Factors associated with having uncontrolled asthma in rural Appalachia.

BACKGROUND: Chronic respiratory disease disproportionately affects residents of Appalachia, particularly those residing in Central Appalachia. Asthma is particularly burdensome to Central Appalachian residents regarding cost and disability. Improving our understanding of how to mitigate these burdens requires understanding the factors influencing asthma control among individuals with asthma living in Central Appalachia, specifically rural Kentucky. METHODS: This community-based, cross-sectional epidemiologic study used survey data to identify characteristics associated with uncontrolled and controlled asthma. The designation of "uncontrolled asthma" was based on a self-report of ≥ 2 asthma exacerbations in the past year. Individuals with ≤ 1 or no exacerbations were considered to have controlled asthma. Chi-square or Fisher exact tests assessed the association between categorical variables and asthma control categories. Logistic regression was conducted to determine the impact of factors on the likelihood of uncontrolled asthma. RESULTS: In a sample of 211 individuals with self-reported asthma, 29% (n = 61, 46 females) had uncontrolled asthma. Predictors of uncontrolled asthma included depression (odds ratio 2.61, 95% CI 1.22-5.61, p = .014) and living in multi-unit housing (odds ratio 4.99, 95% CI 1.47-16.96, p = .010) when controlling for age, sex, financial status, and occupation. Being overweight or obese was not a predictor of uncontrolled asthma. Physical activity and BMI did not predict the likelihood of uncontrolled asthma. CONCLUSION: This study highlights significant challenges rural communities in Appalachian Kentucky face in managing asthma. Factors like depression, housing conditions, and a lack of self-management strategies play pivotal roles in asthma control in this population.

Testing the 'Faith Moves Mountains model' to increase Alzheimer's disease awareness, detection, and diagnosis among rural, racially, and ethnically diverse older adults.

OBJECTIVES: Racially and ethnically diverse populations have recently contributed to the majority of rural and small-town growth. Consequently, the disproportionately high risk and prevalence of Alzheimer's disease and related dementias (ADRD) among rural and minoritized older residents will likely increase. To address this threat, we tested the hypotheses that (1) a faith-based, resident-led approach would increase basic ADRD knowledge and diagnosis, and (2) older age, female gender, lower educational levels, and more years lived rural would predict number of referrals, new dementia diagnoses, and treatment. METHODS: An adaptation of Schoenberg's Faith Moves Mountains model, previously successful in detection and management of other chronic illnesses in rural settings, guided this community-based participatory research. Local faith community members were trained as research assistants to recruit, administer surveys, conduct brief memory assessments, teach brain health strategies, and follow-up with residents. Outreaches were offered virtually during the pandemic, then in-person monthly at rotating church sites, and repeated ∼1 year later. RESULTS: This rural sample was racially and ethnically diverse (74.5% non-White), with 28% reporting eight or less years of formal education. Findings included that referrals and years lived rural were significant and positive predictors of new ADRD treatments [(b = 3.74, χ2(1, n = 235) = 13.01, p < 0.001); (b = 0.02, χ2(1, n = 235 = 3.93, p = 0.048)], respectively, regardless of participant characteristics. CONCLUSION: Resident-led action research in rural, diverse, faith communities is a successful approach to increasing ADRD disease knowledge, detection, diagnosis, and treatment.

Promoting a more diverse and inclusive research workforce through the research scholars program.

