Identification of weight loss interventions for translation among endometrial cancer survivors: A RE-AIM analysis.

Interventions for obesity-related cancers that combine nutrition and physical activity for weight loss exist; however, their application to survivors of endometrial cancer is unknown. Furthermore, little is known about pre-implementation perceptions of existing programs from a variety of interested persons (physicians, researchers) who may be part of the implementation team. Adapting an existing intervention rather than developing a new intervention may speed the translational lag time as long as intervention characteristics and fit within the delivery system are considered during the planning phase. To describe the process of determining the core elements of obesity-related interventions for cancer survivors and determine which one might be best delivered by an urban healthcare system that predominantly serves individuals who live in rural areas of Virginia and West Virginia. A pragmatic review of the literature was conducted via PubMed and Google Scholar with broad search terms of cancer survivor AND weight loss AND health intervention. Identified interventions were scored related to the Practical, Robust Implementation and Sustainability Model-which is an extension of RE-AIM framework to guide the understanding of who, what, where, when, and how the intervention was conducted. Intervention characteristics are reported. In addition, ratings from three independent reviewers on the validated 5-point Likert scale of an intervention's acceptability, appropriateness, and feasibility in the intended delivery system were collected and summarized. Twelve interventions were identified with an average sample size of 241(±195) and a range of 48-683 participants. Target populations included survivors of colorectal, breast, and endometrial cancers as well as general cancer survivors and included both men and women or only women. Most participants (74%) identified as white/Caucasian and average age ranged from 47.1 to 65.9 years. Program duration ranged from 4 weeks to 18 months, with an average duration of 32 weeks. Intervention dosage ranged from three times a week to once a month. Intervention acceptability, appropriateness, and feasibility had average and standard deviation ratings of 3.52(±0.46), 3.41(±0.45), and 3.21(±0.46), respectively, out of 5. The four interventions with the highest combined acceptable, appropriate, and feasible scores are being considered for potential use as an obesity-related intervention for survivors of endometrial cancer. Future work is needed to determine relevant adaptations and efficacy among survivors of endometrial cancer with obesity. Our approach may be beneficial for other interventionists aiming to speed intervention development and implementation.

Weight loss improves morbidity and mortality associated with obesity-related cancer occurrence. Many interventions that target weight loss through physical activity and nutrition already exist. However, interventions specifically designed for endometrial cancer survivors with obesity are limited. Furthermore, the degree to which these programs will work in a given clinical system is unknown. This study explored existing interventions, applied a framework to analyze intervention characteristics, and used a validated tool to score the degree to which interventions would fit within the intended delivery system; in this case, a healthcare system that predominantly serves patients from rural areas.

Exploring biorepository donation patterns, experiences, and recommendations: a mixed-methods study among Appalachian adults enrolled in a sugary drink reduction program.

Background: Under-represented subgroups in biomarker research linked to behavioral health trials may impact the promise of precision health. This mixed methods study examines biorepository donations across an Appalachian sample enrolled in a sugary drink reduction intervention trial. Methods: Participants enrolled in the behavioral trial were asked to join an optional biomarker study and were tracked for enrollment and biospecimen returns (stool and/or buccal sample). At 6 months, participants completed a summative interview on decision-making process, experiences collecting samples, and recommendations to encourage biospecimen donation. Return rates were analyzed across demographics (i.e., age, gender, race, education, income, health literacy status, and rurality status) using chi-squares. Qualitative data were content coded with differences compared by biomarker study enrollment and donation choices. Results: Of the 249 invited participants, 171 (61%) enrolled, and 63% (n = 157) returned buccal samples and 49% (n = 122) returned stool samples. Metro residing participants were significantly more likely (56%) to return stool samples compared to non-metro (39%) counterparts [x2(1) = 6.61; p = 0.01]. Buccal sample return had a similar trend, 67 and 57%, respectively for metro vs. non-metro [x2(1) = 2.84; p = 0.09]. An additional trend indicated that older (≥40 years) participants were more likely (55%) to donate stool samples than younger (43%) participants [x2(1) = 3.39; p = 0.07]. No other demographics were significantly associated with biospecimen return. Qualitative data indicated that societal (66-81%) and personal (41-51%) benefits were the most reported reasons for deciding to donate one or both samples, whereas mistrust (3-11%) and negative perceptions of the collection process (44-71%) were cited the most by those who declined one or both samples. Clear instructions (60%) and simple collection kits (73%) were donation facilitators while challenges included difficult stool collection kits (16%) and inconveniently located FedEx centers (16%). Recommendations to encourage future biorepository donation were to clarify benefits to science and others (58%), provide commensurate incentives (25%), explain purpose (19%) and privacy protections (20%), and assure ease in sample collection (19%). Conclusion: Study findings suggest the need for biomarker research awareness campaigns. Researchers planning for future biomarker studies in medically underserved regions, like Appalachia, may be able to apply findings to optimize enrollment.

