CANCER PREVENTION: EMPOWERING COMMUNITIES IN THE RURAL SOUTH

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: COMPLETE
• Funding Source: OTHER GRANTS
• Reporting Frequency: Annual
• Accession No.: 1010745
• Grant No.: 2016-46100-25844
• Cumulative Award Amt.: $359,487.00
• Proposal No.: 2016-07197
• Project Start Date: Sep 1, 2016
• Project End Date: Aug 31, 2019
• Grant Year: 2016
• Program Code: [LX]- Rural Health & Safety Education

Recipient Organization
UNIVERSITY OF GEORGIA
200 D.W. BROOKS DR
ATHENS,GA 30602-5016

Performing Department
COLLEGE OF FAM/CONSUM COLLEGE

Non Technical Summary
Cancers are the second leading cause of death in the United States and Georgia. In 2013, direct medical costs of cancer in the US were estimated to be more than $73 billion. Rural counties experience health disparities in both cancer incidence (new cases)and mortality. For example, Wilkes County, a rural Georgia County, had the highest breast cancer mortality rate in the state (46.1 deaths/100,000), which is double the state average of 22.9 and the 4th highest breast cancer mortality rate in the nation. Some of the disparities in cancer incidence and mortality may be partly attributable to inadequate participation in screenings. Furthermore, the American Institute for Cancer Research and the World Cancer Research Fund estimate that approximately 1/3 of cancers could be prevented through a healthy diet, being physically active, and maintaining a healthy weight. Rural counties experience disparities in obesity and related nutrition and physical activity behaviors. For example, while 30.2% of Georgian's are obese, 36.3% of adults in Laurens County, in rural Georgia, are obese. Texas faces similar challenges to Georgia with regard to cancer and rural health. Thus the University of Georgia is partnering with Prairie View A&M University (PVAMU) with the goal to empower rural Georgians and Texans to take responsibility for their health by improving their nutrition and physical activity and getting the recommended breast, cervical, and colorectal cancer screenings.This project will expand the reach of our current Cooking for a Lifetime of Cancer Prevention (C4L) program. C4L was started in 2008 as a collaboration between the American Cancer Society (ACS) and UGA Extension to reach uninsured women in Georgia and get them screened for breast and cervical cancer. Later, the program was expanded to address colorectal cancer, as it is the third most common cause of cancer death in the nation. Since 2012, C4L has reached 1,371 individuals in the state of Georgia. Although the initial goal of C4L was to reach women without insurance who would be eligible for reduced cots or free screenings through public health programs, our data suggests women both with and without insurance are not meeting screening recommendations (i.e., for mammograms, with insurance (n = 120): 18% not in compliance; without insurance (n = 35): 31% not in compliance). Furthermore, C4L currently reaches only a small proportion of counties in Georgia, including 11 rural counties. Given the higher burden of cancer in these rural counties, and the potential to reach men and women both with and without insurance, we will expand the reach of C4L to these rural Georgians and will assess current health insurance literacy and educational needs related to cancer screenings.We will do this through educational programs, research, and evaluation. Community members will be invited to attend C4L programs. These 2.5 hour classes include cooking demonstrations and educate participants on the recommended screenings for breast, cervical, and colorectal cancer, as well as nutrition and physical activity guidelines from the American Cancer Society (ACS) and World Cancer Research Fund/American Institute for Cancer Research for cancer prevention. A survey will be provided to participants in the schools to determine: 1) when/if they have had the recommended cancer screenings, 2) how likely they are to get the screenings after attending the program, 3) how likely they were to eat healthy and get adequate physical activity to reduce cancer risk before the school, and 4) after the school, and to determine 5) general understanding of health insurance benefits for getting the recommended cancer screenings. To determine if participants sustain the nutrition and physical activity changes they learned about, C4L participants will be invited to attend a follow-up event with Cooperative Extension about another health related topic where a similar survey to the one from C4L will be conducted. Other community members will also be invited to the follow up event. This survey will help us determine if participants of C4L are more/less likely to get the recommended screenings, eat healthy, and get adequate physical activity compared to people who do not attend C4L.Lastly, the project team will work with the Southern Rural Development Center (SRDC) at Mississippi State University to conduct a survey similar to the ones provided at C4L and follow-up events to determine the need for similar programs and education across the Southern Region.With this information, we will develop and disseminate resources that will be helpful to individuals in the Southern Region to encourage them to engage in the nutrition, physical activity, and screening behaviors necessary to reduce cancer cases and deaths. Overall, we hope this project will empower rural Georgians and Texans to get the recommended cancer screenings, eat healthy, and be more physically active to prevent cancer. If participants do make these changes, it could result in reduced health care costs, disease burden, and mortality.

