Persistent disparities in smoking among rural Appalachians: evidence from the Mountain Air Project.

BACKGROUND: Adult smoking prevalence in Central Appalachia is the highest in the United States, yet few epidemiologic studies describe the smoking behaviors of this population. Using a community-based approach, the Mountain Air Project (MAP) recruited the largest adult cohort from Central Appalachia, allowing us to examine prevalence and patterns of smoking behavior. METHODS: A cross-sectional epidemiologic study of 972 participants aged 21 years and older was undertaken 2015-2017, with a response rate of 82%. Prevalence ratios and 95% confidence intervals for current smoking (compared to nonsmokers) were computed for the entire cohort then stratified by multiple characteristics, including respiratory health. Adjusted prevalence ratios for current smoking versus not smoking were also computed. RESULTS: MAP participants reported current smoking prevalence (33%) more than double the national adult smoking prevalence. Current smoking among participants with a reported diagnosis of chronic obstructive pulmonary disease and emphysema was 51.5 and 53.3%, respectively. Compared to participants age 65 years and older, those age 45 years or younger reported double the prevalence of smoking (PR: 2.04, 95% CI: 1.51-2.74). Adjusted analyses identified younger age, lower education, unmet financial need, and depression to be significantly associated with current smoking. CONCLUSIONS: Despite declining rates of smoking across the United States, smoking remains a persistent challenge in Central Appalachia, which continues to face marked disparities in education funding and tobacco control policies that have benefitted much of the rest of the nation. Compared with national data, our cohort demonstrated higher rates of smoking among younger populations and reported a greater intensity of cigarette use.

"We're, Like, the Most Unhealthy People in the Country": Using an Equity Lens to Reduce Barriers to Healthy Food Access in Rural Appalachia.

INTRODUCTION: Obesity disproportionately affects rural communities, and Appalachia has some of the highest obesity rates in the nation. Successful policy, systems, and environmental (PSE) interventions to reduce obesity must reflect the circumstances of the population. We used a health equity lens to identify barriers and facilitators for healthy food access in Martin County, Kentucky, to design interventions responsive to social, cultural, and historical contexts. METHODS: We conducted 5 focus groups in Martin County, Kentucky, in fall 2019 to obtain perspectives on the local food system and gauge acceptability of PSE interventions. We used grounded theory to identify perceived barriers and facilitators for healthy eating. RESULTS: Thirty-four adults (27 women; median age, 46 years) participated in 5 groups. One prominent theme was declining interest in farming; many participants believed this decline was generational. One participant noted, "Most of my adult male relatives worked in the coal mines, and they worked 6 days a week. . . . My grandpa had the garden, but then my dad's generation is the one quit gardening." Another shared, "You would probably have to have someone to teach [gardening]." Instead of enhancing farmers markets, participants suggested building community capacity for home gardens to increase vegetable consumption. CONCLUSION: Our findings demonstrate the importance of obtaining community input on the development of PSE interventions to mitigate inequities in obesity. Although farmers market interventions were deemed not feasible, other solutions to enhance access to produce were identified. Developers of community-responsive PSE interventions to improve healthy eating in rural, food-insecure locations should consider using an equity-oriented prevention framework to ensure acceptable interventions.

Community-Wide Efforts to Improve the Consumer Food Environment and Physical Activity Resources in Rural Kentucky.

Community interventions to improve access to food and physical activity resources can reduce obesity rates and improve obesity-related health outcomes. We describe a Kentucky community project that consisted of collaborating with grocery store managers to improve the consumer food environment and partnering with community members to improve walking trails, bicycle racks, and other physical activity resources. We surveyed 2 random samples of community residents in 6 participating rural counties, 741 in 2016 (year 1) and 1,807 in 2017 (year 2). Fruit and vegetable intake significantly increased from year 1 (mean servings fruits, 2.71; vegetables, 2.54) to year 2 (mean servings fruit, 2.94; vegetables, 2.72). Although moderate physical activity did not change from year 1 to year 2, concern among residents about places to be physically active improved (P = .04). Involving community members in promoting obesity prevention programs may improve dietary intake and alleviate community concern about physical activity.

