This study consists of an analysis of hospital discharge data from three Northeast Tennessee hospitals to identify maternal demographic factors that may be linked to higher rates of cesarean sections in this region of Appalachia. Maternal age, race, insurance status, length of stay, and birth weight were evaluated to identify regional trends in the prevalence of these factors over a two-year period. There were 1,678 (23.3%) singleton live births by cesarean section of which 7.6% were repeat cesarean section deliveries. Less than one percent of the 7,181 births were vaginal births after cesarean (VBAC) delivery. Overall, insurance and maternal age was found to be significant predictors of cesarean delivery. Using stepwise logistic regression, age was found to be a significant predictor of cesarean birth for women less than 35 years of age. Significance was found for cesarean birth and insurance status (OR=1.09, 95% CI=1.00,1.19) and for cesarean birth and mother’s age (OR=1.31, 95% CI=1.21,1.41). Mothers under the age of 35 who were insured under a managed care plan were at significant risk for cesarean section delivery. This study was limited in that only hospital discharge data were available and the study population was relatively homogeneous. Further research of this population is needed to continue investigation of the predictors of cesarean birth.

ABSTRACT Health Service Utilization and Stigma among HIV-Positive Men-Who-Have-Sex-With-Men (MSM) in Rural Appalachia by Roger Lee Blackwell The world has now entered the third decade of the AIDS epidemic. Men-who-have-sex-with-men continue to be disproportionately affected by HIV/AIDS. The United States still struggles in its response to this ongoing crisis in many areas: disease prevention, treatment, and HIV related stigma, prejudice and discrimination. Much of the information reported on MSM living with HIV has come from urban population centers, but only a few studies have focused on HIV positive MSM living in rural areas. Therefore, the overall aim of this dissertation was to explore the lived experiences of MSM living with HIV/AIDS, in particular the intersection of HIV related stigma with social, behavioral and health outcomes in rural, South Central Appalachia. For this dissertation, data were collected via semi-structured, face-to-face interviews with 23 HIV-positive MSM living in South Central Appalachia. Using a descriptive narrative approach, the researcher sought to address the influence of HIV/AIDS related stigma in the lives of these men and provide a forum for their voices. Qualitative data were sorted into various categories from which emergent themes and topics were generated using Nvivo software for data management and manipulation. In addition to qualitative interviews, demographic data were gathered and analyzed to produce basic, descriptive statistics. Results indicated that MSM participating in this study accessed health services through various agencies. MSM also experienced stigma in multiple and overlapping ways; MSM described stigmatizing experiences stemming from religious sources, communities, family and friends, and from the medical establishment. Moreover, it was revealed that homophobia and HIV-related stigma were related; participants did not differentiate between the two. Homophobia and HIV related stigma were specifically contextualized in relation to rurality and religiosity. The use of health related services was not mediated by stigma. The results within this dissertation are intended to inform health professionals in the planning and implementation of interventions and treatments for this hidden population in Appalachia. This exploratory dissertation provides insight and contextual information for a highly stigmatized population. Lastly, this project provided rural MSM with a voice.

The purpose of this study was to evaluate the prevalence of child psychosocial concerns in rural primary care, hypothesized to be greater than national averages due to lacking mental health services in rural areas. This study was an examination of the role of SES, various definitions of “rural,” and the interaction of SES and rurality, in predicting parent-reported child psychosocial concerns in Appalachian primary care clinics. Caregivers presenting with their child at one of 8 pediatric primary care sites (n=2,672) were recruited to complete a measure assessing demographics and the Pediatric Symptom Checklist (PSC). Results showed that while rural status was not associated with PSC scores, higher parental education was associated with lower rates of clinically significant psychosocial concerns. The present study failed to replicate prior preliminary findings that child psychosocial concerns are more prevalent in rural primary care. SES, rather than rurality, appeared to be the primary predictor of such concerns.

We introduce the Seasonal Beliefs Questionnaire (SBQ), a self-report inventory of maladaptive thoughts about the seasons, light availability, and weather conditions, proposed to constitute a unique cognitive vulnerability to winter seasonal affective disorder (SAD; Rohan, Roecklein, & Haaga, 2009). Potential items were derived from a qualitative analysis of self-reported thoughts during SAD-tailored cognitive-behavioral therapy (CBT-SAD) and subsequently refined based on qualitative feedback from 48 SAD patients. In the psychometric study (N = 536 college students), exploratory and confirmatory factor analyses pruned the items to a 26-item scale with a 5-factor solution, demonstrating good internal consistency, convergent and divergent validity, and 2-week test-retest reliability. In a known groups comparison, the SBQ discriminated SAD patients (n = 86) from both nonseasonal major depressive disorder (MDD) patients (n = 30) and healthy controls (n = 110), whereas a generic measure of depressogenic cognitive vulnerability (the Dysfunctional Attitudes Scale [DAS]) discriminated MDD patients from the other groups. In a randomized clinical trial comparing CBT-SAD with light therapy (N = 177), SBQ scores improved at twice the rate in CBT-SAD than in light therapy. Greater change in SBQ scores during CBT-SAD, but not during light therapy, was associated with a lower risk of depression recurrence 2 winters later. In contrast, DAS scores improved comparably during CBT-SAD and light therapy, and DAS change was unrelated to recurrence following either treatment. These results support using the SBQ as a brief assessment tool for a SAD-specific cognitive vulnerability and as a treatment target in CBT-SAD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Studies linking exposure to indoor tanning beds that emit ultraviolet radiation with melanoma and other skin cancers began to emerge as early as the 1980s, and a compelling body of evidence now exists to support the carcinogenic effect of indoor tanning. Incidence rates for melanoma have increased among populations with high use of indoor tanning beds, including young women, mirroring increasing rates of use.1 These persuasive data have led to increased attention on the dangers of indoor tanning, along with warnings from the world’s leading public health and medical organizations. Regulatory efforts including restricting access for minors have followed throughout the UK and globally.

In the United States, parents' health beliefs affect HPV vaccination decisions for children. Our team acquired insights into mothers' health beliefs from their reactions and comments to posts on HPV vaccination in a social media adolescent health campaign in a randomized trial (n = 881 mothers; 63.1% reported daughters had 1+ doses of the HPV vaccine) evaluating communication intended to reduce daughters' indoor tanning. A total of 10 HPV vaccination messages in didactic (n = 7) and narrative (n = 3) formats were posted on vaccination need, uptake, and effectiveness and stories of young women who died from cervical cancer and a mother's decision to vaccinate her daughters. These posts received 28 reactions (like, love, and sad buttons; mean = 2.8 per post) and 80 comments (mean = 8.0 per post). More comments were favorable (n = 43) than unfavorable (n = 34). Data was not collected on views for posts. The most common favorable comment reported that daughters were vaccinated (n = 31). Unfavorable comments cited safety concerns, lack of physician support, distrust of pro-vaccine sources, and increased sexual activity of daughters. Mothers posting unfavorable (18.2%) as opposed to favorable (78.6%) comments or not commenting (64.0%) were less likely to have had their daughters vaccinated (chi-square = 22.27, p < 0.001). Favorable comments often did not state reasons for vaccinating. Concerns about lack of vaccine safety remain a barrier. Mothers may express distrust in pro-vaccine sources to reduce discomfort with not vaccinating daughters to reduce their risk for HPV infection. Many mothers who remained silent had vaccinated daughters, which suggests they did not resisit HPV vaccination.

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