Background: The prevalence of diabetes is disproportionately distributed in Central Appalachia compared with other regions in the U.S. Previous research reveals that nearly 65% and 17% of patients with diabetes reported having history of cardiovascular heart disease (CHD) and coronary artery disease (CAD) respectively. This study examined the prevalence of factors associated with subclinical atherosclerosis (measured as coronary artery calcium) in patients with diabetes in geographic locations of rural Central Appalachia. Methods: The study population consisted of 2479 asymptomatic individuals from the rural Central Appalachian region of Kentucky, North Carolina, Tennessee, and Virginia between August 2012 and November 2016. Descriptive analysis was completed for the total sample size with sub analysis of individuals with diabetes. T-test was used for comparison of categorical (example: hypertension and physical inactivity) and continuous variables (example: age and BMI), respectively. In addition, multinomial logistic regression was conducted to assess the association between multiple risk factors including CAC scores, and geographic locations of patients with diabetes in rural Central Appalachia. Results: There was no significant difference between ages for diabetic and non-diabetic patients. Individual factors which are associated with diabetes include current CAC score (p<0.001, CI: 45.90 – 189.98), BMI (p<0.001, CI: 3.01 – 5.64), sedentary lifestyle (p<0.005, CI: 0.039 – 0.215), history of CAD (p<0.001, CI: 0.08 - 0.19), hypercholesterolemia (p<0.001, CI: 0.64 – 0.23), and hypertension (p<0.001, CI: 0.18 – 0.34). There was no significant correlation between geographic locations and diabetes. Among male and female genders, hypertension, hypercholesterolemia, history of CAD, sedentary lifestyle, current CAC score, and BMI have a significant positive correlation with diabetes except for self-reported obesity which only has a significant positive correlation with the female gender. Conclusion: Individual factors remain associated with diabetes across the male and female genders regardless of the geographic locations of the diabetic patients in rural Appalachia. There is strong evidence that cardiovascular related factors could be associated with diabetes across both genders in rural Central Appalachia. We suggest the implementation of evidence-based public health strategies to address the modifiable behaviors that can improve the health of people in rural Central Appalachia.

In 2015, TN had the 9th highest teen birth rate in the United States. School-based sex education programs have shown promise in curbing teen pregnancy rates. In TN public schools, sex education could be taught by teachers of subjects like biology, health education, or invited guests from ministries, or national or local nonprofit agencies. The content, rigor, and approach of sex education taught by these diverse groups of providers remains unknown. This pilot study tested a survey questionnaire and methodology, while providing information on the providers’ sex education practices and perspectives. We adapted validated measures from past sex education surveys to reflect the context of TN. The survey items were reviewed and refined by diverse groups of experts on school-based health education, teen pregnancy prevention programs, and adolescent health. The survey was created and distributed via a web-based tool. A recruitment email or letter with a weblink to the survey was sent to 3,249 potential sex education providers, from April to June 2017. Of all contacts, 509 completed the survey, yielding a response rate of 15.7%. Of those who completed the survey, 137 taught sex education in the 2015-2016 school year to any of grades 5 through 12 students. Survey responses were analyzed using descriptive tests. Abstinence (83.9%) was taught by most respondents, by grade 12, but far less respondents taught topics related to birth control (65.0%) and condoms: how to use condoms (22.6%), how to use and where to get other birth control (31.4%). Providers with more years of experience, and those who expressed that they had received enough training, were more likely to teach more number of topics, including controversial topics, such as condoms and birth control. Most providers indicated that sex education topics should be taught in earlier grades. This study identified the job titles of providers, content being taught, approach to teaching, and how providers would want to teach sex education. Identifying providers is crucial to designing sex education training programs, tracking program effectiveness, and changes in practices over time, to achieve the goal of curbing TN teen pregnancy rates through quality sex education.

People living in rural America face unique social circumstances that can prevent them from reaching optimal health status. This fact holds especially true in the rural Appalachian region of the United States where income, education, living circumstances, and lack of resources create an environment that has some of the highest rates of morbidity and mortality in the country. While the rest of the country has seen improvement in many health behaviors and health outcomes, rural Appalachian communities remain unchanged and further behind other regions. In many cases, programming and policy have failed to create a culture of health in Appalachia. Social determinants of the area should be included in interventions and this practice is imperative to achieve effectiveness. This study examined the social context and definitions of health in a rural, Appalachian community using the Social Quality Theory as a guiding framework. A community-based participatory research approach was adopted and implemented through the use of focus groups. The study generated many meaningful findings. It not only provided a new framework, but also provides an examination of how a rural, impoverished community lacks the social infrastructure to improve health. Current perceptions of health are limited to thoughts of disease or illness and overshadowed by negative social norms. There are few social resources currently available to improve health and a large presence of cultural impediments. Yet this “culture” also provides some advantages and assets that the community may leverage for change.

