"I'm Doing the Best that I Can": Mothers Lived Experience with Food Insecurity, Coping Strategies, and Mental Health Implications.

Background: Food insecurity can have lasting physical and mental health consequences. The experience of food insecurity within a household may disproportionately impact mothers because they tend to manage the household food environment. Objective: This study sought to understand the stresses faced by United States mothers experiencing food insecurity, related coping mechanisms, and the impacts of these stressors on their mental health. Methods: Semistructured interviews were conducted in May and June 2022 with a purposive sample of Virginia mothers who reported experiences of food insecurity. Participants were recruited from a related survey and university and community LISTSERVs. Interviews were transcribed and analyzed by trained coders. A thematic analysis was conducted to describe themes that emerged from the data. Virtual interviews were 20-60 min in duration. Mothers with children living in their household, having experienced food insecurity, and living in Virginia were eligible. Results: The following 3 themes emerged from the interviews with the mothers (n = 15): 1) food insecurity added stress to mothers' lives in multiple ways (e.g. worry about obtaining the "right" foods and internalized or experienced stigma), 2) mothers used positive and negative coping strategies to address the impacts of these stressors (e.g. use of community resources and reduced personal food intake), and 3) the stressors and coping strategies had varying impacts on mothers' mental health (e.g. added to existing mental health challenges or reduced their mental capacity to make changes). Conclusions: Study findings suggest that a multilevel and tailored approach to address diverse stressors is warranted. Future research should explore emotional coping strategies that comprehensively empower mothers to manage stressors, leverage resources, and reduce social stigma associated with food insecurity and accessing nutrition and mental health assistance. This may improve their household food security and mitigate the burden of stressors on their mental health because system-level solutions to food insecurity are pursued.

Pragmatic Adaptations to Kids SIPsmartER's Implementation Protocol Supported Its Delivery During the COVID-19 Pandemic.

OBJECTIVE: Describe the adaptation, implementation, and perceptions of Kids SIPsmartER's classroom component during the coronavirus disease-impacted 2020-2021 school year. DESIGN: Mixed methods process evaluation. SETTING: Seven rural Appalachian middle schools (US). PARTICIPANTS: Middle-school teachers (n = 14) and principals (n = 6). INTERVENTION: Kids SIPsmartER was a multilevel, school-based intervention designed to decrease sugar-sweetened beverage intake. The 12-lesson classroom component was supported by an implementation protocol. MEASURES: Implementation protocol adaptations, program perceptions, and the school context were assessed using teacher and principal interviews, teacher-completed fidelity checklists, and researcher-maintained field notes. Adaptations were mapped to the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). ANALYSIS: Qualitative data were content coded. Quantitative data were summarized using descriptive statistics. RESULTS: All schools maintained Kids SIPsmartER and delivered 100% of lessons. Ten adaptations were made to the implementation protocol. Schools used adapted delivery approaches to meet individual needs. Teachers and principals identified more benefits than barriers to implementing the program. CONCLUSIONS AND IMPLICATIONS: Using a strategically adapted implementation protocol that was flexible to schools' individual needs allowed all middle schools to deliver Kids SIPsmartER during the 2020-2021 school year. Findings identify adaptation considerations that other school-based evidence-based interventions could incorporate to facilitate delivery during high-stress times.

Student and caregiver acceptability of a school-based intervention to improve sugar-sweetened beverage behaviors: a mixed methods study.

