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In the United States, diabetes is the seventh leading cause of death and continues to rise in prevalence, with type 2 diabetes accounting for 90–95% of all cases. Rates of diabetes in Kentucky, and, in particular, the Appalachian region, are among the highest in the nation and are increasing faster than the national average. Despite this disproportionate burden, barriers to clinical appointment attendance have not been fully explored in this population. This article examines the association among perceived barriers to clinical attendance, glycemic control, and diabetes self-care as part of an ongoing study. We used a 25-item checklist developed using the Chronic Care Model to assess participants' barriers to clinic attendance. Glycemic control was assessed via A1C measurement. Diabetes self-care was assessed using the Summary of Diabetes Self-Care Activities measure. At the time of analysis, 123 of the 356 participants (34.6%) did not report any barriers to clinic attendance. For the remainder, the major reported barriers included forgetting appointments, inability to afford medicines or other treatment, and placing faith above medical care. The average A1C was 7.7%, and the average diabetes self-care summary score was 17.1 out of 35 points (with higher values indicating better self-care). Missing clinic appointments is associated with lower health outcomes, especially in vulnerable populations. This study can help educate clinic staff on perceived barriers to type 2 diabetes management among people with diabetes in Appalachia. [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]

Background: In rural Appalachia, numerous geographical, historical, and socioeconomic barriers undermine health. We describe a community/academic partnership that leveraged local assets to implement an on-the-ground enumeration approach to enrolling participants, ultimately achieving an 82.1% response rate in a cross-sectional study of adult respiratory disease. We sought to discuss challenges addressed while establishing an accurate sample frame and a broadly accepted data collection procedure. Methods: Innovative and established epidemiologic methods (household enumeration) were combined within a community-based participatory research (CBPR) framework. Community members partnered with researchers to identify an appropriate, novel sampling unit: hollows. Members of two community advisory boards (CABs) provided extensive guidance, and community health workers (CHWs) administered surveys and spirometry from randomly selected households. Results: Most hollows (28/40) had participation rates of more than 80%. The sample (N = 972) was representative of the study area. Conclusions: Investigators seeking to recruit hard-to-reach populations may consider on-the-ground enumeration guided by community partners. [ABSTRACT FROM AUTHOR]

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]

This study presents a dynamic approach to collecting income information. We conducted a cross- sectional survey of 2,022 residents of historically underserved Appalachian Kentucky, an ideal location due to pervasive low income and our ability to control for potential confounders such as race/ethnicity and residential heterogeneity. In unadjusted analyses, nearly half of the sample indicated they struggled to meet their needs; 43% said they made just enough to get by; and 10% indicated they had more than they needed to live well. Adjusting for socio-demographic characteristics, proportionately more of those with lower self-rated health and a higher number of morbidities reported struggling to make ends meet. Less than 1% refused to respond to the question on self-perceived income sufficiency, compared with 20% who refused to report income levels. We conclude that self-perceived income sufficiency is a useful question to assess resources, both theoretically and practically, in an underserved population. [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]

Comprehension of randomization is a vital, but understudied, component of informed consent to participate in cancer randomized clinical trials (RCTs). This study examines patient comprehension of the randomization process as well as sources of ongoing uncertainty that may inhibit a patient's ability to provide informed consent to participate in RCTs. Cancer patients living in rural Appalachia who were offered an opportunity to participate in a cancer treatment RCT completed in-depth interviews and a brief survey. No systematic differences in randomization comprehension between patients who consented and those who declined participation in a cancer RCT were detected. Comprehension is conceptually distinct from uncertainty, with patients who had both high and low comprehension experiencing randomization-related uncertainty. Uncertainty about randomization was found to have cognitive and affective dimensions. Not all patients enrolling in RCTs have a sufficient understanding of the randomization process to provide informed consent. Healthcare providers need to be aware of the different types of randomization-related uncertainty. Efforts to improve informed consent to participate in RCTs should focus on having patients teach back their understanding of randomization. This practice could yield valuable information about the patient's cognitive and affective understanding of randomization as well as opportunities to correct misperceptions. Education about RCTs should reflect patient expectations of individualized care by explaining how all treatments being compared are appropriate to the specifics of a patient's disease. [ABSTRACT FROM AUTHOR]

