematically analyzed by the research team with NVivo software. The results of this study are expected to inform development of a survey instrument for a larger quantitative evaluation of pharmacists' perceptions on syringe dispensing in the region. Results: Not applicableConclusion: Not applicable

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Opioid analgesics are commonly used to treat acute and chronic pain; in 2016 alone, more than 60 million patients had at least 1 prescription for opioid analgesics filled or refilled. Despite the ubiquitous use of these agents, the effectiveness of long-term use of opioids for chronic noncancer pain management is questionable, yet links among long-term use, addiction, and overdose deaths are well established. Because of overprescribing and misuse, an opioid epidemic has developed in the United States. The health and economic burdens of opioid abuse on individuals, their families, and society are substantial. Part 1 of this supplement will provide a background on the burden of pain and the impact of opioid abuse on individuals, their families, and society; the attempts to remedy this burden through prescription opioid use; and the eventual downward spiral into the current opioid epidemic, including an overview of opioid analgesics and opioid use disorder and the rise in opioid-related deaths

In July 1980, the Barren River District Health Department (BRDHD), serving eight counties (combined population approximately 204,000) in Southcentral Kentucky, was selected as a demonstration site under the auspices of the federal Health Education Risk Reduction (HERR) Program. With continued HERR funding for eight years, the BRDHD developed several successful health promotion projects. Major components of these projects include: 1) community health promotion, which serves to identify high -risk groups in the community and provide them with health education-health promotion services, 2) school health education which included the development of a preschool health education curriculum, 3) teacher education workshop, which instructs primary and secondary public school teachers in health education methods, 4) smoking cessation. and 5) a large industrial wellness program. This study reports on an eight year program evaluation of the HERR demonstration. Overall, the program evaluation suggests an increase in health knowledge and some attitude and behavior change for many of the participants ii BRDHD programs.

Hospital-acquired infections (HAI) are not uncommon in healthcare facilities. They are usually prevented by sanitation techniques and by maintaining a high standard of care. Catheter-associated urinary tract infections (CAUTI) make up a large percentage of hospital-acquired infections and are often the most preventable type of HAI. Patterns in infection rate could provide new ideas on prevention techniques, which might further reduce infection rate, saving lives and cutting costs. CAUTI infection rate was measured from January KJIY to September KJIL and was differentiated based on hospital ward as well as month and season. Overall, ICU units tended to have a higher CAUTI infection rate than ward units, particularly in January, February, April, and May. The CAUTI infection rate was highest in the ICU units during spring and May, and lowest during fall and October. In the ward units, the CAUTI infection rate was highest during summer and March, and lowest during winter and February.

Individuals with type 2 diabetes mellitus (T2DM) are at risk for developing life-threatening comorbidities such as cardiovascular disease (CVD). As a consequence, T2DM is associated with increased morbidity and mortality and decreased quality of life, thus highlighting the importance of prevention of T2DM. Further, the prevalence of T2DM is substantially greater in rural populations compared to urban populations, making rural individuals particularly appropriate targets for T2DM prevention. T2DM is a largely preventable disease that is associated with modifiable risk factors such as poor diet, sedentary lifestyle, and obesity. Lifestyle interventions to improve these modifiable risk factors have been used to decrease the risk of developing T2DM. There is little evidence that supports lifestyle interventions as a means to decrease T2DM risk in rural populations with prediabetes, the precursor of T2DM. The purpose of this dissertation was to determine whether rural-living individuals with prediabetes would improve modifiable risk factors, specifically diet quality by following a lifestyle intervention; thereby, decreasing their risk of developing T2DM. Specific aims for this dissertation were to, 1) examine and synthesize data from dietary interventions used to reduce risk of T2DM in rural populations on order to identify gaps and guide future research, 2) critically evaluate validity and reliability of indices used to determine diet quality in research, and 3) determine the effect of a risk reduction program on improving diet quality and glucose control (as a measure of T2DM risk) in rural adults with prediabetes and CVD risk factors. Specific aim one was achieved by a review and synthesis of literature focused on lifestyle and dietary interventions used in rural populations to decrease the risk of developing T2DM. Common goals in these studies were a decrease in weight, decrease in dietary fat and calories, and an increase in physical activity. Decreased weight and increased physical activity were demonstrated in all eight studies, and a decrease in T2DM incidence was also demonstrated in one of the studies. However, diet quality was not adequately assessed in the majority of the studies. Furthermore, none of the studies were randomized controlled trials and only half used a control group. It was concluded that research using a more robust design is needed to determine the effect of lifestyle changes, specifically diet, on T2DM risk in rural populations. Specific aim two was addressed by a critical analysis of six common indices of dietary quality. Validity and reliability of the Healthy Eating Index, the Alternative Healthy Eating Index, the DASH diet score, the Diet Quality Index-Revised, the Healthy Diet Indicator, and the Diet Quality Score were examined. Five of the six indices are valid and reliable tools for measure diet quality but all five rely on an extensive food frequency questionnaire that may be burdensome for participants. The Diet Quality Score does not provide adequate evidence to support its use in research. It was concluded that a short, reliable, and validated diet screener may be useful in research. Specific aim three was addressed by a secondary data analysis of a longitudinal, randomized controlled study of rural residents with CVD risk factors and prediabetes. Diet quality, measured by the Mediterranean Diet Adherence Screener (MEDAS), and glucose control, measured by hemoglobin A1c, were analyzed in a subpopulation of 62 participants with prediabetes. Neither diet quality nor glucose control improved between baseline, four month, and 12 month post intervention. The reliability and validity of the MEDAS in this population is not known and may have been a factor in the lack of intervention effect related to diet quality. Participants were also not informed of their prediabetes status, thus it is not known if this knowledge would have made an impact on the outcomes of the study. In addition, the small sample size limits the statistical power to determine changes between the intervention and control groups. It was concluded that further research is needed to determine if a high quality diet will reduce T2DM risk in this rural population Considering the disproportionate prevalence of T2DM in rural populations compared to their urban counterparts, the results of this dissertation demonstrate a continued need for interventions that decrease modifiable risk factors associated with this disease. Interventions that target obesity, poor diet quality, and sedentary lifestyles in at-risk rural populations that are culturally tailored are needed to decrease risk of developing T2DM and the comorbidities associated with this preventable disease.

