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AbstractBackgroundMethodsResultsConclusionChronic respiratory disease disproportionately affects residents of Appalachia, particularly those residing in Central Appalachia. Asthma is particularly burdensome to Central Appalachian residents regarding cost and disability. Improving our understanding of how to mitigate these burdens requires understanding the factors influencing asthma control among individuals with asthma living in Central Appalachia, specifically rural Kentucky.This community-based, cross-sectional epidemiologic study used survey data to identify characteristics associated with uncontrolled and controlled asthma. The designation of “uncontrolled asthma” was based on a self-report of ≥ 2 asthma exacerbations in the past year. Individuals with ≤ 1 or no exacerbations were considered to have controlled asthma. Chi-square or Fisher exact tests assessed the association between categorical variables and asthma control categories. Logistic regression was conducted to determine the impact of factors on the likelihood of uncontrolled asthma.In a sample of 211 individuals with self-reported asthma, 29% (n = 61, 46 females) had uncontrolled asthma. Predictors of uncontrolled asthma included depression (odds ratio 2.61, 95% CI 1.22–5.61, p = .014) and living in multi-unit housing (odds ratio 4.99, 95% CI 1.47–16.96, p = .010) when controlling for age, sex, financial status, and occupation. Being overweight or obese was not a predictor of uncontrolled asthma. Physical activity and BMI did not predict the likelihood of uncontrolled asthma.This study highlights significant challenges rural communities in Appalachian Kentucky face in managing asthma. Factors like depression, housing conditions, and a lack of self-management strategies play pivotal roles in asthma control in this population. [ABSTRACT FROM AUTHOR]

Objectives: In traditionally underserved communities, faith-based interventions have been shown to be effective for health promotion. Religious leaders-generally the major partner in such interventions-however, are seldom are consulted about community health priorities and health promotion preferences. These insights are critical to ensure productive partnerships, effective programming, and sustainability.Methods: Mixed-methods surveys were administered in one of the nation's most under-resourced regions: rural Appalachia. A sample of 60 religious leaders, representing the main denominations in central Appalachia, participated. Measures included closed- and open-ended survey questions on health priorities and recommendations for health promotion. Descriptive statistics were used for closed-ended survey items and conventional qualitative content analysis was used for open-ended responses.Results: Substance abuse, diabetes mellitus, suboptimal dietary intake and obesity/overweight, and cardiovascular and respiratory illnesses constitute major health concerns. Addressing these challenging conditions requires realistically acknowledging sparse community resources (particularly healthcare provider shortages); building in accountability; and leveraging local assets and traditions such as testimonials, intergenerational support, and witnessing.Conclusions: With their extensive reach within the community and their accurate understanding of community health threats, practitioners and researchers may find religious leaders to be natural allies in health-promotion and disease-prevention activities. [ABSTRACT FROM AUTHOR]

Social networks influence health behavior and health status. Within social networks, "key players" often influence those around them, particularly in traditionally underserved areas like the Appalachian region in the USA. From a total sample of 787 Appalachian residents, we identified and interviewed 10 key players in complex networks, asking them what comprises a key player, their role in their network and community, and ideas to overcome and increase colorectal cancer (CRC) screening. Key players emphasized their communication skills, resourcefulness, and special occupational and educational status in the community. Barriers to CRC screening included negative perceptions of the colonoscopy screening procedure, discomfort with the medical system, and misinformed perspectives on screening. Ideas to improve screening focused on increasing awareness of women's susceptibility to CRC, providing information on different screening tests, improving access, and the key role of health-care providers and key players themselves. We provide recommendations to leverage these vital community resources. [ABSTRACT FROM AUTHOR]

Background: Rural Appalachian residents experience among the highest prevalence of chronic disease, premature mortality, and decreased life expectancy in the nation. Addressing these growing inequities while avoiding duplicating existing programming necessitates the development of appropriate adaptations of evidence-based lifestyle interventions. Yet few published articles explicate how to accomplish such contextual and cultural adaptation.Methods: In this paper, we describe the process of adapting the Make Better Choices 2 (MBC2) mHealth diet and activity randomized trial and the revised protocol for intervention implementation in rural Appalachia. Deploying the NIH's Cultural Framework on Health and Aaron's Adaptation framework, the iterative adaptation process included convening focus groups (N = 4, 38 participants), conducting key informant interviews (N = 16), verifying findings with our Community Advisory Board (N = 9), and deploying usability surveys (N = 8), wireframing (N = 8), and pilot testing (N = 9. This intense process resulted in a comprehensive revision of recruitment, retention, assessment, and intervention components. For the main trial, 350 participants will be randomized to receive either the multicomponent MBC2 diet and activity intervention or an active control condition (stress and sleep management). The main outcome is a composite score of four behavioral outcomes: two outcomes related to diet (increased fruits and vegetables and decreased saturated fat intake) and two related to activity (increased moderate vigorous physical activity [MVPA] and decreased time spent on sedentary activities). Secondary outcomes include change in biomarkers, including blood pressure, lipids, A1C, waist circumference, and BMI.Discussion: Adaptation and implementation of evidence-based interventions is necessary to ensure efficacious contextually and culturally appropriate health services and programs, particularly for underserved and vulnerable populations. This article describes the development process of an adapted, community-embedded health intervention and the final protocol created to improve health behavior and, ultimately, advance health equity.Trial Registration: ClinicalTrials.gov Identifier NCT04309461. The trial was registered on 6/3/2020. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Despite numerous benefits of consuming a healthy diet and receiving regular physical activity, engagement in these behaviors is suboptimal. Since primary care visits are influential in promoting healthy behaviors, we sought to describe whether and how diet and physical activity are discussed during older adults’ primary care visits. Methods: 115 adults aged 65 and older consented to have their routine primary care visits recorded. Audio-recorded visits were transcribed and diet and physical activity content was coded and analyzed. Results: Diet and physical activity were discussed in the majority of visits. When these discussions occurred, they lasted an average of a minute and a half. Encouragement and broad discussion of benefits of improved diet and physical activity levels were the common type of exchange. Discussions rarely involved patient behavioral self-assessments, patient questions, or providers’ recommendations. Conclusions: The majority of patient visits include discussion of diet and physical activity, but these discussions are often brief and rarely include recommendations. Practice implications: Providers may want to consider ways to expand their lifestyle behavior discussions to increase patient involvement and provide more detailed, actionable recommendations for behavior change. Additionally, given time constraints, a wider array of approaches to lifestyle counseling may be necessary. [Copyright &y& Elsevier]

