Confirmed Case of Longstanding Respiratory Francisella tularensis holarctica Infection: Nebraska, 2022.

A male patient with distant history of extensive rabbit contact and pulmonary nodules for 6 years developed empyema. Francisella tularensis holarctica was isolated from thoracentesis fluid. Retrospective immunohistochemical examination of a pulmonary nodule, biopsied 3 years prior, was immunoreactive for F. tularensis. These findings suggest the potential for chronic tularemia.

Campylobacteriosis Outbreak Linked to Municipal Water, Nebraska, USA, 20211.

In September 2021, eight campylobacteriosis cases were identified in a town in Nebraska, USA. We assessed potential exposures for a case-control analysis. We conducted whole-genome sequencing on Campylobacter isolates from patients' stool specimens. We collected large-volume dead-end ultrafiltration water samples for Campylobacter and microbial source tracking testing at the Centers for Disease Control and Prevention. We identified 64 cases in 2 waves of illnesses. Untreated municipal tap water consumption was strongly associated with illness (wave 1 odds ratio 15.36; wave 2 odds ratio 16.11). Whole-genome sequencing of 12 isolates identified 2 distinct Campylobacter jejuni subtypes (1 subtype/wave). The town began water chlorination, after which water testing detected coliforms. One dead-end ultrafiltration sample yielded nonculturable Campylobacter and avian-specific fecal rRNA genomic material. Our investigation implicated contaminated, untreated, municipal water as the source. Results of microbial source tracking supported mitigation with continued water chlorination. No further campylobacteriosis cases attributable to water were reported.

Evidence of Lineage 1 and 3 West Nile Virus in Person with Neuroinvasive Disease, Nebraska, USA, 2023.

West Nile virus (WNV) is the most common cause of human arboviral disease in the contiguous United States, where only lineage 1 (L1) WNV had been found. In 2023, an immunocompetent patient was hospitalized in Nebraska with West Nile neuroinvasive disease and multisystem organ failure. Testing at the Centers for Disease Control and Prevention indicated an unusually high viral load and acute antibody response. Upon sequencing of serum and cerebrospinal fluid, we detected lineage 3 (L3) and L1 WNV genomes. L3 WNV had previously only been found in Central Europe in mosquitoes. The identification of L3 WNV in the United States and the observed clinical and laboratory features raise questions about the potential effect of L3 WNV on the transmission dynamics and pathogenicity of WNV infections. Determining the distribution and prevalence of L3 WNV in the United States and any public health and clinical implications is critical.

Reach, Adoption, Implementation, and Sustainability of the Mobile Health for Migrant Health (mHealth-4-Mhealth) Program: Nebraska, 2022‒2023.

Migrant families face challenges to health and well-being from COVID-19. We deployed Mobile Health for Migrant Health (mHealth-4-Mhealth) to migrant families, a household-based program with mHealth-assisted at-home testing and linkages to community resources. We assessed the reach, adoption, and implementation of the program among rural migrant families enrolled in the Title IC Nebraska Migrant Education Program from February 2022 to July 2023. We describe successful adoption and longitudinal use of mHealth screening tools for severe acute respiratory syndrome coronavirus 2 infection risk and social determinants of health. (Am J Public Health. 2024;114(11):1212-1216. https://doi.org/10.2105/AJPH.2024.307746).

Notes from the Field: Enhanced Surveillance for Raccoon Rabies Virus Variant and Vaccination of Wildlife for Management - Omaha, Nebraska, October 2023-July 2024.

On September 28, 2023, a kitten aged approximately 6 weeks found in Omaha, Nebraska, had test results positive for rabies at the Nebraska Veterinary Diagnostic Center (NVDC) after dying with neurologic signs and having bitten and scratched its caretakers. Preliminary investigation identified 10 exposed persons for whom postexposure prophylaxis (PEP)† was recommended. Subsequent variant-typing by NVDC yielded a presumptive positive result for the Eastern raccoon rabies virus variant (RRVV), which CDC confirmed on October 6.

Gut Microbial Composition of Cyprinella lutrensis (Red Shiner) and Notropis stramineus (Sand Shiner): Insights from Wild Fish Populations.