Animal Health Component

100%

Research Effort Categories

Basic

(N/A)

Applied

100%

Developmental

(N/A)

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
724	6099	1010	100%

Knowledge Area
724 - Healthy Lifestyle;

Subject Of Investigation
6099 - People and communities, general/other;

Field Of Science
1010 - Nutrition and metabolism;

Keywords

cancer

health

nutrition

prevention

screening

Goals / Objectives
The goals of the proposed project are to:1) Increase individual responsibility among rural Georgians and Texans to engage in the recommended cancer breast, cervical, and colorectal cancer screenings and nutrition and physical activity behaviors for cancer prevention by expanding the outreach and impact of the Current Cooking for A Lifetime of Cancer Prevention Cooking School (C4L), and 2) Determine rural southern region needs for C4L and similar programs related to preventative health care.The objectives are to:Provide the program in rural counties statewide and selected Texas countiesImprove C4L participant intention to engage in breast, cervical, and colorectal cancer screenings and nutrition and physical activity behaviors for cancer preventionAssess the health insurance literacy needs of C4L participants related to cancer screening and preventative careAssess C4L impact on sustained behavior change and cancer screeningAssess the health insurance literacy needs across the southern region related to preventative health care, andProvide follow up education and/or resources to meet those needs

Project Methods
This project involves recruitment of participants to attend an educationalprogram, Cooking for a Lifetime of Cancer Prevention (C4L), delivered by Cooperative Extension Agents in Georgia and in Texas, C4L program delivery, C4L program evaluation, recruitment of both C4L participants and non-participants to a follow-up health education event, evaluation at that follow-up event, and surveying of the Southern Region by working with the Southern Rural Development Center (SRDC) at Mississippi State University. All research relatedprotocols and procedures will be approved by the Institutional Review Board on Human Subjects at the University of Georgia.Efforts:C4L Programs: Participants will be recruited (word of mouth, print advertisements, establishedExtension communications, emails to listservs, etc) toattend the C4L educationalprogram in rural counties in Georgia and Texas. These programs will be delivered by Family and Consumer Sciences Extension Agents/Educators in Georgia and Texas. C4L educates participants on the evidence-based guidelines from the American Cancer Society (ACS) and World Cancer Research Fund/American Institute for Cancer Research on nutrition and physical activity/exercise (PA/EX) behaviors associated with decreased cancer risk. C4L focuses on four ACS recommendations including, 1) achieving and maintaining a healthy weight, 2) being physically active, 3) reducing alcohol consumption, 4) consuming a plant-base diet, and limiting alcohol intake [8], and discusses behaviors necessary to meet these recommendations, such as increasing fruits and vegetables, choosing whole grains, meeting PA/EX guidelines, and limiting red meat and avoiding processed meat. Furthermore, C4L educates participants on evidence-based screening guidelines (American Cancer Society, and US Preventative Services Task Force) for breast, cervical, and colorectal cancer.Follow-up events: At the end of the C4L programs, FACS agents will invite participants to return for a follow-up Extension program (1 month post C4L). At these programs, evidence-based information about health related topics, such as nutrition and physical activity for cancer prevention and general health, use of health insurance for preventative services, helathy child care, and/orpositive relationships, will be provided to participants.Webinar: The project team will develop a webinar to share program outcomes and lessons learnedRegional dissemination of resources:The Southern Rural Development Center (SRDC) will assist the project team to disseminate health, preventative health care, and health insurance (i.e., using health insurance to access preventive health care) information determined to be of interest following the SRDC evaluation.Evaluation:C4L Program Evaluation: The C4L program evaluation will utilize a retrospective post- then pre- design to assess change inintention to engage inrecommended nutrition and physical activity behaviors for cancer prevention and recommended breast, cervical, and colorectal cancer screenings. The evaluation will also include additional questions to assess participant health insurance literacy related to preventative services and screenings. Demographic data will be collected.Follow-up event evaluation: At the end of the C4L programs, FACS agents will invite participants to return for a follow-up Extension program (1 month post C4L). At the follow-up event, we will collect evaluation data from all attendees (those who attended C4L and those who did not). Participants will be asked whether or not they attended C4L and then will be asked about cancer screening behaviors and nutrition and physical activity behaviors. Demographic data will also be collected.Southern Region Preventative Health Survey: The PD and Co-PDs will work with the Southern Region to develop a survey to collect data on the health, health care, and health insurance needs of people in the southern region.Evaluation analysis: Using this quasi-experimental design, we will be able to assess, 1) whether sustained behavior change occurred among program participants (~ 1 month post-participation), and 2) whether C4L program participants are more likely to engage in screening behaviors and recommended health behaviors than non-participants. Descriptive statistics (eg, means, standard deviations, medians, confidence intervals) will be calculated. Changes in behavior and behavioral intention will be exploredusing paired t-tests or equivalent non-paramteric tests orother statistical testsappropriate to the distribution, quantity, and qualityof the data. Relationships between independent variables (i.e. demographics, health insurance status) and dependent variables (i.e. intention to engage in nutrition and physical activity and recommended screenings) will be explored with regression analysis orother statistical testsappropriate to the distribution, quantity, and qualityof the data.