Breast and cervical cancer account for nearly one-third of new cancer cases and one-sixth of cancer deaths. Cancer, the second leading cause of all deaths in the United States, will claim the lives of nearly 800,000 women this year, which is particularly unfortunate because effective modes of early detection could significantly reduce mortality from breast and cervical cancer. Researchers examined patterns of non-screening among Appalachian women. In-person interviews were conducted with 222 Appalachian women who fell outside of screening recommendations for timing of Pap tests and mammograms. These women, from six Appalachian counties, were participating in a group-randomized, multi-component trial aimed at increasing adherence to cancer screening recommendations. Results indicated that participants who were rarely or never screened for breast cancer were also likely to be rarely or never screened for cervical cancer. In addition, four key barriers were identified as independently and significantly associated with being rarely or never screened for both cervical and breast cancer. An improved understanding of cancer screening patterns plus the barriers underlying lack of screening may move researchers closer to developing effective interventions that facilitate women's use of screening. [ABSTRACT FROM AUTHOR]

Objective: Patterns of overweight and obesity have an unequal geographic distribution, and there are elevated rates in Appalachia. Perceptions of Appalachian youth toward healthful eating and influences on food choice were examined as part of formative research to address these disparities. Methods: Eleven focus groups, averaging 6 youth (n = 68) and moderated by experienced local residents, were conducted with participants aged 8-17. Session transcripts were coded for thematic analysis, using measures to enhance rigor and transferability. Results: Participants discussed numerous internal and external factors affecting dietary choices. They expressed confidence in their own nutritional knowledge, and they stressed the importance of taste preferences, cost, convenience, social influences, and advertising on diet. Conclusions and Implications: Appalachian youth awareness of the multiple influences on diet may create opportunities for multifaceted, ecologically based interventions. In particular, participants stressed the importance of social influences on diet and on successful nutrition programming. [ABSTRACT FROM AUTHOR]

The prevalence of multiple health conditions, or multiple morbidity (MM), is increasing. Providing medical care for adults with MM presents challenges, including balancing disease management with prevention. We conducted in-depth semistructured interviews with 12 primary care physicians to explore their perspectives on prevention counseling among patients with MM. Participants described the complex relationship between disease management and prevention, highlighted the importance of patient motivation, and discussed various strategies to promote receptivity to prevention recommendations. The perceived potential benefits of prevention recommendations encouraged physicians to persist with such counseling, despite challenges presented by visit time constraints, reimbursement procedures, and concerns over futility. Physicians recommended the development of alternate care delivery and reimbursement models to overcome challenges of the existing health care system and to meet the prevention needs of patients with MM. We explore the implications of these findings for maximizing the health and quality of life of adults with MM. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to determine the relation among multiple morbidities and the prevalence of colorectal cancer (CRC) screening among older adult Appalachian residents of Kentucky. This is the first known study to address multiple morbidities exclusively with a health-disparities population.Methods: This was a cross-sectional study of 1153 subjects, aged 50 to 76 years, from Appalachian Kentucky.Results: White race, post-high school education, and perception of having more than enough income on which to survive were associated with higher rates of any guideline concordant CRC screening. Statistically significant trends in the outcome of adjusted odds ratios for colonoscopy with greater number of morbidities (P < 0.05) were noted; the higher number of morbidities, the higher rates of screening.Conclusions: Contrary to much existing research, within a health-disparities population, we found a dose-response relation between comorbidities and greater likelihood of CRC screening. Future research in this area should focus on explanations for this seldom-described finding. In addition, this finding has meaningful clinical and behavioral implications, including ensuring provider screening recommendation during routine office visits and outreach, perhaps through community clinics and public health departments, to extremely vulnerable populations lacking access to preventive care. [ABSTRACT FROM AUTHOR]

The author discusses how the periodical "The Gerontologist" is committed to promoting qualitative research. She considers qualitative and quantitative research, qualitative scholarship, guidance given to authors submitting qualitative articles as well as reviewers who assess these works, and efforts made to publish more qualitative works in the journal.

