Background: Nearly half of the US population is overweight or obese, carrying with them a higher risk for morbidity and mortality and rising healthcare costs. Rural women are disproportionately affected, with higher rates of obesity, obesity-related chronic diseases, and poorer health outcomes (Befort, Nazir, & Perri, 2012; Penney, Rainham, Dummer & Kirk, 2014). There may be several factors. In general, rural health systems are more isolated, with a lack of healthcare resources including quality providers, technology, and public health services (IOM, 2009). Purpose: The purpose of this quality improvement project was to assess how obesity is managed in women residing in one rural community - Ritzville, Washington. Methods and Aims: Charts of all women ≥ 18 years of age receiving care at Hometown Family Medicine clinic (HTFM) were queried for a diagnosis of obesity. The prevalence of obesity in this group was calculated. Of those identified as obese, thirty charts were selected at random and reviewed. The following was determined: 1) Prevalence of chronic disease in adult women who receive care at HTFM; and 2) The management of obesity at HTFM compared with current evidence-based guidelines. This was followed by a community assessment to determine the resources available for the prevention and treatment of obesity in Ritzville, WA. Results: The prevalence of obesity (36.9%) and chronic diseases (hypertension, diabetes type 2, dyslipidemia, and heart disease) in the population studied were found to be significantly higher than both state and national averages. Due to a lack of basic resources, (access to weight loss specialties, exercise facilities, healthy foods, etc.) management of obesity in Ritzville, WA may be challenging. Findings from this study helped to inform resource allocation and identified opportunities to improve the management of obesity based on current practice guidelines. Primary health care may be the only opportunity to promote healthy behaviors and improve health outcomes in this vulnerable population. Action needs to be taken or the burden of obesity will continue to rise.

Mental health has become an increasingly importantly focus in the UK policy landscape because of its social and economic impact. However, most research to date has focused on living with mental health issues, or providing mental health services, in urban settings. There is limited understanding of the experiences of rural dwellers with mental health issues or the role of the voluntary sector in terms of its contribution to mental health service provision in rural areas. Thus, this PhD explores the experiences of rural mental health service users and providers in Scotland and Canada, and also considers the contribution of mental health voluntary organisations in helping to overcome the challenges of social exclusion for service users, as identified in previous research. Two theoretical lenses were used to frame the research questions. First, the concept of social inclusion provided a lens to analyse the processes by which service users achieve, or not, a sense of belonging and connection in society (Philo 2000). Second, Putnam's (2000) theory of social capital provided a further analytical lens by which to explore the contribution of rural voluntary organisations. Social capital focuses on the features of populations such as social networks, trust and norms of reciprocity that shape the quality and quantity of social interactions (McKenzie & Harpham 2006). The aims of the research were to: To explore the impact of rural life for mental health service users' daily life and access of services To understand the contribution of rural mental health services to tackling social exclusion for service users The five research questions used in this thesis were: What does it mean to experience mental health problems in remote and rural areas? What are the challenges that service providers face in remote and rural areas? What benefits are there for service users attending voluntary groups in remote and rural areas?

Emergency Medical Services (EMS) is an institution and product of public health, health care, and public safety that is chopped and scattered across multiple jurisdictional deployment methodologies throughout Arizona. To fully-asses the EMS needs of the state, those jurisdictions are considered as a whole; for it is the whole that makes a system, and a system is what truly impacts patient outcomes. Evaluating the ""whole"" is the genesis and driver of the 2016 Arizona Statewide EMS Needs Assessment (ASENA). The primary objective of ASENA is to establish a current ""snap-shot"" of EMS in the state while simultaneously identifying needs and/or areas that can be targeted for further analysis and/or improvement as part of Population Health Management and Emergency Medical Services Integration under the AZ Flex Grant funded by the U.S. Health Resources and Services Administration (HRSA). In addition, the secondary objective of ASENA is to compare and contrast this current ""snap-shot"" with data obtained in a more narrow needs assessment conducted in 2001, allowing comparison of changes in Arizona's critical access EMS system over 15 years. To accomplish this, a 105-question needs assessment survey tool was developed and distributed to EMS agencies throughout the state. The fully-vetted survey tool collected information pertaining to sixteen core functional sections. Eighty-six agencies fully-completed the needs assessment survey tool, with respondents evenly distributed across the state's four EMS coordinating regions and representative of the various service-delivery methodologies. The combined service areas of the respondents cover over 85% of the state's population. Arizona's statewide EMS system is well organized and positioned to deliver advanced levels of prehospital care for the vast majority of its citizens and visitors, with some variation between urban and rural regions. Key needs identified relate to: patient care reporting between EMS providers, emergency departments and receiving hospitals; quality assurance activities; education and skills training programs; dispatch system capabilities; mass casualty and public health preparedness; equipment and supplies; and more robust use of data and analyses to inform continuous EMS system improvement.