Background: Transgender or nonbinary (TNB) individuals in the United States experience higher rates of sexual and reproductive health disparities when compared to their cisgender counterparts, along with lower access to care. TNB people in the south experience higher rates of disparities. Societal, interpersonal, and individual barriers contribute to these disparities in the TNB population. However, there is a paucity of research examining the sexual and reproductive health experiences of TNB people living in Central Appalachia. Methods: An interpretive phenomenological analysis (IPA) research design was used to collect and analyze semi-structured interviews with TNB individuals living in central Appalachia regarding their sexual and reproductive health experiences. Transcribed interviews were analyzed repeatedly by the primary investigator and the study equity committee to identify emergent themes which focused on understanding an individual’s lived experiences through interpretation. Results: Twenty participants from eastern Tennessee and western North Carolina from four Appalachian states within three Appalachian sub-regions participated in this study. Four themes were identified: a) perceptions and/or experiences receiving SRH healthcare shaped the individual’s self-agency regarding accessing and receiving SRH care, along with influencing their sense of self regarding their gender; b) heteronormative expectations within the medical field influenced interactions with providers and the care system; c) community is integral to SRH experiences, and d) policy and laws impact willingness and ability to access SRH care. Discussion: TNB individuals living in central Appalachia experience individual, interpersonal, community, and social factors that impact their sexual and reproductive healthcare experiences. By addressing these factors based on recommendations from participants, public health leaders, policy makers, and providers can improve sexual and reproductive healthcare experiences of TNB people living in central Appalachia.

COVID-19 presented unique challenges for rural Mississippi communities including impacts on the mental health of rural individuals. This research study aimed to identify opportunities for mental health interventions to provide health promotion professionals with quantitative data on the accessibility and the likelihood of engagement with mental health-fostering behaviors. A secondary objective of this research was to categorize these behaviors within the constructs of the Social Ecological Model. Demographics for rural Mississippi communities were collected and displayed, and using multivariate analyses including Spearman’s correlation and a Mann-Whitney U test the correlation between mental health fostering behaviors and demographic factors was obtained. Results showed differences in self-reported accessibility and likelihood of engagement when broken down by race, age, and gender.

Taste is one of the crucial factors that contributes to shaping eating behaviors and is also one of the leading reasons that affects our preferences to like or dislike some foods that mainly have a bitter taste. Variation in bitter phenotype (tasters and non-tasters) could influence diet quality and in turn body weight, which overall influenced health outcomes. The objective of this study was to identify whether bitter taste phenotype status influences anthropometric measurements, body fat percentage, and eating behaviors (liking and intake) in female college students. In this cross-sectional study (n = 86), female college students aged 18 to 22 from Mississippi State University were classified into one of two groups (taster or non-taster) by means of a taste test of filter paper saturated with the bitter compound 6-n-propylthiouracil (PROP). Adiposity was measured using anthropometric measurements and body composition was measured using bioelectrical impedance analysis. A food liking survey was administrated to identify how much participants liked or disliked various foods and beverages. Dietary intake of total energy intake, macronutrients, fruits, and vegetables were evaluated using the NIH Diet History Questionnaire. Bitter phenotype status was not significantly associated with adiposity indicators; however, it was associated with food liking scores for foods that have bitter and umami tastes such as kale and mushrooms. Additionally, bitter phenotype was associated with dietary intake for total fruits and vitamin C intakes. Ethnic background was the strongest independent variable that was significantly correlated with adiposity indicators and food liking. These results suggested that while bitter taste phenotype may influence eating behaviors in certain foods, it does not affect adiposity indicators and body fat percentage.

The College of Public Health at East Tennessee State University started a program in 2011 to teach the skills needed to protect and promote health and well-being in resource-limited settings. The need to provide public health services in resource-limited settings exists in both wilderness and isolated settings and when a disaster disrupts basic societal infrastructure. In these settings, lives may depend on the ability to provide water, sanitation, hygiene, shelter, first aid, and other basic services. Over the last decade, the college expanded the program considerably into what is now known as Project EARTH (Employing Available Resources to Transform Health) that now includes several different academic courses as well as programs designed to develop innovative solutions to address the needs of people in resource-limited settings. Working in a resource-limited setting requires effectively utilizing locally available resources to improve and protect people's health and well-being. Project EARTH focuses on teaching students to design and create specific products for these situations while progressively honing those cross-cutting skills necessary to work effectively in these settings-notably teamwork, creativity, and resilience. To this end, Project EARTH implements a sequential learning process that includes significant hands-on training and simulated experiences with debriefing opportunities at the end of each activity. Project EARTH may serve as a useful model for others considering a similar training program.