Approximately three fourths of middle-aged and older adults have at least two simultaneously occurring chronic conditions (“multiple morbidity,” or MM), a trend expected to increase dramatically throughout the world. Rural residents, who tend to have fewer personal and health resources, are more likely to experience MM. To improve our understanding of the ways in which vulnerable, rural residents in the United States experience and manage MM, we interviewed 20 rural Appalachian residents with MM. We identified the following themes: (a) MM has multifaceted challenges and is viewed as more than the sum of its parts; (b) numerous challenges exist to optimal MM self-management, particularly in a rural, underresourced context; however, (c) participants described strategic methods of managing MM, including prioritizing certain conditions and management strategies and drawing heavily on assistance from informal and formal sources. [ABSTRACT FROM PUBLISHER]

Objective: To provide a conceptual description of Faith Moves Mountains (FMM), an intervention designed to reduce the disproportionate burden of cervical cancer among Appalachian women. Methods: FMM, a community-based participatory research program designed and Implemented in collaboration with churches in rural, southeastern Kentucky, aims to increase cervical cancer screening (Pap tests) through a multiphase process of educational programming and lay health counseling. Results: We provide a conceptual overview to key elements of the intervention, including programmatic development, theoretical basis, intervention approach and implementation, and evaluation procedures. Conclusions: After numerous modifications, FMM has recruited and retained over 400 women, 30 churches, and has become a change agent in the community. [ABSTRACT FROM AUTHOR]

Purpose: On average, adults aged 60 years or older have 2.2 chronic diseases, contributing to the over 60 million Americans with multiple morbidities. We aimed to understand the financial implications of the most frequent multiple morbidities among older adults. Design and Methods: We analyzed Health and Retirement Study data, determining out-of-pocket medical expenses from 1998 and 2002 separately and examining differences in the impact of multiple-morbidity constellations on these expenses. We paid particular attention to the most common disease constellations-hypertension, arthritis, and heart disease. Results: An increasing prevalence of multiple morbidity (58% compared with 70% of adults had two or more chronic conditions in 1998 and 2002, respectively) was accompanied by escalating out-of- pocket expenditures ($2, 1 64 in 1 998, increasing by 104% to $3,748 in 2002). Individuals with two, three, and four chronic conditions had health care expenditure increases of 41%, 85%, and 100%, respectively, over 4 years. Such patterns were particularly noticeable among the oldest old, those with higher educational attainment, and women, although having supplementary health insurance or Medicaid mitigated these expenses. Finally, there were significant differences in out-of-pocket expenditure levels among the multiple-morbidity combinations. Implications: Increasing rates of multiple morbidities in conjunction with escalating health care costs and stable or declining incomes among elders warrant creative attention from providers, researchers, and policy makers. Further understanding how specific multiple-morbidity constellations impact out-of-pocket spending moves us closer to effective interventions to support vulnerable elders. [ABSTRACT FROM AUTHOR]

Although cervical cancer rates in the U.S. have declined sharply, certain groups remain at elevated risk, including Appalachian women. To establish culturally-relevant cervical cancer prevention programs requires a comprehensive, current understanding of the factors which influence women's decisions to undergo Pap tests. Since most studies that found low rates of Pap test use in Appalachia were carried out decades ago, an in-depth update is warranted. Local, trained interviewers conducted interviews with rarely or never screened Appalachian women from Kentucky and West Virginia. Sessions were tape recorded, transcribed, and content analyzed. Participants (N = 25) suggested the following positive influences on obtaining screening: having an orientation toward the use of preventive health services; having health insurance and access to a good medical environment; and maintaining a flexible enough schedule to keep appointments. Screening barriers included: fear of subjecting oneself to medical scrutiny because of obesity or being a smoker; inadequate health care access such as clinician shortages, scarcity of specialty providers, long travel time to services, and clinic schedules that do not accommodate working women; and lack of providers' recommendations. Rarely mentioned were some previously reported factors including male relatives' refusal to permit Pap tests, concern over privacy, and lack of belief in Pap tests. [ABSTRACT FROM AUTHOR]

Abstract: In Western nations, cardiovascular disease (CVD) is the leading cause of death and disability, and myocardial infarction (MI or heart attack) is responsible for the most significant proportion of these deaths. Over the past decades, however, mortality rates from CVD in general and MI specifically have been decreasing due in large part to the proliferation of time-dependent therapies. As their description suggests, the use of such effective therapies is associated with early hospital presentation, thus reducing treatment time has significant benefits. Previous research most often has focused on sociodemographic or clinical factors influential in treatment timing, while the activities that individuals undertake during the critical hours prior to presentation for formal medical treatment remain insufficiently examined. Since self-care activities provide a window into how cardiac symptom sufferers conceptualize and act on their distress and, subsequently, how these conceptualizations shape treatment timing, we sought a more complete understanding of the relationship between self-care behaviours and treatment timing. Employing a complementary design, we examined data from 2972 survivors participating in the MI Onset study in the United States and 35 survivors from the MI Illness Narrative Study. Results indicate that cardiac self-care played a defining role in time to treatment, while other factors (i.e., sociodemographic and clinical factors) did not. Specifically, taking over-the-counter medications (i.e., analgesics and antacids) was associated with a longer treatment time. A closer look at who was likely to pursue these strategies and their reasons behind so doing leads us to conclude that (1) social location and self-identity; (2) previous health experiences, including personal health history and prior use of self-care strategies and; (3) social interaction play important roles in cardiac self-care responses which, in turn, shape treatment timing. [Copyright &y& Elsevier]

