Background. Obesity has reached epidemic proportions over the past 20 years. Methods. This study investigated the differences in rates of obesity and perceptions of health status between rural, urban, and suburban Southern women based on selected socioeconomic factors. Using data from a national health survey, the reports from 4,391 women aged 40 to 64 years were included in the study. Results. Significantly more rural women lived in poverty, reported a poorer health status, and had a greater prevalence of obesity. Urban women had the next highest obesity rate and a moderate health status. The healthiest group with the lowest obesity and poverty rates were suburban women. Conclusion. Obesity and poor overall health are closely related in rural women. The greatest challenge to health care providers is to provide appropriate community-based weight-management programs.

Approximately 1 in 5 adults in the U.S. identify as a caregiver. Caregiver is defined as providing care for friends, family members or others on a regular basis, who need medical care. Providing care may be rewarding, it may also be significant burden on the caregiver. Prior research has found that caregiver status has been linked to increase levels of stress. This may be of an increased burden in rural/non-metropolitan areas, where transportation is limited, along with other challenges including access to care, and other factors. The proposed study examines the association of caregiver status and substance use (marijuana, alcohol, and smoking) and depression among rural populations, using a nationally representative sample. We used cross-sectional data from the 2021 Behavioral Risk Factor Surveillance System a nationally representative U.S. telephone-based survey of adults over the age of 18 years and extracted data for non-metropolitan/rural counties. Logistic regression analyses were conducted separately to test the association between self-identified caregiver status and three outcomes, including depression, current marijuana use, and current alcohol use. We controlled for past month alcohol use, income, race, educational status, and age. Caregiver status was identified based on providing care or assistance to a friend of family member over the last 30 days. Overall, 21.7% (n=13,653) of our participants self-identified as a caregiver, while 19.5% reported depression, past month alcohol use (48.2%) , past month smoking (13.5%), and past month marijuana use (4.2%). Self-identified caregiver status was associated with higher odds of depression (OR=1.51, 95% CI, 1.44,1.58), past month marijuana use (OR =1.74, 95% CI, 1.51, 2.01), and past month smoking (OR=1.38 95% CI, 1.31, 1.45). Self-identified caregiver status was not associated with past month alcohol use. The data indicates a need for intervention concerning caregivers in rural areas. These caregivers are working without fiscal compensation for their efforts, as a result, they are more likely to be suffering from depression, and use marijuana and/or tobacco, as a coping mechanism. A few feasible interventions which could be incorporated include professionally led group psycho-social support programs, expanding telehealth services, or developing a standardized protocol for the clinicians of the caregivers. If incorporated in rural areas, these interventions could have a significant impact on the mental/ physical health of caregivers in rural areas. For the areas which do have interventions in place for rural caregivers, expanding awareness and access to the impact of them should be explored.

TITLE: Intent to Vaccinate Children Against COVID-19 by Caregiver Vaccination Status in Northeast Tennessee AUTHOR INFO Yordanos Tafesse MD1 tafesse@etsu.edu Olivia A. Sullivan, EMT, MPH1 sullivano@etsu.edu Samuel Pettyjohn, DrPH, MPH1 pettyjohns@etsu.edu 1 Center for Rural Health Research, East Tennessee State University, Johnson City, TN. Addressing vaccine hesitancy is crucial in mitigating the spread of the ongoing COVID-19 pandemic. Children are mostly asymptomatic or have milder symptoms of COVID-19 than adults, and thus may remain undiagnosed, allowing the disease to spread to a large number of people; they are also at a high risk of long-term morbidity from as-of-yet undetermined effects of “long COVID.” Therefore, this analysis sought to examine caregivers’ intent to have their children vaccinated against COVID-19 based on the caregivers’ vaccination status and the age of the children. Using a secondary dataset from a survey in Northeast Tennessee, researchers found a significant difference between vaccinated and unvaccinated caregivers in intent to vaccinate their children in all age groups. Among caregivers with vaccine-eligible (12+ years children), unvaccinated caregivers (n=16) were significantly more likely than vaccinated caregivers (n=71) to not have had their child vaccinated (X2=24, df=1, p=7.8x10-7). Among caregivers who had not yet had their children vaccinated, unvaccinated caregivers (n=23) were significantly more likely to indicate they would “definitely not” get their children vaccinated than vaccinated caregivers (n=76) among all age groups of children: 0-4 years (X2=7.8, df=1, p=5.1x10-3), 5-9 years (X2=28, df=1, p=1.4x10-7), 10-13 years (X2=30, df=1, p=3.6x10-8), and 14+ years (X2=16, df=1, p=6.1x10-5) (Figure 2). The percentage of caregivers indicating they would “definitely not” get their child vaccinated differed by age of children among vaccinated caregivers (X2=11, df=3, p=0.011) but not unvaccinated caregivers (X2=5.1, df=3, p=0.16). Limitations include a small number of unvaccinated caregivers in the sample and the inability to account for correlation in the data. These results corroborate other findings nationwide, and demonstrate the need to provide high-quality education to address vaccine hesitancy in Northeast Tennessee.