Older Americans will soon outnumber children and younger adults. In 2022, there were 58 million older adults. By 2050, older adult numbers will grow to 82 million, and by 2060, 100 million. The National Institute on Aging calls for ongoing research on the impact that a historically large aging population will have on health, well-being, and quality of life. A key concern is how to meet needs while decreasing costs associated with institutional long-term care. Most of these elders reside in the community and wish to live in their homes throughout their lives, but they will experience an increased need for age-related healthcare and resources in their rural communities. There is little in the literature about these issues. A qualitative, descriptive, phenomenological study was undertaken to describe the availability of resources for aging in place through the lens of rural community service workers' lived experience and perceptions. The study was underpinned theoretically with Rural Nursing Theory and conceptually by principles of aging in place. Resulting themes included easily vs not easily accessible resources for aging in place, bridges or battles to support aging in place, and big dysfunctional puzzle of fragmented and scattered resources. By focusing on aspects of rural environments and concepts of aging in place, the study describes the contextual differences of rural aging in place, illuminates the reality of rural aging, and highlights the need for cost-effective expansion of age-related resources for rural aging in place.

Nail technicians can be exposed to more chemicals and allergens than the general population due to the unique exposures they experience in their day-to-day operations. This study focused on behaviors nail technicians participated in that may have increased their risk of infection, pain, allergy, or ailment. A cross-sectional study was organized, assessing the prevalence of behavioral exposures among nail technicians and their correlation with other factors like prior education, workplace type, and symptoms experienced. The goal was to create a better understanding of how the modern-day nail technician is protecting themselves while working, by identifying gaps to facilitate the creation of more impactful education interventions.

This study was designed to explore the literature on competitive food policy implementation (CFPI); examines demographic and school factors associated with CFPI; and explores the experiences of school leaders and staff in CFPI using a proposed theoretical framework to guide the research. Competitive foods are those sold in vending machines, a la carte settings, fundraisers, class parties and other venues which compete with foods offered through the national school lunch and breakfast programs. Competitive foods have traditionally been of low nutritional value and high energy density. CFPI may be effective in reducing student calorie intake and BMI. However, evaluation of competitive food policy effectiveness is difficult due to variability in policy implementation. A theoretical framework is needed to guide research on CFPI. This research was a mixed methods study including a review of the literature, quantitative secondary analysis, and a qualitative content analysis of transcripts from semi-structured interviews with school personnel to understand their experience with CFPI. First, a systematic review of the research literature on CFPI was conducted. Demographic and school factors, policy features, and school and parent/community-level factors that impact CFPI were identified. Second, the association of multiple demographic and school factors with CFPI scores was examined. CFPI scale (overall) and sub-scales (“inside” and “outside” school) were developed and validated to evaluate CFPI effectiveness in Kentucky middle and high schools (N=640, grades 5-12). The scales were based on responses to 8 questions on competitive food practices from a 2011 School Tobacco and Wellness Policy biannual survey conducted by the University Of Kentucky College Of Nursing Tobacco Policy Research Program. Student BMI tracking and presence of a written wellness policy predicted higher scores on the overall CFPI scale (BMI OR=2.06, p=0.001; Wellness OR=1.74, p=0.02), inside subscale scores (BMI OR=2.46, p<0.0001; Wellness OR=1.58, p=0.05), and outside subscale scores (BMI OR=2.27, p=0.03; Wellness OR=1.54, p=0.0005). Greater county-level adult obesity rates predicted lower overall CFPI scores (OR=0.93, p=0.02). Private school status predicted lower scores on inside CFPI subscale scores (OR=0.47, p=0.004). Third, semi-structured interviews were conducted with 23 school personnel to explore CFPI. Interviews were recorded, transcribed and content analysis was conducted. Kentucky schools were stratified into four groups based on school level (middle or high) and CFPI scores (high or low). Sixteen schools were randomly selected for each of the four groups. A total of eight schools, two from each group, agreed to participate. The interview guide was based on a proposed CFPI framework based on implementation science, educational and organizational theory research. Six key themes emerged: internal/external forces enabling CFPI; internal and external obstacles to CFPI; key organizational values; organization value of CFPI; methods that organizations use to communicate organizational values; and CFPI policies and procedures. Findings were discussed in the context of the proposed theoretical framework. Implications for policy, practice and future research are presented.