Appalachian women's perceptions of their community's health threats

Adult asthma associated with roadway density and housing in rural Appalachia: the Mountain Air Project (MAP)

BACKGROUND

Appalachian Kentucky is a rural area with a high prevalence of asthma among adults. The relative contribution of environmental exposures in the etiology of adult asthma in these populations has been understudied.

OBJECTIVE

This manuscript describes the aims, study design, methods, and characteristics of participants for the Mountain Air Project (MAP), and focuses on associations between small area environmental exposures, including roadways and mining operations, and lifetime and current asthma in adults.

METHODS

A cohort of residents, aged 21 and older, in two Kentucky counties, was enrolled in a community-based, cross-sectional study. Stratified cluster sampling was used to select small geographic areas denoted as 14-digit USGS hydrologic units (HUCs). Households were enumerated within selected HUCs. Community health workers collected in-person interviews. The proximity of nearby active and inactive coal mining operations, density of oil and gas operations, and density of roadways were characterized for all HUCs. Poisson regression analyses were used to estimate adjusted prevalence ratios.

RESULTS

From 1,459 eligible households contacted, 1,190 individuals were recruited, and 972 persons completed the interviews. The prevalence of lifetime asthma was 22.8%; current asthma was 16.3%. Adjusting for covariates, roadway density was positively associated with current asthma in the second (aPR = 1.61; 95% CI 1.04-2.48) and third tertiles (aPR = 2.00; 95% CI 1.32-3.03). Increased risk of current asthma was associated with residence in public, multi-unit housing (aPR = 2.01; 95% CI 1.27-3.18) compared to a residence in a single-family home. There were no notable associations between proximity to coal mining and oil and gas operations and asthma prevalence.

CONCLUSIONS

This study suggests that residents in rural areas with higher roadway density and those residing in public housing units may be at increased risk for current asthma after accounting for other known risk factors. Confirming the role of traffic-related particulates in producing high asthma risk among adults in this study contributes to the understanding of the multiple environmental exposures that influence respiratory health in the Appalachia region.

Place, Power, and Premature Mortality: A Rapid Scoping Review on the Health of Women in Appalachia

OBJECTIVE

Appalachian women continue to die younger than in other US regions. We performed a rapid scoping review to summarize women's health research in Appalachia from 2000 to 2019, including health topics, study populations, theoretical frameworks, methods, and findings.

DATA SOURCE

We searched bibliographic databases (eg, PubMed, PsycINFO, Google Scholar) for literature focusing on women's health in Appalachia.

STUDY INCLUSION AND EXCLUSION CRITERIA

Included articles were: (1) on women's health in Appalachia; (2) published January 2000 to June 2019; (3) peer-reviewed; and (4) written in English. We excluded studies without reported data findings.

DATA EXTRACTION

Two coders reviewed articles for descriptive information to create summary tables comparing variables of interest.

DATA SYNTHESIS

Two coders co-reviewed a sub-sample to ensure consensus and refine data charting categories. We categorized major findings across the social-ecological framework.

RESULTS

A search of nearly 2 decades of literature revealed 81 articles, which primarily focused on cancer disparities (49.4%) and prenatal/pregnancy outcomes (23.5%). Many of these research studies took place in Central Appalachia (eg, 42.0% in Kentucky) with reproductive or middle-aged women (82.7%). Half of the studies employed quantitative methods, and half used qualitative methods, with few mixed method or community-engaged approaches (3.7%). Nearly half (40.7%) did not specify a theoretical framework. Findings included complex multi-level factors with few articles exploring the co-occurrence of factors across multiple levels.

CONCLUSIONS

Future studies should: 1) systematically include Appalachian women at various life stages from under-represented sub-regions; 2) expand the use of rigorous methods and specified theoretical frameworks to account for complex interactions of social-ecological factors; and 3) build upon existing community assets to improve health in this vulnerable population.

