Community and Organizational Readiness to Adopt a Physical Activity Intervention in Micropolitan Settings.

BACKGROUND: Assessing community and organizational readiness is key to successfully implementing programs. The purpose of this study was to assess the baseline readiness of micropolitan communities to adopt an evidence-based physical activity (PA) intervention by exploring three dimensions: (1) attitudes and current efforts toward prevention, (2) community and organizational climate that facilitates (or impedes) change, and (3) capacity to implement change. METHOD: Data were collected from community leaders in 14 communities through an online survey in June 2021 (n = 149). Data were analyzed in aggregate using descriptive statistics for multiple-choice responses and content analysis for open ended responses. One-way repeated analyses of variance were used to compare mean score differences. RESULTS: In reference to their attitudes prior to the pandemic, respondents said that addressing PA was "somewhat a priority" in their professional positions (M = 2.01, SD = 0.94), their organizations (M = 2.08, SD = 0.91), and their communities (M = 2.28, SD = 0.88). Current PA efforts included statewide initiatives, community sponsored events/clubs, and youth sports leagues. The community climate included both PA facilitators (mainly outdoor PA resources) and barriers (cost, lack of social services, and an unsupportive PA environment). Individual-level capacity (M = 2.94; SD = 1.21) to adopt a PA program was regarded lower than the community's capacity (M = 3.95; SD = 0.82), and perceptions of capacity at the community level improved even more if technical assistance (M = 3.96; SD = 0.84) or financial support (M = 4.12; SD = 0.80) were provided. CONCLUSION: Readiness varied by dimension, suggesting the need for tailored implementation supports including technical assistance and financial support.

Effect of rurality and travel distance on contralateral prophylactic mastectomy for unilateral breast cancer.

PURPOSE: Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM. METHODS: Women diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options. RESULTS: Both rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30). CONCLUSION: The impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.

Measuring and addressing health equity: an assessment of cancer center designation requirements.

PURPOSE: By requiring specific measures, cancer endorsements (e.g., accreditations, designations, certifications) promote high-quality cancer care. While 'quality' is the defining feature, less is known about how these endorsements consider equity. Given the inequities in access to high-quality cancer care, we assessed the extent to which equity structures, processes, and outcomes were required for cancer center endorsements. METHODS: We performed a content analysis of medical oncology, radiation oncology, surgical oncology, and research hospital endorsements from the American Society of Clinical Oncology (ASCO), American Society of Radiation Oncology (ASTRO), American College of Surgeons Commission on Cancer (CoC), and the National Cancer Institute (NCI), respectively. We analyzed requirements for equity-focused content and compared how each endorsing body included equity as a requirement along three axes: structures, processes, and outcomes. RESULTS: ASCO guidelines centered on processes assessing financial, health literacy, and psychosocial barriers to care. ASTRO guidelines related to language needs and processes to address financial barriers. CoC equity-related guidelines focused on processes addressing financial and psychosocial concerns of survivors, and hospital-identified barriers to care. NCI guidelines considered equity related to cancer disparities research, inclusion of diverse groups in outreach and clinical trials, and diversification of investigators. None of the guidelines explicitly required measures of equitable care delivery or outcomes beyond clinical trial enrollment. CONCLUSION: Overall, equity requirements were limited. Leveraging the influence and infrastructure of cancer quality endorsements could enhance progress toward achieving cancer care equity. We recommend that endorsing organizations 1) require cancer centers to implement processes for measuring and tracking health equity outcomes and 2) engage diverse community stakeholders to develop strategies for addressing discrimination.

Prioritizing rural populations in state comprehensive cancer control plans: a qualitative assessment.

