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Background: Despite the disparate Human papillomavirus (HPV) infection rates among sexually active black young adults, HPV vaccine uptake remains low among this population. This study aimed to explore HPV beliefs, attitudes, and knowledge among black young adults and provide recommendations on ways to improve vaccine uptake.Methods: We used a mixed-method, convergent design to conduct five focus groups and administered a 40-item electronic survey that was developed with Health Belief Model (HBM) constructs. We assessed HPV and vaccine knowledge, barriers, and attitudes toward vaccination. We analyzed quantitative data using descriptive statistics and bivariate methods. Focus group transcripts were analyzed using content analysis. Results were integrated to obtain a better understanding of the topic.Results: Forty individuals participated in the study. The mean age was 22.2±4.5 years and 55% identified as African immigrants. Integrated data revealed themes mapped to relevant HBM constructs. Almost one third (32.5%) of participants were unaware of their susceptibility to HPV infection and its severity. From focus group discussions, the majority (75%) believed that vaccines are beneficial. Major cues to action include promoting HPV vaccine uptake via community wide informational sessions, provider recommendation, and social and mass media campaigns. Conclusion: Barriers to vaccine uptake, limited HPV knowledge, and lack of vaccine recommendation are important factors contributing to low vaccine uptake among black young adults. Interventions to decrease barriers to HPV vaccination, increase HPV knowledge, address misconceptions, and unfavorable beliefs are needed to promote to promote HPV vaccine uptake.

The Appalachian region of the USA includes 423 counties in 13 states positioned along the spine of the Appalachian Mountains stretching from New York to Mississippi. Approximately 42% of Appalachia is rural, and while the economy of Appalachia has diversified over the past two decades from reliance on agriculture and coal mining, 176 (41.6%) of the 423 counties are classified as economically distressed or at-risk. Patient navigation (PN) has been shown to be effective as an approach to address multiple barriers and enhance access to healthcare services, and yet there are no known PN programs focusing on the Appalachian population. This project was designed to develop, implement, and evaluate a curriculum and training program for PN for cancer prevention and control in Appalachia. The training program was developed through formative evaluation and offered daylong workshops that provided instruction in 60-90-min modules. Workshop topics included an introduction to PN, Appalachian culture, community needs assessment, communication, financial navigation, and navigation for screening and diagnostic follow-up for breast, cervical, and colorectal cancers. A total of 20 workshops were conducted with 334 attendees. The workshops were evaluated using a mixed-method approach using pre- and posttests and participant evaluations. The overall mean posttest scores increased by 4% from pretest (p 0.05). Evaluation also showed that attendees valued the focus on Appalachian culture and judged the content relevant and useful. Attendees also expressed interest in additional opportunities for similar workshops that expanded upon current topics and allowed for exploration of Appalachian health-related issues.

Appalachian regions of Kentucky and Ohio are hotspots for colorectal cancer (CRC) mortality in the USA. Screening reduces CRC incidence and mortality; however, screening uptake is needed, especially in these underserved geographic areas. Implementation science offers strategies to address this challenge. The aim of the current study was to conduct multi-site, transdisciplinary research to evaluate and improve CRC screening processes using implementation science strategies. The study consists of two phases (Planning and Implementation). In the Planning Phase, a multilevel assessment of 12 health centers (HC) (one HC from each of the 12 Appalachian counties) was conducted by interviewing key informants, creating community profiles, identifying HC and community champions, and performing HC data inventories. Two designated pilot HCs chose CRC evidence-based interventions to adapt and implement at each level (i.e., patient, provider, HC, and community) with evaluation relative to two matched control HCs. During the Implementation Phase, study staff will repeat the rollout process in HC and community settings in a randomized, staggered fashion in the remaining eight counties/HCs. Evaluation will include analyses of electronic health record data and provider and county surveys. Rural HCs have been reluctant to participate in research because of concerns about capacity; however, this project should demonstrate that research does not need to be burdensome and can adapt to local needs and HC abilities. If effective, this approach could be disseminated to HC and community partners throughout Appalachia to encourage the uptake of effective interventions to reduce the burden of CRC.

Background HPV self-sampling is an emerging HPV testing method that offers reliable identification of cervical precancer and cancer. To determine the feasibility of HPV self-sampling in the USA, information is needed regarding women's use of HPV test and willingness to use self-sampling, especially among disparate groups such as African American (AA) and sub-Saharan African immigrant (SAI) women. The purpose of this study was to examine factors associated with having had at least one HPV test and willingness to use HPV self-sampling among AA and SAI women. Methods AA and SAI women (n = 91) recruited from community settings completed a survey in a cross-sectional study. Data included sociodemographics, HPV and HPV testing knowledge, and willingness to use a HPV self-sampling test at home. Logistic regressions were performed to evaluate associations with having had a HPV test and willingness to use self-sampling. Results Respondents mean age was 38.2 years (SD = 12.6) and 65% were SAIs. The majority (84%) reported having had at least one Pap test and (36%) had at least one HPV test. Sixty-seven percent were willing to self-sample at home. Age, education, and HPV testing knowledge were associated with having had a HPV test. Being uninsured and likelihood to accept a Pap test if recommended were associated with willingness to use self-sampling at home for an HPV test. Conclusions Health care providers have an important role in recommending cervical cancer screening according to current guidelines. HPV self-sampling may be a promising strategy to reach older, less educated, uninsured, and underinsured Black women.