Identifying Community Perspectives for a Lung Cancer Screening Awareness Campaign in Appalachia Kentucky: The Terminate Lung Cancer (TLC) Study.

Lung cancer screening with low-dose computed tomography (LDCT) scan is now covered by Centers for Medicare & Medicaid Services following an evidence-based recommendation, but a shared decision making process should inform patients of risks and limitations. An awareness campaign promoting LDCT screenings is an opportunity to elicit patient engagement with health providers about the risks and benefits. Focus groups representing three regions of Appalachian Kentucky known for high lung cancer rates discussed development of a lung cancer screening campaign. Recommendations included messaging content, appeals or design, campaign implementation, and trusted information or communication sources. Community health workers (CHWs) from three Eastern Kentucky regions recruited individuals from their local communities using established client files. CHWs hosted six total focus groups (7-11 participants each) using questions guided by the Communication-Persuasion Matrix framework. All sessions were recorded and transcribed for independent content analysis. A total of 54 individuals (61.1 % female; >55 pack year history) were participated. Prior to discussion, most participants had not heard of lung cancer screening. Cited needs for content of a campaign included benefits of early detection and payment information. Messages considered most persuasive were those that include personal testimony, messages of hope, prolonged life, and an emphasis on family and the ambition to survive. Having information come from one's family doctor or specialty provider was considered important to message communication. Messages about survivorship, family, and prolonged life should be considered in lung cancer screening awareness campaigns. Our results provide community input about messages regarding screening options.

Association Between Healthcare Provider Type and Intent to Breastfeed Among Expectant Mothers.

BACKGROUND: The primary purpose of this study was to determine the association between type of healthcare provider delivering prenatal care and intent to exclusively breastfeed. METHODS: A self-report survey was administered to 455 expectant mothers. Logistic regression was performed to determine the association between prenatal care provider type [obstetrician; other primary care physician (family doctor/general practitioner/internist/or other physician); midwife/nurse midwife; more than one provider; and other] with intent to breastfeed (exclusive/non-exclusive). RESULTS: Having a midwife/nurse midwife as a prenatal care provider was associated with intent to breastfeed compared to having an obstetrician (OR 2.544, 95 % CI 1.385-4.675). There was no difference in intent between women with another primary care physician and an obstetrician. Women with another type of health care provider, no prenatal care from a health professional, or no knowledge of who is providing prenatal care were less likely to intend to breastfeed (OR 0.228, CI 0.068-0.766) as compared to those with an obstetrician. DISCUSSION/CONCLUSIONS: Provider type is associated with intent to breastfeed among pregnant women. Women's intent to breastfeed is an important predictor of breastfeeding initiation, continuation, and duration that may be assessed by healthcare providers during the prenatal period. A consideration of what features of provider care are associated with improved breastfeeding outcomes and characteristics of women seeking prenatal care with midwives may serve to formulate future prenatal care policies and education during prenatal care visits.

Adherence to highly active antiretroviral therapy impact on clinical and economic outcomes for Medicaid enrollees with human immunodeficiency virus and hepatitis C coinfection.