This study describes complementary and alternative medicine (CAM) use for diabetes self-management among a multiethnic sample with an aim of better understanding lay perspectives on CAM's utility and determining whether CAM practices undermine conventional diabetes self-management.During in-depth interviews with 80 older adults, data were collected on sociodemographics, the full range of self-management practices, and attitudes toward CAM. Analysis included descriptive measures of association and line-by-line coding.Trained interviewers recruited respondents from four health or social service sites. Sites were selected because they contained a large clientele of the targeted ethnic group and had been involved successfully in previous research studies.Twenty (20) adults age 50 and older from each of the groups most adversely affected by diabetes (African Americans, Hispanics, Native Americans, rural whites) participated in the study.Self-management strategies (included CAM) were assessed through a semistructured interview guide. Structured instruments obtained data on sociodemographics and health history. The 15-item Summary of Diabetes Self-Care Activities Questionnaire (SDSCA) assessed the frequency of completing recommended self-management activities.One in four elders reported using CAM, with respondents' cultural background associated with the CAM modality. We found no relationship between standard biomedical regimens and CAM use, supporting respondents' suggestion that CAM supplements rather than substitutes for biomedical self-management. Respondents suggested that use of CAM was limited by CAM's inaccessibility, and, underlying all, the dominanceof conventional biomedical therapies that undermines belief in CAM's effectiveness.Older adults with diabetes use a flexible configuration of diabetes–self-management techniques, including culturally specific CAM modalities. CAM use, however, occupies a limited role in diabetes self-management, largely because of the predominance of conventional biomedical regimens. [ABSTRACT FROM AUTHOR]

Presents a study that examined the lay referral patterns involved in cardiac treatment decision making among middle-aged and older adults. Information on coronary heart disease, treatment-seeking behavior and lay consultations; Determinants of myocardial infarction onset study; Logistic regression of decision to seek treatment made by self on selected characteristics.

Presents a study that interviewed middle age and older women living in Kentucky to explore their perceptions on the factors and circumstances that may shape coronary heart disease (CHD) time to treatment. Explanations for women's heightened risk of poor CHD outcomes; Key factors for the delay in women's seeking formal medical care when experiencing symptoms of CHD; Consequences of the gendering of CHD as a male disease.

Evaluates nutritional risk among older persons who receive home-delivered meals in the U.S. Background on the study conducted by the Department of Agriculture's Continuing Survey of Food Intake by Individuals concerning the intake of nutrients among the elderly; Details on a nutrition program established by the Congress for older people; Factors that contribute to the risk of poor dietary intake among meal recipients; Analysis of the individual components of nutritional risk.

Examines the factors accounting the prevalence of coronary heart disease mortality in Kentucky. Level of rates of smoking and poor diets of the residents; Identification of factors beyond the control of older respondents; Concentration of prevention efforts on the removal of structural and information barriers.

We currently lack critical information about an important component of community-based service use-attitudes about these services. To understand such attitudes, 115 older adults (age 65+) participated in in-depth interviews. Because of their vulnerability to poor health status, insufficient resources, and low use of formal services relative to their needs, we oversampled African-American and rural elders. Both positive and negative attitudes were expressed about formal services, with five overarching categories of concern emerging from the analyses. These concerns included (1) the quality of the program or staff; (2) security; (3) cost and eligibility requirements; (4) transportation; and (5) logistical elements. Implications and recommendations are suggested. [ABSTRACT FROM AUTHOR]

This article describes the use of vignettes, or hypothetical scenarios, with semi-structured follow-up questions. The vignette approach offers a number of benefits, particularly for eliciting data on awareness and attitudes, including: (1) flexibility that allows the researcher to design an instrument uniquely responsive to specific topical foci; (2) enjoyment and creativity for the informant; and (3) depersonalization that encourages an informant to think beyond his or her own circumstances, an important feature for sensitive topics or for illuminating future use patterns of services. In this article, we illustrate the vignette approach by examining the awareness and attitudes of older adults toward the use of formal community-based or home-health services. Although researchers generally acknowledge the importance of understanding informants' awareness of and attitudes toward formal services, these factors are often overlooked in formal service utilization literature, possibly owing to a lack of methodological tools. By employing the vignette approach, we avoided prestuctured questionnaires that often contain investigator bias while encouraging topical focus unavailable in most 'grand tour questions'. We provide a description of and evidence for how this vignette approach circumvented frequently encountered problems in awareness and attitudinal research, while more richly capturing the voices of the informants. [ABSTRACT FROM AUTHOR]

Purpose: Clinical guidelines recommend early palliative care for patients with advanced lung cancer. In rural and underserved community oncology practices with limited resources, both primary palliative care from an oncologist and specialty palliative care are needed to address patients’ palliative care needs. The aim of this study is to describe community oncology clinicians’ primary palliative care practices and perspectives on integrating specialty palliative care into routine advanced lung cancer treatment in rural and underserved communities. Methods: Participants were clinicians recruited from 15 predominantly rural community oncology practices in Kentucky. Participants completed a one-time survey regarding their primary palliative care practices and knowledge, barriers, and facilitators to integrating specialty palliative care into advanced-stage lung cancer treatment. Results: Forty-seven clinicians (30% oncologists) participated. The majority (72.3%) of clinicians worked in a rural county. Over 70% reported routinely asking patients about symptom and physical function concerns, whereas less than half reported routinely asking about key prognostic concerns. Roughly 30% held at least one palliative care misconception (e.g., palliative care is for only those who are stopping cancer treatment). Clinician-reported barriers to specialty palliative care referrals included fear a referral would send the wrong message to patients (77%) and concern about burdening patients with appointments (53%). Notably, the most common clinician-reported facilitator was a patient asking for a referral (93.6%). Conclusion: Educational programs and outreach efforts are needed to inform community oncology clinicians about palliative care, empower patients to request referrals, and facilitate patients’ palliative care needs assessment, documentation, and standardized referral templates. [ABSTRACT FROM AUTHOR]

Describes parents' understanding, or explanatory models, of attention-deficit/hyperactivity disorder and examines how such explanatory models differ by ethnicity, child gender, treatment status and sociodemographic status. Relationships between sociodemographic characteristics and parents' preferred treatments; Concerns and expectations of parents.