Children being Reared by their Grandparents in Rural Appalachia: A Pilot Study of Relations Between Psychosocial Stress and Changes in Salivary Markers of Inflammation Over Time

Grandparents in rural Appalachia with primary caregiving responsibilities for their grandchildren often struggle with high levels of stress, inadequate resources, and poor physical and mental health. However, implications for children of being raised by grandparents rarely have been examined, particularly in terms of stress biomarkers. The present study investigated salivary C-reactive protein, interleukin-6, and tumor necrosis factor alpha in a small sample of children (N = 20) aged 5 to 18 years being reared by grandparents in two rural counties in Kentucky, a region well known for its resource scarcity. Saliva samples were collected from children 30 min after waking at two time points spaced one year apart. Grandparents and children completed a series of questionnaires via interview. Children's internalizing symptoms were related to greater markers of inflammation over time. Grandparent stress and poor mental health were also related to greater inflammation, while grandparent positive parenting and religiosity were associated with lower inflammation.

Identifying Communication Barriers to Colorectal Cancer Screening Adherence among Appalachian Kentuckians

Utilizing data from 40 in-depth interviews, this article identifies both barriers and facilitators to colorectal screening guideline adherence among Appalachian Kentucky adults recruited through a community-based research network. Key findings identify (a) varying levels of knowledge about screening guidelines, (b) reticence to engage in screening processes, and (c) nuanced communication with healthcare providers and family members regarding screening adherence. What participants knew about the screening process was often derived from personal stories or recalled stories from family members about their screening experiences. Reticence to engage in screening processes reflected reports of cumbersome preparation, privacy issues, embarrassment, medical mistrust, fear of receiving a cancer diagnosis, and lack of symptoms. Participants cited many ways to enhance patient-centered communication, and the findings from this study have implications for health communication message design and communication strategies for healthcare practices in Appalachian Kentucky clinics.

Rural Grandparent Headed Households: A Qualitative Description

Purpose

To explore, from an emic perspective, the unique socio ecological context in which rural grandparent headed households (GHH) exist, and therefore provide a foundation for the development of culturally-appropriate interventions that might impact their health.

Methods

This qualitative descriptive study was based on the conduct of in-depth, semi-structured interviews with fifteen grandparents, residing in rural Appalachian Kentucky, who were the primary caretakers for their grandchildren. The interviews were conducted using an interview guide that was based on the premises of the Social Ecological Model (SEM). A basic assumption of this model is that intrapersonal, social-cultural, organizational, and policy factors influence individual health and health behaviors, and that these influences are interrelated and reciprocal. Data was analyzed by the research team using line by line coding of the audio recorded transcriptions of the interviews.

Findings

GHH experience both barriers and facilitators to maintaining the health of GHH. Many grandparents viewed the experience of belonging to a GHH as a positive one, believing that having their grandchildren in their home improved their health. They relied on formal and informal networks such as extended family and churches to help with caretaking responsibilities. Grandparents experienced notable barriers to health related to having the primary responsibility of their grandchildren, including lack of resources and family tension related to incarceration and/or opioid drug use by biological parents.

Conclusions

GHH, one of the fastest growing family constellations in rural Appalachia and the US, may be particularly vulnerable to health threats elevating their risk for many chronic diseases. Effective health related interventions to address this risk should be based on the socio-ecological context in which these families exist.

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.

Managing cancer and employment: Decisions and strategies used by breast cancer survivors employed in low-wage jobs

Advances in breast cancer screening and treatment have led to an overall 5-year survival rate of 90%. Many of these cancer cases are diagnosed in working women. Few studies have explicitly examined the cancer-work interface, as experienced by low-wage earning women with breast cancer. This study uses in-depth, semistructured interviews with 24 low-wage breast cancer survivors to identify employment decisions and factors that influenced or enabled these decisions, and examine the individual strategies and workplace supports used to manage the cancer-work interface among a subset of women (n = 13) who continued to work. Future research areas and clinical implications are discussed.

Colorectal cancer prevention: Perspectives of key players from social networks in a low-income rural US region

Social networks influence health behavior and health status. Within social networks, “key players” often influence those around them, particularly in traditionally underserved areas like the Appalachian region in the USA. From a total sample of 787 Appalachian residents, we identified and interviewed 10 key players in complex networks, asking them what comprises a key player, their role in their network and community, and ideas to overcome and increase colorectal cancer (CRC) screening. Key players emphasized their communication skills, resourcefulness, and special occupational and educational status in the community. Barriers to CRC screening included negative perceptions of the colonoscopy screening procedure, discomfort with the medical system, and misinformed perspectives on screening. Ideas to improve screening focused on increasing awareness of women's susceptibility to CRC, providing information on different screening tests, improving access, and the key role of health-care providers and key players themselves. We provide recommendations to leverage these vital community resources.