Magister Curationis - MCur / South Africa has a general shortage of most categories of health professionals, which include nurses, doctors, dentists and pharmacists. However, the problem is exacerbated by the fact that most of these professionals either work in the private health sector or have migrated to more affluent countries. Shortages of nurses in the rural setting continue to pose a problem for the Department of Health. The community service policy is stated in Section 40 of the Nursing Act, of 2005, and in the Regulations relating to Performance of Community Service published in the Government Notice No. 765 of 24 August 2005. In 2008, the first professional nurses started with their community service. Community service for health professionals is a policy proposal of the Department of Health that reacts to the lack of meeting the health requirements in poor communities, particularly in rural areas. It offers graduating health professionals with the prospect of gaining first-hand working experience in conditions of poverty and underdevelopment. South Africa is implementing community service for health professionals as a plan to manage the difficulties of human resources in the health sector. The transition period for community service practitioners in a rural setting is different, which implies that most support may need to be strengthened due to the remoteness of the rural setting. The purpose of this study was to describe the experiences of community service practitioners during their community service at a rural health facility. From the findings, guidelines were described for the operational managers who are responsible for supporting the community service practitioners at a health facility in a rural area. A qualitative, exploratory, and descriptive design was applied, using individual unstructured interviews and field notes. Each interview took around 30-45 minutes to complete. The purposively selected sample consisted of community service practitioners (n = 10) who were practicing at rural health facilities. The process of inductive coding of Thomas (2003:5) was used to analyse the data. The results of this study indicate that a process is needed for community service practitioners fresh from university and an urban environment to adapt to a remote rural health facility. Some of the participants did receive an orientation programme at the beginning of their community service year. However, most of the community service practitioners that took part in the study learned from their experience during the year of their placements. For some, the learning opportunities were more available in the rural setting than when they had worked as students at the urban hospital during their training.

Introducción. En Perú, durante el servicio social en salud se han reportado problemas como condiciones laborales riesgosas, mortalidad asociada a accidentes de tránsito y déficit de cobertura de aseguramiento.Objetivo. Describir los problemas percibidos y experimentados por los profesionales de salud que realizan el Servicio Rural y Urbano Marginal de Salud (SERUMS) en Ancash, Perú, y evaluar su asociación con la práctica de los profesionales y la categoría del establecimiento donde se realiza el SERUMS.Materiales y métodos. Durante abril del 2015, se realizó un estudio transversal analítico con profesionales de salud que realizaban el SERUMS en establecimientos del Ministerio de Salud de Ancash. Se aplicaron encuestas para recolectar datos generales, características y problemas del SERUMS.Resultados. Se analizaron 364 encuestas. El 79.3% de los participantes fue de sexo femenino, la edad promedio fue de 27.4±5.0 años, 80.0% percibió carencia de insumos, 54.4% percibió carga laboral excesiva, y 14.7% sufrió algún accidente de tránsito durante el SERUMS. Ser médico y laborar en establecimientos I-1 fueron factores asociados a haber sufrido accidentes de tránsito y otros imprevistos.Conclusiones. Los encuestados reportan carga laboral excesiva, carencia de insumos y accidentes. Los accidentes son más frecuentes en médicos y en establecimientos de categoría I-1.