PURPOSE: The Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP) requires that states develop comprehensive cancer control (CCC) plans and recommends that disparities related to rural residence are addressed in these plans. The objective of this study was to explore rural partner engagement and describe effective strategies for incorporating a rural focus in CCC plans. METHODS: States were selected for inclusion using stratified sampling based on state rurality and region. State cancer control leaders were interviewed about facilitators and barriers to engaging rural partners and strategies for prioritizing rural populations. Content analysis was conducted to identify themes across states. RESULTS: Interviews (n = 30) revealed themes in three domains related to rural inclusion in CCC plans. The first domain (barriers) included (1) designing CCC plans to be broad, (2) defining "rural populations," and (3) geographic distance. The second domain (successful strategies) included (1) collaborating with rural healthcare systems, (2) recruiting rural constituents, (3) leveraging rural community-academic partnerships, and (4) working jointly with Native nations. The third domain (strategies for future plan development) included (1) building relationships with rural communities, (2) engaging rural constituents in planning, (3) developing a better understanding of rural needs, and (4) considering resources for addressing rural disparities. CONCLUSION: Significant relationship building with rural communities, resource provision, and successful strategies used by others may improve inclusion of rural needs in state comprehensive cancer control plans and ultimately help plan developers directly address rural cancer health disparities.

Health Care Provider Knowledge and Attitudes Regarding Adult Pneumococcal Conjugate Vaccine Recommendations - United States, September 28-October 10, 2022.

Despite the availability of effective vaccines against pneumococcal disease, pneumococcus is a common bacterial cause of pneumonia, causing approximately 100,000 hospitalizations among U.S. adults per year. In addition, approximately 30,000 invasive pneumococcal disease (IPD) cases and 3,000 IPD deaths occur among U.S. adults each year. Previous health care provider surveys identified gaps in provider knowledge about and understanding of the adult pneumococcal vaccine recommendations, and pneumococcal vaccine coverage remains suboptimal. To assess the feasibility and acceptability domains of the Advisory Committee on Immunization Practices (ACIP) Evidence to Recommendations (EtR) framework, a health care provider knowledge and attitudes survey was conducted during September 28-October 10, 2022, by the Healthcare and Public Perceptions of Immunizations Survey Collaborative before the October 2022 ACIP meeting. Among 751 provider respondents, two thirds agreed or strongly agreed with the policy option under consideration to expand the recommendations for the new 20-valent pneumococcal conjugate vaccine (PCV20) to adults who had only received the previously recommended 13-valent pneumococcal conjugate vaccine (PCV13). Gaps in providers' knowledge and perceived challenges to implementing recommendations were identified and were included in ACIP's EtR framework discussions in late October 2022 when ACIP updated the recommendations for PCV20 use in adults. Currently, use of PCV20 is recommended for certain adults who have previously received PCV13, in addition to those who have never received a pneumococcal conjugate vaccine. The survey findings indicate a need to increase provider awareness and implementation of pneumococcal vaccination recommendations and to provide tools to assist with patient-specific vaccination guidance. Resources available to address the challenges to implementing pneumococcal vaccination recommendations include the PneumoRecs VaxAdvisor mobile app and other CDC-developed tools, including summary documents and overviews of vaccination schedules and CDC's strategic framework to increase confidence in vaccines and reduce vaccine-preventable diseases, Vaccinate with Confidence.

Perceptions of the Right to Food Among Adults Aged 60 Years and Older.

This study explores perceptions of the right to food and issues around food assistance and access among older adults. We conducted 20 semi-structured interviews with adults aged 60+ in Iowa, half of whom were food insecure. Most respondents expressed the right to food concerns freedom of choice rather than physical and financial access. The respondents said poor food access was due to improper choices or not accessing food assistance. While respondents believed food insecurity was morally wrong, they also believed current food assistance services are sufficient. These results have important implications for understanding how older adults think about food access.

How cancer programs identify and address the financial burdens of rural cancer patients.

