Public Health Commons^™

Gender Disparities In Sheltered Status And Systemic Drivers Of Homelessness In Johnson City, Tennessee, Preet Patel, Dr. Opal Frye-Clark

Journal of Appalachian Health

The article examines the homelessness crisis in Johnson City, Tennessee, a mid-sized Appalachian city. First, analysis of Point-in-Time (PIT) counts from 2023 to 2025, conducted in 2025, showed persistently high unsheltered rates (35.88% – 47.17%), with men comprising 60 – 65% of the unhoused population. Men experiencing homelessness also had approximately half the odds of being counted as sheltered compared with women, indicating a gender disparity in sheltered status. Second, an interview with an experienced public health practitioner from the Appalachian Region contextualized these findings by identifying systemic drivers, including the regional housing crisis and policy restrictions, and supporting equitable …

Improving Diabetes Self-Management Through A Partnership Between Clinical Providers And Community Educators In Appalachian Communities, Soghra Jarvandi, Lydia Hoskins, Karen Carver, Andrew May

Journal of Appalachian Health

Introduction: The burden of diabetes is an increasing public health challenge, especially in the Appalachian Region.

Purpose: This study assessed the impact of a community-based diabetes education program on glycemic control.

Methods: Health Extension for Diabetes (HED) is a 4-month diabetes education program offered by Extension educators in collaboration with clinical providers. Participants’ data were collected via phone interviews at baseline and after completing the program. Assessments included self-reported HbA1c, socio-demographics, diabetes knowledge, self-efficacy, and self-management behaviors. Data were analyzed by SAS software using paired analyses.

Results: Of the 105 participants in the program, 87 (83%) completed the post-assessment. Among …

School-Centered Tobacco Retailer Exposure And Neighborhood Opportunity Across Urban And Rural Tennessee, Sima Namin Dr, Jacob Black, Jennifer Ferris, Robert E. Heidel Dr

Journal of Appalachian Health

Introduction: Tobacco retailer availability contributes to youth tobacco use, and retailers are concentrated in socioeconomically disadvantaged communities. However, few studies have examined how school-centered retailer exposure intersects with neighborhood opportunity in a predominantly rural Appalachian state.

Purpose: The purpose of this study is to assess the association between neighborhood opportunity and school-centered tobacco retailer exposure across Tennessee (TN), including differences by rurality and Appalachian status.

Methods: We constructed a tract-level, school-centered youth tobacco exposure index for TN using tobacco retailer locations and public and private K-12 school data. The index incorporated retailer proximity, density, and distance-decay accessibility measures. Child Opportunity …

Deaths Of Despair Among Cancer Survivors In Rural/Urban Appalachia (2000-2022), Jason Semprini, Anders Erickson, Nosa Osazuwa-Peters

Journal of Appalachian Health

Introduction: Rising deaths of despair (premature deaths from suicide, overdose, alcohol, and violence) in adults under age 65 persist across the United States, especially in Appalachia. People diagnosed with cancer may face elevated risks of such deaths due to pain, psychosocial distress, and financial hardship.

Purpose: Deaths of despair trends were compared among adults with cancer across Appalachian and non-Appalachian regions, stratified by sex and rurality.

Methods: Analyzing SEER-21 Incidence-Based Mortality data (2000–2022), deaths caused by suicide, cirrhosis of the liver, or accidents (includes overdose) were identified among adults aged 20–64 years. Annual mortality rates per 100,000 total population were …

Disparities In Access To Medicare-Approved Medical Specialists In Rural Kentucky, Logan Hurm, Jacob A. Welch, James Adkins

Journal of Appalachian Health

Introduction: Approximately 20% of the United States population resides in a rural community; however, only 10% of all healthcare resources and physicians are dedicated to these areas. Appalachia, and Kentucky (KY) in particular, have higher populations living in rural areas which leads to a greater number of individuals affected by medical access disparities. As of 2026, 21% of KY’s population is eligible for Medicare, making access to Medicare-accepting specialty physicians crucial for the state’s population.