The gut microbiome is a highly intricate ecosystem that exerts a pivotal influence on the host's physiology. Characterizing fish microbiomes is critical to understanding fish physiology and health, but little is known about the ecology and colonization dynamics of microorganisms inhabiting fish species. In this study, we investigated the bacterial communities of two small-bodied fish species, Cyprinella lutrensis (red shiner) and Notropis stramineus (sand shiner), two fish species where gut microbiomes have not been investigated previously and surrounding waters, collected from rivers in Nebraska, USA. Our study focused on evaluating microbial diversity in small-bodied fish and identifying autochthonous microbes present within these species irrespective of location to better understand bacterial community composition and possible roles of such bacterial species. Our results revealed that both red shiner and sand shiner exhibited gut bacterial communities dominated by typical bacterial phyla found in freshwater fish. The phylum Bacteroidota was minimally abundant in both species and significantly lower in relative abundance compared to the surrounding water microbial community. Furthermore, we found that the gut microbiomes of red shiner and sand shiner differed from the microbial community in the surrounding water, suggesting that these fish species contain host-associated bacterial species that may provide benefits to the host such as nutrient digestion and colonization resistance of environmental pathogens. The fish gut bacterial communities were sensitive to environmental conditions such as turbidity, dissolved oxygen, temperature, and total nitrogen. Our findings also show bacterial community differences between fish species; although they shared notable similarities in bacterial taxa at phyla level composition, ASV level analysis of bacterial taxa displayed compositional differences. These findings contribute to a better understanding of the gut bacterial composition of wild, freshwater, small-bodied fish and highlight the influence of intrinsic (host) and environmental factors on shaping the bacterial composition.

Differences in Role and Support Between Volunteer and Paid Community Health Workers in the State of Nebraska.

Despite the growing importance of community health workers (CHWs) in public health, it has been difficult to characterize the roles and scope of services for this workforce in part because of the variability in the employment status of CHWs, ranging from full-time, part-time, to volunteer. Based on analysis of survey data from a statewide assessment of the CHW workforce in Nebraska (n = 142) conducted between 2019 and 2020, the proportions of CHWs who worked full-time, part-time, or volunteer were respectively 64%, 12%, and 21%. Over three quarters (76.7%) of volunteer CHWs were primarily working with Hispanic communities, as compared to less than 30% among full-time and part-time CHWs. About 80% of volunteer CHWs received training before becoming a CHW, substantially higher than the corresponding proportions among full-time (46.2%) and part-time CHWs (52.9%). In terms of tasks performed, the proportion of volunteer CHWs who provided health screenings (70%) were much higher than full or part-time CHWs (41.8% and 11.8% respectively, p < 0.001); whereas the latter two groups were significantly more likely than volunteer CHWs to provide other tasks such as coordinating care, health coaching, social support, transportation, interpretation, data collection, advocacy, and cultural awareness. Volunteer CHWs may hold potential for serving non-Hispanic communities. Future development of the CHW workforce can benefit from understanding and leveraging the significant differences in roles and scope of services among CHWs with various employment statuses.

Community-engaged Systems for Population Health Improvement: A Novel Approach to Improve Diabetes Outcomes in Rural Communities.

BACKGROUND: Approaches to prevent and manage diabetes at a community population level are hindered because current strategies are not aligned with the structure and function of a community system. We describe a community-driven process based on local data and rapid prototyping as an alternative approach to create diabetes prevention and care management solutions appropriate for each community. We report on the process and provide baseline data for a 3-year case study initiative to improve diabetes outcomes in two rural Nebraska communities. METHODS: We developed an iterative design process based on the assumption that decentralized decision-making using local data feedback and monitoring will lead to the innovation of local sustainable solutions. Coalitions act as community innovation hubs and meet monthly to work through a facilitated design process. Six core diabetes measures will be tracked over the course of the project using the electronic health record from community clinics as a proxy for the entire community. RESULTS: Baseline data indicate two-thirds of the population in both communities are at risk for prediabetes based on age and body mass index. However, only a fraction (35% and 12%) of those at risk have been screened. This information led both coalitions to focus on improving screening rates in their communities. DISCUSSION: In order to move a complex system towards an optimal state (e.g., improved diabetes outcomes), stakeholders must have access to continuous feedback of accurate, pertinent information in order to make informed decisions. Conventional approaches of implementing evidence-based interventions do not facilitate this process.

Impact of the COVID-19 pandemic on pharmacists practicing in community pharmacies in the state of Nebraska.