Determining the level of belief one has in themselves, or their self-efficacy, can be a key factor to improve certain dietary patterns and choices in the rural youth population. Sugar sweetened food and beverage consumption continues to rise and fruit and vegetable intake remains a struggle in rural areas; addressing both the food environment and adolescents’ self-efficacy could have a lasting impact on changing the nature of a generation of rural student’s food and beverage choices. This study measured self-efficacy levels of (n=425) adolescents in rural Kentucky and North Carolina using the Youth Impact Questionnaire and dietary intake using the NHANES Dietary Screener. Multiple linear regression analysis found that higher levels of self-efficacy resulted in a statistically significant ability to consume more vegetables. Further associations found that higher levels of self-efficacy resulted in increased fruit consumption, and improved added sugar food and beverage selections. These findings suggest that it could be beneficial to target adolescents’ self-efficacy as a way to modify certain health behaviors in a sparse food environment such as these rural Appalachian areas.

ABSTRACT Background Private Emergency Medical Services serve a vital role in the community, as such they are subject to job related stress. Currently, there is a limited amount of research related to the stressors related to the job. Objective The purpose of this study was to define the type of daily stressors faced by Private EMS personnel and investigate how they impact their Sense of Coherence. Study Design A mixed methods approach was used in this study to obtain the necessary data. Semi-structured one-on-one interviews were conducted with current employees of an EMS agency that provides 911 service in their area. After the interviews, the participants were administered a survey. Participants/setting Current EMS employees were invited to participate in an interview, in a location and time of their choosing. Both Paramedics and Emergency Medical Technicians (EMT) were invited to participate. Results Critical call incidents, while impacting the mental health of EMS provides, it does not impact them with the same magnitude of operational stress. Operational stress originates from the daily task, interactions and availability of resources. Operational stress was demonstrated to have a large impact on Sense of Coherence. Conclusion Operational stress can have a larger impact on Sense of Coherence of EMS personnel. Research is needed to determine which EMS model helps mitigate the impacts of operational stress on the EMS personnel.

Efforts to improve inclusion in research have included mandating the recruitment of ethnic minorities and women into NIH funded studies. However, little research has been completed on who attends such interventions. This is particularly worrisome in populations for which attendance to interventions can have dire consequences. HIV is a public health concern for pregnant women in substance using communities, as pregnant women are much less likely to use condoms during intercourse to prevent HIV. Group modular HIV prevention interventions have long been the standard for HIV prevention. However, little attention in research on HIV prevention interventions RCTs has been focused on attendance to these interventions. This study examined predictors of intervention and control group attendance in a randomized controlled trial comparing a 5-session Safer Sex Skill Building (SSB) intervention to a 1-session HIV education control group in a sample of pregnant women at risk for prenatal substance use. This study identified psychosocial and mental health variables associated with both 1 session control group and 5-session SSB intervention attendance as well as endeavored to identify the number of sessions necessary to attend to achieve an adequate dose in treatment. Findings include younger age and marital status as being predictive of participation in the one session HE control group and having a trade, skill, or profession as being predictive of participation in the five session SSB intervention group. Further research is needed to understand what factors may impact five-session SSB group attendance.