Purpose: This research aims to quantify healthcare disparities among rural communities in KY through quantification of the potential distance required to travel to access specialty …

Rural And Urban Availability Of Substance Use Treatment Facilities, Aaron P. Smith, Tyrone F. Borders

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• Rural counties have higher per capita numbers of substance use disorder treatment facilities than urban counties on average, but also greater variability and large pockets of unmet need.

• The highest proportions of residents living in counties without any treatment facilities are concentrated in rural areas within the Midwestern and Southern United States.

• Rural and urban treatment facilities offer medications for opioid use disorder (MOUD) at similar rates, with inpatient facilities most likely to provide MOUD, followed by residential and outpatient settings.

Non-Metropolitan Vs. Metropolitan Variations In Alcohol, Illicit Drug, And Prescription Therapeutic Drug Misuse, Tyrone F. Borders

Rural & Underserved Health Research Center Publications

Key Findings

Alcohol Use. The prevalence of past year and past 30-day drinking was lower among non-metropolitan (non-metro) than metropolitan (metro) residents. However, non-metro drinkers engaged in more frequent binge drinking than metro drinkers. Drinking 3-5, 6-19, and 20-30 days over the past 30 days were higher among non-metro than metro residents.

Illicit Drug Use. Hallucinogens were the mostly commonly used illicit drugs among non-metro as well as metro residents. Methamphetamine use was significantly higher among non-metro than metro residents.

Prescription Pain Reliever Use. The misuse of prescription pain killers, primarily prescription opioids, was higher among non-metro than …

High-Deductible Health Plans In Rural And Urban Populations: Outpatient Utilization And Out-Of-Pocket Costs, Aaron P. Smith, Jefferey Talbert

Rural & Underserved Health Research Center Publications

Overview of Key Findings This policy brief explores rural-urban differences in High-Deductible Health Plan (HDHP) enrollment, subsequent healthcare utilization, and out-of-pocket (OOP) costs. ▪ HDHP enrollment was uncommon. Rural residents were slightly less likely to enroll than urban residents across all demographic groups. ▪ Switching plans influenced utilization. Compared to those who did not change healthcare plans, switching from a Traditional plan to a HDHP was associated with a larger reduction in 2022 outpatient visits for both rural and urban residents. Moving from a HDHP to a Traditional plan was associated with a smaller reduction in 2022 outpatient visits for …

Rural/Urban Disparities In Utilization Of Diabetes Self-Management Training (Dsmt) To The Fee-For-Service Medicare Population, 2017–2024, Wanying Zhu, Aleksandr Taraskin, Jeffrerey Talbert

Rural & Underserved Health Research Center Publications

Key Report Highlights

• A significant rural DSMT access gap exists. Rural beneficiaries accounted for 20.1% of Medicare beneficiaries with diabetes but only 7.8% of DSMT participants.

• Geographic availability remains limited. Only 16.8% of counties with DSMT utilization were rural.

• Access, not demand, appears to be the primary challenge. Rural counties offering DSMT achieved utilization rates more than twice those observed in urban counties (6.0% vs. 2.5%).

• Expanding rural DSMT capacity may represent a high-impact opportunity to improve diabetes self-management support among underserved Medicare beneficiaries.

First Covid-19 Vaccination Rates Among Pregnant Tennessee Women By Month Of Conception And Urbanization Level: March 2021 – November 2021, Claudia Valenzuela, Anne K. Driscoll, Elizabeth Harvey, Heather Wingate

Journal of Appalachian Health

Introduction: Throughout the pandemic, COVID-19 vaccination coverage was lower for the general population living in rural counties than in urban counties. In Tennessee (TN), COVID-19 vaccinations became available to pregnant women in March 2021. Little is known about rates of COVID-19 vaccination in pregnancy during the pandemic, or whether these rates changed or differed by urbanization level.

Purpose: The purpose of this study is to describe COVID-19 vaccination rates among pregnant women in TN by month of conception and urbanization level.

