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"Wayfaring Strangers: The Musical Voyage from Scotland and Ulster to Appalachia" is a book by Fiona Ritchie and Doug Orr that explores the cultural pathways of traditional Scottish and Irish folk music as it traveled to Appalachia. The book examines the influences of Welsh, English, German, Dutch, French, African American, and Cherokee cultures on these songs. It is structured into three main sections and includes photographs, maps, and sidebars covering various topics related to folk music. The authors also exchange letters discussing their perspectives on Old and New World music. The book sheds light on the history of American folk music and its connection to immigrant experiences. It includes a contextual timeline, resource centers, a discography, and a bibliography for further exploration. Scholars and music enthusiasts will find this book to be a valuable resource. [Extracted from the article]

There have been 188 rural hospital closures in the United States since 2010 with approximately 20% of these in Appalachia. Telehealth has become a way that nurses can reach rural patients who might not otherwise receive health care. The purpose of this paper is to (1) outline the federal policies enacted during COVID-19 for broadband expansion; and (2) suggest how advanced practice nursing care might be affected by broadband expansion and telehealth in the region. A search of PubMed was conducted in January 2023, using the search words, "policy", "telehealth", "broadband", and "Appalachia". New laws appropriated funds to expand broadband infrastructure that made it possible for telehealth to be used by nurses to deliver health care to rural patients. This discussion paper found that broadband legislation was instrumental in expanding telecommunications and telehealth by NPs. There is a great need for broadband to continue to expand and for trained nurses to provide care via telehealth. [ABSTRACT FROM AUTHOR]

Prostate cancer is the most common cancer after non-melanoma skin cancer and the second leading cause of cancer deaths in US men. Its incidence and mortality rates vary substantially across geographical regions and over time, with large disparities by race, geographic regions (i.e., Appalachia), among others. The widely used Cox proportional hazards model is usually not applicable in such scenarios owing to the violation of the proportional hazards assumption. In this paper, we fit Bayesian accelerated failure time models for the analysis of prostate cancer survival and take dependent spatial structures and temporal information into account by incorporating random effects with multivariate conditional autoregressive priors. In particular, we relax the proportional hazards assumption, consider flexible frailty structures in space and time, and also explore strategies for handling the temporal variable. The parameter estimation and inference are based on a Monte Carlo Markov chain technique under a Bayesian framework. The deviance information criterion is used to check goodness of fit and to select the best candidate model. Extensive simulations are performed to examine and compare the performances of models in different contexts. Finally, we illustrate our approach by using the 2004-2014 Pennsylvania Prostate Cancer Registry data to explore spatial-temporal heterogeneity in overall survival and identify significant risk factors. [ABSTRACT FROM AUTHOR]

In this paper, we analyze double modal use in American English based on a multi-billion-word corpus of geolocated posts from the social media platform Twitter. We identify and map 76 distinct double modals totaling 5,349 examples, many more types and tokens of double modals than have ever been observed. These descriptive results show that double modal structure and use in American English is far more complex than has generally been assumed. We then consider the relevance of these results to three current theoretical debates. First, we demonstrate that although there are various semantic tendencies in the types of modals that most often combine, there are no absolute constraints on double modal formation in American English. Most surprisingly, our results suggest that double modals are used productively across the US. Second, we argue that there is considerable dialect variation in double modal use in the southern US, with double modals generally being most strongly associated with African American Language, especially in the Deep South. This result challenges previous sociolinguistic research, which has often highlighted double modal use in White Southern English, especially in Appalachia. Third, we consider how these results can help us better understand the origins of double modals in America English: although it has generally been assumed that double modals were introduced by Scots-Irish settlers, we believe our results are more consistent with the hypothesis that double modals are an innovation of African American Language. [ABSTRACT FROM AUTHOR]

In a time of multiple, competing, and nested crises, the draw to storytelling is intuitive. Stories help us make sense of the world around us. People are drawn to stories because of their emphasis on community, and the way they create possibilities when it feels like there are none. This paper builds upon geographic research on storytelling, articulating how stories are critical for creating meaning in light of crises. Based on 14 months of fieldwork with storytellers in Appalachia and Alaska, two regions facing profound social, climatic, and economic change and with culturally rich storytelling traditions, research for this paper discusses the practice of storytelling, as told by storytellers, and how different approaches to storytelling help address the climate crisis specifically with notes for crises more broadly. Further, considering calls to use storytelling to address climate change, this paper examines and critiques the stories that are currently being told and valued. Finally, this paper outlines the kinds of stories that could be told to address crises, noting specifically how stories are sites of cultural and political struggle. [ABSTRACT FROM AUTHOR]