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.

Kids SIPsmartER reduces sugar-sweetened beverages among Appalachian middle-school students and their caregivers: a cluster randomized controlled trial.

BACKGROUND: High consumption of sugar-sweetened beverages (SSB) is a global health concern. Additionally, sugar-sweetened beverage (SSB) consumption is disproportionately high among adolescents and adults in rural Appalachia. The primary study objective is to determine the intervention effects of Kids SIPsmartER on students' SSB consumption. Secondary objectives focus on caregivers' SSB consumption and secondary student and caregiver outcomes [e.g, body mass index (BMI), quality of life (QOL)]. METHODS: This Type 1 hybrid, cluster randomized controlled trial includes 12 Appalachian middle schools (6 randomized to Kids SIPsmartER and 6 to control). Kids SIPsmartER is a 6-month, 12 lesson, multi-level, school-based, behavior and health literacy program aimed at reducing SSB among 7th grade middle school students. The program also incorporates a two-way text message strategy for caregivers. In this primary prevention intervention, all 7th grade students and their caregivers from participating schools were eligible to participate, regardless of baseline SSB consumption. Validated instruments were used to assess SSB behaviors and QOL. Height and weight were objectively measured in students and self-reported by caregivers. Analyses included modified two-part models with time fixed effects that controlled for relevant demographics and included school cluster robust standard errors. RESULTS: Of the 526 students and 220 caregivers, mean (SD) ages were 12.7 (0.5) and 40.6 (6.7) years, respectively. Students were 55% female. Caregivers were mostly female (95%) and White (93%); 25% had a high school education or less and 33% had an annual household income less than $50,000. Regardless of SSB intake at baseline and relative to control participants, SSB significantly decreased among students [-7.2 ounces/day (95% CI = -10.7, -3.7); p < 0.001, effect size (ES) = 0.35] and caregivers [-6.3 ounces/day (95% CI = -11.3, -1.3); p = 0.014, ES = 0.33]. Among students (42%) and caregivers (28%) who consumed > 24 SSB ounces/day at baseline (i.e., high consumers), the ES increased to 0.45 and 0.95, respectively. There were no significant effects for student or caregiver QOL indicators or objectively measured student BMI; however, caregiver self-reported BMI significantly decreased in the intervention versus control schools (p = 0.001). CONCLUSIONS: Kids SIPsmartER was effective at reducing SSB consumption among students and their caregivers in the rural, medically underserved Appalachian region. Importantly, SSB effects were even stronger among students and caregivers who were high consumers at baseline. TRIAL REGISTRATION: Clincialtrials.gov: NCT03740113. Registered 14 November 2018- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03740113 .

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.

Potential role of fructose on human colon DNA methylation in racial disparities observed for colorectal cancer risk.

Background and aims: An increasing body of observational studies has linked fructose intake to colorectal cancer (CRC). African Americans (AAs) are significantly more likely than European Americans to consume greater quantities of fructose and to develop right-side colon cancer. Yet, a mechanistic link between these two associations remains poorly defined. We aimed to identify differentially methylated regions (DMRs) associated with dietary fructose consumption measures obtained from food frequency questionnaires in a cohort of normal colon biopsies derived from AA men and women (n=79). Methods: DNA methylation data from this study was obtained using the Illumina Infinium MethylationEPIC kit and is housed under accession GSE151732. DMR analysis was carried out using DMRcate in right and matched left colon, separately. Secondary analysis of CRC tumors was carried out using data derived from TCGA-COAD, GSE101764 and GSE193535. Differential expression analysis was carried out on CRC tumors from TCGA-COAD using DESeq2 . Results: We identified 4,263 right-side fructose-DMRs. In contrast, only 24 DMRs survived multiple testing corrections (FDR<0.05) in matched, left colon. To identify targets by which dietary fructose drives CRC risk, we overlaid these findings with data from three CRC tumor datasets. Remarkably, almost 50% of right-side fructose-DMRs overlapped regions associated with CRC in at least one of three datasets. TNXB and CDX2 ranked among the most significant fructose risk DMRs in right and left colon respectively that also displayed altered gene expression in CRC tumors. Conclusions: Our mechanistic data support the notion that fructose has a greater CRC-related effect in right than left AA colon, alluding to a potential role for fructose in contributing to racial disparities in CRC.