BACKGROUND: Novel and comprehensive approaches are needed to address shortcomings in the diversity and inclusiveness of the scientific workforce. In response to this need and informed by multiple programs and data sources, we created the Research Scholars Program (RSP). The RSP is a yearlong program for early-career faculty with an overall objective to overcome barriers to the academic success, retention, progression, and promotion of groups underrepresented in biomedical and behavioral research. The goal of the RSP is to increase research confidence and productivity, build a supportive research community, and reduce isolation by providing personal and group research enrichment to junior faculty through professional development, mentorship, and networking. METHODS: We adapted evidence-based approaches for our institutional context and vetted the RSP across our campus. The resulting RSP consists of three main elements: (1) five levels of Mosaic Mentorship; (2) group and tailored professional development programming; and (3) scientific and social networking. To determine the potential of the RSP to improve research confidence critical to success, we used a modified shortened version of the Clinical Research Appraisal Inventory (CRAI-12) to assess participants' confidence in performing a variety of research tasks before and after program participation. We collected information about retention, promotion, and grants submitted and awarded. Additionally, we conducted semi-structured exit interviews with each scholar after program participation to identify programmatic strengths and areas for improvement. Data for Cohorts 1 and 2 (N = 12) were analyzed. RESULTS: Our assessment finds, with one exception, increasing confidence in participants' research skills across all items, ranging from 0.4 (4.7%) to 2.6 (40.6%). In their exit interviews, the Research Scholars (RS) described their improved productivity and increased sense of belonging and support from others. Research Scholars noted numerous components of the RSP as strengths, including the Mosaic Mentorship model, professional development programming, and opportunities for both informal and formal interactions. Respondents identified time pressure, a lack of feedback, and unclear expectations of the various mentorship roles as areas in which the program can improve. CONCLUSION: Preliminary findings indicate that the RSP is successful in building the research confidence of underrepresented and disadvantaged early-career faculty. While this report focuses on the development and protocol of the RSP, additional cohorts and data will provide the evidence base to support dissemination as a national model of research professional development. Such programming is critical to ensure sustainable support structures, institutional networks, infrastructure, and resources that will improve discovery and equity through inclusive excellence.

Palliative care use and utilization determinants among patients treated for advanced stage lung cancer care in the community and academic medical setting.

PURPOSE: Despite clinical guidelines, palliative care is underutilized during advanced stage lung cancer treatment. To inform interventions to increase its use, patient-level barriers and facilitators (i.e., determinants) need to be characterized, especially among patients living in rural areas or those receiving treatment outside academic medical centers. METHODS: Between 2020 and 2021, advanced stage lung cancer patients (n = 77; 62% rural; 58% receiving care in the community) completed a one-time survey assessing palliative care use and its determinants. Univariate and bivariate analyses described palliative care use and determinants and compared scores by patient demographic (e.g., rural vs. urban) and treatment setting (e.g., community vs. academic medical center) factors. RESULTS: Roughly half said they had never met with a palliative care doctor (49.4%) or nurse (58.4%) as part of cancer care. Only 18% said they knew what palliative care was and could explain it; 17% thought it was the same as hospice. After palliative care was distinguished from hospice, the most frequently cited reasons patients stated they would not seek palliative care were uncertainty about what it would offer (65%), concerns about insurance coverage (63%), difficulty attending multiple appointments (60%), and lack of discussion with an oncologist (59%). The most common reasons patients stated they would seek palliative care were a desire to control pain (62%), oncologist recommendation (58%), and coping support for family and friends (55%). CONCLUSION: Interventions should address knowledge and misconceptions, assess care needs, and facilitate communication between patients and oncologists about palliative care.

A New Look at Barriers to Clinical Care Among Appalachian Residents Living With Diabetes.

In the United States, diabetes is the seventh leading cause of death and continues to rise in prevalence, with type 2 diabetes accounting for 90-95% of all cases. Rates of diabetes in Kentucky, and, in particular, the Appalachian region, are among the highest in the nation and are increasing faster than the national average. Despite this disproportionate burden, barriers to clinical appointment attendance have not been fully explored in this population. This article examines the association among perceived barriers to clinical attendance, glycemic control, and diabetes self-care as part of an ongoing study. We used a 25-item checklist developed using the Chronic Care Model to assess participants' barriers to clinic attendance. Glycemic control was assessed via A1C measurement. Diabetes self-care was assessed using the Summary of Diabetes Self-Care Activities measure. At the time of analysis, 123 of the 356 participants (34.6%) did not report any barriers to clinic attendance. For the remainder, the major reported barriers included forgetting appointments, inability to afford medicines or other treatment, and placing faith above medical care. The average A1C was 7.7%, and the average diabetes self-care summary score was 17.1 out of 35 points (with higher values indicating better self-care). Missing clinic appointments is associated with lower health outcomes, especially in vulnerable populations. This study can help educate clinic staff on perceived barriers to type 2 diabetes management among people with diabetes in Appalachia.

Examining Psychological and Knowledge Barriers to Colorectal Cancer Screening in Rural Appalachian Kentucky.

