Journal of Appalachian health最新文献

Introduction: Transgender and gender-diverse (TGD) individuals face barriers to accessing primary and gender-affirming care, especially in rural regions where a national shortage of medical providers with skills in caring for TGD people is further magnified. This care may also be impacted by individual providers' strongly held personal or faith beliefs and associated conscientious objection to care.

Purpose: This study assesses the prevalence of conscientious objection to providing care and gender-affirming hormone (GAH) therapy to TGD individuals among physicians in an Appalachian academic medical center.

Methods: An anonymous, online, cross-sectional survey of physicians was distributed to resident and faculty physicians in an Appalachian medical center. Survey domains included demographics, personal religious affiliations and practices, and assessments of willingness to provide specific types of care.

Results: Surveyed physicians (n = 115) had no objection to caring for TGD patients but notable objection to prescribing GAH therapy to adults (23.5%) and minors (33.0%). Self-identified "very religious" physicians were more likely to object.

Implications: Physician objection may present a barrier to care for TGD individuals in Appalachia. Provider and system-level interventions should be considered to ensure access to these necessary medical services.

Involvement of community and organizational groups is fundamental to most public ventures. Most social, health, economic, and educational improvements in Appalachia have been characterized by successfully integrating community input and finding ways to encourage organizational change and collaboration. Managing group process and related facilitation skills are fundamental competencies for public health professionals and others guiding change efforts. Groups from communities and organizations can get stalled in their deliberations; a facilitator frequently must think quickly to diagnose the situation and propose alternative approaches. Creative and flexible approaches, learned through practice experiences, can blend with theories and frameworks learned in academic preparation from multiple disciplines in order to effectively encourage group progress. Over a 50-year career (1972-2022), sets of three related concepts were formed as trilogies and used during work with groups of diverse compositions, in multiple locations, and addressing varied topics. The trilogies proved helpful in encouraging group tasks related to assessment, planning, monitoring, and evaluation. Trilogies also were deployed as a facilitation technique to pose thoughtful options as groups considered difficult issues and maneuvered through stagnant or conflict-prone situations. This paper presents twelve trilogies organized around six common group-process questions. A reference for the source of each trilogy is provided, and several Appalachian-specific examples of how trilogies were deployed are described.

Rapidly rising waters due to flash floods and thunderstorms on the night of July 27, 2022, resulted in hundreds of water rescues throughout 14 rural Appalachian Kentucky counties. Lives were lost, thousands were injured, homes and property were damaged or destroyed, and many roadways were unpassable. Community partners serving these counties collaborated to design and conduct an assessment to gain a better understanding of the needs of individuals residing in certain remote sections within the communities. The assessment, conducted three months after the flood, collected information regarding flooding impact on housing, physical and behavioral health, transportation, work, and finances.

Introduction: Adequate prenatal care (PNC) is essential to the overall health of mother and infant. Teen age and advanced maternal age (AMA) are known risk factors for poor birth outcomes. However, less is known about whether these age groups are associated with inadequate PNC.

Purpose: This study sought to determine the potential association between maternal age (in groups, aged 20-24, 25-29, 30-34, 35-39, and >40) and inadequate PNC (visits).

Methods: West Virginia (WV) Project WATCH population-level data (May 2018-March 2022) were used for this study. Multiple logistic regressions were performed on inadequate PNC (less than 10 visits) with maternal age categories, adjusting for covariates including maternal race, smoking status, substance use status, parity, education, geographic location, and insurance status.

Results: Results demonstrate that both young and AMA pregnant people are more likely to receive inadequate PNC. PNC is particularly important for these groups, as they are at increased risk of poor birth outcomes. Just over 11% of pregnant people who gave birth in WV received inadequate PNC. Participants aged 19 years and younger (aOR:1.3, CI:(1.2,1.4)), 35-39 years (aOR:1.1, CI:(1.0,1.2)), and 40 years (aOR:1.3, CI:(1.1,1.5)) were at increased odds of inadequate PNC relative to 25-29-year-olds.

Implications: Results indicate that easily obtained demographics, such as a pregnant person's age, can be utilized by policymakers and clinical interventionists to improve birth outcomes by increasing PNC outreach for these groups.

Introduction: West Virginia has a disproportionately large population of rural adults with diabetes and hypertension, two common chronic, comorbid conditions that represent a national economic, social, and public health burden. Anxiety, depression, and severe mental illness are associated with poor motivation to engage in coping/self-care behaviors and related increased morbidity/mortality.

Purpose: This study examines the relationship between self-reported mental health, selected social and emotional health factors, health-related quality of life (HRQoL), and clinical outcomes among adults with comorbid diabetes and hypertension.

Methods: This cross-sectional study consisted of 75 participants who participated in a diabetes and hypertension self-management program (DHSMP) in West Virginia. Baseline measures (2018-2019) were used to explore associations and included demographics, self-rated mental health, diabetes distress, HRQoL, HbA1c, and blood pressure. One-way ANOVA was performed to compare mentally healthy v. unhealthy participants by their demographics, diabetes distress and its domains, HRQoL and its domains, and clinical outcomes.

Results: The mean age and BMI were 60.8 ± 12.2 and 36.4 ± 8.1, respectively, indicating that the average participant was older and obese. Participants who self-reported fair or poor mental health had significantly higher BMI, higher diabetes distress, and lower HRQoL. Participants with good to excellent mental health had lower systolic blood pressure.

Implications: Findings indicate the potential role of social and emotional health on clinical outcomes and HRQoL among patients with comorbid chronic conditions, especially for older obese patients. Future studies with larger sample sizes should explore tailoring lifestyle and educational programs to address these factors for improved health outcomes.