Recent research indicates that pregnant women in rural communities are at increased risk of experiencing IPV and comorbid illicit opioid use compared to urban-residing pregnant women. Few studies of the interactions among rurality, substance use, and victimization in pregnant women exist. The current study sought to examine the relationship between IPV and opioid use and the interaction effects of rurality in Appalachian pregnant women. A convenience sample of pregnant women who were enrolled in a smoking cessation research study was used for this analysis. Participants included 488 pregnant women from five prenatal clinics in South-Central Appalachia. Data were from self-reported assessments and semi-structured interviews on substance use and IPV conducted from first trimester of pregnancy through eight months postpartum. Four hundred and ten participants reported experiencing any form of IPV in the past year. Logistic regression results indicated that physical IPV was associated with opioid use, but sexual and psychological IPV were not. The moderation model indicated direct effects between IPV and opioid use, but were not moderated by rurality. This study suggests a need to further understand the relationship between substance use, IPV, and rurality in pregnant women. The specific subtopic of opioid use by pregnant women living in rural communities, and its relationship to IPV victimization and adverse fetal and maternal health outcomes, continues to be an understudied, but critically important area. Limitations and future directions pertaining to IPV screenings and interventions for pregnant women are discussed.

Despite the well-known benefits for youth, fewer than half of adolescents, both nationally and in Maine, meet current physical activity recommendations. Impacting young people’s physical activity is important for their physical, mental, emotional, and social health, as youth health behaviors are predictive of the same behaviors in adulthood, and physical activity levels decline in the transition from adolescence to adulthood. Rural areas have unique challenges that negatively impact physical activity including fewer physical education classes, sidewalks, and exercise facilities. While evidence is emerging on the best approaches to physical activity promotion in urban settings, best practices for rural areas are less well-defined. Rural communities interested in improving adolescent physical activity need to develop strategies that are based on existing evidence and theory, but also meet local needs. Intervention Mapping (IM) is a framework that can effectively guide strategy development. It involves six steps, beginning with a community assessment and ending with an evaluation plan to assess the implementation and effectiveness of the selected intervention strategies. IM was implemented in Machias, a rural Maine community, to develop a community-specific strategic plan to increase adolescent physical activity. Lessons learned from formative evaluation of the framework’s implementation included the importance of having an individual lead the process, how to complete the work within a specific number of meetings, which phases require more time to complete, and how to complete multiple phases simultaneously. Based on the experience in Machias, recommendations for the Maine Center for Disease Control and Prevention (Maine CDC) were developed to replicate the process in other communities. The recommendations, building on the existing Health Maine Partnership (HMP) structure, include creating a workgroup of Maine CDC and local HMP staff to identify a common planning process that could be used by all communities, be it IM or another process; developing a toolkit and worksheets to guide that process; and implementing a training plan. The experience in Machias is an example for similar communities on how to engage in a systematic strategic planning process to improve adolescent physical activity behaviors and potentially the health challenges faced by of other population groups.

Mental and behavioral health difficulties are prevalent among children, and research suggests that the vast majority of these children do not receive needed services. Treatment disparities are even larger among rural youth given the scarcity of qualified specialty mental health providers, increased barriers to care, and greater mental health-related stigma compared to their urban counterparts. Many parents seek help and resources from their child’s primary care provider (PCP); however, the comprehensive management of psychosocial and behavioral concerns are often not feasible in traditional primary care settings. Integrating behavioral health services into pediatric primary care clinics has the potential to increase access to needed services, improve comprehensiveness and quality of care for patients, and reduce burdens on PCPs. Research on integrated behavioral health (IBH) models have indicated that it is a cost-effective service leading to improved treatment outcomes compared to usual primary care and that parents and physicians are generally satisfied and interested in this service delivery model. However, little is known about parents’ attitudes toward IBH and factors that may influence the acceptability of this type of care. Previous research has identified several factors associated with parent acceptability of mental health services for their child including symptom severity, attitudes toward child therapy, parenting stress, stigma, perceived barriers to care, and past experiences with services. However, it is unclear how these factors influence attitudes toward IBH, especially in rural areas. The current study examined parents’ attitudes toward co-located and integrated models of care, identified factors that affect acceptability of IBH, and explored differences between rural and urban parents’ attitudes. Results demonstrated that both rural and urban parents hold generally favorable attitudes toward IBH models and that parent attitudes toward general child therapy was strongly associated with IBH acceptability. Demographic variables (e.g., parent age, child age, minority status, socioeconomic status), need characteristics (e.g., parenting stress, child psychosocial symptoms), and other enabling factors (e.g., mental health-related stigma, prior service use, barriers to care) were not predictive of parent IBH acceptability. Urban parents rated co-located models of care as more acceptable and reported higher levels of parent psychosocial symptoms, stigma, and barriers to care compared to rural parents. These findings support efforts to continue integrating behavioral health services into pediatric primary care and highlight parent therapy attitudes as an important target for intervention to improve parent IBH acceptability. Findings also shed light on the need for more mixed-method research to understand the impact rural identity has on the acceptability and use of behavioral health services.