Kids SIPsmartER is a 6-month behavioral and health literacy intervention effective at reducing sugar-sweetened beverage (SSB) intake among middle school students and their caregivers in the rural Appalachian region. This exploratory mixed methods study utilized a convergent parallel design to assess participant acceptability of a school-based curriculum for students and a text messaging program for caregivers. Acceptability was assessed using surveys (873 students and 453 caregivers), five focus groups (34 students) and telephone interviews (22 caregivers). Quantitative data were analyzed descriptively, and qualitative data were content coded. On a 5-point scale, average quantitative survey acceptability ratings ranged from 2.7 to 3.3 among three student-rated questions and 4.1 to 4.2 among four caregiver-rated questions. Qualitative focus group findings suggested that students preferred curricular activities that were hands-on and involved social interaction, while caregiver interview results showed high acceptability of the text messaging program's design, including usability, content messages and personalization. Students and caregivers reported similar program benefits: increased knowledge of SSBs and health risks, increased awareness of SSB behaviors and support to make beverage behavior changes. Results from this study can be used to understand Kids SIPsmartER's effectiveness data, communicate the intervention's acceptability with stakeholders and plan for future implementation studies.

Associations of Body Mass Index with Self-Rated Health and Weight Perceptions Among Rural Appalachian Adolescent Students.

BACKGROUND: Adolescents with overweight or obesity are at greater risk of having physical and psychosocial consequences. With increased disparities and inadequate literature on prevalence of adolescent weight status in rural Appalachia, there is potential for further complications. Unfortunately, adolescent obesity treatment options are often limited, especially in medically underserved regions. METHODS: This cross-sectional study of adolescents at eight rural Appalachian schools examined weight status among and associations between body mass index percentile (BMIp) categories and health-related perceptions and weight-control intentions. Previously validated instruments were utilized. Analyses included independent samples t-tests, ANOVA tests, and chi-squared tests. RESULTS: Of 814 adolescents (ages 11-13; 55.0% girls), BMIp revealed 20.8% overweight, 22.7% obese, and 10.6% severely obese. Adolescents with higher BMIp categories reported poorer self-rated health, inaccurate weight perceptions, and greater weight loss intentions (all p < .05). CONCLUSIONS: Findings, including high prevalence of adolescents with overweight and obesity, emphasize the need for more obesity prevention and treatment options. Schools may be an ideal setting to reach at-risk adolescents and provide obesity prevention and treatment options, especially in medically underserved regions such as rural Appalachia. Opportunities and challenges to apply findings, including school-based obesity programs, are discussed.

Embedding lifestyle interventions into cancer care: has telehealth narrowed the equity gap?

Lifestyle interventions targeting energy balance (ie, diet, exercise) are critical for optimizing the health and well-being of cancer survivors. Despite their benefits, access to these interventions is limited, especially in underserved populations, including older people, minority populations and those living in rural and remote areas. Telehealth has the potential to improve equity and increase access. This article outlines the advantages and challenges of using telehealth to support the integration of lifestyle interventions into cancer care. We describe 2 recent studies, GO-EXCAP and weSurvive, as examples of telehealth lifestyle intervention in underserved populations (older people and rural cancer survivors) and offer practical recommendations for future implementation. Innovative approaches to the use of telehealth-delivered lifestyle intervention during cancer survivorship offer great potential to reduce cancer burden.

Outcomes of a Caregiver-Focused Short Message Service (SMS) Intervention to Reduce Intake of Sugar-Sweetened Beverages in Rural Caregivers and Adolescents.

This study examined enrollment, retention, engagement, and behavior changes from a caregiver short message service (SMS) component of a larger school-based sugar-sweetened beverage (SSB) reduction intervention. Over 22 weeks, caregivers of seventh graders in 10 Appalachian middle schools received a two-way SMS Baseline Assessment and four monthly follow-up assessments to report their and their child's SSB intake and select a personalized strategy topic. Between assessments, caregivers received two weekly one-way messages: one information or infographic message and one strategy message. Of 1873 caregivers, 542 (29%) enrolled by completing the SMS Baseline Assessment. Three-quarters completed Assessments 2-5, with 84% retained at Assessment 5. Reminders, used to encourage adherence, improved completion by 19-40%, with 18-33% completing after the first two reminders. Most caregivers (72-93%) selected a personalized strategy and an average of 28% viewed infographic messages. Between Baseline and Assessment 5, daily SSB intake frequency significantly (p < 0.01) declined for caregivers (-0.32 (0.03), effect size (ES) = 0.51) and children (-0.26 (0.01), ES = 0.53). Effect sizes increased when limited to participants who consumed SSB twice or more per week (caregivers ES = 0.65, children ES = 0.67). Findings indicate that an SMS-delivered intervention is promising for engaging rural caregivers of middle school students and improving SSB behaviors.