While recent rates of colorectal cancer (CRC) screening have improved in Appalachian Kentucky due to public health efforts, they remain lower compared to both KY as a whole, and the USA. Suboptimal screening rates represent a missed opportunity to engage in early detection and prevention. The purpose of this study is to determine the impact that lack of knowledge has on psychological barriers (e.g., fear and embarrassment) to CRC screening as well as the potential effect of a psychosocial intervention to reduce these barriers. Participants were recruited through faith-based organizations and other community sites. After randomizing participants to either an early or delayed group, a faith-based group education and motivational interviewing intervention was administered. Existing and pilot tested instruments were used to assess knowledge and potential psychological barriers. Data were analyzed using paired t tests and linear regression. We hypothesized that (1) psychological barriers are associated with inadequate knowledge and (2) the intervention, by improving knowledge, could reduce these barriers and increase screening rates. There was a small but significant reduction in psychological barriers (-0.11, p value = 0.015) and moderate increases in CRC knowledge scores (+0.17, p value = 0.06). There was no evidence that the intervention affected these measures (+0.10, p value = 0.58). The relationship between lower barrier scores and increased knowledge was significant at follow up (-0.05, 95% CI (-0.09, -0.00)). An increase in CRC knowledge was correlated with a small but significant decrease in psychological barriers, although there was no evidence that these changes were associated with one another. Future cognitive-based interventions may be effective in increasing CRC knowledge and reducing barriers, but new intervention approaches should be considered.

Adaptation and study protocol of the evidence-based Make Better Choices (MBC2) multiple diet and activity change intervention for a rural Appalachian population.

BACKGROUND: Rural Appalachian residents experience among the highest prevalence of chronic disease, premature mortality, and decreased life expectancy in the nation. Addressing these growing inequities while avoiding duplicating existing programming necessitates the development of appropriate adaptations of evidence-based lifestyle interventions. Yet few published articles explicate how to accomplish such contextual and cultural adaptation. METHODS: In this paper, we describe the process of adapting the Make Better Choices 2 (MBC2) mHealth diet and activity randomized trial and the revised protocol for intervention implementation in rural Appalachia. Deploying the NIH's Cultural Framework on Health and Aaron's Adaptation framework, the iterative adaptation process included convening focus groups (N = 4, 38 participants), conducting key informant interviews (N = 16), verifying findings with our Community Advisory Board (N = 9), and deploying usability surveys (N = 8), wireframing (N = 8), and pilot testing (N = 9. This intense process resulted in a comprehensive revision of recruitment, retention, assessment, and intervention components. For the main trial, 350 participants will be randomized to receive either the multicomponent MBC2 diet and activity intervention or an active control condition (stress and sleep management). The main outcome is a composite score of four behavioral outcomes: two outcomes related to diet (increased fruits and vegetables and decreased saturated fat intake) and two related to activity (increased moderate vigorous physical activity [MVPA] and decreased time spent on sedentary activities). Secondary outcomes include change in biomarkers, including blood pressure, lipids, A1C, waist circumference, and BMI. DISCUSSION: Adaptation and implementation of evidence-based interventions is necessary to ensure efficacious contextually and culturally appropriate health services and programs, particularly for underserved and vulnerable populations. This article describes the development process of an adapted, community-embedded health intervention and the final protocol created to improve health behavior and, ultimately, advance health equity. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04309461. The trial was registered on 6/3/2020.

The mediating/moderating role of cultural context factors on self-care practices among those living with diabetes in rural Appalachia.

BACKGROUND: The aim of this study was to examine whether cultural factors, such as religiosity and social support, mediate/moderate the relationship between personal/psychosocial factors and T2DM self-care in a rural Appalachian community. METHODS: Regression models were utilized to assess for mediation and moderation. Multilevel linear mixed effects models and GEE-type logistic regression models were fit for continuous (social support, self-care) and binary (religiosity) outcomes, respectively. RESULTS: The results indicated that cultural context factors (religiosity and social support) can mediate/moderate the relationship between psychosocial factors and T2DM self-care. Specifically, after adjusting for demographic variables, the findings suggested that social support may moderate the effect of depressive symptoms and stress on self-care. Religiosity may moderate the effect of distress on self-care, and empowerment was a predictor of self-care but was not mediated/moderated by the assessed cultural context factors. When considering health status, religiosity was a moderately significant predictor of self-care and may mediate the relationship between perceived health status and T2DM self-care. CONCLUSIONS: This study represents the first known research to examine cultural assets and diabetes self-care practices among a community-based sample of Appalachian adults. We echo calls to increase the evidence on social support and religiosity and other contextual factors among this highly affected population. TRIAL REGISTRATION: US National Library of Science identifier NCT03474731. Registered March 23, 2018, www.clinicaltrials.gov .

Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report.