PURPOSE: Financial toxicity is associated with negative patient outcomes, and rural populations are disproportionately affected by the high costs of cancer care compared to urban populations. Our objective was to (1) understand cancer programs' perceptions of rural-urban differences in cancer patients' experiences of financial hardship, (2) evaluate the resources available to cancer patients across the rural-urban continuum, and (3) determine how rural and urban health care teams assess and address financial distress in cancer patients. METHODS: Seven research teams within the Cancer Prevention and Research Control Network conducted semi-structured interviews with cancer program staff who have a role in connecting cancer patients with financial assistance services in both rural and urban counties. Interviews were audio-recorded and transcribed. We identified themes using descriptive content and thematic analysis. RESULTS: We interviewed 35 staffs across 29 cancer care programs in seven states, with roughly half of respondents from programs in rural counties. Participants identified differences in rural and urban patients' experiences of financial hardship related to distance required to travel for treatment, underinsurance, and low socioeconomic status. Insufficient staffing was an identified barrier to addressing rural and urban patients' financial concerns. CONCLUSIONS: Improved financial navigation services could mitigate the effects of financial toxicity experienced by cancer patients, particularly rural patients, throughout treatment and survivorship. Future research is needed to improve how cancer programs assess financial hardship in patients and to expand financial navigation services to better serve rural cancer patients.

Disparities in dialysis modality decision-making using a social-ecological lens: a qualitative approach.

BACKGROUND: Patients with end-stage kidney disease (ESKD) may choose to undergo dialysis in-center or at home, but uptake of home dialysis in the US has been minimal despite its benefits over in-center dialysis. Factors that may have led patients to select home dialysis over in-center dialysis are poorly understood in the literature, and interventions to improve selection of home dialysis have focused on patient knowledge and shared decision-making processes between patients and providers. The purpose of this study was to explore micro- and macro-level factors surrounding dialysis modality decision-making among patients undergoing in-center and home dialysis, and explore what leads patients to select home dialysis over in-center dialysis. METHODS: Semi-structured qualitative interviews were conducted in a dialysis clinic at a large Midwestern research hospital, from September 2019 to December 2020. Participants were 18 years or older, undergoing dialysis for ESKD, and had the cognitive ability to provide consent. Surveys assessing demographic and clinical information were administered to participants following their interviews. RESULTS: Forty patients completed interviews and surveys (20 [50%] in-center dialysis, 17 [43%] female, mean [SD] age, 59 [15.99] years). Qualitative findings suggested that healthcare access and engagement before entering nephrology care, after entering nephrology care, and following dialysis initiation influenced patients' awareness regarding their kidney disease status, progression toward ESKD, and dialysis options. Potential modifiers of these outcomes include race, ethnicity, and language barriers. Most participants adopted a passive-approach during decision-making. Finally, fatigue, concerns regarding one's dialyzing schedule, and problems with fistula/catheter access sites contributed to overall satisfaction with one's dialysis modality. CONCLUSIONS: Findings point to broader factors affecting dialysis selection, including healthcare access and racial/ethnic inequities. Providing dialysis information before entering nephrology and after dialysis initiation may improve patient agency in decision-making. Additional resources should be prioritized for patients of underrepresented backgrounds. Dialysis decision-making may be appropriately modeled under the social-ecological framework to inform future interventions.

The Use of Medical Claims Data for Identifying Missed Opportunities for HPV Immunization Among Privately Insured Adolescents in the State of Iowa.

BACKGROUND: Rates of adolescent human papillomavirus (HPV) vaccination remain low, despite decades of safety and effectiveness data. We sought to quantify the extent of missed opportunities (MOs) for HPV vaccination among adolescents ages 11 to 13 in Iowa and compare the number of these MOs by gender and rurality. METHODS: Medical claims data from a midwestern insurance provider were used to calculate total numbers of MOs for HPV vaccination for adolescents with continuous health insurance enrollment between ages 11 and 13 (n = 14,505). We divided MOs into several categories: total, among non-initiators, occurring before initiation, occurring after the first dose, and occurring between first and last dose. Finally, we used t-tests to perform subgroup comparisons (urban vs. rural; male vs. female). RESULTS: Over half of adolescents failed to initiate vaccination by age 13. The majority of MOs occurred prior to initiation. Urban adolescents had more MOs than rural counterparts and males tended to have more MOs than females. Females experienced significantly fewer overall MOs than males 5.98 (SD = 5.49) compared to 6.18 (SD = 6.04) for males. Additionally, among non-initiators, urban females had significantly more MOs overall (M = 7.13; SD = 6.41) compared to rural females (M = 6.58; SD = 5.51). CONCLUSIONS: Results highlight the extent of MOs that occur at the critical time period between ages 11 and 13. A lack of opportunity was not the barrier to HPV vaccination, particularly among both males and urban adolescents. It will be critical for providers to use known strategies to reduce MOs and utilize all adolescent visits to ensure vaccination is completed by age 13.