Methods: COVID-19 vaccination data from the TN Immunization Information System and the TN Surveillance for Emerging Threats to Mothers …

Evaluating The Feasibility And Preliminary Effectiveness Of A Tailored Diabetes Education Program For Rural Residents, Brittany L. Smalls, Oluwatosin Leshi, Suraksha Khanal, Grejika E. Abram-Erby

Journal of Appalachian Health

Introduction: Diabetes is a top ten Rural Healthy People 2030 priority for health improvement among rural Americans. Socioeconomic, environmental, geographic and political barriers contribute to the type 2 diabetes (T2D) prevalence and its disparate impact in rural communities. However, promoting proper self-care behaviors via self-management education can help people with diabetes better manage their condition.

Purpose: To account for the social environmental factors that affect rural residents, a tailored diabetes education program was developed, and the program’s effectiveness in improving diabetes knowledge and T2D-related health outcomes was assessed.

Methods: Using data collected from Appalachian Kentucky residents enrolled in a six-week, …

Rural Community Perspectives On Hurricane Helene In Western North Carolina, Jennifer A. Horney, Lilly Moreau, Search Wnc

Journal of Appalachian Health

Introduction: After making landfall on the Florida Gulf Coast in September 2024, Hurricane Helene impacted Western North Carolina (WNC) with historic flooding, landslides, and hurricane-force winds. More than 100 deaths in the region were attributed to the storm’s direct impacts.

Purpose: The purpose of this study was to assess community perspectives of long-term recovery in Mitchell and Yancey Counties, two rural WNC counties severely impacted by Hurricane Helene.

Methods: A 14-question interview guide was developed based on prior disaster research and the community engagement work of Sustaining Essential and Rural Community Healthcare (SEARCH). Questions covered post-Helene experiences related to access …

Exploring Systemic Challenges In The Western North Carolina Dental Safety Net: A Qualitative Analysis, Blaire Mirmow, Bill Milner, Nadia Laniado

Journal of Appalachian Health

Introduction: Despite statewide growth, rural communities in Western North Carolina (WNC) face persistent barriers to oral health care driven by chronic dental workforce shortages and systemic geographic disparities. Within this Appalachian region, the dental safety net serves as a vital yet strained support system, struggling with limited financial resources and a lack of provider participation that leaves many underserved populations without essential oral health services.

Purpose: This study aims to explore the experiences of individuals working within the WNC dental safety net to identify barriers and strategies required to strengthen the delivery of oral health care in high-need rural settings. …

Infective Endocarditis Hospitalizations In Kentucky, 2008-2018: Spatial And Temporal Trends, Meera Marji, Steve Browning, W. Jay Christian, Richard Charnigo, Steve W. Leung, Anna Kucharska-Newton

Journal of Appalachian Health

Introduction: Infective endocarditis (IE) hospitalization rates have increased significantly in the last decade, primarily due to the opioid epidemic. In 2016, Kentucky (KY) ranked among the top ten states for opioid-related overdose deaths, but limited data exist on IE trends in KY.

Purpose: This study seeks to examine county-level spatial and temporal trends in IE hospitalization rates in KY.

Methods: Hospital inpatient discharge data from 2008–2018 for KY residents aged 18 and older were analyzed. IE admissions and drug use status were identified using ICD-9 & 10 diagnosis codes. U.S. Census data calculated yearly IE hospitalization rates per 100,000 residents. …

The Effects Of Hurricane Helene On Mental Health And Physical Activity, Hunter Smathers, Robyn York, Jarrett Walbolt

Journal of Appalachian Health

Introduction: Hurricane Helene brought widespread damage to Southern Appalachia, disrupting utilities, health care, and recreation. While natural disasters are linked to declines in mental and physical health, few studies have examined their effects on distinct types of physical activity (PA).

Purpose: This study evaluated the effects of Hurricane Helene on perceived stress, depressive symptoms, post-traumatic stress disorder (PTSD) symptomology, and intentional (exercise for health benefits) and incidental (physical labor or transportation) PA. Evacuation status influence was also explored.

Methods: Twenty participants completed assessments four weeks before (BASE), immediately after (0POST), and four weeks after landfall (4POST). Measures included the Perceived …

Starting With Story, Not Symptom: Narrative Collapse And Cultural Repair In Appalachia, Wayne Coombs Ph.D.