Cardiovascular disparities remain pervasive in the United States. Unequal disease burden is evident among population groups based on sex, race, ethnicity, socioeconomic status, educational attainment, nativity, or geography. Despite the significant declines in cardiovascular disease mortality rates in all demographic groups during the last 50 years, large disparities remain by sex, race, ethnicity, and geography. Recent data from modeling studies, linked micromap plots, and small-area analyses also demonstrate prominent variation in cardiovascular disease mortality rates across states and counties, with an especially high disease burden in the southeastern United States and Appalachia. Despite these continued disparities, few large-scale intervention studies have been conducted in these high-burden populations to examine the feasibility of reducing or eliminating cardiovascular disparities. To address this challenge, on June 22 and 23, 2017, the National Heart, Lung, and Blood Institute convened experts from a broad range of biomedical, behavioral, environmental, implementation, and social science backgrounds to summarize the current state of knowledge of cardiovascular disease disparities and propose intervention strategies aligned with the National Heart, Lung, and Blood Institute mission. This report presents the themes, challenges, opportunities, available resources, and recommended actions discussed at the workshop.

Health Behaviors in Rural Appalachia.

OBJECTIVES: To better understand the disproportionate burdens from cancer, cardiovascular disease, diabetes mellitus, stroke, and other chronic conditions related to energy balance, we studied diet and physical activity patterns in younger and older adults in rural Appalachia by using a nonclinical, cross-sectional, community-based sampling approach. METHODS: A total of 651 younger (ages 18-59) and 254 older (ages ≥60) Appalachians were recruited from 43 churches or community organizations. Participants answered questions about fruit and vegetable intake and physical activity. Analyses were adjusted for clustering within churches. RESULTS: Compared with older Appalachians, younger Appalachians consumed significantly fewer fruits and vegetables (P = 0.01) and reported significantly more moderate-to-vigorous physical activity (P = 0.01). Regardless of age, engagement in healthy behaviors was suboptimal and well below national averages. CONCLUSIONS: This community-based sample demonstrated elevated behavioral risk factors that likely contribute to some of the nation's highest rates of premature mortality. Despite suboptimal dietary intake and physical activity, results indicate some potential leverage points between the generations that may be used to improve health. For example, the older generation could benefit from engaging with their younger relatives in physical activities while advocating for a better-rounded diet. Given traditions of intergenerational connectedness, mutual aid, and self-reliance, transmission of healthier behaviors across the generations may be beneficial in the rural Appalachian context.

Solutions to the Challenge of Meeting Rural Transportation Needs: Middle-Aged and Older Adults' Perspectives.

This study aimed to explore how the aging population in Appalachia manages its transportation and plans for the transition to non-driving and to seek possible solutions to the challenge of meeting rural transportation needs. Four focus groups (N = 38) were conducted, supplemented by a questionnaire, in Appalachian Kentucky. The results showed that few alternative transportation existed except a local paratransit service and informal transportation support. Compared to older adults, middle-aged adults reported a greater willingness to use mobile phones and the Internet to arrange transportation if they were available. Participants also recommended expanding the use of existing transportation in the community - such as church vans - to better meet the aging population's needs. The findings suggest that partnership between government, non-profit, and private sectors is needed, not solely focusing on a tax-dependent solution. Additionally, information and communication technology-based transportation management system would help maximize the use of scare but existing resources in rural areas.

The Role of Primary Care Providers in Encouraging Older Patients to Change Their Lifestyle Behaviors.

OBJECTIVES: This study sought to identify older patients' perceptions of primary care providers' influence on their likelihood of improving diet and physical activity. METHODS: 104 adults ages 65 and older were interviewed immediately following a routine primary care visit about their plans and motivations for behavior change and how their clinic visit would influence their likelihood of making lifestyle changes. All interviews were recorded, transcribed and analyzed using a constant comparison approach. RESULTS: Participants reported that their providers influence their health behaviors by developing strong relationships, addressing concerns and encouraging change, and providing concrete instruction. When providers did not discuss diet or physical activity, or mentioned these topics only briefly, participants often perceived the message that they should continue their current behaviors. CONCLUSIONS: Whether and how diet and physical activity are discussed in primary care influences the likelihood that older adults will make changes in these behaviors. CLINICAL IMPLICATIONS: These findings highlight the need for a patient-centered counseling approach and caution providers to think twice before omitting discussion of the need for lifestyle change.

Physical activity levels and counseling by health care providers in cancer survivors.