Challenges to Adolescent HPV Vaccination and Implementation of Evidence-Based Interventions to Promote Vaccine Uptake During the COVID-19 Pandemic: "HPV Is Probably Not at the Top of Our List".

INTRODUCTION: The COVID-19 pandemic has prevented many adolescents from receiving their vaccines, including the human papillomavirus (HPV) vaccine, on time. However, little is known about the impact of the pandemic on implementation of clinic-level evidence-based interventions (EBIs) that help to improve HPV vaccine uptake. In this qualitative study, we explored the pandemic's impact on EBI implementation and HPV vaccine delivery. METHODS: During August-November 2020, we interviewed clinic managers in a rural, midwestern state about their experiences implementing EBIs for HPV vaccination during the COVID-19 pandemic. We used a multipronged sampling approach with both stratified and purposive sampling to recruit participants from Vaccines for Children clinics. We then conducted a thematic analysis of transcripts. RESULTS: In interviews (N = 18), 2 primary themes emerged: decreased opportunities for HPV vaccination and disruption to HPV-related implementation work. Most participants reported decreases in opportunities to vaccinate caused by structural changes in how they delivered care (eg, switched to telehealth visits) and patient fear of exposure to COVID-19. Disruptions to EBI implementation were primarily due to logistical challenges (eg, decreases in staffing) and shifting priorities. CONCLUSION: During the pandemic, clinics struggled to provide routine care, and as a result, many adolescents missed HPV vaccinations. To ensure these adolescents do not fall behind on this vaccine series, providers and researchers will need to recommit to EBI implementation and use existing strategies to promote vaccination. In the long term, improvements are needed to make EBI implementation more resilient to ensure that progress does not come to a halt in future pandemic events.

What Do Parents Think About School Meals? An Exploratory Study of Rural Middle School Parents' Perceptions.

Interventions targeting school meals have been used to combat obesity in rural youth. Parents play a powerful role in childhood nutrition; however, we know little about parents' perceptions of school meal programs. This study aimed to understand parents' perceptions of school meal programs. Surveys were administered to middle school parents (n = 576) at six schools in a rural state. We conducted univariate and multivariate analyses to measure parents' overall perceptions of the school meals program and to identify differences in perceptions by their children's participation in the Free and Reduced Price School Meals (F&RM) program. Parents had largely negative views of school meals but agreed that they met students' needs. Results of the multivariate analysis revealed differences in perceptions by participation in F&RM including the relative importance of meal components. Including parents in meal-related experiences and decision making could improve their perceptions and increase children's participation in school lunch programs.

Middle School Students' Perceptions of the Lunchroom: Implications for Future Interventions.

The National School Lunch Program provides nutritious and inexpensive lunches, but low participation and food waste are challenges in many schools. Interventions aim to improve participation in the program, but little is known about how students' perceptions affect their participation. This study explored how middle school students in a rural state perceive school food service staff, food served, and lunchroom atmosphere. An online survey was administered to middle school students at six schools participating in a larger lunchroom intervention. Mean perception scores were calculated for all measures. Multilevel logistic regression was used to examine the relationship between perceptions and consumption. Overall perceptions of staff, food, and atmosphere were positive, and students classified as school lunch eaters had more positive perceptions in all three areas than noneaters. Interventions to increase participation in school lunch programs and promote consumption of healthy food items should address multiple factors that contribute to school lunch participation.