Background: Cancer risk factors awareness and cancer perceptions may influence individuals’ engagement or lack of engagement in preventive health behaviors including cancer screening and lifestyle changes. Blacks in the US have disproportionately higher death rates and the shortest survival rates than any ethnic or racial group for most cancers. Many factors may contribute to the elevated cancer burden, including level of awareness of cancer lifestyle risk factors and negative cancer perceptions. However, further research is needed to know more about cancer risk awareness and perceptions among ethnic sub-groups of Blacks. Therefore, the objective of this study was to assess awareness of cancer risk factors and cancer perceptions among African Americans and sub-Saharan African immigrant adults. Methods: We conducted a cross-sectional self-administered survey of 109 African Americans and 88 sub-Saharan African Black adults recruited from a medium size city in the Southeastern US and surrounding towns. Data collected included sociodemographics, measures of cancer risk awareness, and cancer perceptions. Linear regression models evaluated associations among sociodemographics and cancer risk factor awareness and cancer perceptions variables. Results: Participants’ average age was 41.5 years (SD=12.9), the majority were female (59%), and (45%) self-identified as sub-Saharan African immigrants. Based on a list of 13 cancer risk factors, the average number identified correctly was 6.5 (SD = 3.3). For cancer risk perceptions, with higher scores reflecting more negative cancer perceptions, scores were moderate (M = 13.8, SD = 2.8; potential range 5-25). Age, insurance status, education, and financial comfort were significantly associated with cancer risk factor awareness. For cancer risk perceptions, insurance status, education, and financial comfort were significant in the unadjusted analysis. Education was the only significant predictor for each outcome. Every one-level increase in educational attainment was associated with a 0.5-point increase in cancer risk factor awareness (b = 0.499, SD = 0.229; p = .031) and a 0.5-point decrease in cancer risk perception scores (b = -0.500, SE = 0.201; p = .014). Age, gender, ethnicity, marital status, insurance status, and financial comfort were not associated with either outcome in the adjusted model. Conclusion: Additional research is needed to improve cancer awareness and perceptions among Black adults. Future research should target women at higher risk of low awareness of cancer risk factors and negative cancer perceptions due to lower educational attainment. Increased attention to health promotion using different avenues and ensuring literacy may improve awareness of cancer risk factors and cancer risk perceptions. Citation Format: Adebola Adegboyega, Adaeze Aroh, Amanda Wiggins, Mark Dignan. Cancer risk factors awareness and cancer perceptions among African Americans and Sub-Saharan African immigrants [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A093.

Background The cervical cancer burden is high among women living in Appalachia. Cigarette smoking, a cervical cancer risk factor, is also highly prevalent in this population. This project aims to increase smoking cessation among women living in Appalachia by embedding a smoking cessation program within a larger, integrated cervical cancer prevention program. Methods The broader program, the Take CARE study, is a multi-site research collaborative designed to address three risk factors for cervical cancer incidence and mortality: tobacco use, human papillomavirus (HPV) infection, and cervical cancer screening. Break Free is a primary care clinic-based implementation program that aims to promote smoking cessation among female smokers in Appalachia by standardizing clinical practice protocols. Break Free includes: (1) implementation of a tobacco user identification system in the Electronic Health Record, (2) clinic staff and provider training on the Ask, Advise and Refer (AAR) model, (3) provider implementation of AAR to identify and treat women who want to quit smoking within the next 6 months, (4) facilitated access to cessation phone counseling plus pharmacotherapy, and (5) the bundling of Break Free tobacco cessation with HPV vaccination and cervical cancer screening interventions in an integrated approach to cervical cancer prevention. The study spans 35 Appalachian health clinics across 10 healthcare systems. We aim to enroll 51 adult female smokers per health system (total N = 510). Baseline and follow-up data will be obtained from participant (provider and patient) surveys. The primary outcome is self-reported 12-month point prevalence abstinence among enrolled patients. All randomized patients are asked to complete follow-up surveys, regardless of whether they participated in tobacco treatment. Data analysis of the primary aims will follow intent-to-treat methodology. Secondary outcomes will assess program implementation and cost effectiveness. Discussion Addressing high tobacco use rates is critical for reducing cervical cancer morbidity and mortality among women living in Appalachia. This study evaluates the implementation and effectiveness of a smoking cessation program in increasing smoking cessation among female smokers. If results demonstrate effectiveness and sustainability, implementation of this program into other health care clinics could reduce both rates of smoking and cervical cancer. Trial registration NCT04340531 (April 9, 2020)

OBJECTIVES:: Despite the availability of preventive methods for cervical cancer (CC), uptake has been low among African American and Sub-Saharan Immigrant (AA/SAI) women. The purpose of this study was to understand AA/SAI women’s values and beliefs of CC screening and explore willingness, acceptability, and concerns related to the HPV self-sampling method for CC. DESIGN:: Thirty AA/SAI women participated in one of six focus groups, each lasted 60–90 min, and were held over Zoom video conferencing. The sessions were audio-recorded, transcribed verbatim, and checked for accuracy by research staff prior to data analysis. Transcripts were content analyzed by two qualitatively trained research staff. NVivo software was used for data management and analysis. RESULTS:: The average age of participants was 33.67 ± 9.03, more than half were not married (53.3%), and less than half reported having health insurance coverage (46.7%). Participants included 16 AA and 14 SAI. Three main themes emerged from data analysis. (1) Beliefs and values related to CC Screening, (2) perceived barriers to attending CC screening, (3) recommendations to motivate regular CC screening. In addition, three factors emerged in the discussion on the HPV self-sampling method: confidence in ability to self-sample for CC, willingness to use HPV self-sampling kit, and result delivery. CONCLUSIONS:: This study identified a variety of reasons for the disproportionately low utilization of CC prevention services among AA/SAI women. Multidimensional approaches including educational and community engagement programs for this population could improve CC screening uptake and adoption of HPV self-sampling among AA/SAI women.