Physical activity guidelines for cancer survivors issued by the American Cancer Society and the American College of Sports Medicine emphasize the essential role of a health care provider (HCP) in counseling cancer survivors to achieve healthier lifestyles. However, research has not established whether HCP's recommendations to engage in physical activity are associated with increased physical activity levels of cancer survivors. The study examines this potential association using the 2005 and 2010 National Health Interview Survey data. The final analytic sample consisted of 3320 cancer survivors and 38,955 adults without cancer who reported seeing or talking to a HCP and if or not they had received a physical activity recommendation in the prior year. Consistent with the aforementioned guidelines, physical activity levels were categorized as inactive, insufficiently active, and sufficiently active (i.e., meeting guidelines). Average adjusted predictions and marginal effects were estimated from generalized ordered logit models. Multivariable regressions controlled for socio-demographic and health-related characteristics and survey year. On average, receipt of a HCP's physical activity recommendation was associated with a lower adjusted prevalence of inactivity by 8.3 percentage points and a higher adjusted prevalence of insufficient and sufficient activity by 4.6 and 3.7 percentage points, respectively, regardless of cancer diagnosis (P's<0.05). A HCP's recommendation is associated with higher levels of leisure-time aerobic physical activity among cancer survivors and adults without cancer. The communication between cancer survivors and their HCPs may act as a 'window' of opportunity to increase physical activity levels among the U.S. cancer survivors.

Rural Religious Leaders' Perspectives on their Communities' Health Priorities and Health.

OBJECTIVES: In traditionally underserved communities, faith-based interventions have been shown to be effective for health promotion. Religious leaders-generally the major partner in such interventions-however, are seldom are consulted about community health priorities and health promotion preferences. These insights are critical to ensure productive partnerships, effective programming, and sustainability. METHODS: Mixed-methods surveys were administered in one of the nation's most under-resourced regions: rural Appalachia. A sample of 60 religious leaders, representing the main denominations in central Appalachia, participated. Measures included closed- and open-ended survey questions on health priorities and recommendations for health promotion. Descriptive statistics were used for closed-ended survey items and conventional qualitative content analysis was used for open-ended responses. RESULTS: Substance abuse, diabetes mellitus, suboptimal dietary intake and obesity/overweight, and cardiovascular and respiratory illnesses constitute major health concerns. Addressing these challenging conditions requires realistically acknowledging sparse community resources (particularly healthcare provider shortages); building in accountability; and leveraging local assets and traditions such as testimonials, intergenerational support, and witnessing. CONCLUSIONS: With their extensive reach within the community and their accurate understanding of community health threats, practitioners and researchers may find religious leaders to be natural allies in health-promotion and disease-prevention activities.

What Motivates Older Adults to Improve Diet and Exercise Patterns?

Dietary intake and physical activity are lifestyle behaviors that are learned, developed, and practiced throughout an individual's lifetime. These lifestyle behaviors have a profound role on health and quality of life--with late-life changes still resulting in notable improvements. Despite well documented benefits of behavior change, such changes are extremely challenging. The purpose of this study is to better understand from the perspective of older adults themselves, the factors that may influence their likelihood of making lifestyle changes. Participants were recruited two primary care clinics. 104 older adults ranging in age from 65 to 95 were included. Participants were interviewed about their motivations and plans to change diet and physical activity behaviors following a routine primary care visit. All interviews were transcribed and transcripts were analyzed using a line-by-line coding approach. Older adults reported that their likelihood of making a lifestyle change related to perceptions of old age, personal motivation, and perceived confidence in the ability to make effective changes. These findings suggest the importance of creating more positive images of old age and tailoring health promotion efforts to older adults' motivations and confidence in their ability to make behavior changes.

Engaging Elements of Cancer-Related Digital Stories in Alaska.

The tradition of storytelling is an integral part of Alaska Native cultures that continues to be a way of passing on knowledge. Using a story-based approach to share cancer education is grounded in Alaska Native traditions and people's experiences and has the potential to positively impact cancer knowledge, understandings, and wellness choices. Community health workers (CHWs) in Alaska created a personal digital story as part of a 5-day, in-person cancer education course. To identify engaging elements of digital stories among Alaska Native people, one focus group was held in each of three different Alaska communities with a total of 29 adult participants. After viewing CHWs' digital stories created during CHW cancer education courses, focus group participants commented verbally and in writing about cultural relevance, engaging elements, information learned, and intent to change health behavior. Digital stories were described by Alaska focus group participants as being culturally respectful, informational, inspiring, and motivational. Viewers shared that they liked digital stories because they were short (only 2-3 min); nondirective and not preachy; emotional, told as a personal story and not just facts and figures; and relevant, using photos that showed Alaskan places and people.

