Rural risk environments for hepatitis c among young adults in appalachian kentucky

David H. Cloud, Umedjon Ibragimov, Nadya Prood, April M. Young, Hannah L.F. Cooper

Research output: Contribution to journalArticlepeer-review

27 Scopus citations


Background: Rural Kentucky is an epicenter of hepatitis C(HCV), especially among young adults who inject drugs. While the Risk Environment Framework (REF) has been used widely to study and address socio-ecological determinants of infectious disease among people who inject drugs (PWID), it has been almost exclusively applied to urban environments. Applying REF to rural environments can enhance our understanding of the drivers of HCV epidemics in these hard-hit areas, and inform the creation and implementation of harm reduction interventions in this local context. Methods: Participants were recruited between March and August 2017 via community-based outreach methods (e.g., cookouts, flyers) and peer referral. Individuals who met eligibility criteria (aged 18–35, recently used prescription opioids and/or heroin to get high, lived in one of the 5 target counties) participated indepth, semi-structured interviews. The interview guide was informed by the REF, and covered HCV-related risk behaviors and environmental features that shaped vulnerability to engaging in these behaviors. Interviews were transcribed and analyzed using constructivist grounded-theory methods. Results: Participants (N=19) described multiple intersecting risk environment features that shaped vulnerability to HCV transmission. Economic decline generated intergenerational poverty, dwindling employment prospects, and diminished social enrichment opportunities that collectively contributed to substance misuse and risky injection practices. Geographic isolation, lack of collective knowledge about HCV transmission risks, scarce harm reduction services, familial poverty, and fear of law enforcement interacted to increase the odds of people injecting in “trap houses” (akin to shooting galleries) or secluded areas, spaces in which they rushed to inject and shared injection equipment. Pervasive stigma was a structural barrier to adopting, expanding, and using harm reduction services. Conclusion: This exploratory study identified features of rural risk environments that may contribute to significant HCV burdens in Appalachian Kentucky. Findings signal the importance of expanding proven harm reduction strategies and anti-stigma interventions tailored to rural contexts.

Original languageEnglish
Pages (from-to)47-54
Number of pages8
JournalInternational Journal of Drug Policy
StatePublished - Oct 2019

Bibliographical note

Funding Information:
This study was funded by the National Institute on Drug Abuse ( R21 DA042727 ; PIs: Cooper and Young). Community partners who provided feedback during the development of the quiz were identified through an ongoing study supported by the National Institute on Drug Abuse, CDC , SAMHSA , and the Appalachian Regional Commission (ARC) ( UG3 DA044798 ; PIs: Young and Cooper); the content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, CDC, SAMHSA, or ARC. We declare no conflicts of interest.

Publisher Copyright:
© 2019 Elsevier B.V.


  • Hepatitis C
  • Kentucky
  • Opioid
  • Risk environment
  • Rural

ASJC Scopus subject areas

  • Medicine (miscellaneous)
  • Health Policy


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