Retention and engagement of rural caregivers of adolescents in a short message service intervention to reduce sugar-sweetened beverage intake.

Objective: This study investigates a 6-month short message service (SMS) intervention to reduce adolescent sugar-sweetened beverage (SSB) intake. The objectives are to describe caregiver retention and SMS engagement as well as explore differences by caregiver characteristics. Methods: Caregivers completed a baseline survey then messages were sent two times per week. Message types included the following: SSB intake assessments, educational information, infographic URLs, and strategies. Engagement was measured through interaction with these messages and included: assessment completion, reminders needed, number of strategies chosen, and URLs clicked. Results: Caregivers (n = 357) had an average baseline SSB intake of 23.9 (SD = 26.8) oz/day. Of those, 89% were retained. Caregivers with a greater income and education were retained at a higher rate. Average engagement included: 4.1 (SD = 1.3) of 5 assessments completed with few reminders needed [4.1 (SD = 3.7) of 14 possible], 3.2 (SD = 1.1) of 4 strategies selected, and 1.2 (SD = 1.6) of 5 URLs clicked. Overall, average engagement was relatively high, even where disparities were found. Demographic characteristics that were statistically related to lower engagement included younger age, lower income, lower educational attainment, single caregivers, lower health literacy. Furthermore, caregivers with a reduced intention to change SSB behaviors completed fewer assessments and needed more reminders. Higher baseline SSB intake was associated with lower engagement across all indicators except URL clicks. Conclusions: Results can be used to develop targeted retention and engagement strategies (e.g., just-in-time and/or adaptive interventions) in rural SMS interventions for identified demographic subsets. Trial registration: Clincialtrials.gov: NCT03740113.

Improving Fecal Immunochemical Test Return Rates: A Colorectal Cancer Screening Quality Improvement Project in a Multisite Federally Qualified Health Center.

The goal of this quality improvement project was to improve colorectal cancer (CRC) screening rates in a multicenter federally qualified health center (FQHC) within the Central Appalachian region of rural, southwestern Virginia. Guided by the Plan-Do-Study-Act (PDSA) cycle, the objectives were to (1) evaluate implementation processes and effectiveness of an automated electronic medical record patient reminder system to promote fecal immunochemical test (FIT) completion, compared with live telephone reminders delivered by a care coordinator (i.e., usual care), and (2) explore staff perceptions related to improving CRC screening rates. In total, 119 FITs were distributed with 59 assigned to usual care and 60 to the automated groups. In the usual care group, 79% patients with completed protocol returned their FIT; 9% were positive. In the automated reminder group, 76% patients with completed protocol returned their FIT; 10% were positive. There was no significant difference in the number of contacts per patients between the usual care (2.0, SD = 0.82 contacts/patient) and automated (1.8, SD = 0.98 contacts/patient) groups (p = .248). In total, the usual care and automated groups required 56 and 17 live calls, respectively. Overall, FQHC system-wide CRC screening rates increase from 30.5% to 47.3%. Ten staff interviews revealed perceptions of CRC screening, the QI project, and organizational change processes that may inform future cancer control projects. Researcher and practitioners should consider PDSA quality improvement projects as an initial step to build capacity and improve CRC screening rates, especially when working in FQHC with limited resources to engage in large complex research projects.

Relationships among changes in physical activity, quality of life, and obesity-Status following a behavioral intervention for rural Appalachian adults.