Purpose As the population living with several concurrent chronic conditions or multiple morbidity (MM) increases, understanding how to effectively fit prevention efforts into disease management becomes more important, particularly among rural, underserved populations. Compared to their urban counterparts, rural residents suffer higher rates of disease, receive fewer preventive services, and often live in environments limiting access to optimal medical care. This study describes rural residents' perceived burdens of disease management and explores the relationship between these burdens, as proxies of individuals' competing demands, and colorectal cancer screening (CRCS). Methods We conducted a cross-sectional study, based on telephone survey data from 1,012 Appalachian residents, ages 50-75, with 1 or more chronic conditions. Measures of perceived MM burdens were developed based on 85 pilot interviews previously undertaken with providers and patients with MM residing in Appalachian Kentucky. Results Many participants (81%) agreed with 1 or more statements indicating perceived burdens of disease management effects on receiving CRCS. A higher percentage of rural (vs nonrural) Appalachians perceived burdens related to physician's recommendation, preparation to colonoscopy, and time management and affordability of both current diseases and screening. These differences did not modify the overall association between perceiving MM as burdensome and forgoing CRCS. The negative effect on CRCS of perceived burdens related to interaction with physician and time management was lower for participants with multiple rather than single morbidity. Conclusion Future research designed to address perceived burdens of MM and improved interaction with health care providers may enhance critical prevention efforts among vulnerable populations. [ABSTRACT FROM AUTHOR]

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]

Purpose Extensive attention has been focused on improving the dietary intake of Americans. Such focus is warranted due to increasing rates of overweight, obesity, and other dietary-related disease. To address suboptimal dietary intake requires an improved, contextualized understanding of the multiple and intersecting influences on healthy eating, particularly among those populations at greatest risk of and from poor diet, including rural residents. Methods During 8 focus groups (N = 99) and 6 group key informant interviews (N = 20), diverse Appalachian rural residents were queried about their perceptions of healthy eating, determinants of healthy food intake, and recommendations for improving the dietary intake of people in their communities. Participants included church members and other laypeople, public health officials, social service providers, health care professionals, and others. Findings Participants offered insights on healthy eating consistent with the categories of individual, interpersonal, community, physical, environmental, and society-level influences described in the socioecological model. Although many participants identified gaps in dietary knowledge as a persistent problem, informants also identified extraindividual factors, including the influence of family, fellow church members, and schools, policy, advertising and media, and general societal trends, as challenges to healthy dietary intake. We highlight Appalachian residents' recommendations for promoting healthier diets, including support groups, educational workshops, cooking classes, and community gardening. Conclusions We discuss the implications of these findings for programmatic development in the Appalachian context. [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]

There are meaningful cancer-related disparities in the Appalachian region of the U.S. To address these disparities, the Appalachia Community Cancer Network (ACCN), a collaboration of investigators and community partners in five states (Kentucky, Ohio, Pennsylvania, Virginia, and West Virginia), is involved in increasing cancer education and awareness, conducting community-based participatory research (CBPR), and creating mentorship and training opportunities. The primary objective of this paper is to describe cancer-related disparities in the Appalachian region of the U.S. as an example of the disparities experienced by underserved, predominantly white, rural populations, and to describe ACCN activities designed to intervene regarding these disparities. An ACCN overview/history and the diverse activities of ACCN-participating states are presented in an effort to suggest potential useful strategies for working to reduce health-related disparities in underserved white populations. Strengths that have emerged from the ACCN approach (e.g., innovative collaborations, long-standing established networks) and remaining challenges (e.g., difficulties with continually changing communities, scarce resources) are described. Important recommendations that have emerged from the ACCN are also presented, including the value of allowing communities to lead CBPR efforts. Characteristics of the community-based work of the ACCN provide a framework for reducing health-related disparities in Appalachia and in other underserved white and rural populations. [ABSTRACT FROM AUTHOR]

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]

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: 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]

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]

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]

While recent rates of colorectal cancer (CRC) screening have improved in Appalachian Kentucky due to public health efforts, they remain lower compared to both KY as a whole, and the USA. Suboptimal screening rates represent a missed opportunity to engage in early detection and prevention. The purpose of this study is to determine the impact that lack of knowledge has on psychological barriers (e.g., fear and embarrassment) to CRC screening as well as the potential effect of a psychosocial intervention to reduce these barriers. Participants were recruited through faith-based organizations and other community sites. After randomizing participants to either an early or delayed group, a faith-based group education and motivational interviewing intervention was administered. Existing and pilot tested instruments were used to assess knowledge and potential psychological barriers. Data were analyzed using paired t tests and linear regression. We hypothesized that (1) psychological barriers are associated with inadequate knowledge and (2) the intervention, by improving knowledge, could reduce these barriers and increase screening rates. There was a small but significant reduction in psychological barriers (-0.11, p value = 0.015) and moderate increases in CRC knowledge scores (+0.17, p value = 0.06). There was no evidence that the intervention affected these measures (+0.10, p value = 0.58). The relationship between lower barrier scores and increased knowledge was significant at follow up (-0.05, 95% CI (-0.09, -0.00)). An increase in CRC knowledge was correlated with a small but significant decrease in psychological barriers, although there was no evidence that these changes were associated with one another. Future cognitive-based interventions may be effective in increasing CRC knowledge and reducing barriers, but new intervention approaches should be considered., (© 2022. The Author(s) under exclusive licence to American Association for Cancer Education.)