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Maternal residency in Central Appalachian coalfields has been associated with low birth weight at the county-level. To refine the relationship between proximity and adverse birth outcomes, this study employs finer spatial scales of exposure. Spatiotemporal characterizations of surface mining boundaries in Central Appalachia between 1986-2015 were developed using Landsat data. The maternal address field on births records from VA, WV, KY, and TN were geocoded and assigned amount of surface mining within a 5km radius of residence (street-level). Births were also assigned exposures based on the amount of surface mining within residential ZIP code tabulation area (ZCTA) (ZIP code-level). Using linear and logistic regression, associations between surface mining activities during gestation and birth weight, preterm birth, low birth weight, and term low birth weight were determined, adjusting for available demographic factors. An increase in surface mining activities was negatively associated with birth weight at the street-level (β = −8.93g; (95% CI = -12.69 -5.7, P= <0.001) and ZIP code-level (β = −4.41g ; 95% CI = -6.30, -2.52, P= <0.001). Small, statistically significant associations were also found between preterm birth and mining within 5km of residence (OR = 1.003; 95% CI = 1.001, 1.005, P= 0.003) and within maternal ZCTA (OR = 1.002; 95% CI = 1.001, 1.003, P=0.001). Relationships were also found between amount of mining within 5km of residence and low birth weight and term low birth weight outcomes. This study found subtle, but significant associations between proximity to active surface mining during gestation and adverse birth outcomes. / M.S. / Central Appalachian surface mining produces air, water, and noise pollution, all of which have been associated with increased risk of adverse birth outcomes. Previous studies examining associations between surface mining and adverse birth outcomes rely upon relatively coarse county-level data. This research compares outcomes from hundreds of thousands of individual birth records and proximity of maternal home address to surface mines for a fine-scale, epidemiological study. Surface mining boundaries between 1986-2015 were developed using satellite imagery. Birth records from VA, WV, KY, and TN were geocoded and assigned the amount of surface mining within a 5km radius of residence. Births were also assigned exposures based on the amount of surface mining within residential ZIP code since geocoding led to a considerable loss of records. Associations between proximity to surface mining during gestation and birth weight, preterm birth (PTB), low birth weight (LBW), and term low birth weight (tLBW) were determined by linear and logistic regression, adjusting for available demographic factors. Results demonstrate significantly decreased birth weights were found near active mining operations. Mothers living near active surface mining also saw a slight increase in the odds of their birth being PTB, LBW or tLBW. These results suggest there is a subtle, but significant relationship between proximity to surface mining and adverse birth outcomes.

Around 46.2 million Americans living in rural areas are disproportionately burdened by health disparities. Likewise, obesity and obesity-associated diseases (e.g., diabetes, cardiovascular disease) are much higher for rural residents when compared to their urban counterparts. There is a high need to understand and address the nutritional determinants of these health inequities among adults and adolescents. One area of concern in rural dietary habits pertains to added sugars and more specifically, sugar-sweetened beverages (SSB). Excessive added sugars and SSB intake have been strongly linked to many of the nutrition and chronic disease disparities impacting rural residents. Moreover, studies conducted in rural populations have found high consumptions of these in both adults and adolescents. There is an opportunity to better understand added sugars and SSB patterns in rural populations to inform the development of culturally relevant, multi-level interventions that address high consumption. Study #1 is a cross-sectional study that explores top food and beverage sources of added sugars in the diet of adults (n = 301) living in rural areas of Southwest Virginia. Study #2 uses a nationally representative sample of adolescents (n = 1,560) from the Family Life, Activity, Sun, Health and Eating (FLASHE) study sponsored by the National Cancer Institute, to explore factors across the levels of the socioecological model associated with adolescent SSB intake. Study #3 utilizes focus groups and a pilot trial to understand language preferences, acceptability and use of SMS aimed at caregivers to reduce SSB intake in both caregivers and adolescents living in rural areas of Southwest Virginia (n = 33). Collectively, these three studies offer recommendations and culturally relevant strategies for future large-scale trials aimed at reducing SSB intake among adolescents and caregivers in rural communities and ultimately reducing rural health disparities. / Doctor of Philosophy / Rural populations in the United States are at higher risk for being diagnosed with and dying from preventable and obesity-associated diseases like heart disease and cancer. Excessive added sugars and sugary drink (i.e. sodas, sweet tea/coffee, energy drinks, sweetened fruit drinks, sports drinks) intake have been strongly linked to many of the chronic diseases afflicting rural residents. Moreover, studies conducted in rural populations have found high consumptions of these, in both adults and adolescents. There is a great need to better understand added sugars and sugary drink patterns in rural populations so that we can develop programs to reduce consumption that are also culturally well received. Study #1 in this dissertation explores top food and beverage sources of added sugars in the diet of 301 adults living in rural areas of Southwest Virginia. Study #2 uses a nationally representative sample of 1,560 adolescents to explain why adolescent SSB intake might be higher. Study #3 aims to understand language preferences, acceptability and use of a text message program to reduce sugary drink intake in both caregivers and adolescents living in rural areas of Southwest Virginia. Collectively, these three studies offer recommendations and culturally relevant strategies for future large scale trials aimed at reducing sugary drink intake among adolescents and caregivers in rural communities and ultimately improving rural health.