Background Culturally relevant education is an opportunity to reduce health disparities, and online learning is an emerging avenue for health promotion. In 2014–2019, a team based at the Alaska Native Tribal Health Consortium developed, implemented, and evaluated culturally relevant online cancer education modules with, and for, Alaska’s tribal primary care providers. The project was guided by Indigenous Ways of Knowing and the principles of community-based participatory action research and was evaluated in alignment with empowerment theory. About 265 unique learners completed 1,898 end-of-module evaluation surveys between March 2015 and August 2019, and 13 people completed a follow-up survey up to 28 months post module completion. Key Findings Learners described the modules as culturally respectful and informative and reported feeling more knowledgeable and comfortable talking about cancer as a result of the modules. About 98% of the learners planned to reduce their cancer risk because of the modules, and all follow-up survey respondents had reduced their risk, including by quitting smoking, getting screened for cancer, eating healthier, and exercising more. About 98% of the learners planned to share information with their patients, families, friends, and community members because of the modules, with all follow-up survey respondents indicating that they had shared information about cancer from the modules. Implications for Practice and Further Research Culturally relevant online modules have the capacity for positive behavioral change and relatively high correlations between intent and behavior change. Future research could determine which aspects of the modules catalyzed reduced cancer risk and increased dissemination of cancer information.

Numerous national guidelines now include primary human papillomavirus (HPV) testing as a recommended screening option for cervical cancer in the United States yet little is known regarding screening intentions for this specific screening strategy or interventions that may increase uptake. Gain- and loss-framed messaging can positively impact health behaviors; however, there is mixed evidence on which is more effective for cervical cancer screening, with no published evidence examining HPV testing. To help address this gap, this study compared the effects of message framing on screening knowledge and intentions related to primary HPV testing. We randomized females aged 21–65 (n=365) to receive brief messaging about cervical cancer screening with either gain- or loss-framing. In January-February 2020, participants completed pretest and posttest measures evaluating cervical cancer knowledge, beliefs, and intentions to be screened using HPV testing. We used generalized estimating equations to model message and framing effects on screening outcomes, controlling for age, education, race, and baseline measures. In comparison to pretest, messaging significantly increased HPV-related screening intentions [aOR: 2.4 (1., 3.5)] and knowledge [aOR: 1.7 (1.2, 2.4)], perceived effectiveness of HPV testing [aOR: 4.3 (2.8, 6.5)], and preference for primary HPV screening [aOR: 3.2 (1.2, 8.5), regardless of message framing. For all outcomes, no significant interaction by message framing was observed. Brief public health messaging positively impacted HPV-related screening intentions, knowledge, and beliefs, independent of message framing. In conjunction with other strategies, these results suggest that messaging could be an effective tool to increase uptake of primary HPV testing.

Culturally relevant health promotion is an opportunity to reduce health inequities in the cancer burden, and online learning is an emerging avenue for health promotion. To address a desire for synchronous online cancer education, a project team offered 10 1-hour cancer education webinars for Alaska's rural tribal health workers. The project was guided by the framework of Community-Based Participatory Action Research, honored Indigenous Ways of Knowing, and was informed by Empowerment Theory. The evaluation of this community-based intervention included end-of-webinar surveys. Between February and April 2018, 41 surveys were completed by 11 unique participants. All participants reported that, as a result of the webinars, they both planned to change their own behavior to reduce cancer risk, and planned to talk with their patients more often about cancer prevention strategies such as screenings, physical activity, tobacco cessation, and eating healthy. While the webinars addressed desires for synchronous actions to support cancer learning, and led to intentions to positive change behaviors, the ten webinars engaged far fewer unique learners than the team’s asynchronous cancer education modules. This experience may inform other cancer educators’ efforts to develop, implement, and evaluate online learning opportunities. Despite the small numbers, these webinars resulted in increased learners’ intent to reduce cancer risk behaviors, share cancer information, and improved learners’ capacity to talk about cancer in their communities.

PURPOSE: Women who receive an abnormal Pap result may experience negative psychological factors. The purpose of this study is to assess the baseline occurrence of negative psychological factors and evaluate the relationships between psychological factors and demographic characteristics among Appalachian women who received abnormal Pap results. METHODS: We conducted a secondary analysis of data collected from Appalachia Kentucky women (N = 521) ages ≥18 enrolled in an intervention. Data included sociodemographics, Beck depression and anxiety inventories, fatalism, and personal control measures. Multiple variable logistic regression was used to investigate the association between demographics and psychological factors. FINDINGS: Participants were predominantly White (96.2%), with mean age 28.93 ± 11.03 years, and the majority (77%) had yearly income below $20,000. Depression was reported by 34.6% (n = 173); 10% (n = 50) experienced moderate or severe anxiety; 20.6% (n = 107) had fatalistic beliefs; and 55.1% (n = 289) believed they lacked personal control over cancer. Women with lower income had higher occurrence of depression (P = .003). Women with moderate to severe anxiety were significantly older than those with low to moderate depression (34.44 vs 28.34, P < .001). Controlling for other variables, as age increased, the odds of fatalistic beliefs increased, OR (95%) = 1.042 (1.022,1.062). When education level increased, the odds of fatalistic beliefs decreased, OR (95%) = 0.873 (0.800,0.952). CONCLUSIONS: Given the high occurrence of depression, anxiety, and fatalistic beliefs among this population, health care providers should assess for underlying mental health diagnoses and psychological distress during each patient encounter and provide recommendations to address them.