Class of 2017 Abstract / Objectives: To facilitate a discussion among various healthcare professionals about the facets of interprofessionalism that occur, or do not occur, in a rural acute healthcare setting, and how interprofessionalism could be integrated into the facility’s current healthcare professional student programs. Methods: A focus group was conducted with 8 participants lasting about 45 minutes. Participants were one of three different professions (nurse, medical doctor, or pharmacist) and included administrators as well as staff employees. Six questions were discussed among participants and the answers from each participant were scripted onto a word document. This document was thematically analyzed and compared and contrasted to a previous study, which asked the same six questions in a different rural acute healthcare site. Results: The main findings of this study were that workforce shortage, lack of computerized physician order entry (CPOE), and lack of a uniformity throughout the hospital affected interprofessional practice, learning, and education. Conclusions: Perceived barriers of interprofessional practice at Canyon Vista Medical Center included: poor communication, understaffing, lack of a unified, computerized EHR throughout the hospital, and unclear policies. Some proposed ways to overcome these barriers include having a full staff, creating a unified electronic health record (EHR) system, offering interprofessional learning opportunities, and providing employees the opportunity to gain experience in departments other than their own.

Title: MENTAL HEALTH INTERVENTION STRATEGIES FOR YOUTH IN RURAL NORTHEAST TN Introduction: A major need in Hawkins County entails lack of access to mental health resources. As a rural Appalachian county, this scarcity is especially felt by the area’s youth, who are subject to peer pressure, higher ACE scores, and may lack the autonomy to seek out professional help. Methods: The community-based intervention spanned in three consecutive weekly small-group sessions. Eligible participants were recruited from the afterschool program at the Boys and Girls Club of Hawkins County and must have been in the 5th to 8th grade (middle school) during the course of the study (n=13). Each participant completed a pre-­intervention assessment, a series of short weekly surveys (one per session) and a post-­intervention assessment to determine effectiveness and retention of the material presented. Statistical significance was determined using a paired T-Test. Results: Results did not provide any statistically significant relationships but trends were observed in perceived stress which decreased overall from pre-survey to post-survey (p=0.716), as did the self-reported use of negative coping strategies in the group (p=0.193). There was also a slight increase (p=0.653) in self-reported use of positive coping skills. A trend for greater change in the male participants was also observed. The mindfulness activity was perceived with a higher affinity than the baseline knowledge (Unpacking Mental Health) session (p=0.017). Conclusions: The results of this study suggest that short 1-hour interventions per week, especially those incorporating mindfulness strategies, can influence attitudes and coping strategies in rural adolescent children compared to mental health knowledge sessions alone (p=0.017). Trends in gender differences could underlie cultural and societal norms. Due to the limited number of mental health providers, evaluating behaviors were considered but not utilized. These trends, especially in mindfulness activities, could help further guide community partner mental health strategies for youth in rural Appalachia. Overall, these initial trends warrant further work in a much larger sample size and power of the study to draw definitive results.

People who inject drugs (PWIDs) are the most stigmatized and marginalized people in the general population (Ahern, Stuber, & Galea, 2007; Birtel, Wood, & Kempa, 2017). This group is not easily accessed by typical means of patient outreach and is one of the most underserved populations for primary care, mental health services, and care for chronic infectious diseases associated with injection drug use including HIV and HCV (Ahern et al., 2007; Dean et al., 2000; Livingston, Milne, Fang, & Amari, 2012; Zeremski et al., 2013). Syringe Service Programs (SSPs) can give public health and social support organizations and agencies access to an otherwise underserved population and give PWID potential access to a constellation of care to address multiple comorbidities associated with injection drug use (Barocas et al., 2014; Pollack, Khoshnood, Blankenship, & Altice, 2002; Zeremski et al., 2013). Additionally, the potential access to primary and secondary care that SSPs may connect PWID to, perceived social support is one of the strongest predictors of well-being and mental health among people with stigmatized conditions including HIV/AIDS, HCV, and PWID (Birtel et al., 2017). Wider adoption of SSPs and bridging of SSP clients to Medication Assisted Treatment providers is a potential tool in combating the current opioid epidemic in Tennessee. The Tennessee Poll by ETSU was conducted between March and April of 2017. The Tennessee Poll is an annual statewide public opinion poll conducted by the Applied Social Research Lab (ASRL). In the Tennessee Poll, questions were asked about attitudes and beliefs associated with SSPs and PWID in Tennessee. In a previous project, the research team, using generational demographic categories used in Pew surveys, looked at attitudes about both illicit and medical use of marijuana. In comparison of generations, Millennials were 15.62 times (95% CI 5.6, 43.56, p < .001) more likely to support recreational marijuana legalization versus the reference category (The Silent Generation or the generation before Baby boomers and sometimes called “The Greatest Generation”) and 3.7 times (95% CI 1.47, 9.3, p