Introduction: Older adults living alone in rural areas frequently experience health declines, social isolation, and limited access to services. To address these challenges, our medical academic university supported a quality improvement project for developing and evaluating the Visiting Neighbors program in two rural Appalachian counties. Our Visiting Neighbors program trained local volunteers to visit and guide rural older adults in healthy activities. These age-appropriate activities (Mingle, Manage, and Move– 3M's) were designed to improve the functional health of older adults. The program includes four in-home visits and four follow-up telephone calls across three months. Purpose: The purpose of this paper was to describe the 3M's Visiting Neighbors protocol steps guiding the quality improvement procedures relating to program development, implementation, and evaluation. Methods and materials: This Visiting Neighbors study used a single-group exploratory quality improvement design. This program was tested using quality improvement standards, including collecting participant questionnaires and visit observations. Results: Older adults (> 65 years) living alone (N = 30) participants were female (79%) with a mean age of 82.96 (SD = 7.87) years. Volunteer visitor participants (N = 10) were older adult females. Two volunteer visitors implemented each visit, guided by the 3M's activities manual. All visits were verified as being consistently delivered (fidelity). Enrollment and retention data found the program was feasible to conduct. The older adult participants' total program helpfulness ratings (1 to 5) were high (M = 51.27, SD = 3.77). All volunteer visitor's program helpfulness ratings were also high (M = 51.78, SD = 3.73). Discussion: The Visiting Neighbors program consistently engaged older Appalachian adults living alone in the 3M's activities. The feasibility and fidelity of the 3M's home visits were verified. The quality improvement processes included engaging the expert advisory committee and rural county stakeholders to ensure the quality of the program development, implementation, and evaluation. [ABSTRACT FROM AUTHOR]

This paper is an aesthetic analysis of the practice of serpent handling by Christians in the Appalachian region of the United States. The purpose of this analysis is to understand serpent handling's aesthetic relationship to the Pentecostal tradition and exposit the implications of this relationship for the practice's legal status. The first section examines the history and defining characteristics of serpent handling and introduces the controversial problem of whether the practice can be categorized within the Pentecostal movement. The second section argues that serpent handling can be understood as belonging within the broader global Pentecostal tradition through engagement with the Pentecostal aesthetics of Nimi Wariboko. The final section concludes that if serpent handling is legible according to the aesthetic norms of Pentecostalism, a now broadly tolerated religious tradition in the United States, then this necessitates a wholesale reconsideration of antiserpent handling legislation. [ABSTRACT FROM AUTHOR]

The objective of this study was to examine the accuracy of indexing for "Appalachian Region"[Mesh]. Researchers performed a search in PubMed for articles published in 2019 using "Appalachian Region"[Mesh] or "Appalachia" or "Appalachian" in the title or abstract. Only 17.88% of the articles retrieved by the search were about Appalachia according to the ARC definition. Most articles retrieved appeared because they were indexed with state terms that were included as part of the mesh term. Database indexing and searching transparency is of growing importance as indexers rely increasingly on automated systems to catalog information and publications. [ABSTRACT FROM AUTHOR]

This study aimed to identify factors for successful cross-sector collaboration with faith-based responses to the opioid epidemic in southern Appalachia. In-depth interviews were conducted with representatives from organizations responding to the opioid epidemic (N = 25) and persons who have experienced opioid dependency (N = 11). Stakeholders perceived that collaboration is hindered by stigma, poor communication, and conflicting medical and spiritual approaches to opioid dependency. Collaborations are facilitated by cultivating compassion and trust, sharing information along relational lines, and discerning shared commitments while respecting different approaches. The study concludes with theoretical and practical implications for both religious leaders and potential cross-sector collaborators., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Forgiveness, a construct common to religiousness/spirituality and positive psychology, and resentment are thought to be critical factors in addiction and recovery therefrom. Although empirical evidence is accumulating to support forgiveness as an important factor in addiction recovery, very little work has empirically examined the role of resentment in addiction recovery, including the role of the forgiveness – resentment interface. The association of forgiveness with addiction recovery-related outcomes, as mediated by resentment, in the context of substance (mis)use was examined in two cross-sectional studies among undergraduate college students from three institutions, in this IRB-approved study. Self-forgiveness was consistently associated – both directly and indirectly through resentment – with less psychological distress and less vulnerability to use substances in the context of both alcohol (mis)use and drug (mis)use. Other-forgiveness was similarly associated, but less frequently. Empirical evidence is beginning to emerge to support the long-held anecdotal assumptions regarding the importance of forgiveness and resentment to addiction recovery, with implications for interventions and approaches to treatment for those struggling with substance (mis)use. [ABSTRACT FROM AUTHOR]