A Technology-Driven, Healthcare-Based Intervention to Improve Family Beverage Choices: Results from a Pilot Randomized Trial in the United States.

Background: Healthcare-based interventions to address sugary beverage intake could achieve broad reach, but intensive in-person interventions are unsustainable in clinical settings. Technology-based interventions may provide an alternative, scalable approach. Methods: Within an academic health system in the United States that already performs electronic health record-based sugary drink screening, we conducted a pilot randomized trial of a technology-driven family beverage choice intervention. The goal of the intervention was to reduce sugar-sweetened beverage (SSB) and fruit juice (FJ) consumption in 60 parent-child dyads, in which children were 1-8 years old. The pediatrician-initiated intervention consisted of a water promotion toolkit, a video, a mobile phone application, and 14 interactive voice-response phone calls to parents over 6 months. The study was conducted between June 2021 and May 2022. The aim of the pilot study was to assess the potential feasibility and efficacy of the newly developed intervention. Results: Intervention fidelity was excellent, and acceptability was high for all intervention components. Children in both the intervention and the control groups substantially decreased their consumption of SSB and FJ over follow-up (mean combined baseline 2.5 servings/day vs. 1.4/day at 6 months) and increased water consumption, but constrained linear mixed-effects models showed no differences between groups on these measures. Compared to parents in the control group, intervention parents had larger decreases in SSB intake at 3 months (-0.80 (95% CI: -1.54, -0.06, p = 0.03) servings daily), but these differences were not sustained at 6 months. Conclusion: These findings suggest that, though practical to implement in a clinical care setting and acceptable to a diverse participant group, our multicomponent intervention may not be universally necessary to achieve meaningful behavior changes around family beverage choice. A lower-intensity intervention, such as EHR-based clinical screening alone, might be a less resource-intense way for health systems to achieve similar behavioral outcomes. Future studies might therefore explore whether, instead of applying a full intervention to all families whose children overconsume SSB or FJ, a stepped approach, starting with clinical screening and brief counseling, could be a better use of health system resources.

Preschool- and childcare center-based interventions to increase fruit and vegetable intake in preschool children in the United States: a systematic review of effectiveness and behavior change techniques.

BACKGROUND: Fruit and vegetable (FV) consumption in children in the United States (US) is very low. Adequate FV consumption is required for proper development during childhood, and dietary habits are established during preschool-age and tend to persist into adulthood. As most U.S. preschool-aged children attend childcare or preschool, this may be an opportune time and setting to conduct interventions to improve FV intake. These interventions should be based in theory and use behavior change techniques (BCTs) to explain mechanisms for expected change. To date, no published reviews have examined the effectiveness of childcare- or preschool-based FV interventions in preschoolers and their use of theoretical frameworks and BCTs. METHODS: This systematic review was completed adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were randomized controlled trials (RCTs) published between 2012 and 2022 of interventions to improve diet or FV intake in preschoolers (aged 2-5 years) in childcare or preschool-settings. A search of four databases was conducted between in September 2022 using search terms pertaining to the study's primary aim (FV consumption), age group (preschool-aged), settings (US childcare or preschool settings), and study design (RCT). Additional criteria were objective measures of FV consumption or skin carotenoids, as a proxy for FV intake. Included studies were narratively synthesized based on intervention type, measured effect, and use of theory and BCTs. RESULTS: The search resulted in six studies that reported on nine interventions. Overall, six interventions increased FV intake, of which five used nutrition education and one manipulated the feeding environment. Among the three interventions with no measured effect, two manipulated the feeding environment and one used peer modeling. Effective studies used at least three BCTs, though no pattern was observed between use of theory or BCTs and intervention effect. CONCLUSIONS: While several studies have shown promising results, the limited number of studies identified in this review highlights key gaps in this field: there is a need for studies to test FV interventions in US childcare settings that use objective measures of FV intake, directly compare intervention components and BCTs, are theory-based, and assess long-term behavior change.