This study describes the development of a colorectal cancer (CRC) screening multilevel intervention with four primary care clinics in rural Appalachian Kentucky. We also discuss barriers experienced by the clinics during COVID-19 and how clinic limitations and needs informed project modifications. Four primary care clinics were recruited, key informant interviews with clinic providers were conducted, electronic health record (EHR) capacity to collect data related to CRC screening and follow-up was assessed, and a series of meetings were held with clinic champions to discuss implementation of strategies to impact clinic CRC screening rates. Analysis of interviews revealed multilevel barriers to CRC screening. Patient-level barriers included fatalism, competing priorities, and financial and literacy concerns. The main provider- and clinic-level barriers were provider preference for colonoscopy over stool-based testing and EHR tracking concerns. Clinics selected strategies to address barriers, but the onset of COVID-19 necessitated modifications to these strategies. Due to COVID-19, changes in clinic staffing and workflow occurred, including provider furloughs, a state-mandated pause in elective procedures, and an increase in telehealth. Clinics adapted screening strategies to match changing needs, including shifting from paper to digital educational tools and using telehealth to increase annual wellness visits for screening promotion. While significant delays persist for scheduling colonoscopies, clinics were encouraged to promote stool-based tests as a primary screening modality for average-risk patients.

Background Whether recognition and prompt response to worsening symptoms are worse in older compared with younger patients with heart failure (HF) is unclear. Objectives The aims of this study were to compare older and younger patients (1) perceptions, evaluations, and responses to worsening HF symptoms, and (2) responses once worsening symptoms were perceived. Methods A mixed-methods study was conducted and to compare data between older (≥ 65) and younger ( Results There were few differences attributed to age. In response to higher perceived symptom distress, patients in both groups did nothing and hoped their symptoms would go away (p = 0.004), ignored symptoms and continued doing what they were doing (p = 0.002), or laid down to relax (p Conclusions The majority of patients, regardless of age, did not recognize, interpret, and respond appropriately to HF symptoms. Interventions should be tested that target better symptom appraisal and promote appropriate symptom responses in patients with HF across all ages.

Background Colorectal cancer (CRC) screening rates are lower in Appalachian regions of the United States than in non-Appalachian regions. Given the availability of various screening modalities, there is critical need for culturally relevant interventions addressing multiple socioecological levels to reduce the regional CRC burden. In this report, we describe the development and baseline findings from year 1 of “Accelerating Colorectal Cancer Screening through Implementation Science (ACCSIS) in Appalachia,” a 5-year, National Cancer Institute Cancer MoonshotSM-funded multilevel intervention (MLI) project to increase screening in Appalachian Kentucky and Ohio primary care clinics. Methods Project development was theory-driven and included the establishment of both an external Scientific Advisory Board and a Community Advisory Board to provide guidance in conducting formative activities in two Appalachian counties: one in Kentucky and one in Ohio. Activities included identifying and describing the study communities and primary care clinics, selecting appropriate evidence-based interventions (EBIs), and conducting a pilot test of MLI strategies addressing patient, provider, clinic, and community needs. Results Key informant interviews identified multiple barriers to CRC screening, including fear of screening, test results, and financial concerns (patient level); lack of time and competing priorities (provider level); lack of reminder or tracking systems and staff burden (clinic level); and cultural issues, societal norms, and transportation (community level). With this information, investigators then offered clinics a menu of EBIs and strategies to address barriers at each level. Clinics selected individually tailored MLIs, including improvement of patient education materials, provision of provider education (resulting in increased knowledge, p = .003), enhancement of electronic health record (EHR) systems and development of clinic screening protocols, and implementation of community CRC awareness events, all of which promoted stool-based screening (i.e., FIT or FIT-DNA). Variability among clinics, including differences in EHR systems, was the most salient barrier to EBI implementation, particularly in terms of tracking follow-up of positive screening results, whereas the development of clinic-wide screening protocols was found to promote fidelity to EBI components. Conclusions Lessons learned from year 1 included increased recognition of variability among the clinics and how they function, appreciation for clinic staff and provider workload, and development of strategies to utilize EHR systems. These findings necessitated a modification of study design for subsequent years. Trial registration Trial NCT04427527 is registered at https://clinicaltrials.gov and was registered on June 11, 2020.

INTRODUCTION: Abundant studies have associated colorectal cancer (CRC) treatment delay with advanced diagnosis and worse mortality. Delay in seeking specialist is a contributor to CRC treatment delay. The goal of this study is to investigate contributing factors to 14-days delay from diagnosis of CRC on colonoscopy to the first specialist visit in the state of Kentucky. METHODS: The Kentucky Cancer Registry (KCR) database linked with health administrative claims data was queried to include adult patients diagnosed with stage I-IV CRC from January 2007 to December 2012. The dates of last colonoscopy and first specialist visit were identified through the claims. Bivariate and logistic regression analysis were performed to identify factors associated with delay to CRC specialist visit. RESULTS: A total of 3,927 patients, from 100 hospitals in Kentucky were included. Approximately 19% of CRC patients visited a specialist more than 14 days after CRC detection on colonoscopy. Delay to Specialist (DTS) was found more likely in patients with Medicaid insurance (OR 3.1, p