Introduction: Rates of cancer mortality in Appalachian Kentucky is among the highest in the nation. It is unknown whether geographic location of treatment for pancreatic ductal adenocarcinoma (PDAC), one of the deadliest cancers worldwide, influences survival in Appalachian Kentuckians.

Purpose: This study compares outcomes among Appalachian Kentuckians with PDAC who received treatment at an academic medical center (AMC) or community facility (CF).

Methods: Using the Kentucky Cancer Registry, patients diagnosed with PDAC between 2003 and 2018 were identified. Patients were categorized according to treatment location (AMC v. CF) and county of residence (Appalachian v. non-Appalachian). Kaplan-Meier curves were constructed to assess survival and multivariate Cox regression analyses were performed.

Results: Overall, out of 4,402 PDAC patients, 87.3% received treatment at CFs and 12.7% at an AMC. When stratified by treatment location and Appalachian status, significant differences were found in clinicopathologic factors, such as age, smoking, insurance status, stage, and treatment (p < .05). Factors significantly associated with decreased survival included treatment at a CF (HR 1.53 for Appalachian, 1.25 for Non-Appalachian), patient age > 75 years (HR 1.44), having Medicare/Medicaid insurance (HR 1.23/1.16), and history of smoking (HR 1.11). Decreased 1- and 5-year survival was associated with treatment at a CF for both Appalachian (27.4% and 3.6%) and Non-Appalachian (36% and 5.7%) patients (p < .001).

Implications: Improved survival of Kentuckians treated at an AMC suggests that poorer PDAC outcomes in Appalachian patients may be related to access to tertiary care. Future research should examine potential reasons for these disparate outcomes and strategies for increasing the quality of cancer care at CFs.

Introduction: The Centers for Medicare and Medicaid Services (CMS) has funded the Accountable Health Communities (AHC) model to test whether systematically identifying and addressing the health-related social needs (HRSNs) of individuals would impact healthcare utilization and total cost of care for Medicare and Medicaid beneficiaries. Toward this effort, AHCs implement screening, referral, and community navigation services in their local areas. There are 28 CMS-funded AHCs nationwide, including the Kentucky Consortium for Accountable Health Communities (KC-AHC).

Purpsoe: This study aims to assess the equity of KC-AHC model activities in three vulnerable subpopulations: dual enrollees, disabled individuals, and women.

Methods: Twenty-eight primary care clinical sites across 19 healthcare organizations administered (inperson or telephonic) the AHC screening instrument from August 2018 to April 2021. Every six months, social needs positivity rates, navigation eligibility, service opted-in rates and delivery data were monitored among dual enrollees, disabled persons, and women. Subpopulations were compared to their comparisons (for example, non-dual enrollees) and to available benchmarked data.

Results: All proportions of subpopulation in screened beneficiaries approximated or exceeded regional benchmarks. While needs among groups fluctuated over time, most reflected positivity rates in excess of comparisons: (1) rates among females ranged from 29.6% to 36.1%, but tended to narrow (relative to males) over time; (2) disabled individuals' positivity rate ranged from 27.8% to 36.1% but also lessened over time compared with non-disabled counterparts; and (3) positive rates among the dually-enrolled ranged from 34.7% to 42.4%, with the disparity to non-dual enrollees remaining relatively stable. Rates of opt-in and receipt of navigation in dual enrollees and women did not show disparities. There was a persistent gap in opt-in rates between disabled and non-disabled beneficiaries, though one was not identified in receipt.

Implications: Results suggest that the KC-AHC adequately screened dual enrollees, disabled individuals, and women during model implementation. The AHC Model may have helped to narrow gaps in social needs between sub-populations and comparison groups, with beneficiaries becoming better connected to community services.

The Journal of Appalachian Health welcomes submissions from a variety of stakeholders interested in and contributing to improvement of health across the Appalachian Region. This editorial provides basic guidelines for those working in community settings who may with to make JAH (or any other journal) their publication home.

Introduction: To date, referral practices based on social determinants of health (SDOH) among primary care providers (PCPs) and clinic staff in rural regions, including Appalachian North Carolina (NC), are not well understood.

Purpose: This study aims to develop and content validate a primary care engagement (PCE) survey to assess (1) engagement and burnout; (2) referral practices; and (3) self-efficacy and confidence in making referrals based on SDOH among PCPs and clinic staff in Appalachian NC.

Methods: Using the Social-Ecological Model as a theoretical framework, researchers developed a 37-item PCE survey. Content validation was completed by a panel of experts recruited from a convenience sample of faculty at a local university and PCPs and clinic staff practicing in Appalachian NC. Participants rated the degree of relevance of survey questions on a four-point Likert scale and provided additional feedback about the wording/appropriateness for the intended audience. Content validity index (CVI) scores were calculated for each question by averaging the degree of relevance ratings.

Results: Ten participants completed the study between August and November 2022 (nurse practitioners, academic researchers, clinical support staff/quality improvement associates, administrative staff supervisor, administrator/practice manager). CVI scores for each item ranged from 3.43 to 4.0. Comments regarding potential improvements were primarily focused on small edits, including grammar-related changes and opportunities for clarity and inclusivity.

Implications: High CVI ratings for all survey items indicate the overall approach/survey aim resonates with local clinicians and individuals with expertise in SDOH. This study and the final survey lay the foundation for collaborative, collective-impact initiatives that are directly informed by the survey findings.

Demographic aging is accelerating in the Appalachian Region, resulting in a growing proportion of caregivers living in areas that lack services to support their needs. Strategies are urgently needed in Appalachia to address deficiencies in the region's long-term supports and services for older adults and their caregivers. Strengthening equitable access to care and community supports for family caregivers is a policy priority for state and community leaders in Appalachia.