Journal of Appalachian Health

Appalachia’s opioid crisis reflects uneven burdens, especially in distressed coalfield counties, and it cannot be solved by symptom tracking alone. This commentary argues for a narrative shift, starting with story and cultural repair alongside clinical care. Narrative collapse is defined here as the loss of shared, dependable public meaning across groups, not the absence of storytelling in families, churches, and recovery circles. Trauma science suggests that chronic threat reshapes nervous systems across generations, making safety a prerequisite for renewed trust. Drawing on narrative identity research, the piece proposes peer story work as infrastructure that can reduce shame, support treatment engagement, …

The Association Between Personal Particulate Matter Exposures And Cognitive Function Among Stroke Patients, Kentucky, Usa, Nana Afua Ankomah Dei

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Stroke, a major cause of long-term disability and cognitive problems in the U.S., significantly affects people’s quality of life. Exposure to particulate matter (PM_2.5) may result in systemic inflammation and oxidative stress, which can worsen the cognitive function of post-thrombectomy stroke patients. This project thus assessed the relationship between PM_2.5 exposure and its effect on the cognitive function of post-thrombectomy stroke patients. Fifteen stroke patients (9 non-Appalachian and 6 Appalachian) undergone thrombectomy were recruited. Personal PM_2.5 exposure was measured using wearable sensors for a week during the study period. Montreal Cognitive Assessment (MoCA) scores and covariates …

Bringing Pandemic Science To The Classroom: Building Public Health Capacity At A Rural Kentucky High School, Sahar Alameh, Anna G. Hoover, James W. Keck, Scott M. Berry, Sagan Goodpaster, Savannah Tucker, Ashley Goodin

Science, Technology, Engineering, and Mathematics (STEM) Education Faculty Publications

In response to the COVID-19 pandemic, a multidisciplinary team at the University of Kentucky developed an interdisciplinary science, technology, engineering, and mathematics and environmental health unit—the Wastewater Assessment for Coronavirus in Kentucky: Implementing Enhanced Surveillance Technology (WACKIEST) Unit—for high school students in summer 2022. This case study outlines the WACKIEST Unit, which focused on wastewater surveillance and COVID-19, the obstacles faced during development and recruitment, and implementation of the WACKIEST Unit in conjunction with a rural wastewater surveillance initiative. The unit was implemented in spring 2023 at a rural high school in Kentucky, spanning 12 days and engaging 190 students. …

Chinese Athletes’ And Parents’ Motivations For U.S. Collegiate Sports Participation, Wenting Sun, Russell D. Ravert, Simran Kaur Sethi

Kinesiology and Health Promotion Faculty Publications

To gain an understanding of international student recruitment and retention in collegiate athletics, this study examines the motivations and decision-making processes of Chinese high school athletes and their parents in pursuing U.S. collegiate sport opportunities. Using the push–pull framework and an ecological perspective, it explores how individual aspirations, family priorities, institutional resources, and national policies shape transnational mobility. Semistructured focus group discussions with 10 athletes and eight parents revealed six key motivational themes and highlighted the influence of recent collegiate sport-related policy changes in China. The findings suggest that while both groups value U.S. sport pathways, athletes and parents may …

Addressing Obesity And Diabetes In Appalachian Kentucky, Hannah E. Orens

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Type 2 diabetes and obesity are major public health concerns in Appalachian Kentucky. Populations in this region experience much higher rates of chronic disease than the rest of the state, have limited access to preventive care, and ongoing economic challenges that affect health. Many rural counties face increased poverty, transportation challenges, and shortages of healthcare professionals, all of which contributed to poor health outcomes and reduced access to evidence-based prevention programs. As a result, there is a strong need for focused, feasible, community-based interventions that improve access to evidence-based prevention while addressing the social and economic factors influencing health in …

Purchasing A Healthier Future: A Nutrition-Focused, Community-Centered Approach To Reduce Obesity And Diabetes In Graves County, Kentucky, Marissa Stephens