Acceptability of Adolescent COVID-19 Vaccination Among Adolescents and Parents of Adolescents - United States, April 15-23, 2021.

On May 10, 2021, the Food and Drug Administration (FDA) expanded its Emergency Use Authorization for the Pfizer-BioNTech COVID-19 vaccine to include adolescents aged 12-15 years; this authorization was followed by interim recommendations from the Advisory Committee on Immunization Practices (ACIP) for the vaccine among this age group (1). Using data from nonprobability-based Internet panel surveys administered by the Healthcare and Public Perceptions of Immunizations (HaPPI) Survey Collaborative, the acceptability of adolescent COVID-19 vaccination and self-reported factors increasing vaccination intent were assessed among independently recruited samples of 985 adolescents aged 13-17 years and 1,022 parents and guardians (parents) of adolescents aged 12-17 years during April 15-April 23, 2021, prior to vaccine authorization for this age group. Approximately one quarter (27.6%) of parents whose adolescents were already vaccine-eligible (i.e., aged 16-17 years) reported their adolescent had received ≥1 COVID-19 vaccine dose, similar to the proportion reported by vaccine-eligible adolescents aged 16-17 years (26.1%). However, vaccine receipt reported by parents of adolescents differed across demographic groups; parents identifying as female or Hispanic, or who had an education lower than a bachelor's degree reported the lowest adolescent COVID-19 vaccination receipt. Among parents of unvaccinated adolescents aged 12-17 years, 55.5% reported they would "definitely" or "probably" have their adolescent receive a COVID-19 vaccination. Among unvaccinated adolescents aged 13-17 years, 51.7% reported they would "definitely" or "probably" receive a COVID-19 vaccination. Obtaining more information about adolescent COVID-19 vaccine safety and efficacy, as well as school COVID-19 vaccination requirements, were the most commonly reported factors that would increase vaccination intentions among both parents and adolescents. Federal, state, and local health officials and primary care professionals were the most trusted sources of COVID-19 vaccine information among both groups. Efforts focusing on clearly communicating to the public the benefits and safety of COVID-19 vaccination for adolescents, particularly by health care professionals, could help increase confidence in adolescent COVID-19 vaccine and vaccination coverage.

Relationships between health literacy, having a cancer care coordinator, and long-term health-related quality of life among cancer survivors.

PURPOSE: Care coordination is a strategy to reduce healthcare navigation challenges for cancer patients. The objectives of this study were to assess the association between having a cancer care coordinator (CCC) and long-term health-related quality of life (HRQoL), and to evaluate whether this association differed by level of health literacy. METHODS: A population-based sample of survivors diagnosed with breast, prostate, or colorectal cancer in 2015 from the Iowa Cancer Registry participated in an online survey conducted in 2017-2018 (N = 368). Chi-squared tests and logistic regression were used to model the association between patient characteristics and having a cancer care coordinator. Linear regression was used to model the association between patient perception of having a cancer care coordinator and post-treatment physical or mental HRQoL by differing levels of health literacy while controlling for sociodemographic and clinical factors. RESULTS: Most survivors (81%) reported having one healthcare professional who coordinated their cancer care. Overall, patient perception of having a coordinator was not significantly associated with physical HRQoL (p = 0.118). However, participants with low health literacy (21%) who had a coordinator had significantly higher physical HRQoL scores compared to those who did not (adjusted mean difference 5.2, p = 0.010), while not so for medium (29%) or high (51%) health literacy (p = 0.227, and p = 0.850, respectively; test for interaction p = 0.001). Mental HRQoL was not associated with having a coordinator in our analyses. CONCLUSION: Findings suggest that care coordinators improved post-treatment physical HRQoL, particularly for participants with low health literacy. Care coordinators may be beneficial to the most vulnerable patients struggling to navigate the complex healthcare system during cancer treatment. Future research should focus on the mechanisms by which care coordination may affect post-treatment HRQoL.

Implementation and outcome evaluation of a team nutrition intervention: increasing knowledge, attitudes, and preferences.