We examined the impact of antiretroviral treatment adherence among hepatitis C (HCV) coinfected human immunodeficiency virus (HIV) patients on survival and clinical outcomes. We analyzed Medicaid claims data from 14 southern states from 2005 to 2007, comparing survival and clinical outcomes and cost of treatment for HIV and HCV coinfected patients (N = 4115) at different levels of adherence to antiretroviral therapy (ART). More than one in five patients (20.5%) showed less than 50% adherence to antiretroviral treatment, but there were no racial/ethnic or gender disparities. Significant survival benefit was demonstrated at each incremental level of adherence to ART (one-year mortality ranging from 3.5% in the highest adherence group to 26.0% in the lowest). Low-adherence patients also had higher rates of hospitalization and emergency department visits. Relative to patients with high (>95%) ART adherence, those with less than 25% treatment adherence had fourfold greater risk of death (adjusted odds ratio 4.22 [95% CI: 3.03, 5.87]). Nondrug Medicaid expenditures were lower for high-adherence patients, but cost of medications drove total Medicaid expenditures higher for high-adherence patients. Cost per quality-adjusted life year (QALY) saved (relative to the <25% low-adherence group) ranged from $21,874 for increasing adherence to 25-50% to $37,229 for increasing adherence to 75-95%. Adherence to ART for patients with HIV and HCV coinfection is associated with lower adverse clinical outcomes at a Medicaid cost per QALY commensurate with other well-accepted treatment and prevention strategies. Further research is needed to identify interventions which can best achieve optimal ART adherence at a population scale.

Enduring Effects of the COVID-19 Pandemic on Food Access, Nutrition, and Well-Being in Rural Appalachia.

The COVID-19 pandemic produced acute effects on health inequities, yet more enduring impacts in vulnerable populations in rural Appalachia are understudied. This qualitative study included three focus groups with thirty-nine adults (74% female, mean age 52.7 years) to obtain perspectives on the impact of the COVID-19 pandemic on well-being in Martin County, Kentucky, in fall 2022. Grounded Theory was employed using an iterative inductive-deductive approach to capture the lasting effects of the COVID-19 pandemic on health practices and status. Three prominent themes emerged: (1) increased social isolation; (2) household cost of living strains caused by inflation; and (3) higher food prices and diminished food availability causing shifts in food purchasing and consumption. Participants noted that the rising cost of living resulted in residents having to "choose between medication, food and utilities". Increased food prices resulted in residents "stretching" their food, modifying how they grocery shopped, and limiting meat consumption. Persistent food shortages were exacerbated by there being few grocery stores in the county. Lastly, increased social isolation was profoundly articulated as widely impacting mental health, especially among youth. Our findings underscore the ongoing deleterious effects of inflation and food supply chain disruptions in this rural, geographically isolated community, which resulted in difficult spending choices for residents.

Racial disparities in economic and clinical outcomes of pregnancy among Medicaid recipients.

To explore racial-ethnic disparities in adverse pregnancy outcomes among Medicaid recipients, and to estimate excess Medicaid costs associated with the disparities. Cross-sectional study of adverse pregnancy outcomes and Medicaid payments using data from Medicaid Analytic eXtract files on all Medicaid enrollees in fourteen southern states. Compared to other racial and ethnic groups, African American women tended to be younger, more likely to have a Cesarean section, to stay longer in the hospital and to incur higher Medicaid costs. African-American women were also more likely to experience preeclampsia, placental abruption, preterm birth, small birth size for gestational age, and fetal death/stillbirth. Eliminating racial disparities in adverse pregnancy outcomes (not counting infant costs), could generate Medicaid cost savings of $114 to $214 million per year in these 14 states. Despite having the same insurance coverage and meeting the same poverty guidelines for Medicaid eligibility, African American women have a higher rate of adverse pregnancy outcomes than White or Hispanic women. Racial disparities in adverse pregnancy outcomes not only represent potentially preventable human suffering, but also avoidable economic costs. There is a significant financial return-on-investment opportunity tied to eliminating racial disparities in birth outcomes. With the Affordable Care Act expansion of Medicaid coverage for the year 2014, Medicaid could be powerful public health tool for improving pregnancy outcomes.

Exploring Food-Based Cultural Practices to Address Food Insecurity in Rural Appalachia.