Background: Human Papillomavirus (HPV) is the causative agent in nearly all cases of cervical cancer. Cervical cancer is preventable and treatable if detected early through regular screening. While Pap testing is a traditionally accepted screening option, HPV testing offers improved assurance of low cancer risk and reliable identification of cervical precancer and cancer. However, HPV testing is a relatively new testing option and remains underused. Black women, including Sub-Saharan African immigrants, have higher risk for cervical cancer incidence, mortality rates, and later stage of diagnosis for cervical cancer. The purpose of this study was to examine predictors of ever having had an HPV test among African American and Sub-Saharan African immigrant women. Methods: We conducted a cross-sectional 85-item survey with self-described African American or Sub-Saharan African immigrant women recruited from the community in a medium size city in the Southeastern US. Data included demographics, HPV and HPV testing knowledge, and HPV testing history. Logistic regression evaluated predictors of ever having had an HPV test. Results: The average age of the 91 women was 38.2 years (SD = 12.6) and almost two-thirds (65%) were African immigrants. The majority (84%) had ever had a Pap test and more than one-third (36%) had ever had a HPV test. Women were correct on less than half of the HPV knowledge 16-item scale (M = 7.1, SD = 4.7) and HPV testing knowledge was low, with women answering an average of less than two out of five items correctly (M = 1.8, SD = 1.5). Younger age (p=.004), higher education (p=.015), and higher HPV testing knowledge (p=.007) were significant predictors of having had an HPV test. Every one-year increase in age was associated with a 7% decrease in having had an HPV test (OR=.93, 95% CI = 0.88-0.98), while every one-level increase in education was associated with a 2-fold increase (OR=2.1, 95% CI=1.15-3.69). Every one-item increase in HPV testing knowledge was associated with an over two-fold increase in having had an HPV test (OR=2.1, 95% CI = 1.2-3.6). Conclusions: To ensure prompt diagnosis, follow up, and treatment, health care providers must stay abreast of updated screening guidelines and implement them. Future research should prioritize increasing knowledge and HPV testing among older women and those with lower educational attainment. c Citation Format: Adebola Adegboyega, Amanda Wiggins, Lovoria B. Williams, Mark Dignan. Correlates of HPV test history among African American and Sub-Saharan African immigrant women [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-246.

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.

To address a desire for timely, medically accurate cancer education in rural Alaska, ten culturally relevant online learning modules were developed with, and for, Alaska's Community Health Aides/Practitioners (CHA/Ps). The project was guided by the framework of Community-Based Participatory Action Research, honored Indigenous Ways of Knowing, and was informed by Empowerment Theory. A total of 428 end-of-module evaluation surveys were completed by 89 unique Alaska CHA/Ps between January and December 2016. CHA/Ps shared that as a result of completing the modules, they were empowered to share cancer information with their patients, families, friends, and communities, as well as engage in cancer risk reduction behaviors such as eating healthier, getting cancer screenings, exercising more, and quitting tobacco. CHA/Ps also reported the modules were informative and respectful of their diverse cultures. These results from end-of-module evaluation surveys suggest that the collaboratively developed, culturally relevant, online cancer education modules have empowered CHA/Ps to reduce cancer risk and disseminate cancer information. "brought me to tears couple of times, and I think it will help in destroying the silence that surrounds cancer".

Sub-Saharan African immigrant (SSAI) men have significant influence on the health-seeking behavior including cervical cancer screening uptake by their female partners/wives. We conducted a qualitative descriptive study with 21 SSAI men to explore knowledge, perceptions, and support related to cervical screening. Participants were aged 36 ± 9 years, college educated (88%), and 53% have lived in the U.S.5 years. Three themes emerged; inadequate cervical cancer knowledge, willingness and strategies for support, and shared versus autonomous decision making for screening. Social structure with emphasis on male leadership could be leveraged in cervical cancer screening promotion for SSAI women.

Background: Colorectal cancer (CRC) mortality is disproportionately higher in Appalachian counties of Kentucky than in non-Appalachian regions. Part of the mortality gap can be explained by lower screening rates in Appalachian counties. Researchers at Markey Cancer Center partnered with primary care clinics in eastern Kentucky to address this disparity by identifying strategies to implement evidence-based interventions (EBIs) to improve CRC screening and follow-up in Appalachian Kentucky. Methods: Members of the research team conducted formative research activities to identify multilevel barriers to CRC screening. A menu of EBIs was then created to address these barriers, and clinic champions selected EBIs that were feasible in their respective practices. However, because of restrictions during COVID-19, clinics experienced multiple changes to workflow and operations, necessitating modifications to program activities. Over a series of virtual meetings, clinic champions selected adaptations that could allow clinics to continue promoting CRC screening in their practices despite COVID-related limitations. Results: Changes in clinic staffing and workflow resulting from COVID-19 included provider furloughs, a state-mandated pause in elective procedures, mandatory parking lot visits for many in-person visits, and an increase in telehealth. Among our clinic partners, total in-person visits were reduced by nearly half from first to second quarter of 2020, whereas telehealth visits were 23 times higher, though telehealth visits were cut in half by third quarter. To match these changing modes of practice, clinics adapted creative strategies for communicating CRC screening recommendations to patients, including shifting from paper to digital educational tools, promoting screening via telehealth visits, and prioritizing recommendations for stool-based tests over colonoscopy for average-risk patients. As a result, orders for FIT and FIT-DNA were 2 and 3 times higher, respectively, from second to third quarter of 2020. Conclusion: Rural primary care clinics in Appalachia continue to promote CRC screening despite the multiple challenges related to COVID-19. One relevant reference for clinicians is the National Colorectal Cancer Roundtable’s playbook for reigniting CRC screening during COVID-19, a document that promotes stool-based screening for average-risk patients. While elective procedures remain backlogged in rural areas due to state regulations, research partners should emphasize the need to prioritize stool-based CRC screening for average-risk populations and reserve scheduling colonoscopies for high-risk individuals or those with abnormal stool-based test results. While our clinical partners had previously focused on a “colonoscopy first” approach to screening, our findings suggest that our clinic partners increased orders for stool-based CRC tests. Nevertheless, continued outreach is needed to ensure CRC screening rates remain optimal. Citation Format: Aaron J. Kruse-Diehr, Mark Cromo, Melinda Rogers, Angela Carman, Bin Huang, David Gross, Sue Russell, Vickie Fairchild, Mark Dignan. Colorectal cancer screening in Appalachian Kentucky primary care clinics during COVID-19 [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2021 Feb 3-5. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(6_Suppl):Abstract nr P12.