Low-income, rural children are at a greater risk for poor dietary intake. Schools offer a venue to deliver appropriate interventions. Our aim was to evaluate the implementation and effectiveness of Healthy Schools, Healthy Students (HSHS). We conducted a mixed-methods evaluation using a cluster-randomized trial design with 20 schools in a rural, Midwestern state. HSHS included education sessions, cafeteria coaching and taste testing. We interviewed implementers (n = 13) and nutrition educators (n = 8), conducted six focus groups with cafeteria coaches, and surveyed fourth graders (n = 1057) about their nutrition knowledge, attitudes toward and preferences for fruits and vegetables (F&V), F&V consumption and MyPlate awareness. We used multi-level linear models to estimate the intervention effect and qualitative data were coded. There were very few challenges to implementation. HSHS participation was positively associated with knowledge, attitudes toward F&V, preferences for vegetables from the taste tests, MyPlate awareness and vegetable consumption. HSHS was viewed as beneficial and easy to deliver, suggesting this type of intervention could be widely implemented. Improving knowledge and attitudes through nutrition education and preferences through taste testing have the potential to improve dietary intake among rural students. Low-cost nutrition interventions can be successfully implemented in rural elementary schools with positive outcomes.

A Mixed-Methods Examination of Factors Related to HPV Vaccination Promotion in Private Dental Settings, Iowa, 2019.

INTRODUCTION: Human papillomavirus (HPV)-associated oropharyngeal cancer rates are rising, particularly in males, although rates of other HPV-related cancers are decreasing. Although the HPV vaccine is safe and effective, vaccination rates remain below the Healthy People 2030 goal of 80% coverage. Engaging dental providers, who have experience with patient education and oropharyngeal cancer, may prove useful in efforts to increase vaccination rates. Our research explores dental providers' (dentists, dental hygienists) willingness to participate in continuing education about HPV, educate parents of adolescents, recommend the vaccine for adolescents, and refer parents to medical providers. METHODS: We used a mixed-methods approach and conducted a survey with dental hygienists and semistructured interviews with dental providers. We produced frequencies and descriptive statistics for all variables and used regression modeling to explore factors related to willingness to promote the HPV vaccine. We used a deductive approach to code interview transcripts. RESULTS: Regression models using survey data (n = 470) showed that after controlling for demographic and practice-level characteristics, higher levels of willingness were associated with thinking that parents would act on a recommendation and thinking that engaging in HPV promotion is within the scope of practice. Interview data reflected willingness of dental providers to work on HPV vaccination, but revealed barriers (eg, time, knowledge) that need to be addressed. DISCUSSION: Overall, dental providers expressed a willingness to participate in HPV vaccine promotion, and future efforts should focus on addressing barriers to doing so. Engaging dental providers in HPV vaccine recommendation and referral can help prevent future HPV-related cancers.

Extent of Inclusion of "Rural" in Comprehensive Cancer Control Plans in the United States.

INTRODUCTION: The National Comprehensive Cancer Control Program requires states, territories, and tribal organizations to develop comprehensive cancer control plans (CCCPs). In 2019, the National Advisory Committee on Rural Health and Human Services released a series of policy recommendations, including one recommending that CCCPs address rural cancer disparities. The objective of our study was to assess the extent to which jurisdictions considered "rural" in their CCCPs. METHODS: We reviewed the 66 CCCPs available on the Centers for Disease Control and Prevention's website as of January 2020 to assess their inclusion of rural across 7 elements: 1) cancer burden data, 2) reduction of cancer disparities, 3) rural population description, 4) rural definition, 5) goals, 6) objectives, and 7) strategies. We summarized these elements by plan type (state or territory/tribal organization). For state CCCPs, we also compared the number of element types and the inclusion of rural-specific strategies by the percentage of the state's population that was rural and the rural cancer mortality rate. RESULTS: Of 66 plans, 45 included a mention of rural in at least 1 element, including 38 of 50 state plans and 7 of 16 territory/tribal organization plans. Reduction of cancer disparities was the most common element noted. Less than one-third of all CCCPs included a rural-specific strategy. States with a high rural cancer mortality rate tended to have at least 1 rural-specific strategy. CONCLUSION: Technical and financial support to improve rural data inclusion and implementation of rural-specific strategies in CCCPs may help improve the inclusion of rural data and strategy development.