Improved health-related quality of life (HRQoL) is one benefit of physical activity. Yet, there is limited intervention research exploring (1) whether changes in physical activity influence changes in HRQoL among community-based populations and (2) if baseline obesity status influences the relationships. This exploratory analysis used secondary data from rural Appalachian adults who completed the MoveMore arm of a larger randomized control trial (n = 105, Mage = 41.8, 82 % female, 96 % White, Mincome= $25,911). Specifically, this study examined associations among changes in physical activity and HRQOL and whether baseline obesity status moderated changes. Three HRQoL variables (self-rated health status, total unhealthy days, days poor health impacted activities) and two physical activity variables [weekly moderate-vigorous physical activity (MVPA) minutes, weekly strength training minutes] were collected at baseline and 6-months. Regression models, adjusted for age, gender, race, income, education, assessed associations between physical activity and HRQoL change variables. Moderation analyses explored the influence of baseline obesity status on these relationships. Participants reported significant improvements in self-rated health status (P = 0.001), weekly MVPA minutes (P = 0.008), and weekly strength training minutes (P < 0.001). Increasing weekly strength training minutes was associated with fewer days poor health impacted activities (B = -0.040, P = 0.013). Weekly minutes of MVPA was not associated with HRQoL variables. Baseline obesity status did not moderate relationships. Findings suggest increasing weekly strength training may reduce days poor health impacted activities and that relationships among changes in physical activity and HRQoL were not impacted by baseline obesity. Findings have implications for promoting strength activities in community-based physical activity interventions for rural populations.

Evaluating the feasibility of pharmacist-facilitated tobacco cessation interventions in independent community pharmacies in rural Appalachia.

BACKGROUND: Smoking rates in the United States are the highest in underserved rural regions. Thus, more points of contact are needed to link smokers to evidence-based cessation programs. OBJECTIVES: The purpose of this study was to conduct an evaluation to determine the feasibility, acceptability, and interest among rural pharmacists in implementing a pharmacist-facilitated smoking cessation program in independent community pharmacies in rural Appalachian communities in Virginia, North Carolina, Tennessee, and West Virginia. METHODS: This study utilized a complementary sequential mixed-methods approach to explore independent community pharmacists and technicians' experiences and beliefs about implementing a tobacco cessation program in their pharmacy. RESULTS: There were 49 pharmacists or technicians who completed the survey and 7 pharmacists who participated in the interviews. Four main findings emerged from the data: 1) pharmacies can help fill the gap in tobacco cessation services in rural communities, 2) under current practice, tobacco cessation resources when offered by independent community pharmacies are not always formalized, 3) there are known barriers, such as reimbursing for services, that need to be addressed to provide tobacco cessation in an independent pharmacy setting, and 4) the Ask-Advise-Connect model is a feasible tobacco cessation approach in a pharmacy. CONCLUSION: Although pharmacists may be ideally situated to build capacity for smoking cessation in rural areas, smoking cessation interventions need to use existing approaches that compensate pharmacists for their time spent counseling patients. Furthermore, simple documentation and billing systems are needed to maximize utilization of tobacco cessation products and services provided in the pharmacy.

"It Depends on Where You Are and What Job You Do": Differences in Tobacco Use across Career Fields in the United States Air Force.

While tobacco use within the military is often discussed as being homogenously part of U.S. military culture, literature from civilian populations highlights that tobacco use varies by career field (e.g., "white collar" vs. "blue collar"). The objective of this qualitative study was to compare tobacco use by career fields in the U.S. Air Force. Airmen, Military Training Instructors, and Technical Training Instructors participated in 22 focus groups across five major Air Force Technical Training bases. Focus groups were conducted in-person using semi-structured interview guides and were audio-recorded. A conventional content-coding approach was used to code transcripts. Participants described substantial variation across the careers, which was attributed to social norms and the nature of jobs. Individuals in careers that spend most of their time outside were more likely to permit tobacco use. Conversely, tobacco use was seen as stigmatized in medical fields. Additionally, smokeless tobacco was identified as popular in certain careers because it could be used covertly on the job. Findings suggest that a one-size-fits-all approach to reducing tobacco use through policies and programs may not reflect the realities of military tobacco use. These findings may provide insights into other branches of the U.S. military with similar career fields.