Background: The present commentary highlights the pressing need for systematic research to assess the implementation and effectiveness of medications for opioid use disorder, used in conjunction with peer recovery support services, to improve treatment outcomes for individuals with opioid use disorder in Central Appalachia. This region, encompassing West Virginia, Eastern Kentucky, Southwest Virginia, East Tennessee, and Western North Carolina, has long grappled with a disproportionate burden of the opioid crisis. Due to a complex interplay of cultural, socioeconomic, medical, and geographic factors, individuals in Central Appalachia face challenges in maintaining treatment and recovery efforts, leading to lower success rates. Approach: To address the issue, we apply an exploratory approach, looking at the intersection of unique regional factors with the utilization of medications for opioid use disorder, in conjunction with peer recovery support services. This combined treatment strategy shows promise in addressing crucial needs in opioid use disorder treatment and enhancing the recovery journey. However, there are significant evidence gaps that need to be addressed to validate the expected value of incorporating peer support into this treatment strategy. Conclusion: We identify nine obstacles and offer recommendations to address the gaps and advance peer recovery support services research. These recommendations include the establishment of specific partnerships and infrastructure for community-engaged, peer recovery support research; improved allocation of funding and resources to implement evidence-based practices such as peer support and medication-assisted treatment; developing a more precise definition of peer roles and their integration across the treatment and recovery spectrum; and proactive efforts to combat stigma through outreach and education. [ABSTRACT FROM AUTHOR]

The Forestry Reclamation Approach (FRA) is a practical guide to reforesting surface mined lands. Bats, a group of mammals with declining populations, could benefit from mine reforestation. To determine if the FRA can provide suitable bat foraging habitat, we surveyed bat activity at created depressional wetlands on 1-year-old and 8-year-old FRA reforested lands (FRA1; FRA8), wetlands in naturally regenerating forest on traditionally reclaimed mined land (~40 years old; REGEN), and wetlands in mature forest not previously mined (MAT). We passively recorded echolocation calls for 12 nights across 16 sites between June and August 2021. We analyzed bat activity using the number of recordings, pulses, and feeding buzzes in conjunction with nocturnal insect abundance and biomass, microhabitat characteristics, and landscape characteristics via generalized linear mixed effects modeling. Both FRA1 and FRA8 had activity levels similar to MAT. REGEN had significantly greater foraging activity than the other three land classes, possibly due to its distance from roads and proximity to forest edges. Insect abundance and biomass were comparable across sites, indicating FRA practices do not hinder the establishment of a prey base for bats. Overall, bats are utilizing the restored mined land for foraging. Reforestation of mined lands, complemented with wetland creation, provides habitat that could benefit bat species conservation in Appalachia. [ABSTRACT FROM AUTHOR]

The fauna of Diplura, the two-pronged bristletails (Hexapoda), of the southern Appalachians has received little focused systematic attention. Existing literature suggests the fauna to comprise around a dozen species. Based on a broader DNA barcode-based survey of high elevation litter arthropods in the region, we suggest the fauna to be much richer, with automated species delimitation methods hypothesising as many as 35 species, most highly restricted to single or closely proximate localities. Such a result should not be very surprising for such small, flightless arthropods, although it remains to be seen if other markers or morphology support such high diversity. The region still remains sparsely sampled for these more cryptic elements of the arthropod fauna and much larger numbers of species undoubtedly remain to be discovered. [ABSTRACT FROM AUTHOR]