BACKGROUND American Indian and Alaska Native (AI/AN) breast cancer survivors experience disparities in breast cancer incidence and age-adjusted mortality compared with non-Hispanic white (NHW) breast cancer survivors. In addition, mortality-to-incidence rates indicate that AI/ANs continue to have the poorest survival from breast cancer compared with other racial groups. “Native American Cancer Education for Survivors” (NACES) is a cultural education and support intervention for AI/AN patients with cancer that collects data from voluntary participants through the NACES quality-of-life (QOL) survey regarding their cancer experience and survivor journey. METHODS Data from the NACES QOL survey were analyzed to determine whether barriers accessing and during initial cancer treatment impacted QOL domains for AI/AN cancer survivors. Exploratory analyses of selected variables were conducted and were followed by Kruskal-Wallis tests to determine whether these barriers influenced survivorship QOL for AI/AN breast cancer survivors. RESULTS AI/AN breast cancer survivors' social QOL was significantly affected by barriers to accessing cancer treatment. Many respondents experienced barriers, including a lack of cancer care at local clinics and the distance traveled to receive cancer care. During treatment, too much paperwork and having to wait too long in the clinic for cancer care were the most frequently reported barriers. CONCLUSIONS Treatment barriers influence AI/AN breast cancer survivors' social QOL. Mediating these barriers is crucial to ameliorating AI/AN survivors' disparities when accessing and completing cancer treatment and improving survivorship QOL. Cancer 2017;123:861–68. © 2016 American Cancer Society.

Introduction Rural US residents smoke at higher rates than urban or suburban residents. We report results from a community-based smoking cessation intervention in Appalachian Kentucky. Study design Single-blind, group-randomized trial with outcome measurements at baseline, 17 weeks and 43 weeks. Setting/participants This faith-placed CBPR project was located in six counties of rural Appalachian Kentucky. A total of 590 individual participants clustered in 28 churches were enrolled in the study. Intervention Local lay health advisors delivered the 12-week Cooper/Clayton Method to Stop Smoking program, leveraging sociocultural factors to improve the cultural salience of the program for Appalachian smokers. Participants met with an interventionist for one 90 min group session once per week incorporating didactic information, group discussion, and nicotine replacement therapy. Main outcome measures The primary outcome was self-reported smoking status. Secondary outcomes included Fagerström nicotine dependence, self-efficacy, and decisional balance. Results With post-intervention data from 92% of participants, those in intervention group churches (N = 383) had 13.6 times higher odds of reporting quitting smoking one month post-intervention than participants in attention control group churches (N = 154, p

Medically underserved populations in the United States continue to experience higher cancer burdens of incidence, mortality, and other cancer-related outcomes. It is imperative to understand how health inequities experienced by diverse population groups may contribute to our increasing unequal cancer burdens and disparate outcomes. The National Cancer Institute convened a diverse group of scientists to discuss research challenges and opportunities for cancer epidemiology in medically underserved and understudied populations. This report summarizes salient issues and discusses five recommendations from the group, including the next steps required to better examine and address cancer burden in the United States among our rapidly increasing diverse and understudied populations. Cancer Epidemiol Biomarkers Prev; 25(4); 573–80. ©2016 AACR. See all articles in this CEBP Focus section, “Multilevel Approaches to Addressing Cancer Health Disparities.”

To gain input on a proposed culturally responsive, distance-delivered cancer education course informed by empowerment theory and adult-learning principles, Alaska's Community Health Aides/Practitioners (CHA/Ps) and CHA/P leadership were invited to take an online survey in February 2015. The proposed course will be developed as part of the "Distance Education to Engage Alaskan Community Health Aides in Cancer Control" project. The results of the survey demonstrate that respondents are both interested in taking the proposed class and engaging in course development. The results also indicate that respondents have the technological comfort and capacity to be engaged in online learning and have primarily positive experiences and perceptions of distance education. This survey is the beginning of the interactive development of the online cancer education course and part of a continuing endeavor to promote wellness with, and for, Alaska's people by empowering Alaska's CHA/Ps and inspiring positive behavioral change to both prevent cancer and support those who feel its burdens.