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Obesity and type 2 diabetes are among the most significant public health challenges in the United States, with Kentucky consistently ranking among the states with the highest prevalence of both conditions. Together, these conditions contribute to reduced quality of life, rising healthcare costs, and increased morbidity and mortality, underscoring the need for targeted, community-centered interventions. The disease burden of obesity and diabetes is particularly pronounced in rural areas, including the state’s westernmost region, the Jackson Purchase. Among rural populations, chronic disease risk is driven by a combination of factors, including low socioeconomic status, limited access to healthcare/supermarket options, and food …

Delivering Safe Sleep And Breastfeeding Education To Pregnant And New Mothers Through Private Facebook Groups: Study Protocol For A 4-Armed Randomized Controlled Trial, Rebecca F. Carlin, Margaret G. Parker, Ann L. Kellams, Fern R. Hauck, Stephen Kerr, Benjamin T. Cornwell, Marc T. Kiviniemi, Nicole Geller, Katherine E. Boguszewski, Michael J. Corwin, Eve R. Colson, Rachel Y. Moon

Health, Behavior & Society Faculty Publications

Background: Annually, more than 3500 US infants die suddenly and unexpectedly. Many sudden unexpected infant deaths (SUID) are preventable with greater adherence to safe infant sleep guidelines. There are racial and economic disparities in guideline adherence and SUID rates. Education alone has proven ineffective at altering behavior for many parents, and social networks and social norms regarding infant care have been found to influence rates of unsafe sleep. Using the power of social networks to shape social norms by delivering education through moderated online social media groups provides a unique opportunity to influence these practices in large groups of parents. …

Characteristics Of Pulmonary Vs. Extrapulmonary Tuberculosis Cases In Kentucky From 2020 To 2024, Mariam M. Alkhairat

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Objective: Tuberculosis (TB) remains an important public health concern in the United States, especially among people experiencing social and clinical vulnerabilities. Extrapulmonary TB, which occurs outside of the lungs, can be harder to detect and diagnose than pulmonary TB. This study aimed to describe the demographic and clinical characteristics of people with active TB in Kentucky and to identify factors associated with extrapulmonary TB.

Methods: Secondary surveillance data were obtained from the Kentucky Department for Public Health (KDPH) using the National Tuberculosis Surveillance System (NTSS). The study sample included 301 confirmed active TB cases reported in Kentucky. Descriptive statistics were …

Preventing Teen Pregnancy Through Expanded Contraceptive Access In Mccreary County, Kentucky, Dacey B. Chitwood

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

This capstone project proposes a school-based Condom Availability Program to reduce teen pregnancy risk by expanding discreet contraceptive access for adolescents in McCreary County, Kentucky. Teen pregnancy remains a persistent public health concern in rural communities where stigma, privacy concerns, transportation barriers, and limited healthcare access can prevent adolescents from obtaining reproductive health resources. McCreary County faces elevated teen birth rates, socioeconomic disadvantage, and limited maternal healthcare infrastructure, making teen pregnancy prevention an important local priority. The proposed program would place free latex and non-latex condoms in student restrooms at McCreary Central High School, with QR-code-linked information connecting students to …

The Impact Of Food Insecurity And Associated Variables On Colon Cancer In Kentucky: An Ecologic Study, Claire E. Lynch

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Objective: Given colorectal cancer incidence rates are increasing, especially in socioeconomic disadvantaged areas, this study aims to determine if there is an association between specific socioeconomic variables, such as food insecurity, and colon cancer at the county-level in Kentucky.

Methods: Colorectal cancer age-adjusted incidence rates at the county-level were collected from the Kentucky Cancer Registry. Conty-level data was collected from County Health Ranking, The U.S Census Bureau, National Institute on Minority Health and Health Disparities and the Behavioral Risk Factor Surveillance System from 2019 to 2023. R was used to run statical analyses such as a linear regression and a …

Environmental Predictors Of Human Lyme Disease Incidence Across Appalachian Counties In Kentucky, Virginia, And West Virginia, 2000-2019, Karlie D. Rennison

Theses and Dissertations--Epidemiology and Biostatistics

This ecological study examined county-level environmental, landscape, and host-related predictors of Lyme disease incidence across Kentucky, Virginia, and West Virginia from 2000-2019. Lyme disease is an emerging public health concern in the Appalachian region, where geographic expansion and shifting ecological conditions may influence disease risk.