Perspectives on Implementation: Challenges and Successes of a Program Designed to Support Expectant and Parenting Community College Students in Rural, Midwestern State.

OBJECTIVES: Expectant and parenting students (EPS) at community colleges are an underserved and often under-resourced group. In a rural, Midwestern state, the department of public health was awarded the Pregnancy Assistance Fund (PAF) grant to assist this population. This paper outlines the results of the implementation evaluation and offers suggestions for programs and evaluators working with this population in the community college setting. METHODS: We conducted a multicomponent evaluation utilizing quantitative and qualitative methods. Evaluation activities included tracking activities/services, surveys and interviews with participants, and interviews with community college staff implementing grant activities. The research team calculated frequencies for quantitative data and coded qualitative data for themes. RESULTS: Data from the community colleges and students' self-reports revealed that EPS most commonly received concrete support from the program, often in the form of stipends or gift cards. Students reported that concrete support was beneficial and helped to relieve financial stress during the semester. Students' major barriers to participation were lack of knowledge about the program and busy schedules that prevented them from accessing PAF services. Staff reported that difficulty identifying EPS and the short one-year project period were major implementation challenges. CONCLUSIONS FOR PRACTICE: We recommend that community colleges work to identify EPS, use fellow EPS to recruit program participants, and implement programming that works with the students' schedules.

Exploring Opportunities to Leverage Pharmacists in Rural Areas to Promote Administration of Human Papillomavirus Vaccine.

Rural pharmacists have been identified as potential partners, along with health care providers, schools, and public health agencies, in administering and promoting the human papillomavirus (HPV) vaccine. We sought to understand the role of pharmacists in this work. We interviewed 11 pharmacists working at independently owned pharmacies in Iowa to explore their perspectives on HPV vaccine administration and promotion. Most pharmacists agreed that HPV vaccination was within their professional scope. They identified factors that facilitate vaccine administration (eg, accessibility of pharmacies). They also reported personal barriers (eg, lack of information, concerns about safety) and organizational barriers (eg, time and staff capacity). Future work should focus on alleviating barriers and building on strengths to improve vaccination rates and ultimately prevent HPV-related cancers.

Challenges of using nationally representative, population-based surveys to assess rural cancer disparities.

Population-based surveys provide important information about cancer-related health behaviors across the cancer care continuum, from prevention to survivorship, to inform cancer control efforts. These surveys can illuminate cancer disparities among specific populations, including rural communities. However, due to small rural sample sizes, varying sampling methods, and/or other study design or analytical concerns, there are challenges in using population-based surveys for rural cancer control research and practice. Our objective is three-fold. First, we examined the characterization of "rural" in four, population-based surveys commonly referenced in the literature: 1) Health Information National Trends Survey (HINTS); 2) National Health Interview Survey (NHIS); 3) Behavioral Risk Factor Surveillance System (BRFSS); and 4) Medical Expenditures Panel Survey (MEPS). Second, we identified and described the challenges of using these surveys in rural cancer studies. Third, we proposed solutions to address these challenges. We found that these surveys varied in use of rural-urban classifications, sampling methodology, and available cancer-related variables. Further, we found that accessibility of these data to non-federal researchers has changed over time. Survey data have become restricted based on small numbers (i.e., BRFSS) and have made rural-urban measures only available for analysis at Research Data Centers (i.e., NHIS and MEPS). Additionally, studies that used these surveys reported varying proportions of rural participants with noted limitations in sufficient representation of rural minorities and/or cancer survivors. In order to mitigate these challenges, we propose two solutions: 1) make rural-urban measures more accessible to non-federal researchers and 2) implement sampling approaches to oversample rural populations.