Understanding the Relationship between Food Security and Mental Health for Food-Insecure Mothers in Virginia.

Food insecurity, which disproportionately impacts mothers, can have chronic consequences on physical and mental health. There is a relationship between food insecurity and mental health, but the relationship's mechanisms are unclear. This study aimed to understand how mental health outcomes differ by food insecurity severity and race among Virginia mothers. A cross-sectional survey employed previously validated food security status measures, physical and mental health, social support, and food coping strategies. Results were analyzed using descriptive statistics, Spearman's rank-order correlations, linear regression, and chi-squared with effect sizes. Overall, respondents (n = 1029) reported worse mental health than the U.S. average (44.3 ± 10.1 and 50, respectively). There was a large effect of food security on mental health (d = 0.6), with worse mental health outcomes for mothers experiencing very low food security (VLFS) than low food security (LFS; p < 0.001). There was a small effect of race on mental health (φc = 0.02), with Black mothers having better mental health than White mothers (p < 0.001). Compared to mothers experiencing LFS, mothers experiencing VLFS had less social support (d = 0.5) and used more food coping strategies, especially financial strategies (d = −1.5; p < 0.001). This study suggests that food-insecure mothers experience stressors and lack adequate social support, which is even more distinct for mothers experiencing VLFS.

Using the Socio-ecological Model to Explore Facilitators and Deterrents of Tobacco Use Among Airmen in Technical Training.

INTRODUCTION: Military personnel have some of the highest rates of tobacco use in the USA. Within the Air Force, a common point of Airmen's (re-)initiation of tobacco use is during technical training once the tobacco ban has been lifted. Unfortunately, little is known about what factors facilitate and deter tobacco use during technical training. The socio-ecological model, which emphasizes multiple levels of influence on behavior (e.g., personal, intrapersonal, and environmental), provides a strong and comprehensive basis for which to explore factors that may impact tobacco use during technical training. MATERIALS AND METHODS: Twenty-two focus groups were conducted among Airmen (n = 10), Military Training Leaders (MTLs, n = 7), and Technical Training Instructors (TTIs, n = 5). Semi-structured focus group protocols were developed based on the socio-ecological model and included questions intended to elicit factors that facilitated and deterred tobacco use during technical training. Focus groups were transcribed and then coded using a hybrid deductive-inductive process. RESULTS: At the personal level, five factors were identified that influenced tobacco use: choice, fit with lifestyle, associations with the tobacco experience, association with military job outcomes, and association with health outcomes. Three interpersonal level factors were identified: peer influence, leadership influence, and normative beliefs. There were two influential environmental level factors: pricing and promotion and access to tobacco. Except for normative beliefs, all personal, interpersonal, and environmental-level factors were discussed as having aspects that could either facilitate or deter tobacco use. Normative beliefs, an interpersonal-level factor, were only discussed as a facilitator of tobacco use. CONCLUSIONS: Taken together, study findings can be used to enhance the effectiveness of tobacco prevention and cessation programs for Air Force Technical Trainees. Specific strategies to support the reduction of tobacco use among Airmen are presented.

Factors Influencing the Sugar-Sweetened Beverage Intake of Caregivers of Adolescents in Appalachia.