Explores perspectives on the origin and management of non-insulin-dependent diabetes mellitus (NIDDM) among women aged 65 and above in the United States. Adherence to dietary recommendations; Attribution of NIDDM to dietary practices, heredity, physical malfunctioning, overweight and personal risk factors; Treatment approaches.

Examines the roles of physicians and clergy as facilitators of formal services for older adults in the United States. Influence of facilitators on the use of formal services; Challenges associated in the proliferation of managed care; Ways to enhance the opportunities for appropriate receipt of care services by the facilitators.

Examines the relationship between ethnicity and the attention deficit hyperactivity disorder (ADHD), and the amount of knowledge which persons have on ADHD. Reference to some of the measures being implemented to educate persons on the condition; Symptoms of the disorder; Findings of studies conducted.

Focuses on a study which examined the attitude of African-American women over the age of 65, toward the possibility of moving into a nursing home. Methodology used to conduct study; Indepth look at the positive responses to this concept; Discussion on other findings of the study.

Investigates ethnic differences in the prevalence of oral health decrements for the understanding of factors that may contribute to the disproportionate prevalence of life-threatening illnesses among African-Americans. Use of the Florida Dental Care Study to find oral health status differences between African-Americans and white adults in the United States.

Examines the relationship between perceptions of social support and adherence to dietary recommendations among African-American elders with hypertension using semi-structured interviews in the United States. Indication that informants perceived themselves to be well-supported by family and friends; Moderate to high level of dietary adherence of the informants.

This study aimed to explore how the aging population in Appalachia manages its transportation and plans for the transition to non-driving and to seek possible solutions to the challenge of meeting rural transportation needs. Four focus groups (N = 38) were conducted, supplemented by a questionnaire, in Appalachian Kentucky. The results showed that few alternative transportation existed except a local paratransit service and informal transportation support. Compared to older adults, middle-aged adults reported a greater willingness to use mobile phones and the Internet to arrange transportation if they were available. Participants also recommended expanding the use of existing transportation in the community – such as church vans – to better meet the aging population's needs. The findings suggest that partnership between government, non-profit, and private sectors is needed, not solely focusing on a tax-dependent solution. Additionally, information and communication technology-based transportation management system would help maximize the use of scare but existing resources in rural areas. [ABSTRACT FROM AUTHOR]

The article provides information related to the publication "The Gerontologist." The author relates that the journal applied aging research findings of the highest standard. Authors are encouraged to submit their most innovative and significant research that has the potential to enhance the lives of older people and those who care for, and about them. The journal would also like to provide guidance for qualitative authors in the reviewers evaluating such contributions in the hopes of increasing publications of qualitative manuscripts.

Purpose: Despite clinical guidelines, palliative care is underutilized during advanced stage lung cancer treatment. To inform interventions to increase its use, patient-level barriers and facilitators (i.e., determinants) need to be characterized, especially among patients living in rural areas or those receiving treatment outside academic medical centers. Methods: Between 2020 and 2021, advanced stage lung cancer patients (n = 77; 62% rural; 58% receiving care in the community) completed a one-time survey assessing palliative care use and its determinants. Univariate and bivariate analyses described palliative care use and determinants and compared scores by patient demographic (e.g., rural vs. urban) and treatment setting (e.g., community vs. academic medical center) factors. Results: Roughly half said they had never met with a palliative care doctor (49.4%) or nurse (58.4%) as part of cancer care. Only 18% said they knew what palliative care was and could explain it; 17% thought it was the same as hospice. After palliative care was distinguished from hospice, the most frequently cited reasons patients stated they would not seek palliative care were uncertainty about what it would offer (65%), concerns about insurance coverage (63%), difficulty attending multiple appointments (60%), and lack of discussion with an oncologist (59%). The most common reasons patients stated they would seek palliative care were a desire to control pain (62%), oncologist recommendation (58%), and coping support for family and friends (55%). Conclusion: Interventions should address knowledge and misconceptions, assess care needs, and facilitate communication between patients and oncologists about palliative care. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Faith Moves Mountains assessed the effectiveness of a faith-placed lay health advisor (LHA) intervention to increase Papanicolaou (Pap) test use among middle-aged and older women in a region disproportionately affected by cervical cancer and low screening rates (regionally, only 68% screened in prior 3years). Method: This community-based RCT was conducted in four Appalachian Kentucky counties (December 2005–June 2008). Women aged 40–64 and overdue for screening were recruited from churches and individually randomized to treatment (n =176) or wait-list control (n =169). The intervention provided LHA home visits and newsletters addressing barriers to screening. Self-reported Pap test receipt was the primary outcome. Results: Intention-to-treat analyses revealed that treatment group participants (17.6% screened) had over twice the odds of wait-list controls (11.2% screened) of reporting Pap test receipt post-intervention, OR=2.56, 95% CI: 1.03–6.38, p =0.04. Independent of group, recently screened participants (last Pap >1 but <5years ago) had significantly higher odds of obtaining screening during the study than rarely or never screened participants (last Pap ≥5years ago), OR=2.50, 95% CI: 1.48–4.25, p =0.001. Conclusions: The intervention was associated with increased cervical cancer screening. The faith-placed LHA addressing barriers comprises a novel approach to reducing cervical cancer disparities among Appalachian women. [Copyright &y& Elsevier]