Background: Appalachia is a rural, socioeconomically disadvantaged region with high rates of cancer and obesity. Using community-based participatory research principles, the Appalachia Community Cancer Network tested an initiative to reduce weight among overweight and obese participants by partnering with churches, an important community-based institution in Appalachia. Methods: A group randomized trial was conducted with counties or groups of counties in five Appalachian states. These groups were randomly assigned to receive either monthly diet and exercise education sessions ("Walk by Faith"; WbF) or an educational program focused on cancer screening and education ("Ribbons of Faith"; RoF) to examine effects on weight change. Participants completed questionnaires and biometric measurements at baseline and 12 months. The primary outcome of the study was weight change from baseline to 12 months. Results: The relative difference in weight loss from baseline to 12 months for WbF compared with RoF was 1.4% but was not statistically significant ( P = 0.13). However, results varied by sex and marital status. WbF men experienced a significant 2.8% decrease in body weight, married WbF women a 1.5% decrease, and unmarried WbF women a 1.5% increase compared with their respective RoF subgroups (interaction P = 0.016). Among WbF participants, greater participation in monthly educational sessions was associated with greater weight loss ( P = 0.002). Conclusions: WbF facilitated weight loss mainly in male participants. Level of participation in WbF activities correlated with weight loss. Impact: Findings suggest that additional research is needed to better understand factors associated with participation in health promotion programs for underserved rural communities. Cancer Epidemiol Biomarkers Prev; 27(11); 1289-97. ©2018 AACR., (©2018 American Association for Cancer Research.)

Nowhere is improving understanding and accurate assessment of physical activity more important for disease prevention and health promotion than among health disparities populations such as those residing in rural and Appalachian regions. To enhance accurate assessment of physical activity and potentially improve intervention capacity, we conducted a mixed-methods study examining the acceptability and feasibility of self-report physical activity questionnaires, pedometers, and accelerometers among rural Appalachian children, adolescents, and adults. Most participants reported positive experiences with all three physical activity assessment tools. Several acceptability ratings differed by age group and by sex within each age group. With very few exceptions, no significant differences in acceptability were found by race, education, employment status, health status, BMI categories, income levels, or insurance status within age groups or overall. Several factors may impact the choice of the physical activity assessment method, including target population age, equipment cost, researcher burden, and potential influence on physical activity levels. Children and adolescents appear to have more constraints on when they can wear pedometers and accelerometers. While pedometers are inexpensive and convenient, they may influence physical activity levels, rather than simply measure them. Accelerometers, while less influential on behavior, consume extensive resources, including high purchase costs and researcher burden.

Although cervical cancer rates in the United States have declined sharply in recent decades, certain groups of women remain at elevated risk, including middle-aged and older women in central Appalachia. Cross-sectional baseline data from a community-based randomized controlled trial were examined to identify barriers to cervical cancer screening. Questionnaires assessing barriers were administered to 345 Appalachian women aged 40-64, years when Papanicolaou (Pap) testing declines and cervical cancer rates increase. Consistent with the PRECEDE/PROCEED framework, participants identified barriers included predisposing, enabling, and reinforcing factors. Descriptive and bivariate analyses are reported, identifying (a) the most frequently endorsed barriers to screening, and (b) significant associations of barriers with sociodemographic characteristics in the sample. Recommendations are provided to decrease these barriers and, ultimately, improve rates of Pap tests among this traditionally underserved and disproportionately affected group.

Background: Most children in the United States receive far less physical activity (PA) than is optimal. In rural, under resourced areas of Appalachian Kentucky, physical inactivity rates are significantly higher than national levels. We sought to understand children's perceptions of PA, with the goal of developing culturally appropriate programming to increase PA., Methods: During 11 focus groups, we explored perspectives on PA among 63 Appalachian children, ages 8-17. Sessions were tape recorded, transcribed, content analyzed, and subjected to verification procedures., Results: Several perspectives on PA emerged among these rural Appalachian youth, including the clear distinction between PA (viewed as positive) and exercise (viewed as negative) and an emphasis on time and resource factors as barriers to adequate PA. Additional PA determinants expressed in the focus groups are similar to those of other populations. We include children's recommendations for appealing PA programs., Conclusions: Appalachian and other rural residents contend with the loss of rural health advantages (due to declines in farming/other occupational and avocational transitions). At the same time, Appalachian residents have not benefitted from urban PA facilitators (sidewalks, recreational facilities, clubs and organized leisure activities). Addressing low PA levels requires extensive community input and creative programming.