Knowing Is Not Doing: A Qualitative Study of Parental Views on Family Beverage Choice.

OBJECTIVE: Sugary drink consumption is associated with adverse health outcomes in children, highlighting the need for scalable family interventions that address barriers to water consumption. To inform development of a scalable, health-care-system-based intervention targeting family beverage choice, a formative qualitative study was conducted using semi-structured interviews with parents whose children were identified as over-consuming sugar-sweetened beverages (SSB) and/or fruit juice (FJ). The first goal of these interviews was to understand, in a diverse real-world patient population, what parents viewed as the primary drivers of their family's beverage choices, and explore how these drivers might need to be addressed in order to make changes to beverage consumption. A second goal was to explore parental preferences for planned intervention components. An exploratory goal of the interviews was to examine whether knowledge, attitudes, and beliefs around family beverage choice differed across racial and ethnic groups in this sample. DESIGN: Semi-structured phone interviews were conducted and interviews audio-recorded and transcribed. PARTICIPANTS: 39 parents/caregivers of children ages 1-8 who over-consumed sugary drinks as determined by screenings at pediatric visits. PHENOMENON OF INTEREST: Parents were interviewed about family beverage choices and preferences to inform development of a multi-component intervention. ANALYSIS: Thematic analysis was performed, including comparison of themes across racial/ethnic groups. RESULTS: Parents expressed that sugary drinks were unhealthy and water was a better alternative. Most were familiar with the health consequences of excess sugar consumption. They identified many reasons why sugary drinks are chosen over water despite this knowledge. One common reason was concern about tap water safety. Few differences were noted across racial and ethnic groups in our sample. Parents were enthusiastic about a technology-based intervention to be delivered through their child's doctor's office. CONCLUSIONS AND IMPLICATIONS: Knowledge is not enough to change behavior. Beverage interventions need to be easy to access, make water more appealing, and elevate beverage choice above the "white noise" of everyday life. Delivering an intervention in a clinical setting could provide an extra level of care, while technology would reduce the amount of live contact and decrease the burden for clinicians and parents.

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.

Barriers and facilitators to resilience for rural cancer survivors during COVID-19.

The purpose of this study was to identify the barriers and facilitators of resilience for rural cancer survivors during COVID-19. A descriptive qualitative study design was used to achieve the study objected. We recruited six posttreatment cancer survivors, four caregivers of cancer survivors, and one survivor who also identified as a caregiver, all from rural Southwest Virginia. Participants completed 60-90 minute virtual interviews that were recorded, transcribed, and verified in Dedoose qualitative software. Data was analyzed using an inductive and deductive coding strategies, and thematic analysis was used to develop key themes. Four key themes emerged from the data: 1) Religious faith is a primary source of resilience, 2) Spiritual cancer care strengthens resilience, 3) Virtual platforms provide critical connections to faith communities, and 4) Fearful and fatalistic cancer beliefs reduce resilience. The findings provide critical descriptive evidence that faith facilitates resilience for rural cancer survivors, while rural cultural norms of fearful and fatalistic cancer beliefs reduce resilience. In the context of COVID-19, rural survivors prioritize utilizing virtual support groups to strengthen their resilience. Nurses should incorporate a spiritual assessment into survivorship care, and guide survivors to existing virtual support groups.

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.

Development of a Digital Behavioral Intervention to Reduce the Consumption of Sugar-Sweetened Beverages Among Rural Appalachian Adults: Multiphased, Human-Centered Design Approach.