Background: High consumption of sugar-sweetened beverages (SSB) is a global health concern. Additionally, sugar-sweetened beverage (SSB) consumption is disproportionately high among adolescents and adults in rural Appalachia. The primary study objective is to determine the intervention effects of Kids SIPsmartER on students' SSB consumption. Secondary objectives focus on caregivers' SSB consumption and secondary student and caregiver outcomes [e.g, body mass index (BMI), quality of life (QOL)]. Methods: This Type 1 hybrid, cluster randomized controlled trial includes 12 Appalachian middle schools (6 randomized to Kids SIPsmartER and 6 to control). Kids SIPsmartER is a 6-month, 12 lesson, multi-level, school-based, behavior and health literacy program aimed at reducing SSB among 7th grade middle school students. The program also incorporates a two-way text message strategy for caregivers. In this primary prevention intervention, all 7th grade students and their caregivers from participating schools were eligible to participate, regardless of baseline SSB consumption. Validated instruments were used to assess SSB behaviors and QOL. Height and weight were objectively measured in students and self-reported by caregivers. Analyses included modified two-part models with time fixed effects that controlled for relevant demographics and included school cluster robust standard errors. Results: Of the 526 students and 220 caregivers, mean (SD) ages were 12.7 (0.5) and 40.6 (6.7) years, respectively. Students were 55% female. Caregivers were mostly female (95%) and White (93%); 25% had a high school education or less and 33% had an annual household income less than $50,000. Regardless of SSB intake at baseline and relative to control participants, SSB significantly decreased among students [-7.2 ounces/day (95% CI = -10.7, -3.7); p < 0.001, effect size (ES) = 0.35] and caregivers [-6.3 ounces/day (95% CI = -11.3, -1.3); p = 0.014, ES = 0.33]. Among students (42%) and caregivers (28%) who consumed > 24 SSB ounces/day at baseline (i.e., high consumers), the ES increased to 0.45 and 0.95, respectively. There were no significant effects for student or caregiver QOL indicators or objectively measured student BMI; however, caregiver self-reported BMI significantly decreased in the intervention versus control schools (p = 0.001). Conclusions: Kids SIPsmartER was effective at reducing SSB consumption among students and their caregivers in the rural, medically underserved Appalachian region. Importantly, SSB effects were even stronger among students and caregivers who were high consumers at baseline. Trial registration: Clincialtrials.gov: NCT03740113. Registered 14 November 2018– Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03740113. [ABSTRACT FROM AUTHOR]

Forest ecosystem attributes and their spatial variation across the landscape have the potential to subsequently influence variations in fire behavior. Understanding this variation is critical to fire managers in their ability to predict fire behavior and rate of spread. However, a fine-scale description of fuel patterns and their relationship with overstory and understory attributes for north-central Appalachia is lacking due to the complicated quantification of variations in topography, forest attributes, and their interactions. To better understand the fire environment in north-central Appalachia and provide a comprehensive evaluation based on fine-scale topography, ninety-four plots were established across different aspects and slope positions within an oak–hickory forest located in southeast Ohio, USA, which historically fell within fire regime group I with a fire return interval ranging from 7 to 26 years. The data collected from these plots were analyzed by four components of the fire environment, which include the overstory, understory, shrub and herbaceous layers, surface fuels, and fuel conditions. The results reveal that fuel bed composition changed across aspects and slope position, and it is a primary factor that influences the environment where fire occurs. Specifically, the oak fuel load was highest on south-facing slopes and in upper slope positions, while maple fuel loads were similar across all aspects and slope positions. Oak and maple basal areas were the most significant factors in predicting the oak and maple fuel load, respectively. In the shrub and undergrowth layers, woody plant coverage was higher in upper slope positions compared to lower slope positions. Overstory canopy closure displayed a significant negative correlation with understory trees/ha and woody plant variables. The findings in this study can provide a better understanding of fine-scale fuel bed and vegetation characteristics, which can subsequently feed into fire behavior modeling research in north-central Appalachia based on the different characterizations of the fire environment by landscape position. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of type 2 diabetes (T2D) is 17% higher in rural dwellers compared to their urban counterparts, and it increases with age, with an estimated 25% of older adults (≥ 65 years) diagnosed. Appropriate self-care is necessary for optimal clinical outcomes. Overall, T2D self-care is consistently poor among the general population but is even worse in rural-dwellers and older adults. In rural Kentucky, up to 23% of adults in Appalachian communities have been diagnosed with T2D and, of those, 26.8% are older adults. To attain optimal clinical outcomes, social environmental factors, including social support, are vital when promoting T2D self-care. Specifically, peer support has shown to be efficacious in improving T2D self-care behaviors and clinical and psychosocial outcomes related to T2D; however, literature also suggests self-selected social support can be obstructive when engaging in healthful activities. Currently available evidence-based interventions (EBIs) using peer support have not been used to prioritize older adults, especially those living in rural communities. Method: To address this gap, we conducted formative research with stakeholders, and collaboratively identified an acceptable and feasible peer support EBI—peer health coaching (PHC)—that has resulted in improved clinical and psychosocial T2D-related outcomes among participants who did not reside in rural communities nor were ≥65 years. The goal of the proposed study is to use a 2x2 factorial design to test the adapted PHC components and determine their preliminary effectiveness to promote self-care behaviors and improve glycemic control among older adults living in Appalachian Kentucky. Testing the PHC components of the peer support intervention will be instrumental in promoting care for older adults in Appalachia, as it will allow for a larger scale intervention, which if effective, could be disseminated to community partners in Appalachia. Trial registration: This study was registered at www.clinicaltrials.gov (NCT06003634) in August 2023. [ABSTRACT FROM AUTHOR]