BACKGROUND: The rapid increase in COVID-19 combined with uncertainty surrounding transmission and treatment protocols resulted in unprecedented burnout amongst health care workers. As other health care workers scrambled to support patients, community pharmacists quickly responded to the pandemic by extending their services. This constantly changing environment amongst other factors created a high degree of psychological burden associated with COVID-19 for pharmacists. Although studies have examined the psychological impact of the pandemic on frontline health care workers, pharmacists are rarely included in these studies. OBJECTIVE: To examine the impact of COVID-19 on work and personal well-being from the perspective of pharmacists practicing in community pharmacies in Nebraska. METHODS: A cross-sectional online survey collected data from pharmacists with an active Nebraska Pharmacist license (N=2763) from November 2022 to January 2023. The survey was a hybrid of researcher-developed items and the validated abbreviated Maslach Burnout Inventory (aMBI). The aMBI is a 9-item Likert-scale scored instrument, which captures three domains of burnout: Personal Accomplishment; Emotional Exhaustion; and Depersonalization. Data was analyzed using IBM SPSS Statistics version 27. RESULTS: The response rate to the survey was 12.3% (n=339). Mean age of the respondents was 44.8 years with an average of 18.7 years in practice. Most respondents (n = 113, 50.7%) practiced in a community pharmacy followed by hospital (n = 72, 32.3%). 55.8% of community pharmacists reported that they considered leaving their current employer. Chi-square analysis confirmed that community pharmacists are more burned out than noncommunity pharmacists. CONCLUSIONS: Pharmacists realized they had not been recognized for their contributions as frontline health care workers, which motivated them to consider leaving their employer and even the profession of pharmacy. This study found community pharmacists are burned out more than non-community pharmacists. Within community pharmacies, it was found that pharmacists practicing at corporate-owned community pharmacies had increased burnout compared to those practicing in independent community pharmacies.

Effect of Biomass Water Dynamics in Cosmic-Ray Neutron Sensor Observations: A Long-Term Analysis of Maize-Soybean Rotation in Nebraska.

Precise soil water content (SWC) measurement is crucial for effective water resource management. This study utilizes the Cosmic-Ray Neutron Sensor (CRNS) for area-averaged SWC measurements, emphasizing the need to consider all hydrogen sources, including time-variable plant biomass and water content. Near Mead, Nebraska, three field sites (CSP1, CSP2, and CSP3) growing a maize-soybean rotation were monitored for 5 (CSP1 and CSP2) and 13 (CSP3) years. Data collection included destructive biomass water equivalent (BWE) biweekly sampling, epithermal neutron counts, atmospheric meteorological variables, and point-scale SWC from a sparse time domain reflectometry (TDR) network (four locations and five depths). In 2023, dense gravimetric SWC surveys were collected eight (CSP1 and CSP2) and nine (CSP3) times over the growing season (April to October). The N0 parameter exhibited a linear relationship with BWE, suggesting that a straightforward vegetation correction factor may be suitable (fb). Results from the 2023 gravimetric surveys and long-term TDR data indicated a neutron count rate reduction of about 1% for every 1 kg m-2 (or mm of water) increase in BWE. This reduction factor aligns with existing shorter-term row crop studies but nearly doubles the value previously reported for forests. This long-term study contributes insights into the vegetation correction factor for CRNS, helping resolve a long-standing issue within the CRNS community.

Strengthening Linkages Between Health Care and Public Health: A Novel Framework for Public Health Action in Health Care Settings to Improve Cardiovascular Disease Risk.

The Chronic Disease Prevention and Control Program (CDPCP) at the Nebraska Department of Health and Human Services developed a novel public health framework and tools to translate public health knowledge, grant work, and terminology to a health care audience in order to inform clinical practice changes in the management of hyperlipidemia and hypertension. The CDPCP piloted the tools with 2 accountable care organizations that included 19 clinics and then funded 9 independent clinics. The project sought to empower clinics to design and implement interventions for reducing high blood pressure and high blood cholesterol focused on populations disproportionately at risk for those conditions utilizing electronic health records. A team comprising the CDPCP and evaluation specialists created a framework called CAAPIE (Capture, Assess, Action Plan, Implement, Evaluate) to provide a clinic-friendly approach to the public health-focused work. For the capture phase, baseline data were collected from clinics. To guide the assess, action plan, and evaluate phases, the team created a Scan & Plan Tool for clinics to assess practices and policies and then use results to develop an action plan. The assessment was repeated upon completion of the project to evaluate change. Interviews were conducted to assess the utility of these tools and capture information related to the implementation of the project. Clinicians reported the framework and tools provided a useful approach, aiding clinics in understanding public health terminology and intended outcomes of the project. Work resulted in the creation of new or enhanced clinical policies and procedures that led to modest improvements in the management of high blood pressure and high cholesterol. The CAAPIE framework is a novel approach for state health departments to utilize in translating public health grant work to health care professionals, promoting a working relationship between the spheres to achieve positive impacts on individual and population-based health care.

