In 1968, Alabama segregationist George Wallace received the highest percentage of votes in the 4 counties surrounding Cincinnati

Which includes Butler County, where Middletown is located. 

Map and election results:  Wikipedia (boxes added)

Headline:  New York Times, 7/16/2024

Mr. Vance, 39, wrote about his chaotic upbringing there, raised in the intermittent care of a single mother struggling with addiction. In his depiction, Middletown was “little more than a relic of American industrial glory,” a place “hemorrhaging jobs and hope.” 

His bleak portrait of the city, just north of Cincinnati, was initially held up as a reference guide for urbanites on the coasts desperate to understand Mr. Trump’s appeal among the struggling white working class. 

Mr. Vance’s explanation was a stark one: some of Middletown’s woes were caused by the damaging decisions of government and big business, but the deeper problems lay in the fatalism, indolence and victim mentality of the city’s white working class.

Since 1948, Butler County has voted for a Democratic presidential candidate just once:  In 1964.