Negative health consequences of illicit drug use, such as cardiovascular complications and infectious diseases, increase the likelihood of the need for health care. However, evidence suggests that, with the exception of emergency services, drug users generally are medically underserved. Furthermore, the effect of illicit drug use on health care utilization is becoming an especially important issue for the criminal justice system, because an increasing proportion of inmates in correctional institutions have a history of drug use. This 1998–1999 study of 661 incarcerated men in the Kentucky prison system focused on predictors of unmet physical, behavioral, and overall health care needs among chronic substance users. Analyses revealed that White incarcerated drug users were more likely to report unmet physical and overall health care needs than non-Whites and those with high school education or above were more likely to report unmet physical, behavioral, and overall health care needs. In addition, more episodes of serious illness, more mental health problems, and poorer self-rated health were predictive of all three types of unmet health care needs. A longer career of drug use emerged as a significant predictor of unmet behavioral health care needs, whereas more frequent drug use in the year before incarceration predicted unmet physical health care needs. Further research directions and implications for in-prison health care planning are discussed. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to examine whether cultural factors, such as religiosity and social support, mediate/moderate the relationship between personal/psychosocial factors and T2DM self-care in a rural Appalachian community.Methods: Regression models were utilized to assess for mediation and moderation. Multilevel linear mixed effects models and GEE-type logistic regression models were fit for continuous (social support, self-care) and binary (religiosity) outcomes, respectively.Results: The results indicated that cultural context factors (religiosity and social support) can mediate/moderate the relationship between psychosocial factors and T2DM self-care. Specifically, after adjusting for demographic variables, the findings suggested that social support may moderate the effect of depressive symptoms and stress on self-care. Religiosity may moderate the effect of distress on self-care, and empowerment was a predictor of self-care but was not mediated/moderated by the assessed cultural context factors. When considering health status, religiosity was a moderately significant predictor of self-care and may mediate the relationship between perceived health status and T2DM self-care.Conclusions: This study represents the first known research to examine cultural assets and diabetes self-care practices among a community-based sample of Appalachian adults. We echo calls to increase the evidence on social support and religiosity and other contextual factors among this highly affected population.Trial Registration: US National Library of Science identifier NCT03474731. Registered March 23, 2018, www.clinicaltrials.gov . [ABSTRACT FROM AUTHOR]

Objective: Appalachian women continue to die younger than in other US regions. We performed a rapid scoping review to summarize women's health research in Appalachia from 2000 to 2019, including health topics, study populations, theoretical frameworks, methods, and findings. Data Source: We searched bibliographic databases (eg, PubMed, PsycINFO, Google Scholar) for literature focusing on women's health in Appalachia. Study Inclusion and Exclusion Criteria: Included articles were: (1) on women's health in Appalachia; (2) published January 2000 to June 2019; (3) peer-reviewed; and (4) written in English. We excluded studies without reported data findings. Data Extraction: Two coders reviewed articles for descriptive information to create summary tables comparing variables of interest. Data Synthesis: Two coders co-reviewed a sub-sample to ensure consensus and refine data charting categories. We categorized major findings across the social-ecological framework. Results: A search of nearly 2 decades of literature revealed 81 articles, which primarily focused on cancer disparities (49.4%) and prenatal/pregnancy outcomes (23.5%). Many of these research studies took place in Central Appalachia (eg, 42.0% in Kentucky) with reproductive or middle-aged women (82.7%). Half of the studies employed quantitative methods, and half used qualitative methods, with few mixed method or community-engaged approaches (3.7%). Nearly half (40.7%) did not specify a theoretical framework. Findings included complex multi-level factors with few articles exploring the co-occurrence of factors across multiple levels. Conclusions: Future studies should: 1) systematically include Appalachian women at various life stages from under-represented sub-regions; 2) expand the use of rigorous methods and specified theoretical frameworks to account for complex interactions of social-ecological factors; and 3) build upon existing community assets to improve health in this vulnerable population. [ABSTRACT FROM AUTHOR]

Objectives: To better understand the disproportionate burdens from cancer, cardiovascular disease, diabetes mellitus, stroke, and other chronic conditions related to energy balance, we studied diet and physical activity patterns in younger and older adults in rural Appalachia by using a nonclinical, cross-sectional, community-based sampling approach.Methods: A total of 651 younger (ages 18-59) and 254 older (ages ≥60) Appalachians were recruited from 43 churches or community organizations. Participants answered questions about fruit and vegetable intake and physical activity. Analyses were adjusted for clustering within churches.Results: Compared with older Appalachians, younger Appalachians consumed significantly fewer fruits and vegetables (P = 0.01) and reported significantly more moderate-to-vigorous physical activity (P = 0.01). Regardless of age, engagement in healthy behaviors was suboptimal and well below national averages.Conclusions: This community-based sample demonstrated elevated behavioral risk factors that likely contribute to some of the nation's highest rates of premature mortality. Despite suboptimal dietary intake and physical activity, results indicate some potential leverage points between the generations that may be used to improve health. For example, the older generation could benefit from engaging with their younger relatives in physical activities while advocating for a better-rounded diet. Given traditions of intergenerational connectedness, mutual aid, and self-reliance, transmission of healthier behaviors across the generations may be beneficial in the rural Appalachian context. [ABSTRACT FROM AUTHOR]