BACKGROUND: Health behaviors, like diet, are influenced by a person's culture and the society where they reside, contributing to the presence of health disparities within a unique region. Such disparities are evident in Central Appalachia where a unique cultural identity exists. Culture-based initiatives focused on improving food security and other nutritional challenges have had success in other diverse groups, yet similar interventions considering geographically tied culture, like Appalachia, are limited. AIM: This study aims to identify specific aspects of Appalachian culture that address food insecurity to inform future initiatives that may improve adult dietary habits and food security status. METHODS: Qualitative data were collected from five focus groups in one rural Central Appalachian community in 2021 (n=59). Data were analyzed using Grounded Theory Approach. RESULTS: Four primary themes related to culture and food insecurity emerged: 1) Community decline and economic hardship 2) Shifts in multigenerational food traditions 3) Response to limited food access and 4) Community decline and economic hardship. Participants revealed adaptations they have made in the face of geographic isolation and poverty and the pride they take in providing for themselves and one another. CONCLUSION: These findings indicate the people of Appalachia are unknowingly leveraging cultural practices to address food insecurity, yet the impact of these practices on nutritional status remains unknown. These results have implications for future studies and interventions in Appalachia which may have greater success by accounting for cultural influences compared to traditional approaches for reducing food insecurity in the region.

Impact of community-driven interventions on dietary and physical activity outcomes among a cohort of adults in a rural Appalachian county in Eastern Kentucky, 2019-2022.

Several environmental level factors exacerbate poor health outcomes in rural populations in the United States, such as lack of access to healthy food and locations to be physically active, which support healthy choices at the individual level. Thus, utilizing innovative place-based approaches in rural locations is essential to improve health outcomes. Leveraging community assets, like Cooperative Extension, is a novel strategy for implementing community-driven interventions. This prospective cohort study (n = 152), recruited in 2019 and surveyed again in 2020 and 2021, examined individual level changes in diet and physical activity in one rural Appalachian county. During this time, multiple community-driven interventions were implemented alongside Cooperative Extension and several community partners. Across the three-year study, the cohort indicated increases in other vegetables and water and reductions in fruits and legumes. There were also reductions in less healthy items such as French fries and sugar-sweetened beverages. The cohort also reported being less likely to engage in physical activity. Our findings suggest that key community-driven programs may have indirect effects on dietary and physical activity choices over time. Outcomes from this study are relevant for public health practitioners and community organizations working within rural Appalachian communities to address health-related behaviors.

The Impact of a Grocery Store Closure in One Rural Highly Obese Appalachian Community on Shopping Behavior and Dietary Intake.

Research has examined how the entry of grocery stores into neighborhoods influences dietary outcomes, yet limited evidence suggests a direct correlation between opening a store and changes in dietary intake. A factor that might influence individuals' behavior more directly is the closing of a grocery store where residents shop. This study aims to examine how a grocery closure in a rural Appalachian high poverty county is associated with dietary intake. A cohort of n = 152 individuals were recruited to participate in a longitudinal study examining purchasing habits and dietary intake. At time point two, one year later, n = 74 individuals completed the survey via phone. Results indicate those that switched from shopping at a local grocery store to a supercenter significantly increased their dietary intake of fruit (0.2 ± 0.8), fruits and vegetables (1.4 ± 2.7), alcohol (grams) (17.3 ± 54.1), and tomato sauce (0.1 ± 0.3). A local grocery store closure was associated with a change in shopping behavior and dietary intake. Community-level interventions targeting dietary behaviors must account for neighborhood food environment influences, including grocery store availability. Policy aimed at improving food access in rural communities need to consider approaches to improving a variety of food venues with affordable healthy food, while addressing the evolving grocery shopping behaviors of consumers.

Losses, Gains, and Changes to the Food Environment in a Rural Kentucky County during the COVID-19 Pandemic.