OBJECTIVE: To identify factors that influence the sugar-sweetened beverage (SSB) intake of caregivers of middle school-aged adolescents. DESIGN: Cross-sectional. SETTING: Southwestern Virginia, US, part of Central Appalachia. PARTICIPANTS: Caregivers (n = 362) of adolescents enrolled in the Kids SIPsmartER trial. Participants were mostly female (91%) and non-Hispanic White (96%), and 21% received Supplemental Nutrition Assistance Program (SNAP) benefits. MAIN OUTCOME MEASURES: Caregiver daily SSB intake and demographics, personal-level, interpersonal-level, and environmental-level determinants. ANALYSIS: Descriptive statistics, 1-way ANOVA, and stepwise regression. RESULTS: On average, caregivers consumed 25.7 (SD, 33.2) fluid ounces of SSB per day. In the final model, which included all variables, age (ß = -0.41; P < 0.05), receiving SNAP benefits (ß = 14.19; P ≤ 0.01), behavioral intentions (ß = -5.48; P ≤ 0.001), affective attitudes (ß = -2.15, P < 0.05), perceptions of whether their adolescent frequently consumes high amounts of SSB (ß = 1.92; P ≤ 0.001), and home availability (ß = 7.43; P ≤ 0.01) were significantly associated with SSB intake. CONCLUSIONS AND IMPLICATIONS: Caregivers of Appalachian middle school students are high SSB consumers. Findings highlight the importance of implementing behavioral interventions for caregivers of adolescents that target multiple levels of influence, including demographic, personal-level, interpersonal-level, and environmental-level factors. Interventions may be particularly important for communities and groups with higher SSB intakes, such as those in Appalachia and who receive SNAP benefits.

Spatial analysis of colorectal cancer outcomes and socioeconomic factors in Virginia.

BACKGROUND: Colorectal cancer (CRC) disparities vary by country and population group, but often have spatial features. This study of the United States state of Virginia assessed CRC outcomes, and identified demographic, socioeconomic and healthcare access contributors to CRC disparities. METHODS: County- and city-level cross-sectional data for 2011-2015 CRC incidence, mortality, and mortality-incidence ratio (MIR) were analyzed for geographically determined clusters (hotspots and cold spots) and their correlates. Spatial regression examined predictors including proportion of African American (AA) residents, rural-urban status, socioeconomic (SES) index, CRC screening rate, and densities of primary care providers (PCP) and gastroenterologists. Stationarity, which assesses spatial equality, was examined with geographically weighted regression. RESULTS: For incidence, one CRC hotspot and two cold spots were identified, including one large hotspot for MIR in southwest Virginia. In the spatial distribution of mortality, no clusters were found. Rurality and AA population were most associated with incidence. SES index, rurality, and PCP density were associated with spatial distribution of mortality. SES index and rurality were associated with MIR. Local coefficients indicated stronger associations of predictor variables in the southwestern region. CONCLUSIONS: Rurality, low SES, and racial distribution were important predictors of CRC incidence, mortality, and MIR. Regions with concentrations of one or more factors of disparities face additional hurdles to improving CRC outcomes. A large cluster of high MIR in southwest Virginia region requires further investigation to improve early cancer detection and support survivorship. Spatial analysis can identify high-disparity populations and be used to inform targeted cancer control programming.

Study protocol for iSIPsmarter: A randomized-controlled trial to evaluate the efficacy, reach, and engagement of a technology-based behavioral intervention to reduce sugary beverages among rural Appalachian adults.

Sugar-sweetened beverage (SSB) consumption is disproportionately high among rural Appalachian adults, with intakes double the national average and nearly four times the recommended amount. This trial targets this major dietary risk factor and addresses notable gaps in the rural digital health intervention literature. iSIPsmarter is a technology-based behavior and health literacy intervention aimed at improving SSB behaviors. It is comprised of six Internet-delivered, interactive Cores delivered weekly, an integrated short message service (SMS) strategy to engage users in tracking and reporting SSB behaviors, and a cellular-enabled scale for in-home weighing. iSIPsmarter is adapted from an evidence-based intervention and is grounded by the Theory of Planned Behavior and health literacy, numeracy, and media literacy concepts. The RCT is guided by the RE-AIM framework and targets 244 rural Appalachian adults. The goal is to examine the efficacy of iSIPsmarter to reduce SSB in a two-group design [iSIPsmarter vs. static Participant Education website] with four assessment points. Changes in secondary outcomes (e.g., diet quality, weight, quality of life) and maintenance of outcomes will also be evaluated. Additional secondary aims are to examine reach and representativeness, patterns of user engagement, and cost. Two tertiary aims are exploratory mediation analyses and a systems-level, participatory evaluation to understand context for future organizational-level adoption of iSIPsmarter. The long-term goal is to sustain an effective, scalable, and high reach behavioral intervention to reduce SSB-related health inequities and related chronic conditions (i.e., obesity, diabetes, some obesity-related cancers, heart disease, hypertension, dental decay) in rural Appalachia and beyond. ClinicalTrial registry: NCT05030753.