American ginseng (Panax quinquefolius) is a slow-growing medicinal root native to eastern North America. Though it is possible to farm, wild ginseng can sell for twenty (or more) times as much as cultivated ginseng. Declining wild ginseng populations due to habitat loss and overharvesting has led to harvest restrictions, but strong demand for wild ginseng remains. One potential solution is "wild-simulated" ginseng, where ginseng is grown under conditions crafted to mimic a wild forest with the goal of producing roots that look wild. I contend, however, that despite the fact that wild-simulated ginseng grows in a habitat actively tended and monitored by humans, is nevertheless wild. I explore wildness as "productive unruliness" and show how wild-simulated ginseng actively crafts wildness through management to maintain if not add complexity, to foster unpredictability, or to facilitate stress. Furthermore, the habitat that wild-simulated ginseng growers are attempting to emulate—"wild" Appalachian woodlands dominated by an assemblage of "native" plants that pre-date the arrival of Europeans in the Americas—are themselves the product of human manipulation. In Appalachia, the boundaries between the wild and the cultivated are blurred. Wild-simulated ginseng is an example of how conservation goals can be achieved by crafting "wild" environments that are not untouched, pristine wildernesses. [ABSTRACT FROM AUTHOR]

Kentucky is one of the largest coal-producing states; surface coal mining has led to changes in natural land cover, soil loss, and water quality. This study explored relationships between actively mined and reclaimed areas, vegetation change, and water quality parameters. The study site evaluated 58 watersheds with Landsat-derived variables (reclamation age and percentage of mining, reclaimed forest, and reclaimed woods) as well as topographic variables (such as elevation, slope, drainage density, and infiltration). Water samples were collected in spring (n = 9), summer (n = 14), and fall (n = 58) 2017 to study changes in water quality variables (SO42−, alkalinity, conductivity, Ca2+, Mg2+, Mn2+, Al3+, and Fe2+, Fe3+) in response to changes in land cover. Pearson correlation analyses indicated that conductivity has strong to very strong relationships with water quality variables related to coal mining (except Al3+, Fe2+, Fe3+, Mn2+, elevation, slope, and drainage density) and land cover variables. In addition, separate regression analyses were performed, with conductivity values based on samples collected in the fall. First, conductivity responses to mining percentage, reclamation age and topographic variables were examined (adjusted R2 = 0.818, p < 0.01). Next, vegetation cover change parameters were added to the same model, which yielded slightly improved R2 (adjusted R2 = 0.826, p < 0.01). Finally, reclamation age and mining percentages were used to explain the quantity of reclaimed forested areas as a percentage of watersheds. The model was significant (p < 0.01), with an adjusted R2 value of 0.641. Results suggest that the quantity (area as a percentage) of reclaimed forests may be a predictor of the mining percentage and reclamation age. This study indicated that conductivity is a predictable water quality indicator that is highly associated with Coal-Mine-Related Stream Chemistry in areas where agriculture and urban development are limited. Water quality is not suitable for various purposes due to the presence of contaminants, especially in mined sites. These findings may help the scientific community and key state and federal agencies improve their understanding of water quality attributes in watersheds affected by coal mining, as well as refine land reclamation practices more effectively while such practices are in action. [ABSTRACT FROM AUTHOR]