The COVID-19 pandemic has caused alterations to be made in the way many people access, prepare, and consume food. Rural communities are particularly impacted due to pre-existing structural vulnerabilities, i.e., poverty, lack of infrastructure, and limited fresh food options. This study aimed to characterize experiences of one rural Appalachian community's changes to the food environment during the pandemic. In April 2021, six focus groups were conducted with residents of Laurel County, Kentucky. Using grounded theory, we identified losses, gains, and overall changes to the community food environment since the onset of COVID-19. Seventeen Laurel Countians (17 female; ages 30-74) participated in the six focus groups. Three main themes emerged regarding food environment changes-(1) modifications of community food and nutrition resources, (2) expansion and utilization of online food ordering, and (3) implications of the home food environment. Rural communities faced considerable challenges during the COVID-19 pandemic, in part, due to gaps in existing infrastructure and loss of pre-existing resources. This study illustrates the complexity of changes occurring during COVID-19. Using the preliminary data obtained, we can better understand pre-existing issues in Laurel County and suggestions for future programming to address the inequitable access and response during public health emergencies and beyond.

Physical Activity Barriers and Assets in Rural Appalachian Kentucky: A Mixed-Methods Study.

Obesity is an increasing public health concern in the U.S. and a contributor to chronic illness, with trends revealing a rise in adult obesity and chronic disease rates among the most vulnerable and disadvantaged populations, including those in rural communities. A mixed-methods approach was used to examine perspectives on perceived physical activity barriers, resources, and level of community support. Researchers utilized the socioecological model to examine the multiple domains that support physical activity in rural Appalachia. The present study focuses on baseline data, including a cohort survey to assess physical activity, health status, and barriers to physical activity, and five focus groups with elected community leaders, community residents, members, and key stakeholders to assess perspectives on physical activity barriers and resources within the county. The cohort survey sample (N = 152) reported a median of 6 barriers (range 0-13) to participating in at least 30 min of physical activity daily. The qualitative analysis yielded three overarching themes related to physical activity participation: lack of motivation, physical environment, and cultural barriers. This mixed-methods study revealed the challenges and perceptions among rural residents across the socioecological model when assessing physical inactivity. Findings can be used to tailor future interventions focused on expanding social support, designing infrastructure, and creating policies that promote physical activity.

Sugar-sweetened beverage consumption among adults in rural Appalachia.

Sugar-sweetened beverage (SSB) consumption is decreasing nationally, yet intakes remain high in certain sub-populations as new varieties of SSBs are introduced. This study aims to expand on SSB intake patterns among adults living in Appalachia to develop policy, systems, and environmental (PSE) interventions to reduce consumption. Baseline cohort surveys were conducted to examine beverage consumption patterns of adults in one rural Appalachian county in Kentucky using a validated BEVQ-15 instrument. Ages were collapsed into three generational groups - Millennials (22-38 years), Generation X (39-54 years), and Boomers/Silents (≥55 years). Over half (n = 81; 54%) of the sample (n = 150) were Boomers/Silents. Age was a significant predictor of SSB consumption, with Millennials drinking more daily calories of SSB compared to older adults (329.2 kcal v 157.0 kcal v 134.6 kcal, p = 0.05); a significant amount of those calories coming from non-soda SSBs. Millennials were twice as likely to drink sweetened fruit juice drinks (p = 0.0002) and energy drinks (p = 0.01) daily and consumed six times more daily calories from sweetened fruit juice drinks than the other groups (73.5 kcal v 11.1 kcal v 8.0 kcal, p < 0.01). To our knowledge, this is the first study to show beverage choices and consumption patterns in Appalachian adults vary by age and non-soda SSBs are significant sources of added sugar. These findings inform PSE interventions for reducing SSB consumption, such as tailored marketing approaches and technology-based strategies, within a unique setting, and offer insight for nutrition educators and public health professionals working within rural, remote communities.

Policy Implications of the COVID-19 Pandemic on Food Insecurity in Rural America: Evidence from Appalachia.