Low Health Literacy Is Associated With Energy-Balance-Related Behaviors, Quality of Life, and BMI Among Rural Appalachian Middle School Students: A Cross-Sectional Study.

BACKGROUND: Many studies document associations between low health literacy (HL) and poor health behaviors and outcomes. Yet, HL is understudied among adolescents, particularly from underserved, rural communities. We targeted rural adolescents in this cross-sectional study and explored relationships between HL and (1) energy-balance-related health behaviors and (2) body mass index (BMI) and quality of life (QOL). METHODS: Surveys were administered to 7th graders across 8 middle schools in rural Appalachia. HL was assessed using the Newest Vital Sign. Energy-balance-related behaviors and QOL were assessed using validated instruments. Height and weight were objectively measured. Analyses were conducted using the Hodges-Lehmann nonparametric median difference test. RESULTS: Of the 854 adolescent students (mean age = 12; 55% female), 47% had limited HL. Relative to students with higher HL, students with lower HL reported significantly lower frequency of health-promoting behaviors (water, fruit and vegetable intake, physical activity, sleep), higher frequency of risky health behaviors (sugar-sweetened beverages, junk food, screen time), and had higher BMI percentiles and lower QOL (all p < .05). CONCLUSIONS: Low HL is associated with energy-balance-related behaviors, BMI, and QOL among rural, Appalachian adolescents. Findings underscore the relevance of HL among rural middle school students and highlight implications for school health.

Advancing engagement and capacity for rural cancer control: a mixed-methods case study of a Community-Academic Advisory Board in the Appalachia region of Southwest Virginia.

BACKGROUND: The objectives are to: 1) describe engagement processes used to prioritize and address regional comprehensive cancer control needs among a Community-Academic Advisory Board (CAB) in the medically-underserved, rural Appalachian region, and 2) detail longitudinal CAB evaluation findings. METHODS: This three-year case study (2017-2020) used a convergent parallel, mixed-methods design. The approach was guided by community-based participatory research (CBPR) principles, the Comprehensive Participatory Planning and Evaluation process, and Nine Habits of Successful Comprehensive Cancer Control Coalitions. Meeting artifacts were tracked and evaluated. CAB members completed quantitative surveys at three time points and semi-structured interviews at two time points. Quantitative data were analyzed using analysis of variance tests. Interviews were audio recorded, transcribed, and analyzed via an inductive-deductive process. RESULTS: Through 13 meetings, Prevention and Early Detection Action Teams created causal models and prioritized four cancer control needs: human papillomavirus vaccination, tobacco control, colorectal cancer screening, and lung cancer screening. These sub-groups also began advancing into planning and intervention proposal development phases. As rated by 49 involved CAB members, all habits significantly improved from Time 1 to Time 2 (i.e., communication, priority work plans, roles/accountability, shared decision making, value-added collaboration, empowered leadership, diversified funding, trust, satisfaction; all p < .05), and most remained significantly higher at Time 3. CAB members also identified specific challenges (e.g., fully utilizing member expertise), strengths (e.g., diverse membership), and recommendations across habits. CONCLUSION: This project's equity-based CBPR approach used a CPPE process in conjunction with internal evaluation of cancer coalition best practices to advance CAB efforts to address cancer disparities in rural Appalachia. This approach encouraged CAB buy-in and identified key strengths, weaknesses, and opportunities that will lay the foundation for continued involvement in cancer control projects. These engagement processes may serve as a template for similar coalitions in rural, underserved areas.