Physical activity guidelines for cancer survivors issued by the American Cancer Society and the American College of Sports Medicine emphasize the essential role of a health care provider (HCP) in counseling cancer survivors to achieve healthier lifestyles. However, research has not established whether HCP's recommendations to engage in physical activity are associated with increased physical activity levels of cancer survivors. The study examines this potential association using the 2005 and 2010 National Health Interview Survey data. The final analytic sample consisted of 3320 cancer survivors and 38,955 adults without cancer who reported seeing or talking to a HCP and if or not they had received a physical activity recommendation in the prior year. Consistent with the aforementioned guidelines, physical activity levels were categorized as inactive, insufficiently active, and sufficiently active (i.e., meeting guidelines). Average adjusted predictions and marginal effects were estimated from generalized ordered logit models. Multivariable regressions controlled for socio-demographic and health-related characteristics and survey year. On average, receipt of a HCP's physical activity recommendation was associated with a lower adjusted prevalence of inactivity by 8.3 percentage points and a higher adjusted prevalence of insufficient and sufficient activity by 4.6 and 3.7 percentage points, respectively, regardless of cancer diagnosis (P's<0.05). A HCP's recommendation is associated with higher levels of leisure-time aerobic physical activity among cancer survivors and adults without cancer. The communication between cancer survivors and their HCPs may act as a 'window' of opportunity to increase physical activity levels among the U.S. cancer survivors. [ABSTRACT FROM AUTHOR]

Cancer is the leading cause of mortality among Alaska Native people. Over half of Alaska Native people live in rural communities where specially trained community members called Community Health Aides/Practitioners (CHA/Ps) provide health care. In response to CHA/Ps' expressed desire to learn more about cancer, four 5-day cancer education and digital storytelling courses were provided in 2014. Throughout each course, participants explored cancer information, reflected on their personal experiences, and envisioned how they might apply their knowledge within their communities. Each course participant also created a personal and authentic digital story, a methodology increasingly embraced by Indigenous communities as a way to combine storytelling traditions with modern technology to promote both individual and community health. Opportunities to learn of CHA/Ps' experiences with cancer and digital storytelling included a 3-page end-of-course written evaluation, a weekly story-showing log kept for 4 weeks post-course, a group teleconference held 1-2 weeks post-course, and a survey administered 6 months post-course. Participants described digital storytelling as a culturally respectful way to support cancer awareness and education. Participants described the process of creating digital stories as supporting knowledge acquisition, encouraging personal reflection, and sparking a desire to engage in cancer risk reduction activities for themselves and with their families and patients. As a result of creating a personalized digital story, CHA/Ps reported feeling differently about cancer, noting an increase in cancer knowledge and comfort to talk about cancer with clients and family. Indigenous digital stories have potential for broad use as a culturally appropriate health messaging tool. [ABSTRACT FROM AUTHOR]

Background Increased prevalence of overweight and obesity among Appalachian residents may contribute to increased cancer rates in this region. This manuscript describes the design, components, and participant baseline characteristics of a faith-based study to decrease overweight and obesity among Appalachian residents. Methods A group randomized study design was used to assign 13 churches to an intervention to reduce overweight and obesity (Walk by Faith) and 15 churches to a cancer screening intervention (Ribbons of Faith). Church members with a body mass index (BMI) ≥ 25 were recruited from these churches in Appalachian counties in five states to participate in the study. A standard protocol was used to measure participant characteristics at baseline. The same protocol will be followed to obtain measurements after completion of the active intervention phase (12 months) and the sustainability phase (24 months). Primary outcome is change in BMI from baseline to 12 months. Secondary outcomes include changes in blood pressure, waist-to-hip ratio, and fruit and vegetable consumption, as well as intervention sustainability. Results Church members (n = 664) from 28 churches enrolled in the study. At baseline 64.3% of the participants were obese (BMI ≥ 30), less than half (41.6%) reported regular exercise, and 85.5% reported consuming less than 5 servings of fruits and vegetables per day. Conclusions Church members recruited to participate in a faith-based study across the Appalachian region reported high rates of unhealthy behaviors. We have demonstrated the feasibility of developing and recruiting participants to a faith-based intervention aimed at improving diet and increasing exercise among underserved populations. [ABSTRACT FROM AUTHOR]

Objectives: To identify perspectives on smoking cessation programs in Appalachian Kentucky, a region with particularly high smoking rates and poor health outcomes. Methods: Insufficient existing research led us to conduct 12 focus groups (smokers and nonsmokers) and 23 key informant interviews. Results: Several findings previously not described in this high-risk population include (1) transition from pro-tobacco culture toward advocacy for tobacco cessation approaches, (2) region-specific challenges to program access, and (3) strong and diverse social influences on cessation. Conclusions: To capitalize on changes from resistance to support for smoking cessation, leaders should incorporate culturally appropriate programs and characteristics identified here. [ABSTRACT FROM AUTHOR]