Outcome Evaluation of a Public Health Intervention on Cardiovascular Disease (CVD) Prevention Among Women Aged 40-64 with Low Incomes in Nebraska.

OBJECTIVES: To evaluate the effectiveness of the program interventions on cardiovascular disease in Nebraska women who are low income and have no health insurance. DESIGN: This evaluation used pre- and post-comparison approach. Paired t test and McNemar's test were used to examine the changes after the program interventions. PARTICIPANTS: Nebraska women aged 40 to 64 years, without health insurance, and with household incomes up to 225% Federal Poverty Level. SETTING AND INTERVENTION: A network of community-clinical linkages in which medical providers provided preventive screening services and risk reduction counseling in clinical settings and community health workers provided lifestyle interventions in community settings either over the phone or in person. MAIN OUTCOME MEASURE: The data included weight, blood pressure measures, self-blood pressure monitoring and management, total cholesterol, fasting glucose or A1C, smoking status, nutrition, and physical activities. RESULTS: Among 2649 participants, 82.2% were overweight, 50.3% had hypertension, 52.7% had high cholesterol, 20.7% had diabetes, 22.5% were current smokers, and 56.4% had more than 1 risk factor. A total of 1312 participants (57.3%) participated in at least 1 lifestyle intervention session, and among them, 65.8% completed at least 3 sessions. Paired t test and McNemar's test indicated significant improvement in hypertension control and self-management; a significant amount of weight loss with 24.1% losing at least 5 pounds; and an increase in healthy eating and physical activity. CONCLUSIONS: These participants benefited from the Nebraska program. Utilizing a statewide clinical network and participating in lifestyle interventions through local health departments, participants improved some chronic health conditions and decreased their risks of developing cardiovascular diseases.

Psychometrics of psychosocial behavior items under age 6 years: Evidence from Nebraska, USA.

Because healthy psychosocial development in the first years of life is critical to lifelong well-being, governmental, and nongovernmental organizations are increasingly interested in monitoring psychosocial behaviors among populations of children. In response, the World Health Organization is developing the Global Scales of Early Development Psychosocial Form (GSED PF) to facilitate population-level psychosocial monitoring. Once validated, the GSED PF will be an open-access, caregiver-reported measure of children's psychosocial behaviors that is appropriate for infants and young children. This study examines the psychometric validity evidence from 45 items under consideration for inclusion in the GSED PF. Using data from N = 836 Nebraskan (USA) children aged 180 days to 71 months, results indicate that scores from 44 of the 45 (98%) items exhibit positive evidence of validity and reliability. A bifactor model with one general factor and five specific factors best fit the data, exhibited strong reliability, and acceptable model fit. Criterion associations with known predictors of children's psychosocial behaviors were in the expected direction. These findings suggest that measurement of children's psychosocial behaviors may be feasible, at least in the United States. Data from more culturally and linguistically diverse settings is needed to assess these items for global monitoring.

Debido a que el desarrollo sicosocial en los primeros años de vida es crítico para el bienestar de toda la vida, las organizaciones gubernamentales y no gubernamentales están más y más interesadas en observar vigilantemente las conductas sicosociales en la población infantil. Como respuesta, la Organización Mundial de la Salud está desarrollando el Formulario Sicosocial de las Escalas Globales del Temprano Desarrollo (GSED PF) para facilitar la observación sicosocial alerta al nivel del grupo de población. Una vez que se haya convalidado, el GSED PF será una medida de acceso abierto, que reportará el cuidador, sobre las conductas sicosociales de los niños que son apropiadas para infantes y niños pequeñitos. Este estudio examina la evidencia de la validez sicométrica de 45 puntos bajo consideración para ser incluidos en el GSED PF. Usando datos de N = 836 niños de Nebraska (Estados Unidos), de edad entre 180 días y 71 meses, los resultados indican que los puntajes de 44 de los 45 (98%) puntos muestran evidencia positiva de validez y confiabilidad. Un modelo bifactorial con un factor general y cinco factores específicos, que mejor encaja con los datos, mostró una fuerte confiabilidad y un modelo aceptable que encaja. Las asociaciones de criterio con factores de predicción conocidos acerca de las conductas sicosociales de los niños se encontraban en la dirección esperada. Estos resultados sugieren que la medida de las conductas sicosociales de los niños pudiera ser posible, por lo menos en los Estados Unidos. Se necesitan datos de escenarios más diversos cultural y lingüísticamente para evaluar estos puntos para la estar alerta en la observación global.