There has been notable progress among state and local cancer coalitions in developing and implementing comprehesive cancer control plans. Yet, gaps exist in rural communities and cancer remains a leading cause of death in rural populations. This paper reports on how the involvement of a Community-Academic Advisory Board (CAB) helped to prioritize cancer control and research needs in the medically-underserved, rural Appalachian region. CAB members were asked to participate in meetings and to share their experiences through surveys and interviews. Through this three-year process, four cancer control needs were prioritized: human papillomavirus vaccination, tobacco control, colorectal cancer screening, and lung cancer screening. Also, over the course of the project, CAB members' experiences improved, including: communication, priority work plans, roles/accountability, shared decision making, value-added collaboration, empowered leadership, diversified funding, trust, satisfaction. During the interviews, CAB members identified specific challenges, strengths, and recommendations. The opportunities and barriers at building and sustaining capacity as well as advancing a community-driven research agenda to address cancer disparities in rural Appalachia is discussed.

A Novel Behavioral Intervention for Rural Appalachian Cancer Survivors (weSurvive): Participatory Development and Proof-of-Concept Testing.

BACKGROUND: Addressing the modifiable health behaviors of cancer survivors is important in rural communities that are disproportionately impacted by cancer (eg, those in Central Appalachia). However, such efforts are limited, and existing interventions may not meet the needs of rural communities. OBJECTIVE: This study describes the development and proof-of-concept testing of weSurvive, a behavioral intervention for rural Appalachian cancer survivors. METHODS: The Obesity-Related Behavioral Intervention Trials (ORBIT) model, a systematic model for designing behavioral interventions, informed the study design. An advisory team (n=10) of community stakeholders and researchers engaged in a participatory process to identify desirable features for interventions targeting rural cancer survivors. The resulting multimodal, 13-week weSurvive intervention was delivered to 12 participants across the two cohorts. Intervention components included in-person group classes and group and individualized telehealth calls. Indicators reflecting five feasibility domains (acceptability, demand, practicality, implementation, and limited efficacy) were measured using concurrent mixed methods. Pre-post changes and effect sizes were assessed for limited efficacy data. Descriptive statistics and content analysis were used to summarize data for other domains. RESULTS: Participants reported high program satisfaction (acceptability). Indicators of demand included enrollment of cancer survivors with various cancer types and attrition (1/12, 8%), recruitment (12/41, 30%), and attendance (median 62%) rates. Dietary (7/12, 59%) and physical activity (PA; 10/12, 83%) behaviors were the most frequently chosen behavioral targets. However, the findings indicate that participants did not fully engage in action planning activities, including setting specific goals. Implementation indicators showed 100% researcher fidelity to delivery and retention protocols, whereas practicality indicators highlighted participation barriers. Pre-post changes in limited efficacy outcomes regarding cancer-specific beliefs and knowledge and behavior-specific self-efficacy, intentions, and behaviors were in desired directions and demonstrated small and moderate effect sizes. Regarding dietary and PA behaviors, effect sizes for fruit and vegetable intake, snacks, dietary fat, and minutes of moderate-to-vigorous activity were small (Cohen d=0.00 to 0.32), whereas the effect sizes for change in PA were small to medium (Cohen d=0.22 to 0.45). CONCLUSIONS: weSurvive has the potential to be a feasible intervention for rural Appalachian cancer survivors. It will be refined and further tested based on the study findings, which also provide recommendations for other behavioral interventions targeting rural cancer survivors. Recommendations included adding additional recruitment and engagement strategies to increase demand and practicality as well as increasing accountability and motivation for participant involvement in self-monitoring activities through the use of technology (eg, text messaging). Furthermore, this study highlights the importance of using a systematic model (eg, the ORBIT framework) and small-scale proof-of-concept studies when adapting or developing behavioral interventions, as doing so identifies the intervention's potential for feasibility and areas that need improvement before time- and resource-intensive efficacy trials. This could support a more efficient translation into practice.