Background: Colorectal cancer (CRC) screening is lower in Appalachian regions of Kentucky and Ohio than in their non-Appalachian counterparts, with lower screening contributing to increased CRC incidence and mortality. To address CRC disparities in these underserved regions, researchers from the University of Kentucky and The Ohio State University partnered with two federally qualified health centers (FQHCs) to develop and implement multilevel interventions (MLIs) during year one of a 5-year National Cancer Institute funded Cancer Moonshot project to increase CRC screening and follow-up in Appalachian Kentucky and Ohio. Methods: Drawing from the Model for the Analysis of Population Health and Health Disparities and using a social determinants of health framework, researchers selected and partnered with Community Advisory Boards (CAB) to guide project formation in two Appalachian counties, one in Kentucky and one in Ohio. These formative activities included creating community profiles, conducting key informant interviews with clinic and community champions, and completing data inventories to assess clinic capacity, ultimately resulting in two primary care clinics being selected for pilot year implementation activities. Results: Key informant interviews revealed barriers to CRC screening at multiple levels: patient (e.g., fear of screening results), provider (e.g., competing priorities), clinic (e.g., lack of reminder or tracking systems), and community (e.g., cultural norms). Clinic champions were provided with menus of evidence-based interventions (EBIs) to address barriers at each level and were encouraged to select locally relevant, implementable EBIs. Clinics chose to implement the following EBIs: improved patient education materials (patient-level), additional provider education (provider-level), improvement of electronic health record (EHR) reporting and creation of clinic-wide screening protocols (clinic-level), and provision of interactive screening education at community events (community- level). Conclusion: Results from pilot year activities were used to refine the project approach for years two through five. Project activities will be expanded to 10 more Appalachian counties in Kentucky and Ohio using a design wherein counties will be paired by participating clinic patient volume. As in pilot year activities, clinic/community champions will be encouraged to select EBIs appropriate to their patients, providers, clinics, and communities. To measure clinical outcomes, self- reported screening will be monitored using data from county-wide telephone surveys with additional data from clinic EHRs. Using an MLI approach may be well- received in underserved rural Appalachian communities and may ultimately be successful at reducing CRC screening disparities. Citation Format: Aaron J. Kruse-Diehr, Jill M. Oliveri, Mira L. Katz, Mark Cromo, Robin C. Vanderpool, Michael L. Pennell, Darrell M. Gray II, Paul L. Reiter, Bin Huang, Gregory S. Young, Darla Fickle, Melinda Rogers, David Gross, Sue Russell, Electra D. Paskett, Mark Dignan. Increasing colorectal cancer screening in rural underserved communities with multilevel interventions: Formative evaluation of accelerating colorectal cancer screening and follow-up through implementation science in Appalachia [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-253.

Introduction: The National Cancer Institute (NCI) Center to Reduce Center Health Disparities (CRCHD) Geographic Management of Cancer Health Disparities Program (GMaP) initiated in 2009 brings together investigators, trainees, students, and community health educators to network and share information, scientific resources, and tools to promote cancer and cancer health disparities research, as well as community education outreach within and across regions. To reach their goals, CRCHD initiated 7 GMaP regional “hubs” across the United States to enhance their capacity in areas of disparities research, contribute to the next generation of researchers, and achieve measurable reductions in cancer health disparities. Each hub is led by Regional Coordinating Directors (RCDs) who facilitate connections, provide funding and training resources and “leverage the strengths of its people, programs, and resources to provide greater access to cancer information.” Methods: The GMaP Region 1 North (R1N) hub is based at the Markey Cancer Center in Lexington, Kentucky. R1N partners with Johns Hopkins University's Sidney Kimmel Comprehensive Cancer Center, the University of South Carolina, and the University of Virginia Cancer Center to serve Delaware, Kentucky, Maryland, Maine, New Hampshire, Vermont, Virginia, West Virginia, Washington, DC, and West Virginia. The overall goal of GMaP R1N is to enhance the capacity of regional cancer centers, associated academic partners, community partners, and early-stage investigators to contribute to the reduction of cancer health disparities in the region. As part of the Continuing Umbrella of Research Experiences (CURE) Program, GMaP R1N promotes the F31, K series, and Diversity Supplement funding opportunities to potential applicants. R1N implemented pilot awards and travel scholarships for CURE-eligible candidates; developed a listserv to communicate with researchers, trainees, and potential applicants; and maintains regular contact with trainees to answer questions and encourage applications for NCI CURE Program and other grant opportunities. Results: R1N awarded 11 pilot projects, 22 travel scholarships, helped identify mentors and 146 potential applicants for NCI CURE Program grants, and collaborated with points of contact (POC) at colleges and universities, including Historically Black Colleges and Universities to identify potential applicants for NCI CURE and other funding. Conclusions: Methods have been successful in increasing interest in NCI Cancer health disparities training opportunities. RCDs are critical in establishing and maintaining linkages to support mentor-mentee relationships supported by available funding mechanisms; to engage institutional support for pre- and post-award activities, especially for new investigators; and for shrinking delays in the IRB review and approval process. RCDs have identified process barriers and work with regional POCs to eliminate these barriers and increase efficiencies to further the GMaP mission. Citation Format: Marcela Blinka, Mark Cromo, Julia F. Houston, Mark Dignan, Nathan Vanderford, B. Mark Evers, Janice Bowie, Adrian Dobs, James Hebert, Tisha Felder, Roger Anderson. Results to date: Efforts to increase cancer health disparities training in Geographic Management of Cancer Health Disparities Program Region 1 North [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A068.