Purpose. Despite the well-established benefits of physical activity (PA), most Americans, especially those in rural, traditionally underserved areas, engage in considerably less PA than recommended. This study examines perceived barriers to and facilitators of PA and promising organized PA programs among rural Appalachians. Design. Eight focus groups and seven group key informant interviews were conducted. Setting. This study was conducted in eastern Kentucky, in central Appalachia. Subjects. One hundred and fourteen rural Appalachian residents (74% female, 91 % white) participated. Measures. Open-ended, semistructured, and structured questions regarding perceptions of barriers to/facilitators of and examples of successful/failed PA programs were asked. Analysis. Qualitative data analysis was conducted, including codebook development and steps taken to ensure rigor and transferability. Interrater reliability was over 94 %. Results. In addition to barriers that are consistent with those found in other populations, rural Appalachian residents indicated that travel time, family commitments, and inadequate community resources undermine PA. Suggested avenues to increase PA include partnership with churches and the U.S. Department of Agriculture's Cooperative Extension Service; programs that include families, are well advertised, and focus on health rather than appearance; and, underlying all suggestions, culturally relevant yet nonstereotyping activities. Conclusions. When developing PA interventions in rural Appalachia, it is important to employ community-based participatory approaches that leverage unique assets of the population and show potential in overcoming challenges to PA. [ABSTRACT FROM AUTHOR]

Abstract: The implementation of cigarette smoking abstinence reinforcement programs may be hindered by the time intensive burden placed on patients and treatment providers. The use of remote monitoring and reinforcement of smoking abstinence may enhance the accessibility and acceptability of this intervention, particularly in rural areas where transportation can be unreliable and treatment providers distant. This study determined the effectiveness of an Internet-based abstinence reinforcement intervention in initiating and maintaining smoking abstinence in rural smokers. Sixty-eight smokers were enrolled to evaluate the efficacy of an Internet-based smoking cessation program. During the 6-week intervention period, all participants were asked to record 2 videos of breath carbon monoxide (CO) samples daily. Participants also typed the value of their CO readings into web-based software that provided feedback and reinforcement based on their smoking status. Participants (n =35) in the Abstinence Contingent (AC) group received monetary incentives contingent on recent smoking abstinence (i.e., CO of 4 parts per million or below). Participants (n =33) in the Yoked Control (YC) group received monetary incentives independent of smoking status. Participants in the AC group were significantly more likely than the YC group to post negative CO samples on the study website (OR=4.56; 95% CI=2.18–9.52). Participants assigned to AC were also significantly more likely to achieve some level of continuous abstinence over the 6-week intervention compared to those assigned to YC. These results demonstrate the feasibility and short-term efficacy of delivering reinforcement for smoking abstinence over the Internet to rural populations. [Copyright &y& Elsevier]

Using a combined qualitative/quantitative approach, we interviewed 132 older African-Americans and whites with either osteoarthritis of the hip or knee (OAK/OAH) or ischemic heart disease (IHD) to address two questions: 1) What types of reactions to illness are expressed by this group of older adults who have OA or IHD? 2)? Are there differences in the characteristics of the respondents who respond more positively than those who respond more negatively? The responses were coded to illustrate those that reflected positive, negative, or combined (positive/negative) statements. The majority of the respondents, who were categorized as positive or combined, approached the illness experience with statements illustrating their ability to cope with their illness and adapt their lifestyles to the limitations imposed by the disease such as acceptance, feeling that others were worse off, or changing their lifestyles to adapt to their limitations. Those expressing negative reactions to their illness were fewer in number and responded with terms reflecting loss of identity, physical limitations, and other disease symptoms. The differences were more pronounced between the positive and negative groups where the latter were somewhat more likely to be African-American and female and significantly more likely to have less income, greater perceived disease severity, and more disability. We should look to the larger group in both the positive only and combined responses to explore how culture may play a role in perceptions of subjective well-being and the importance of "the local worlds of experience" experienced by both men and women, and African-Americans and whites. This study illustrates that using a simple, open-ended question that stimulates older people to narrate their reactions to having a chronic illness may allow clinicians to identify the persons most at-risk and intervene appropriately. [ABSTRACT FROM AUTHOR]

Using a combined qualitative/quantitative approach, we interviewed 132 older African–Americans and whites with either osteoarthritis of the hip or knee (OAK/OAH) or ischemic heart disease (IHD) to address two questions: 1) What types of reactions to illness are expressed by this group of older adults who have OA or IHD? 2)? Are there differences in the characteristics of the respondents who respond more positively than those who respond more negatively? The responses were coded to illustrate those that reflected positive, negative, or combined (positive/negative) statements. The majority of the respondents, who were categorized as positive or combined, approached the illness experience with statements illustrating their ability to cope with their illness and adapt their lifestyles to the limitations imposed by the disease such as acceptance, feeling that others were worse off, or changing their lifestyles to adapt to their limitations. Those expressing negative reactions to their illness were fewer in number and responded with terms reflecting loss of identity, physical limitations, and other disease symptoms. The differences were more pronounced between the positive and negative groups where the latter were somewhat more likely to be African–American and female and significantly more likely to have less income, greater perceived disease severity, and more disability. We should look to the larger group in both the positive only and combined responses to explore how culture may play a role in perceptions of subjective well-being and the importance of “the local worlds of experience” experienced by both men and women, and African–Americans and whites. This study illustrates that using a simple, open-ended question that stimulates older people to narrate their reactions to having a chronic illness may allow clinicians to identify the persons most at-risk and intervene appropriately. [ABSTRACT FROM AUTHOR]