BACKGROUND: To avoid the low engagement and limited efficacy of digital behavioral health interventions, robust human-centered design (HCD) processes are needed. OBJECTIVE: The primary objective of this study was to describe a flexible, step-by-step HCD process to develop digital behavioral health interventions by illustrating iSIPsmarter as an example. iSIPsmarter is a digital intervention for reducing the consumption of sugar-sweetened beverages (SSBs) that comprises 6 internet-based cores metered out over time to deliver the program content, an integrated SMS text message strategy to engage users in reporting SSB behaviors, and an electronic cellular-enabled scale for in-home weighing. The secondary objective is to illustrate the key components and characteristics of iSIPsmarter that resulted from the HCD process. METHODS: The methods were guided by the Model for Internet Interventions and by best practices in HCD and instructional design processes (eg, rapid prototype development and think-aloud protocol). The 3-phased (ie, contextual, prototype testing, end user testing phases) process followed in this study included a series of 13 semistructured one-on-one interviews with 7 advisory team participants from the targeted Appalachian user group. The interviews were content coded by 2 researchers and then deductively coded to the suggested areas of digital behavioral health interventions. RESULTS: The participants provided rich perspectives pertaining to iSIPsmarter's appearance, behavioral prescriptions, burdens, content, delivery, message, participation, and assessment. These inputs included requests for built-in flexibility to account for varying internet and SMS text message accessibility among users; ideas to resolve the issues and problems encountered when using the prototypes, including those related to navigation and comprehension of content; ideas to enhance personalized feedback to support motivation and goal setting for SSB consumption and weight; and feedback to refine the development of realistic and relatable vignettes. The participants were able to interact with multiple prototype drafts, allowing researchers to capture and incorporate feedback related to the iSIPsmarter dashboard, daily SSB and weight diaries, action planning, core content, interactions, and vignettes. CONCLUSIONS: Using scientific models and established processes is critical for building robust and efficacious interventions. By applying an existing model and HCD and instructional design processes, we were able to identify assumptions and address the key areas of the iSIPsmarter intervention that were hypothesized to support users' engagement and promote behavior change. As evidenced by the rich feedback received from the advisory team members and the resulting iSIPsmarter product, the HCD methodology was instrumental in the development process. Although the final iSIPsmarter content is specific to improving SSB consumption behaviors among adults in rural areas, the intent is that this HCD process will have wide applications in the development of digital behavioral health interventions across multiple geographic and behavioral contexts.

Feasibility of an Adapted Community-Based Lifestyle Intervention to Prevent Cancer in the Rural South: Healthy Living Partnerships to Prevent Cancer (HELP PC).

Obesity increases risk of cancer onset and promulgates cancer mortality. Healthy Living Partnerships to Prevent Cancer (HELP PC) is an adapted intensive lifestyle intervention that is facilitated by community health workers (CHWs). The primary objective of this one-arm pilot study was to test the feasibility of evaluating HELP PC in a rural community by assessing participant recruitment, retention, and adherence to the intervention. The secondary objectives of this study were to evaluate the feasibility of collecting study measures and analyze intervention effects to inform future studies. Adults of all races and a BMI ≥ 25 kg/m2 who resided in the Dan River Region of Southern Virginia were recruited. Participants received 24 weekly (hour-long) group sessions led by a CHW and two consultations with a registered dietitian (RDN). Seventy-five percent (21/28) of eligible subjects were enrolled (n = 21; mean age = 46 years; 67% African American; 90% female; median BMI = 36.1), and recruitment was completed in 2 weeks. Fifty-two percent (11/21) of participants attended >70% of group sessions (adherence) and 98% of RDN consultations were attended. Eighty-six percent (n=18) of participants completed the 6-month follow-up visit (retention), and showed improvements in moderate physical activity, health literacy, general health, energy, and emotional well-being. Feasibility of HELP PC was established through efficient participant recruitment, modest attendance, high retention, and execution of data collection procedures. Importantly, findings can be applied to advance cancer prevention lifestyle interventions in rural communities.

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.

SRDA: Mobile Sensing based Fluid Overload Detection for End Stage Kidney Disease Patients using Sensor Relation Dual Autoencoder.