The Appalachian region includes 13 states, ranging from southern New York to Mississippi. The region encompasses large areas experiencing high unemployment rates, poverty, and high rates of chronic disease, including cancer. Patient navigation (PN) is a patient-centered intervention designed to address barriers to timely cancer screening and treatment. Results of a prior project in the region indicated that existing PN training programs did not adequately address issues specific to working in Appalachia. To address this gap, we developed a culturally relevant PN training program to be delivered across the Appalachian region. We supported and delivered 20 trainings to over 300 participants from 2015 through the present, averaging 15 attendees per session. Participants included nurses, social workers, patient navigators, community health workers, and administrators living and working in Appalachia. The training's focus on integrating the unique aspects of Appalachian culture into patient navigation for cancer screening and care was rated high by participants. Additionally, participants appreciated the opportunity to network, since many participants work in isolation. Despite our model of providing multiple trainings in various locations throughout Appalachia, we noted there were still barriers to attendance. We conducted a formative evaluation to understand the challenges and identify solutions. We spent considerable time focusing on curricula development, but more attention was needed for detailed logistical considerations such as 1) earlier engagement of local community resources, including potential barriers to attending workshops and 2) local assistance in selecting training sites that would attract maximum attendance. Application of the guiding concepts in planning and data describing the workshop locations, participants, and evaluation results will be presented. Citation Format: Mark Dignan, Sharon Dwyer, Elizabeth Rohan, Dana White, Georgina Castro, Reda Wilson, Eric Stockton. Pearls and pitfalls of implementing a patient navigation training workshop for Appalachia [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A055.

Background Lung cancer is an important public health issue, particularly among American Indians (AIs). The reported decline in tobacco use for most racial/ethnic groups is not observed among AIs. This project was designed to address the research question, “Why don't more Northern Plains American Indians alter tobacco use behaviors known to increase the risk of cancer?” Methods Guided by the Theory of Planned Behavior, a multi-component intervention study was implemented. Adult AIs, age 18 years or older and currently smoking, were enrolled. Eligible subjects were randomized to one of 15 groups and exposed to either a MINIMAL or an INTENSE level of 4 intervention components. The intervention was delivered face-to-face or via telephone by Patient Navigators (PN). The primary outcome was self-reported abstinence from smoking verified by carbon monoxide measurement. Results At 18 months post-quit date, 88% of those who were still in the study were abstinent. This included 6% of all participants who enrolled in the study (14/254) and 13% of those who made it to the quit date (14/108). No intervention groups were found to have significant proportions of participants who were abstinent from smoking at the quit date (visit 5) or primary outcome visit (18 months post-quit date, visit 11), but use of pharmacologic support for abstinence was found to be an effective strategy for individuals who continued participation throughout the study. Those who remained in the study received more visits and were more likely to be abstinent. Conclusions Use of NRT increased the odds of not smoking, as assessed at the 18-month follow-up visit, but no other interventions were found to significantly contribute to abstinence from smoking. Although the intervention protocol included numerous points of contact between CRRs and participants (11 visits) loss to follow-up was extensive with only 16/254 remaining enrolled. Additional research is needed to improve understanding of factors that influence enrollment and retention in smoking cessation interventions for AI and other populations.

When starting new and healthy habits or encouraging vigilance against returning to poor habits, a simple text message can be beneficial. Text messages also have the advantage of being easily accessible for lower-income populations spread over a rural area, who may not be able to afford smartphones with apps or data plans. Users benefit the most from text messages that are customized for them, but personalization requires time and effort on part of the user and the counselor. However, personalization that focuses on the cultural background of a pool of recipients, in addition to general personal preferences, can be a low-cost method of ensuring the best experience for patients interested in taking up new habits. In this paper, we discuss the development of a system for motivating users to quit smoking designed for Native American users in South Dakota, using text messaging as a daily intervention method for patients. Our results show that focusing on modular message customization options and messages with a conversational tone best helps our goal of providing users with customization options that help motivate them to live happy and healthy lifestyles.

It is necessary for a cancer survivor to have good health behavior. Essential exercise and proper diet are helpful to decrease the risk of recurrence of the disease and the development of a new cancer type. People from low socioeconomic status are more likely to participate in risky health behaviors and have a higher chance of recurrence of cancer. It is important to have a motivational system for cancer survivors that motivates them to perform regular physical activities. In this article, we discuss the development of an mHealth system, which aims to increase physical activity in Native American populations with culturally appropriate motivational text and video messages. The system also includes an e-journal to monitor and maintain proper healthcare. We will also analyze the pilot data to evaluate the usability and the effectiveness of the system.

The objective of this study was to test the efficacy of a pilot intervention to increase mammography utilization among African-American women recruited from those waiting in the emergency department (ED)for non-urgent complaints. In a 3-armed pilot of a randomized controlled trial we compared the effects of a brief motivational interview delivered by a lay health worker with those of a culturally targeted brochure and a usual care control group. The results showed that one quarter (23%) of the sample reported having never had a mammogram prior to the study. There was no group difference by mammography status at the 3-month interview. More than one quarter of those retained in the study indicated they had received a mammogram during the study (27.4%). The conclusions from the study were that lay health workers are a valuable asset and may be used in innovative settings such as the ED to increase screening among vulnerable populations.

Background Rural residents in the U.S., particularly residents of Appalachia, are underrepresented in biomedical research, limiting the generalizability of research findings. Objective To examine factors associated with Appalachian adults' willingness to participate in biospecimen donation and banking. Methods A survey assessing willingness to donate blood, saliva, and buccal specimens and to have these biospecimens stored for future use in genetic studies was conducted among 493 Appalachian adults. Results Most participants 73% (358/493) were willing to donate one or more biospecimen type; among them, 75% (268/358) were willing to donate blood, saliva, and buccal specimens. Approximately 61% (300/493) were willing to have their biospecimens banked and 97% (290/300) of these were willing to have their samples used for genetic studies. Appalachian self-identity predicted willingness to donate biospecimens, to have them stored, and used in genetic studies (OR1.52, 95% CI 1.03-2.24). Conclusions Appalachian adults were generally willing to participate in biobanking research.