Phylogeny and paleobiogeography of the enigmatic North American primate Ekgmowechashala illuminated by new fossils from Nebraska (USA) and Guangxi Zhuang Autonomous Region (China).

Ekgmowechashala is a poorly documented but very distinctive primate known only from the late early Oligocene (early Arikareean) of western North America. Because of its highly autapomorphous dentition and spatiotemporal isolation, the phylogenetic and biogeographic affinities of Ekgmowechashala have long been debated. Here, we describe the oldest known fossils of Ekgmowechashala from the Brown Siltstone Beds of the Brule Formation, White River Group of western Nebraska. We also describe a new ekgmowechashaline taxon from the Nadu Formation (late Eocene) in the Baise Basin of Guangxi Zhuang Autonomous Region in southern China. Phylogenetic analysis suggests that North American Ekgmowechashala and the new Chinese taxon are sister taxa that are nested within a radiation of southern Asian adapiforms that also includes Gatanthropus, Muangthanhinius, and Bugtilemur. The new Chinese ekgmowechashaline helps fill the considerable disparity in dental morphology between Ekgmowechashala and more primitive ekgmowechashalids known from southern Asia. Our study underscores the fundamental role of southern Asia as a refugium for multiple primate clades during the cooler and drier climatic regime that prevailed after the Eocene-Oligocene transition. The colonization of North America by Ekgmowechashala helps define the beginning of the Arikareean Land Mammal Age and corresponds to an example of the Lazarus effect, whereby a taxon (in this case, the order Primates) reappears suddenly in the fossil record after a lengthy hiatus.

Factors associated with delaying medical care: cross-sectional study of Nebraska adults.

BACKGROUND: Delayed medical care may result in adverse health outcomes and increased cost. Our purpose was to identify factors associated with delayed medical care in a primarily rural state. METHODS: Using a stratified random sample of 5,300 Nebraska households, we conducted a cross-sectional mailed survey with online response option (27 October 2020 to 8 March 2021) in English and Spanish. Multiple logistic regression models calculated adjusted odds ratios (aOR) and 95% confidence intervals. RESULTS: The overall response rate was 20.8% (n = 1,101). Approximately 37.8% of Nebraskans ever delayed healthcare (cost-related 29.7%, transportation-related 3.7%), with 22.7% delaying care in the past year (10.1% cost-related). Cost-related ever delay was associated with younger age [< 45 years aOR 6.17 (3.24-11.76); 45-64 years aOR 2.36 (1.29-4.32)], low- and middle-income [< $50,000 aOR 2.85 (1.32-6.11); $50,000-$74,999 aOR 3.06 (1.50-6.23)], and no health insurance [aOR 3.56 (1.21-10.49)]. Transportation delays were associated with being non-White [aOR 8.07 (1.54-42.20)], no bachelor's degree [≤ high school aOR 3.06 (1.02-9.18); some college aOR 4.16 (1.32-13.12)], and income < $50,000 [aOR 8.44 (2.18-32.63)]. Those who did not have a primary care provider were 80% less likely to have transportation delays [aOR 0.20 (0.05-0.80)]. CONCLUSIONS: Delayed care affects more than one-third of Nebraskans, primarily due to financial concerns, and impacting low- and middle-income families. Transportation-related delays are associated with more indicators of low socio-economic status. Policies targeting minorities and those with low- and middle-income, such as Medicaid expansion, would contribute to addressing disparities resulting from delayed care.

The news about rollover protective structures: Findings from an analysis of news from Iowa, Nebraska, Kansas, and Missouri.

INTRODUCTION: Rollover protective structures (ROPS) can prevent fatal tractor overturns, a leading cause of death among farmers. This content analysis aims to understand how this life-saving strategy appears in news about farm safety. METHODS: As part of a larger study of farm safety news coverage from four agricultural states, we conducted a content analysis of articles that mentioned ROPS. RESULTS: Few (10%) articles about farm safety explicitly mentioned ROPS. When ROPS were mentioned, they were described in terms of their potential to save lives or prevent injury. CONCLUSION: Despite proven success, ROPS-and programs to make ROPS more widely available to farmers-are all but absent from news coverage in key agricultural states. This represents a missed opportunity not only to motivate farmers to install ROPS, but also to demonstrate to policymakers the importance of establishing and maintaining funding to prevent the most frequent cause of death on farms. Farmers face barriers to installing life-saving equipment. Without an increase in ROPS utilization and improved access to prevention programs, farmers, especially low-income farmers, will remain at disproportionate risk for death and injury.

