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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.

In the Kentucky Homeplace Project, specially trained paraprofessionals who live in medically underserved rural communities make home visits, facilitate access to health care, and provide case management and culturally appropriate prevention education for poor families. Strengths include local administration and staff and holistic and traditional frameworks for service delivery. Weaknesses include funding issues, client dependency, and minimal evaluation. (SV)

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]

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]

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]

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]

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]

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]

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]

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]

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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]

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.

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.

Background : The Community Leadership Institute of Kentucky (CLIK), a workforce development and leadership program within the Community Engagement and Research Core of the University of Kentucky's Center for Clinical and Translational Science (UK CCTS), was developed to enhance community members' capacity to address pernicious rural health inequities. Objectives/Methods : In this article, we describe the development, implementation, and results of the program, examining program and project completion rates, quantitative and qualitative evaluations from participants, and professional achievements. Results : Based on existing models from other Clinical and Translational Science Awards Programs (CTSAs), CLIK provides diverse programming in a local, supportive setting and supports mentors/academic partners through education and networking. Now in its sixth year, CLIK participants have included 41 leaders from varied local settings, including public school systems, health departments, county and local governments, and other non-profit organizations. Shaped by extensive CLIK participant input, the program offers eleven didactic and hands-on training sessions in evidence-based programming and health promotion; a mentored research project addressing relevant local health inequities; and extensive networking opportunities. Conclusions : CLIK has become an enrichment opportunity for local communities as well as a platform for academic engagement and bi-directional learning. Such community-academic partnerships are particularly needed in traditionally under-resourced rural communities. [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]

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., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

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: 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.

Well-documented associations between lifestyle behaviors and disease outcomes necessitate evidence-based health promotion interventions. To enhance potential efficacy and effectiveness, interventionists increasingly respond to community priorities, employ comprehensive theoretical frameworks, invest heavily to ensure cultural fit, implement evidence-based programming, and deploy research gold standards. We describe a project that followed all of these recommended strategies, but did not achieve desired outcomes. This community-based participatory research (CBPR) energy balance (diet and physical activity) intervention, conducted in Appalachian Kentucky among 900+ residents, employed a wait list control cluster randomized design. We engaged faith institutions, took an intergenerational approach, and modified two existing evidence-based interventions to enhance cultural relevance. Despite these efforts, fruit and vegetable consumption and physical activity did not change from baseline to post-test or differed significantly between intervention and wait list control groups. Barriers to engaging in optimal energy balance focused more on motivation and attitude than on structural and material barriers. The complex interplay of psychosocial, structural, and physiological processes offers significant challenges to groups with entrenched health challenges.

Despite competing demands of multiple morbidity (MM) management and disease prevention, our recent survey of 1,153 Appalachian residents aged 50 to 76 documented that individuals with MM were more likely to obtain colorectal cancer screening (CRCS) than those without MM. Nearly two thirds of respondents obtained CRCS, and the more MM, the greater the likelihood of screening. To gain insight into this relationship, we conducted nine focus groups, six with providers and three with patients. Three main explanations emerged: (a) patients' MM increases providers' vigilance for other health vulnerabilities; (b) having MM increases patients' own vigilance; and (c) patients' vigilance may stem from experiencing more symptoms, having a family history of cancer, and having successfully obtained health care. More frequent contact with health care providers appears to encourage preventive referral, especially in low-income populations that otherwise may not receive such counselling. We highlight participant recommendations to improve MM management and prevention., (© The Author(s) 2013.)

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.

Background: Colorectal cancer (CRC) is 1 of the leading causes of cancer-related deaths among residents of rural Appalachia. Rates of guideline-consistent CRC screening in Appalachian Kentucky are suboptimal., Objective: This study sought to determine the relationship between CRC screening knowledge, specifically regarding recommended screening intervals, and receipt of screening among residents of rural Appalachian Kentucky., Methods: Residents of Appalachian Kentucky (n = 1096) between the ages of 50 and 76 years completed a telephone survey including questions on demographics, health history, and knowledge about CRC screening between November 20, 2009, and April 22, 2010., Results: Although 67% of respondents indicated receiving screenings according to guidelines, respondents also demonstrated significant knowledge deficiencies about screening recommendations. Nearly half of respondents were unable to identify the recommended screening frequency for any of the CRC screening modalities. Accuracy about the recommended frequency of screening was positively associated with screening adherence., Conclusions: Enhanced educational approaches have the potential to increase CRC screening adherence in this population and reduce cancer mortality in this underserved region., Implications for Practice: Nurses play a critical role in patient education, which ultimately may increase screening rates. To fulfill this role, nurses should incorporate current recommendation about CRC screening into educational sessions. Advanced practices nurses in rural settings should also be aware of the increased vulnerability of their patient population and develop strategies to enhance awareness about CRC and the accompanying screening tests.