Background: Adult smoking rates in the USA are highest in economically depressed rural Appalachia. Pharmacist-delivered tobacco cessation support that incorporates medication therapy management (such as the QuitAid intervention) is a promising approach to address this need. Methods: Twenty-four adult smokers recruited between September and November 2021 through an independent pharmacy in rural Appalachia were randomized in a non-blinded 2 × 2 × 2 factorial design to (1) pharmacist delivered QuitAid intervention (yes vs. no); (2) combination nicotine replacement therapy (NRT) gum + NRT patch (vs. NRT patch); and/or (3) 8 weeks of NRT (vs. standard 4 weeks). Participants received 4 weeks of NRT patch in addition to the components to which they were assigned. Participants completed baseline and 3-month follow-up assessments. Primary outcomes were feasibility of recruitment and randomization, retention, treatment adherence, and fidelity. Results: Participants were recruited in 7 weeks primarily through a referral process, commonly referred to as ask-advise-connect (61%). Participants were on average 52.4 years old, 29.2% were male and the majority were white (91.6%) and Non-Hispanic (91.7%). There was a high level of adherence to the interventions, with 85% of QuitAid sessions completed, 83.3% of the patch used, and 54.5% of gum used. Participants reported a high level of satisfaction with the program, and there was a high level of retention (92%). Conclusions: This demonstration pilot randomized controlled study indicates that an ask-advise-connect model for connecting rural smokers to smoking cessation support and providing QuitAid for smoking cessation is feasible and acceptable among rural Appalachian smokers and independent pharmacists. Further investigation into the efficacy of a pharmacist-delivered approach for smoking cessation is needed. Trial registration: The trial was retrospectively registered at ClinicalTrials.gov. Trial #: NCT05649241. [ABSTRACT FROM AUTHOR]

Background: Personal syringe reuse (i.e., reuse of one's own syringes) can place people who inject drugs at increased risk for infectious disease but has received relatively little attention in published literature. The purpose of this study is to identify factors associated with syringe reuse among people who inject drugs in rural Kentucky., Methods: Participants (n = 238) completed interviewer-administered questionnaires on syringe reuse and demographic, behavioral, and service access characteristics. Unadjusted negative binomial regression with cluster-robust standard errors was used to model the associations with a logged offset for number of injections in the past 30 days., Results: The average age of the sample was 35 and 59.7 % were male. Most participants (77.7 %) reused syringes at least once in the past 30 days, using each syringe a median of three times. Reuse was higher among those who were older and reported a higher street price for syringes. Syringe reuse was lower among people who were within walking distance to a syringe service program (SSP) and who obtained most of their syringes from SSPs or pharmacies., Conclusion: Syringe reuse among people who inject drugs in rural Kentucky is common. However, these data suggest that increased access to syringes from SSPs and pharmacies, as well as policy-level interventions that reduce street syringe price, might reduce syringe reuse and related harms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

While many studies have found positive correlations between greenness and human health, rural Central Appalachia is an exception. The region has high greenness levels but poor health. The purpose of this commentary is to provide a possible explanation for this paradox: three sets of factors overwhelming or attenuating the health benefits of greenness. These include environmental (e.g., steep typography and limited access to green space used for outdoor recreation), social (e.g., chronic poverty, declining coal industry, and limited access to healthcare), and psychological and behavioral factors (e.g., perceptions about health behaviors, healthcare, and greenness). The influence of these factors on the expected health benefits of greenness should be considered as working hypotheses for future research. Policymakers and public health officials need to ensure that greenness-based interventions account for contextual factors and other determinants of health to ensure these interventions have the expected health benefits., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia., Methods and Analysis: KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness., Ethics and Dissemination: The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings., Trial Registration Number: NCT05657106., Competing Interests: Competing interests: AF-B is a co-founder of Voices of Hope, the contracted recovery community organisation providing the recovery coaching services. The device to facilitate syringe disposal and dispensing that will be installed in conjunction with the kiosk is intellectual property of the University of Kentucky, with AMY designated as the inventor. CC is a paid consultant on the implementation of harm reduction vending machines, including on the described project., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)