Creating Effective Media Messaging for Rural Smoke-free Policy

OBJECTIVES

Objectives were to (1) explore perceived effectiveness of existing smoke-free print advertisements in rural communities and (2) generate message content, characteristics, and media delivery channels that resonate with residents.

DESIGN AND SAMPLE

Qualitative methods design. Thirty-nine rural adults recruited by community partners.

MEASURES

Content analysis of findings from individuals in four focus groups who participated in general discussion and reviewed eight print ads related to secondhand smoke (SHS) and smoke-free policy.

RESULTS

Six content themes were identified: smoking/SHS dangers, worker health, analogies, economic impact, rights, and nostalgia. Seven message characteristics were recognized: short/to the point, large enough to read, graphic images, poignant stories, statistics/charts/graphs, message sender, and messages targeting different groups. Four media delivery channels were considered most effective: local media, technology, billboard messages, and print materials.

CONCLUSIONS

Seeking input from key informants is essential to reaching rural residents. Use of analogies in media messaging is a distinct contribution to the literature on effective smoke-free campaigns. Other findings support previous studies of effective messaging and delivery channels. Further research is needed to examine effectiveness of themes related to message content in smoke-free ads and delivery strategies. Effective media messaging can lead to policy change in rural communities to reduce exposure to SHS.

Culturally-specific smoking cessation outreach in a rural community

OBJECTIVE

Tobacco use is the leading preventable cause of death, resulting in 443,000 US deaths per year. Rural adults have higher smoking prevalence and less access to tobacco dependence treatment than their urban counterparts. This study examined exposure to a culturally specific smoking cessation outreach intervention, assessing whether exposure was associated with cessation behaviors.

DESIGN AND SAMPLE

Post-test only quasi-experimental study. Targeted adult smokers (N = 251) living in a rural, economically distressed southeastern US county for at least 6 months.

MEASUREMENTS

Five outreach elements (brochures/pushcards, posters, print and radio advertisements, quilt made by local artisans) based on themes from focus groups with current and former smokers and paired with brief tobacco cessation counseling, and were delivered over 6 months in 2009-2010. Exposure and cessation behavior indicators were collected via cross-sectional random-digit dial survey. The total intervention exposure score was 4.8 (SD = 4.3, range 0-19).

RESULTS

Intervention exposure was associated with having talked to a health care provider about quitting smoking in the past 6 months and planning to quit smoking in the next 6 months.

CONCLUSIONS

Culturally specific outreach materials based on personal narratives are a promising population-based intervention to motivate rural smokers to consider cessation.

Are obese women more likely to participate in a mobile mammography program?

Mobile mammography services are typically offered as a means to increase access and adherence to mammography screenings. As mobile mammography becomes a viable strategy to increase screening, a 3 year study of such a state-wide program in WV found surprisingly high rates of obesity within the study population. Thus, the objectives were to: (1) describe the demographic characteristics and comorbidities of women who utilized the WV program, and (2) determine the association between body mass index (BMI) and personal health and screening history, preventive care and wellness behaviors, nutrition and exercise behaviors, and demographics. Data collected from 1,099 women, age 40 and above, were analyzed using descriptive statistics, bivariate analyses, and a multivariate regression model. The majority (60.4 %) were married, had an income <$25,000 (59.2 %), and had health insurance (53.5 %). Major comorbidities were hypertension (49 %) and high cholesterol (43.9 %). Based on BMI scores, 884 participants were either overweight (26.6 %), mildly obese (27.7 %), moderately obese (15.1 %), or severely obese (11.1 %). Bivariate analyses indicated that increasing BMI was significantly associated with factors such as having hypertension or diabetes, limited daily activities, perceived health, and not smoking or drinking. The regression model was significant (p < 0.001; R2 = 0.425) indicating that women who engaged in preventive care behaviors were less likely to be obese than those who did not. The WV mobile mammography program appeared to attract women who were disproportionately obese and had multiple comorbidities, thus providing a great opportunity for targeted interventions related to improving preventive care and screening behaviors.