Introduction: Although breast and cervical cancer screening rates have been increasing over the three past decades, many Appalachian women in the USA do not receive screening, leading to disproportionate mortality rates. The aims of this study were to: (1) better understand barriers to and facilitators of breast and cervical cancer screening among Appalachian women; and (2) identify strategies to increase cancer screening., Methods: Eight focus groups and 19 key informant interviews were conducted with 79 participants. Tape-recorded session were transcribed and content analyzed., Results: Findings consistent with screening determinants research include: inadequate personal and community resources, attitudinal and knowledge barriers, and competing demands. Less commonly described factors include family cancer history, personal health habits, and the multiple influences of healthcare providers., Conclusions: Interpreting findings in terms of consumer information processing theory, healthcare providers and supports play a key role in educating and influencing the screening uptake among Appalachian Kentucky women. These findings have the potential to inform innovative and culturally consonant intervention approaches capable of increasing screening and decreasing mortality rates.

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.

Central Appalachian residents suffer disproportionate health disparities, including an all-cancer mortality rate 17% higher than the general population. During 10 focus groups and 19 key informant interviews, 91 Appalachian residents identified cancer screening challenges and strategies. Challenges included (1) inadequate awareness of screening need, (2) insufficient access to screening, and (3) lack of privacy. Strategies included (1) witnessing/storytelling, (2) capitalizing on family history, (3) improving publicity about screening resources, (4) relying on lay health advisors, and (5) bundling preventive services. These insights shaped our community-based participatory research intervention and offered strategies to others working in Appalachia, rural locales, and other traditionally underserved communities.

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.

Researchers have long held that fatalism (the belief in a lack of personal power or control over destiny or fate) constitutes a major barrier to participation in positive health behaviors and, subsequently, adversely affects health outcomes. In this article, we present two in-depth, ethnographic studies of rural women's health decisions surrounding cancer treatments to illustrate the complexity and contestability of the long-established fatalism construct. Narrative analyses suggest that for these women, numerous and complex factors--including inadequate access to health services, a legacy of self-reliance, insufficient privacy, combined with a culturally acceptable idiom of fatalism--foster the use of, but not necessarily a rigid conviction in, the notion of fatalism.

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.

Context: Decades of behavioral research suggest that awareness of health threats is a necessary precursor to engage in health promotion and disease prevention, findings that can be extended to the community level., Purpose: We sought to better understand local perspectives on the main health concerns of rural Appalachian communities in order to identify the key health priorities. While Kentucky Appalachian communities are often described as suffering from substandard health, resource, and socioeconomic indicators, strong traditions of community mobilization make possible positive, home-grown change., Methods: To assess what women, the key health gatekeepers, perceive as the most significant health threats to their rural communities, 10 focus groups were held with 52 Appalachian women from diverse socioeconomic backgrounds. Tape-recorded narratives were content analyzed and a codebook was developed. Measures designed to increase data trustworthiness included member checks, negative case evidence, and multiple coding., Findings: The following rank-ordered conditions emerged as posing the greatest threat to the health of rural Appalachian communities: (1) drug abuse/medication dependence; (2) cancer; (3) heart disease and diabetes (tied); (4) smoking; (5) poor diet/overweight; (6) lack of exercise; and (7) communicable diseases. These health threats were described as specific to the local environment, deriving from broad ecological problems and were connected to one another., Conclusion: Drawing on participants' community-relevant suggestions, we suggest ways in which rural communities may begin to confront these health concerns. These suggestions range from modest, individual-level changes to broader structural-level recommendations.

Background: Despite widespread agreement on the necessity of protecting human subjects, questions regarding ethical treatment and protection of human subjects remain and are particularly vexing for community-based participatory research (CBPR). There has been a notable lack of attention paid to what type of training should be provided and how to balance "real-life" concerns with official requirements., Objectives: The purpose of this article is to demonstrate how, in consultation with the Office of Research Integrity (ORI) at our institution and our community partners, we developed training that overcame concerns related to instruction of community workers on protection of human subjects., Methods: We developed a training module written in lay terms and containing only information pertinent to non-key personnel and their role in the CBPR project. We designed and piloted this material in collaboration with our community partners who work with us to recruit and train lay health advisors (LHAs) and oversee the day-to-day operations of the CBPR project., Results: The educational module was presented to the community workers as a part of a day-long training session. The written materials were a part of a notebook of information accompanied by an oral Power Point presentation. Each of the workers was given a written test to evaluate knowledge of the content presented. The test was administered by the project director, a community member herself, and then sent to our institution for grading by personnel not involved in this project. To date, all community workers have passed the written test., Conclusions: The community members, research partners, and the ORI are satisfied with the scope and simplicity of the training program developed. Our team's collaborative approach to community-based human subjects training contributes to advancing a grounded, feasible, and rigorous process of protecting human subjects while implementing CBPR ideals.