Rural communities are disproportionally affected by food insecurity, making them vulnerable to the consequences of supply disruptions caused by the COVID-19 pandemic. While access to food was initially diminished due to food supply disruptions, little is known about the mechanisms through which federal emergency assistance programs impacted food access in rural populations. Through a series of five focus groups in spring 2021, we examined the impact of the COVID-19 pandemic on food access in a rural Appalachian community in Kentucky. Data were analyzed using a Grounded Theory Approach. Findings revealed the following four primary themes: food scarcity in grocery stores; expanded federal food assistance; expanded community food resources; and expanded home gardening. Participants provided details regarding the way increased federal assistance, especially expanded benefits within the Supplemental Nutrition Assistance Program, allowed them to purchase greater quantities of nutritious food. This study unveils the specific impacts of the COVID-19 pandemic on one rural population, including the influence of some social determinants of health on food insecurity. Policymakers and stakeholders should recognize the layered protection of multiple federal emergency assistance programs against food insecurity and the potential for long-term population health promotion in rural areas.

The Community Leadership Institute of Kentucky (CLIK): A Collaborative Workforce and Leadership Development Program.

BACKGROUND: The Community Leadership Institute of Kentucky (CLIK), a workforce development and leadership program within the Community Engagement and Research Core of the University of Kentucky's Center for Clinical and Translational Science (UK CCTS), was developed to enhance community members' capacity to address pernicious rural health inequities. OBJECTIVES/METHODS: In this article, we describe the development, implementation, and results of the program, examining program and project completion rates, quantitative and qualitative evaluations from participants, and professional achievements. RESULTS: Based on existing models from other Clinical and Translational Science Awards Programs (CTSAs), CLIK provides diverse programming in a local, supportive setting and supports mentors/academic partners through education and networking. Now in its sixth year, CLIK participants have included 41 leaders from varied local settings, including public school systems, health departments, county and local governments, and other non-profit organizations. Shaped by extensive CLIK participant input, the program offers eleven didactic and hands-on training sessions in evidence-based programming and health promotion; a mentored research project addressing relevant local health inequities; and extensive networking opportunities. CONCLUSIONS: CLIK has become an enrichment opportunity for local communities as well as a platform for academic engagement and bi-directional learning. Such community-academic partnerships are particularly needed in traditionally under-resourced rural communities.

Authentic Youth Engagement in Environmental Health Research and Advocacy.

Training in environmental health (EH) engages and inspires youth to tackle health promotion and policy change. Yet, there is little guidance on how to successfully nurture and sustain youth engagement. This paper compares four case studies of youth engagement to promote EH in rural and urban communities using the Youth Empowerment Solutions (YES!) framework. Of the case studies in rural (Central Appalachia) and urban (Cincinnati, Ohio) communities, two employ citizen science approaches using PhotoVoice and environmental sampling; one engages youth in a science communication camp; and one focuses on policy advocacy. We compare and contrast these case studies using the YES! Critical Components and Empowerment levels. The case studies were discussed at the 2020 Partnerships in Environmental Public Health Meeting, where participants identified challenges and possible solutions for promoting and maintaining authentic youth engagement in EH research and advocacy. Analysis of the case studies indicated that youth engagement activities focusing on the individual were more common than those targeting the organizational setting or the community. Youth demonstrate agency to impact EH issues in their communities by engaging in hands-on opportunities to practice citizen science and advocacy. Overcoming challenges to authentic young engagement is important to sustain this work.

Acculturation and self-reported health among Hispanics using a socio-behavioral model: the North Texas Healthy Heart Study.