Promoting Mammography with African-American Women in the Emergency Department Using Lay Health Workers.

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

Acceptability and Feasibility of Physical Activity Assessment Methods for an Appalachian Population.

Nowhere is improving understanding and accurate assessment of physical activity more important for disease prevention and health promotion than among health disparities populations such as those residing in rural and Appalachian regions. To enhance accurate assessment of physical activity and potentially improve intervention capacity, we conducted a mixed-methods study examining the acceptability and feasibility of self-report physical activity questionnaires, pedometers, and accelerometers among rural Appalachian children, adolescents, and adults. Most participants reported positive experiences with all three physical activity assessment tools. Several acceptability ratings differed by age group and by sex within each age group. With very few exceptions, no significant differences in acceptability were found by race, education, employment status, health status, BMI categories, income levels, or insurance status within age groups or overall. Several factors may impact the choice of the physical activity assessment method, including target population age, equipment cost, researcher burden, and potential influence on physical activity levels. Children and adolescents appear to have more constraints on when they can wear pedometers and accelerometers. While pedometers are inexpensive and convenient, they may influence physical activity levels, rather than simply measure them. Accelerometers, while less influential on behavior, consume extensive resources, including high purchase costs and researcher burden.

Trends in cigarette smoking and obesity in Appalachian Kentucky.

OBJECTIVES: The southern region of the United States, particularly central and southern Appalachia, has long been identified as an area of health inequities. An updated and more complete understanding of the association among the leading risk factors for such health inequities allows researchers, clinicians, and policymakers to focus their efforts on the most effective strategies to minimize these risks. METHODS: Using the most recent survey data from the Behavioral Risk Factor Surveillance System, we examined 10-year trends in rates of cigarette smoking and obesity in Appalachian Kentucky, comparing these trends with national and non-Appalachian Kentucky rates. RESULTS: Women and men from Appalachian Kentucky smoke cigarettes at rates 1.8 times and 1.6 times higher, respectively, than their national counterparts. Although rates of smoking in Appalachian Kentucky, non-Appalachian Kentucky, and the United States have decreased, such decreases among Appalachian Kentucky women have been minimal. Adding to these concerning trends, obesity rates in Appalachian adults are much higher than in non-Appalachian Kentucky or the United States overall, although Appalachian Kentucky smokers are less likely to be obese than nonsmokers. Low socioeconomic status and impeded access to health care characterize the Appalachian communities in which these risk behaviors occur and likely account for the prevalence of these most risky behaviors. CONCLUSIONS: A continuum of approaches to address smoking and obesity is warranted. Such approaches range from ensuring access to smoking cessation programs to implementing community- and state-level policies to curb smoking and unhealthy energy balance (eg, smoke-free policies and increases in tobacco and "junk food" taxes) and culturally appropriate individual-level interventions (evidence-based smoking cessation and weight-loss programming).

Comprehension of Randomization and Uncertainty in Cancer Clinical Trials Decision Making Among Rural, Appalachian Patients.

Comprehension of randomization is a vital, but understudied, component of informed consent to participate in cancer randomized clinical trials (RCTs). This study examines patient comprehension of the randomization process as well as sources of ongoing uncertainty that may inhibit a patient's ability to provide informed consent to participate in RCTs. Cancer patients living in rural Appalachia who were offered an opportunity to participate in a cancer treatment RCT completed in-depth interviews and a brief survey. No systematic differences in randomization comprehension between patients who consented and those who declined participation in a cancer RCT were detected. Comprehension is conceptually distinct from uncertainty, with patients who had both high and low comprehension experiencing randomization-related uncertainty. Uncertainty about randomization was found to have cognitive and affective dimensions. Not all patients enrolling in RCTs have a sufficient understanding of the randomization process to provide informed consent. Healthcare providers need to be aware of the different types of randomization-related uncertainty. Efforts to improve informed consent to participate in RCTs should focus on having patients teach back their understanding of randomization. This practice could yield valuable information about the patient's cognitive and affective understanding of randomization as well as opportunities to correct misperceptions. Education about RCTs should reflect patient expectations of individualized care by explaining how all treatments being compared are appropriate to the specifics of a patient's disease.