Information Sources and Attitudes Toward COVID-19 Vaccination at a Free Clinic in the State of Nebraska, USA.

The full impacts of the COVID-19 pandemic are yet to be determined. While highly effective vaccines are available to prevent and decrease the severity of COVID-19 infection, significant COVID-19 vaccine hesitancy remains. Understanding motivations, discouraging factors, opinions, and information sources regarding COVID-19 is essential to targeting vaccine hesitancy and improving vaccine uptake. A 25 question survey was administered to the patients of a free clinic in the Midwest to assess patient demographic data, opinions about and experience with COVID-19, the COVID-19 vaccines, and information sources. The main outcome of interest was if vaccination status influenced information sources and opinions regarding COVID-19. This study also analyzed motivating and discouraging factors for vaccination. The study had a total of 104 participants with 7 being excluded. There were a total of 97 survey responses included in this study, there were 79 vaccinated patients and 18 unvaccinated patients. This survey study found differences in information sources between vaccinated and unvaccinated groups. Opinions surrounding the COVID-19 vaccine, public health agencies, and perceived severity of COVID-19 also varied between vaccinated and unvaccinated groups. The differential information sources and opinions between vaccinated and unvaccinated groups emphasizes the importance of access to high-quality sources and educating the community to improve public health.

Qualitative Analysis of Colorectal Cancer Screening for African American and Hispanic Populations in Nebraska: an Application of the PRECEDE Framework.

Nationally and in Nebraska, African Americans (AA) and Hispanics have lower colorectal cancer (CRC) screening rates compared to non-Hispanic Whites. We aimed to obtain perspectives from AA and Hispanic cancer survivors and caregivers in Nebraska about CRC screening to improve outreach efforts. Data from four virtual focus groups (AA female, AA male, Hispanic rural, and Hispanic urban) conducted between April-August 2021 were analyzed using a directed content approach based on the Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model. Most of the 19 participants were female (84%) and survivors (58%). Across groups, awareness of colonoscopy was high, but awareness of fecal testing needed to be higher, with confusion about different types of fecal tests. Predisposing factors were trust in the health system; awareness of CRC screening; machismo; fear of cancer; embarrassment with screening methods; and negative perceptions of CRC screening. Enabling factors included provider recommendations, healthcare access, and insurance. Reinforcing factors included prioritizing personal health and having a support system. Suggestions to improve screening included increasing healthcare access (free or low-cost care), increasing provider diversity, health education using various methods and media, and enhancing grassroots health promotion efforts. Lack of awareness, accessibility issues, attitudes and perceptions of CRC and CRC screening, trust, and cultural and linguistic concerns are major issues that need to be addressed to reduce CRC screening disparities among AA and Hispanic adults.

Qualitative Analysis of Colorectal Cancer Screening in Rural Nebraska.

Compared to urban residents, rural populations are less likely to engage in colorectal cancer (CRC) screening. As part of a statewide cancer needs assessment, we aimed to elicit rural perspectives about CRC screening and resources. We conducted three focus groups with rural Nebraska cancer survivors and caregivers (N = 20) in Spring 2021 using a collective case study design. Participant awareness of and knowledge about CRC screening methods varied across focus groups; overall, 95% of participants had heard of colonoscopy. Participants were less familiar with fecal tests and had confusion about them. Colonoscopy was associated with negative perceptions regarding the time, cost, and discomfort of the preparation and procedure, but some providers did not discuss alternative methods unless the patient resisted colonoscopy. Healthcare providers played a key role educating rural communities about CRC screening recommendations (age, risk) and testing options and being persistent in those recommendations. CRC awareness campaigns should include a variety of communication channels (TV, radio, billboards, health fairs, churches, healthcare settings). Promotion of CRC screening should include education about screening age guidelines, alternative test types, and informed decision-making between provider and patient regarding preferred screening methods based on the pros and cons of each test type. Individuals with a family history of colon issues (Crohn's disease, CRC) are considered high risk and need to be aware that screening should be discussed at earlier ages.