BACKGROUND: Acculturation is a continuous, firsthand contact with other cultures functioning at both group and individual levels and is reflected in our culturally diverse society, calling for a greater understanding of the environmental and cultural impact on health. Self-reported health (SRH), a robust and well validated predictor of future mortality for all racial/ethnic groups, has been differentially reported by Hispanics compared to whites, especially based on their acculturation status. This study investigated the relationship between acculturation and SRH among Hispanics. An adapted Andersen framework was used to develop logistic regression models to assess for an association between acculturation and general health status. METHODS: Hispanic participants (n = 135), as part of the North Texas Healthy Heart Study, were administered standardized questionnaires on acculturation, psychosocial measures which included sense of control, stress, depression and social support and a single item SRH measure. In addition, physiological measurements and demographic characteristics including age, gender, body mass index, medical history, and socioeconomic status were also obtained. RESULTS: Bivariate analyses found Mexican-oriented participants 3.16 times more likely to report fair/poor SRH compared to Anglo-oriented Hispanics. Acculturation was also associated with SRH in multiple regression models controlling for enabling, need, and predisposing factors together (OR: 3.53, 95% CI: 1.04, 11.97). CONCLUSIONS: Acculturation status was associated with SRH after accounting for other underlying factors. Medical and public health professionals should promote the use of acculturation measures in order to better understand its role in Hispanic behaviors, health outcomes and health care use. Such research findings will contribute to the design of culturally sensitive prevention and treatment strategies for diverse and immigrant populations.

Self-reported racial discrimination, response to unfair treatment, and coronary calcification in asymptomatic adults--the North Texas Healthy Heart study.

BACKGROUND: Accruing evidence supports the hypothesis that psychosocial factors are related to cardiovascular disease. However, a limited number of studies have investigated the pathophysiologic pathways through which these associations occur. The purpose of this study was to assess whether experiences of self-reported racial discrimination and reactions to unfair treatment were associated with coronary artery calcification (CAC), an indicator of subclinical coronary heart disease (CHD). METHODS: This cross-sectional study recruited 571 subjects (45 years and older) who were asymptomatic of CHD from Fort Worth, Texas from 2006 to 2008. Subjects completed a questionnaire, a multi-slice computed tomography scan to assess for CAC presence (measured as Agatston score >0), and serum chemistries. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between self-reported discrimination and CAC. Results were stratified by response to unfair treatment as it was found to significantly modify the relationship between discrimination and CAC. RESULTS: Among those who passively responded to unfair treatment, the odds of having CAC present were approximately 3 times higher for those experiencing discrimination (OR, 2.95; 95% CI, 1.19-7.32) after adjusting for age, gender, race/ethnicity, education, body mass index, hyperlipidemia, smoking status, hypertension, diabetes, and first degree relative with heart disease. CONCLUSIONS: This is the first multi-racial/ethnic study to find racial discrimination associated with CAC, which differs based on how one responds to unfair treatment.

Rural SNAP Participants and Food Insecurity: How Can Communities Leverage Resources to Meet the Growing Food Insecurity Status of Rural and Low-Income Residents?

The burden of obesity disproportionately influences poor health outcomes in rural communities in the United States. Various social and environmental factors contribute to inadequate food access and availability in rural areas, influencing dietary intakes and food insecurity rates. This study aims to identify patterns related to food insecurity and fruit and vegetable consumption within a SNAP-eligible and low-income, highly obese rural Appalachian community. A prospective cohort was implemented to identify gaps in resources addressing obesity and food insecurity challenges. SAS 9.4 software was used to examine differences in dietary intakes and shopping practices among SNAP participants. Among participants (n = 152), most reported an annual household income less than USD 20,000 (n = 90, 60.4%), 29.1% reported food insecurity, and 39.5% reported receiving SNAP benefits within the last month. The overall mean FV intake was 3.46 daily servings (95% CI: 3.06-3.91) among all participants. SNAP participation was associated with food insecurity (p = 0.007) and those participating in SNAP were two times more likely to report being food insecure (OR = 2.707, 95% CI: 1.317, 5.563), relative to non-participants. These findings further depict the need for intervention, as the burden of food insecurity persists. Tailoring health-promoting initiatives to consider rurality and SNAP participation is vital for sustainable success among these populations.