Lyme disease case rates (per 10,000 population) were analyzed in relation to climate variables, land cover metrics, host density measures, and rurality using publicly available data sources. Descriptive and regression analyses were conducted to evaluate associations between candidate predictors and disease incidence.

Substantial geographic variation in Lyme disease incidence was observed, with higher case rates …

Rural Oral Health Access Coordination Program Proposal, Anna Luu

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Oral health disparities remain a major public health issue in the United States, particularly in rural Kentucky, with barriers such as limited access to preventive dental services, transportation, and insurance coverage contributing to delayed treatment and worsening oral health outcomes. In response, the proposed Rural Oral Health Access Coordination Program aims to improve care access by strengthening referral systems, integrating oral health screenings into public health settings, and enhancing care coordination for high-risk populations. The program intends to focus on the Kentucky River District Health Department Region, connecting individuals to existing services rather than providing direct clinical care. Expected outcomes …

Perry County Perinatal Access Navigator Program (Pc-Pamp) A Public Health Program Proposal To Improve Timely Prenatal Care Access In Perry County, Kentucky, Amber E. Mcguire-Chun

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Delayed initiation of prenatal care remains a significant public health concern in rural Appalachian communities, including Perry County, Kentucky, where structural barriers such as limited provider availability, transportation challenges, and fragmented referral systems contribute to inadequate access to timely care. This capstone project proposes the Perry County Prenatal Access Navigator Program (PC-PANP), a community-based patient navigation model designed to improve initiation of prenatal care in the first trimester. The program is led by the local health department and leverages partnerships with healthcare providers, the University of Kentucky College of Public Health, WIC, Extension services, and community organizations to support early …

Wastewater Surveillance For Sars-Cov-2 In Rural Kentucky, 2021–2023, James W. Keck, Reuben Adatorwovor, Ann Noble, Savannah Tucker, William Strike, Soroosh Torabi, Mohammad Dehghan Banadaki, Blazan Mijatovic, Steven K. Roggenkamp, Donna Mcneil, Lindell Ormsbee, Scott M. Berry

Family and Community Medicine Faculty Publications

Wastewater testing for SARS-CoV-2 provided useful public health information during the COVID-19 pandemic yet was underutilized in rural communities. We addressed this gap by implementing wastewater surveillance and assessing its performance in 10 communities in Eastern Kentucky. We collected wastewater samples 1–2 times weekly at 10 wastewater treatment plants (WWTPs) from May 2021 until April 2023 and measured SARS-CoV-2 RNA concentrations using polymerase chain reaction testing. We calculated time-lagged correlations between wastewater concentrations and county-level reported COVID-19 cases by site. We developed a generalized linear model to estimate COVID-19 incidence from wastewater SARS-CoV-2 concentrations. The 10 participating WWTPs served 2430 …

Perceptions Of The Proposed Food And Drug Administration Graphic Cigarette Warnings Among Adults Who Smoke On A Nondaily Or Daily Basis: A Within-Subjects Experiment, Bethany Shorey Fennell, Renee E. Magnan, Jennifer I. Vidrine, Damon J. Vidrine

Family and Community Medicine Faculty Publications

Introduction: People who smoke nondaily represent nearly one third of U.S. adults who smoke and experience significant smoking-related morbidity and mortality, yet they are rarely considered when evaluating the efficacy of graphic cigarette warnings.

Method: In October 2019, U.S. adults who smoked nondaily ( n =59) and daily ( n =183) evaluated 13 Food and Drug Administration–proposed graphic warnings and 13 equivalent text-only warnings on the extent to which they elicited understanding, perceived new knowledge, worry about smoking, and discouragement to smoke and were believable. Repeated-measures ANOVA and planned comparisons tested for between-subjects (smoking status) and within-subjects (warning type) effects. …