Perspectives on healthy eating among Appalachian residents

PURPOSE

Extensive attention has been focused on improving the dietary intake of Americans. Such focus is warranted due to increasing rates of overweight, obesity, and other dietary-related disease. To address suboptimal dietary intake requires an improved, contextualized understanding of the multiple and intersecting influences on healthy eating, particularly among those populations at greatest risk of and from poor diet, including rural residents.

METHODS

During 8 focus groups (N = 99) and 6 group key informant interviews (N = 20), diverse Appalachian rural residents were queried about their perceptions of healthy eating, determinants of healthy food intake, and recommendations for improving the dietary intake of people in their communities. Participants included church members and other laypeople, public health officials, social service providers, health care professionals, and others.

FINDINGS

Participants offered insights on healthy eating consistent with the categories of individual, interpersonal, community, physical, environmental, and society-level influences described in the socioecological model. Although many participants identified gaps in dietary knowledge as a persistent problem, informants also identified extraindividual factors, including the influence of family, fellow church members, and schools, policy, advertising and media, and general societal trends, as challenges to healthy dietary intake. We highlight Appalachian residents' recommendations for promoting healthier diets, including support groups, educational workshops, cooking classes, and community gardening.

CONCLUSIONS

We discuss the implications of these findings for programmatic development in the Appalachian context.

Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky

OBJECTIVE

Previous intervention research conducted in Appalachian Kentucky resulted in extremely low uptake and adherence to the human papillomavirus (HPV) vaccine among women ages 18-26, despite provision of free vaccine. Because of these findings, the purpose of this qualitative, follow-up study was to elicit health care providers' perspectives on barriers and facilitators to HPV vaccination and suggested strategies for improving vaccination rates.

DESIGN AND SAMPLE

Researchers conducted semi-structured qualitative interviews with a purposive sample of eight health care providers (seven nursing professionals, one physician) at the health clinic where the original HPV vaccination intervention took place. Interviews were audio-recorded and transcribed and authors used a constant-comparative method to analyze the data.

RESULTS

Significant themes emerged from the interviews, centering around two primary issues: vaccine uptake and vaccine adherence. Related to uptake, health care providers identified perceived patient barriers and inadequate HPV vaccine education. They also identified the vaccine schedule and clinic-centered communication deficiencies as adherence-related barriers.

CONCLUSION

These Appalachian Kentucky health care providers provided important insights into barriers and facilitators to HPV vaccine uptake and adherence that need to be readily addressed in this community. As informed by these providers, several suggestions for improving HPV vaccination, such as more targeted education efforts and patient-centered reminder systems, may be applicable to other nursing professionals working in rural and medically underserved communities.

The conceptualization and communication of risk among rural appalachian adolescents

This study uses a meta-theoretical perspective for examining risk perceptions and behavior in the rural Appalachian cultural context, an area that remains largely unexplored. The authors conducted in-depth interviews with 113 rural adolescents to describe how youth conceptualize risk and how risk is communicated in the rural environment. Analyses revealed adolescents viewed behavior as risky when they had personal or vicarious experiences resulting in a loss of control or physical harm. Elements of the rural Appalachian culture including activities, familism, and community ties can prevent and promote adolescent risk taking in various forms. This study demonstrates the conceptualization of risk and messages about risk are culturally situated and communicatively devised and enacted. The implications of these findings for adolescent risk prevention programs are discussed.

Evaluation of Patient Needs and Patient Navigator Communication about Cervical Cancer Prevention in Appalachian Kentucky

Few studies describe the way patient navigation processes may address disparities in treatment and follow-up care for medically underserved populations. Using a social ecological framework, we analyzed survey assessments of 519 patients completing a randomized navigation trial in Appalachia Kentucky to examine patient-reported barriers to follow-up cervical cancer care. We also analyzed in-depth interview transcripts with four lay patient navigators in the trial to identify barriers to follow-up care and to learn what communication strategies navigators use to successfully (or unsuccessfully) help patients navigate around those barriers. Our analysis provides insight into how patient navigation may improve adherence to follow-up care through assisted uncertainty management. We also discuss opportunities for improving navigator training to address disparities in clinical outcomes.