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 3 years)., 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 <5 years ago) had significantly higher odds of obtaining screening during the study than rarely or never screened participants (last Pap ≥5 years 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 © 2012 Elsevier Inc. All rights reserved.)

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.

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.

Social support generally is considered a valuable asset that may compensate for health service deficiencies among rural populations. Employing a mixed methods approach, we explored how vulnerable rural residents described social support in the context of self-management for multiple chronic conditions. Participants generally felt support was available, though emotional/informational support was perceived as less available than other types of support. Participants did not rely heavily on informal support to help them manage their multiple morbidities, preferring to call on their doctor and their own resources. We discuss implications of these findings for meeting this vulnerable population's self-management needs.

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.

Type 2 diabetes constitutes a leading and increasing cause of morbidity and mortality among older adults, particularly African Americans, Native Americans, Mexican Americans, and rural dwellers. To understand diabetes self-care, an essential determinant of diabetic and overall health outcomes, 80 middle aged and older adults from these four disproportionately affected racial/ethnic/residential groups engaged in in-depth interviews, focusing on approaches to and explanations for diabetes self-care. Certain self-care activities (medication-taking, diet, foot care) were performed regularly while others (blood glucose monitoring, exercise) were practiced less frequently. Despite research suggestions to the contrary, only one in four elders used unconventional diabetes therapies, and only one-third listed someone other than a health care provider as a primary information source. Few self-care differences emerged according to race/ethnicity/residence, perhaps because of the influential and common circumstance of low income. Thematic analyses suggest that inadequate resources, perceived efficacy of medication, great respect for biomedical authority, and lack of familiarity with and concerns about unconventional therapies are influential in establishing these patterns of self-care. We discuss the similarity of self-care practices and perspectives irrespective of race/ethnicity/residence and the predominance of biomedical acceptability.

Purpose: Test a practice-based intervention to foster involvement of a relative or friend for the reduction of cardiovascular risk in patients with type 2 diabetes., Methods: We enrolled in a randomized controlled trial 199 patients and 108 support persons (SPs) from 18 practices within a practice-based research network. All patient participants had type 2 diabetes with suboptimal blood pressure control and were prepared to designate a SP. A subset of the patients also had dyslipidemia. All study visits were conducted at the practice sites where staff took standardized blood pressure measurements and collected blood samples. All patients completed one education session and received newsletters aimed at improving key health behaviors. Intervention group patients included their chosen SP in the education session and the SPs received newsletters., Results: After 9 to 12 months, the intervention had no significant effect on systolic blood pressure, HbA1C, health-related quality of life, patient satisfaction, medication adherence, or perceived health competence. Power was insufficient to detect an effect on low-density lipoprotein cholesterol. Baseline cardiovascular risk values were not very high, with mean systolic blood pressure at 140 mm Hg; mean HbA1C at 7.6%; and mean low-density lipoprotein at 137 mg/dL. Patient health care satisfaction was high., Conclusion: This practice-based intervention to foster social support for chronic care management among diabetics had no significant impact on the targeted outcomes.

Objective: A vaccine against common high-risk types of human papillomavirus (HPV) associated with cervical cancer risk was recently approved. We assessed women's acceptance of HPV vaccination for themselves and for adolescent girls, in an Appalachian population with cervical cancer incidence and mortality rates among the highest in the United States., Methods: We conducted a population-based, random-digit telephone survey of over 600 adult women residing in two Appalachian Kentucky counties. The analysis focused on questions of HPV vaccine acceptance, and their relationship to several factors., Results: The majority of women indicated an interest in HPV vaccination for themselves (85.2%), but they were less accepting of a vaccine being administrated to girls of ages 10-15 (67.6%). Women who were younger, lower-income and smokers were more likely to support vaccination., Conclusions: Although a relatively high percentage of women found the HPV vaccination acceptable for their own use, there was less enthusiasm for supporting vaccination to girls. This finding is of concern since the vaccine is being recommended for adolescent girls and young women, prior to sexual initiation. Educational campaigns will be needed for a successful vaccine implementation.

In response to the serious toll diabetes takes on health and resources, researchers increasingly are examining physical and psychological pathways that affect and are affected by diabetes, including stress. Although biomedical researchers and practitioners are beginning to recognize the association between stress and diabetes onset and management, laypersons have long-standing and extensive insights into the multiple ways in which stress is associated with the diabetes disease process. In this article, we examine lay perspectives on stress and diabetes among a multiethnic sample of 80 adults. Participants suggest varying arenas in which stress intersects with diabetes, including stress as implicated in the origin of diabetes, as a threat to maintaining glycemic control, as a challenge to self-management, and as a precursor to and a consequence of diabetes complications. An improved understanding of such perspectives may enhance appropriate disease management and develop a more valid conceptualization of stress in research efforts.