Chronic kidney disease (CKD) is a life-threatening and prevalent disease. CKD patients, especially endstage kidney disease (ESKD) patients on hemodialysis, suffer from kidney failures and are unable to remove excessive fluid, causing fluid overload and multiple morbidities including death. Current solutions for fluid overtake monitoring such as ultrasonography and biomarkers assessment are cumbersome, discontinuous, and can only be performed in the clinic. In this paper, we propose SRDA, a latent graph learning powered fluid overload detection system based on Sensor Relation Dual Autoencoder to detect excessive fluid consumption of EKSD patients based on passively collected bio-behavioral data from smartwatch sensors. Experiments using real-world mobile sensing data indicate that SRDA outperforms the state-of-the-art baselines in both F1 score and recall, and demonstrate the potential of ubiquitous sensing for ESKD fluid intake management.

Exploring differences in adolescent BMI and obesity-related behaviors by urban, suburban, and rural status.

Data from the nationally representative 2014 Family Life, Activity, Sun, Health, and Eating (FLASHE) study was examined to identify differences in adolescent Body Mass Index (BMI) and obesity-related behaviors by rurality status (i.e., urban, suburban, rural) while accounting for relevant demographics (i.e., sex, race/ethnicity, household income). This secondary, cross-sectional analysis included 1,353 adolescents. Analyses included descriptive statistics, one-way analysis of variance, Chi-squared tests, and multiple linear regression models (reported significance level p < 0.05). Rurality was not associated with BMI when controlling for demographics. However, relative to rural adolescents, suburban adolescents had significantly higher junk food, sugar-sweetened beverages (SSB), sugary food (all ß=+0.2, p ≤ 0.001), and fruit/vegetable intake (ß=+0.1, p ≤ 0.05). Compared to Non-Hispanic White adolescents, Non-Hispanic Black adolescents had significantly higher BMI (ß=+4.4, p ≤ 0.05), total sedentary time (ß=+4.1, p ≤ 0.001), junk food, SSB, and sugary food intake (all ß=+0.2, p ≤ 0.05). Relative to their lower-income household counterparts, adolescents from higher-income households had significantly lower BMI (ß = -9.7, p ≤ 0.001), junk food (ß = -0.2, p ≤ 0.05), and SSB intake (ß = -0.5, p ≤ 0.001). Contrary to literature, rurality was not a significant predictor of adolescent BMI. While suburban status was significantly associated with several diet-related risk factors, it was not in the direction anticipated. Being non-Hispanic Black and from a low-income household had the greatest influence on adolescent BMI. Findings highlight the importance of using a three-category classification for rurality.

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.

Beverage behaviors and correlates among Head Start preschooler-parent dyads.

OBJECTIVES: To describe beverage behaviors among preschooler-parent dyads and explore correlates with preschooler's beverage behaviors. METHODS: This exploratory, cross-sectional study includes a convenience sample of 202 parents of preschoolers surveyed from four Head Start programs in Virginia and Ohio. Measurements included parent-child beverage behaviors, parent beverage perceptions, parent beverage rules, home beverage availability, and demographics. Analyses included descriptive statistics, correlations, Kruskal-Wallis test, and Quade's non-parametric ANCOVA tests. RESULTS: Mean sugar-sweetened beverage (SSB; i.e., regular soda, sweetened fruit drinks, sports/energy drinks, and coffee/tea with sugar) intake was 1.3 (SD = 1.4) and 2.3 (SD = 2.0) times/day for preschoolers and parents, respectively. When considering all sugary drink sources [i.e., summing SSB with flavored milk and 100% fruit juice (FJ)], the mean frequency increased to 3.2 (SD = 2.1) and 3.6 (SD = 2.4) times/day, respectively, for preschoolers and parents. A significant positive correlation was observed between preschooler-parent dyads for SSB (r = 0.406, p < 0.001) and for all sugary drinks (r = 0.572, p < 0.001). Parents who were younger, single, less educated, and with lower income had preschoolers with significantly higher SSB and all sugary drink intake (all p < 0.05). Significant correlates with preschoolers' beverage behaviors also included parent perceived behavioral control (SSB: p = 0.003, 100% FJ: p = 0.008, water: p < 0.0001), parenting practices (SSB: p = 0.022), and home availability (SSB: p = 0.011, 100% FJ: p < 0.001, water: p < 0.001). CONCLUSIONS: This study highlights excessive SSB and all sugary drink consumption among Head Start preschooler-parent dyads. Also, intervention targets to improve preschooler's beverage behaviors are identified, including efforts to improve parent's beverage behaviors, perceived behavioral control, parenting practices, and the home environment.