Time perspective and physical activity among central Appalachian adolescents

Time perspective is a cultural behavioral concept that reflects individuals' orientations or attitudes toward the past, present, or future. Individuals' time perspectives influence their choices regarding daily activities. Time perspective is an important consideration when teaching adolescents about the importance of being physically active. However, little is known about the relationship between time perspective and physical activity among adolescents. The purpose of this study was to determine the time perspective of central Appalachian adolescents and explore the relationship between time perspective and physical activity. This study was guided by The theory of planned behavior (TPB). One hundred and ninety-three students completed surveys to examine time perspective and physical activity behaviors. Data were collected in one school. Results of this study can inform school nurses and high school guidance counselors about the importance of promoting a future-oriented time perspective to improve physical activity and educational outcomes.

Young women's perspectives on cervical cancer prevention in Appalachian Kentucky

Human papillomavirus (HPV) vaccination coupled with routine Papanicolaou (Pap) tests can prevent pervasive HPV infections causing cervical cancer. However, both HPV vaccination rates and Pap testing rates in Appalachian Kentucky are lower among all age groups than the rest of the United States. We recruited 19 young women residing in Appalachian Kentucky from university-based and rural clinical settings for group and individual interviews. After considering an integrated behavioral framework, we illustrate these women's perspectives by detailing five themes, including (a) experiential beliefs pose barriers to performing behaviors, (b) three vaccine doses complicate vaccination intention, (c) women have misunderstandings about HPV and the HPV vaccination function, (d) normative influences cue action (and inaction), and (e) specific environmental and contextual barriers exist to performing cervical cancer prevention behaviors in Appalachian Kentucky. These findings related to cervical cancer prevention in Appalachian Kentucky have implications for health-message design and clinical practice.

"I come from a black-eyed pea background": the incorporation of history into women's discussions of diet and health

To promote healthy eating, it is important to understand how people conceptualize diet and factors shaping notions of particular foods and dietary patterns as healthy. We present data from eight focus groups exploring dietary issues among women aged 40-64. We analyze how women referenced their history and background in accounting for current diet. We highlight three emergent themes: (1) how we ate growing up; (2) what we eat where I come from; and (3) what my people see as healthy. We conclude that in these groups, nostalgic presentations of life-course experiences and personal identity were meaningful anchors for explaining current behaviors.

Community strategies to address cancer disparities in Appalachian Kentucky

Central Appalachian residents suffer disproportionate health disparities, including an all-cancer mortality rate 17% higher than the general population. During 10 focus groups and 19 key informant interviews, 91 Appalachian residents identified cancer screening challenges and strategies. Challenges included (1) inadequate awareness of screening need, (2) insufficient access to screening, and (3) lack of privacy. Strategies included (1) witnessing/storytelling, (2) capitalizing on family history, (3) improving publicity about screening resources, (4) relying on lay health advisors, and (5) bundling preventive services. These insights shaped our community-based participatory research intervention and offered strategies to others working in Appalachia, rural locales, and other traditionally underserved communities.

Discussions of cancer clinical trials with the National Cancer Institute's Cancer Information Service

Clinical trials are essential for the development of new and effective treatments for cancer; however, participation rates are low. One reason for this is lack of knowledge about clinical trials. This study assessed how often clinical trials are discussed on calls to National Cancer Institute's Cancer Information Service (CIS). The authors quantitatively analyzed 283,094 calls to the CIS (1-800-4-CANCER) over 3 years (2006-2008). They calculated descriptive statistics and multivariate regressions to determine whether specific caller characteristics are associated with the presence of a clinical trials discussion. In addition, 2 focus groups were conducted with CIS information specialists (n=12) to provide insight into the findings. The authors found that approximately 9.3% of CIS calls discussed clinical trials, with higher percentages for patients (12.5%) and family members (15.4%). Calls with Hispanics, Blacks, and Spanish speakers were less likely to include a conversation. For all cancers, patients who are in treatment or experiencing a recurrence were statistically significantly more likely to discuss clinical trials. CIS information specialists reported callers' limited knowledge of clinical trials. The CIS has the unique ability to make a substantial effect in educating patients about clinical trials as an option in cancer treatment and care.