Rural communities across the United States suffer from multiple health disparities that range from access to care to awareness of medical information. These disparities are characterized by increased incidence of illnesses, mortality rates, lower quality of life, and lower life expectancy when compared to the general urban population. Several risk factors have been identified that play a direct role in these characteristics. These include geographic isolation, lower socioeconomic status, higher rates of health risk behaviors, and limited job opportunities, and less health education. Hawkins County Tennessee is one such rural community that suffers from these disparities. The leading cause of death in Hawkins County is cardiovascular disease (CVD). Due to the nature of disease, early life long modifiable risk factors play a critical role in its development. Health education and awareness of the disease is also a key factor in the disease's effects in the community. Studies have shown that early life healthcare awareness is an “important determinant of adult health status.” This led us to examine the current state of cardiovascular disease awareness and perception among teens in the community. To examine the current perception of CVD in Hawkins country we created an assessment for ninth grade students attending Cherokee Highschool during their health class block. We also aimed to assess the effectiveness of an interactive interventional educational program targeted at both educating the technical knowledge surrounding CVD and at reducing modifiable risk factors that lead to CVD. The interactive educational program was designed and given to students (n=82; 47 Male 35 Female) across 5 class period in two sections (Cardiovascular health and Nutritional & Physical health) that were taught one week apart. Students underwent a Pre-test/survey that examined four areas of interest: perception & technical knowledge of CVD, perception of physical activity, perception of nutrition and diet, and current family health. After completing the program students were then given an identical post-test/survey. Result means were compared between Pre and Post survey using Independent sample T-test. Analysis showed that technical understanding of CVD and of modifiable risk factor significantly increased across all areas (P

Introduction: Prediabetes is major risk factor for the development of Type 2 Diabetes Mellitus (T2DM). One-third of the population in the United States has prediabetes, but 90% remain undiagnosed because healthcare providers are not performing screenings, making this a public health challenge. The purpose of this process improvement project was to implement prediabetes screening, prediabetes identification, and a referral process to a nutritionist to prevent or delay the onset of T2DM in patients in two Federally Qualified Health Centers. Methods: This was a quality improvement project conducted over a six-week period after receiving exemption from the University’s Internal Review Board. The Knowledge to Action framework was used to guide implementation of screening, prediabetes identification, management, and referral process. The outcomes were to measure the number and percent of screenings performed after provider education on prediabetes screening, those at risk for prediabetes, and the evidence-based interventions providers chose for management. The prediabetes risk assessment tool (PRAT) was the “Are you at risk for Type 2 Diabetes?” It was administered in both English and Spanish to adults who were not pregnant and had no previous diagnosis of Type 1 Diabetes Mellitus or T2DM. The preferred interventions included referral to a nutritionist, encourage 5%-7% total body weight loss, and/or 150 minutes of exercise per week. The PRAT and interventions data were coded, extracted into SPSS Version 25, and analyzed. Descriptive statistics were used to report patient characteristics, quantity of screenings performed, evidence-based recommendations offered, and patient risk factors for prediabetes. Results: In both clinics, 41% (n=269) of patients screened were found to be at risk for prediabetes. The most self-reported risk factor for prediabetes was family history of T2DM. Healthcare providers mostly provided education on weight loss and exercise, and recommended/referred less than 20% (n=49) of patients for nutritional education. The screening rates in the clinics were 52% (n=92) at site A and 72% (n=177) in site B, falling below the goal of 100%. Conclusions: There remains a gap in provider knowledge and use of evidence-based recommendations to decrease patients’ risk for prediabetes. The authors project that implementation of the PRAT and evidence-based interventions in the electronic health record would positively impact future screening results. This project set the benchmark for future efforts to educate, encourage, and measure providers successes.