An evidence-based cessation strategy using rural smokers' experiences with tobacco

Little is known about the most effective strategies to motivate rural smokers to quit. This article describes the personal narratives of current and former smokers living in an economically distressed, rural area of Appalachian Kentucky. Three categories emerged: personal motivators to quit smoking, external influences, pride of place. Capturing personal narratives represents an evidence-based, data-rich strategy for development of culturally sensitive, population-based interventions for rural smokers. Such strategies may be effective in reaching rural smokers and motivating them to quit, thereby reducing tobacco-related disease and premature death in rural, economically distressed communities.

Adapting and implementing evidence-based cancer education interventions in rural Appalachia: real world experiences and challenges

INTRODUCTION

There is recognition among public health scholars and community practitioners that translating cancer prevention and control research into practice is challenging. This circumstance is particularly germane to medically underserved communities, such as rural Appalachia, where few evidence-based interventions originate and cancer incidence and mortality are elevated.

METHODS

A case study approach was selected to examine the collective experience of 13 West Virginia community organizations awarded mini-grants requiring the use of an evidence-based cancer control intervention. Methods included a systematic review of grant applications and final programmatic reports, a faxed survey, and qualitative, in-depth interviews with key stakeholders.

RESULTS

Appalachian grantees reported notable challenges with selecting, adapting, and implementing evidence-based cancer education interventions. Evidence-based programming was viewed as a barrier. Grantees made a range of adaptations to meet constituent needs, thereby jeopardizing intervention fidelity. However, programs were perceived as successful due to community participation and engagement, some element of behavioral change, dissemination of the health message, and establishment of collaborative partnerships.

CONCLUSIONS

A descriptive examination provides insights into the challenges of translating research to practice. This Appalachian cancer education grant program also highlights areas of compromise that are important for researchers and practitioners to understand.

Exploring diabetes beliefs in at-risk Appalachia

PURPOSE

This study quantifies and describes perceptions of susceptibility and severity of diabetes; cultural beliefs, barriers, and knowledge about diabetes; and social stigma associated with diabetes in an Eastern Appalachian Kentucky population.

METHODS

A 55-item intercept survey was administered in 2 large retail outlets in Eastern Kentucky. Individuals were screened to ensure an age range of 25-55 and an "at-risk" diabetes status (according to the American Diabetes Association's requirements). Descriptive statistics and t tests were used to describe the data. Differences across demographic variables were tested via an analysis of variance.

FINDINGS

Most respondents agreed that diabetes is a growing problem in their community, yet the overall levels of perceived susceptibility and perceived severity were lower than expected (susceptibility = 3.88 on a 5-point scale and severity = 3.5). Women, however, perceived higher susceptibility than men. Social stigma did not emerge as a strong concern or worry. The only group differences noted focused on barriers to care and disease management. Specifically, men without a family history of diabetes were significantly less likely than men with a family history to agree that the community should help persons living with diabetes manage their disease (P= .034).

CONCLUSIONS

There appears to be a gap between actual and perceived risk levels for developing diabetes. Additionally, it seems that diabetes is viewed as an intrapersonal issue rather than a community-level problem. Yet, for men, a personal experience with the disease may be enough to change the belief that diabetes is an individual problem.

Factors associated with participation in cancer prevention and control studies among rural Appalachian women

Rural Appalachian women bear a disproportionate burden from many types of cancer yet often are underrepresented in cancer research. This article uses 2 case studies to illustrate barriers faced and strategies used when recruiting hard-to-reach rural participants. Recruitment barriers include the population's competing demands and lack of trust of outsiders. Strategies employed include involving insider advocates, highlighting the positive experiences of early participants, spending extensive time in the community, and emphasizing potential community benefits of the study. We suggest recruitment strategies to better involve rural women and others who, by virtue of being "hard-to-reach," often are overlooked.