Progress 09/01/16 to 08/31/19

Outputs
Target Audience:Extension agents delivered 113Cooking for a Lifetime of Cancer Prevention Cooking School programs in 30rural Georgia counties and 3 rural Texascounties. These programs havereached 1424 people (1221 in Georgia and 203 in Texas)of which 1279 provided evaluation data.Participants are primarily middle aged (54.3 ±18.5 y, range: 12 to 96, n = 1188) and approximately 84% female, 56% White, 42% Black, and 12% Hispanic. A little less than half of participants (39.5%) had a high school education or less and 21% were college graduates. Approximately 12% had no health insurance; 17% had Medicare only; 7% had Medicaid only; 38% had private insurance; and the rest had some other combination. Extension agents delivered 76 follow-up programs in 30 rural Georgia counties and 3 rural Texas counties. These programs have reached 1018 people (907 in Georgia and 111 in Texas) of which 926 submitted evaluation data.Participants are primarily middle aged (54.3 ±18 y, range: 12 to 94, n = 894) andapproximately 83% female, 56% White, 42% Black, and 9% Hispanic. A little less than half of participants (37%) had ahigh school education or less and 24% were college graduates. Approximately 9% had no health insurance; 14% had Medicare only; 4% had Medicaid only; 47% had private insurance; and the rest had some other combination. Changes/Problems:Our largest challenge of the project was recruitment (total number and during the period planned) due to natural disasters and general challenges related to recruiting rural populations. Hurricane Michael (Georgia) slowed implementation and caused some problems with scheduling follow-up events during the intended implementation timeframe. In addition, long-term recovery from Hurricane Harvey (Texas) and significant personal health problems among some of the project staff at Prairie View A&M University slowed implementation and caused problems with the follow-up timeframes. With the awarded no cost extension, however, we completed almost the total number of programs proposed (113 completed C4L programs; 114 planned), and we reached more counties than we planned. We aimed to reach 22 counties total and reached more than 30 counties with the C4L and follow-up programs. Our total attendance at C4L programs (1424) was less than intended (3168) and follow-up attendance (1018) was also less than intended (2310). In surveying our agents, we believe transportation to program sites, length of the program (~2.5 hours), and competing needs (i.e. recovery from hurricanes), were primary barriers for rural participant recruitment and attendance. What opportunities for training and professional development has the project provided?Students and Family and Consumer Sciences Extension Agents have been provided training and professional development on evidence-based cancer prevention strategies related to screening, nutrition, and physical activity. Their experience implementing the program has helped them improve their skills in communicating these principles to their community. Thus, they will be better able to educate their community on cancer prevention beyond the life of the project. FACS Extension agents have also received training and professional development on the research process including human subjects research training, informed consent, and evaluation procedures. Through the production of conference presentations and posters, agents have learned about data analysis and reporting. FACS extension agents are serving as coauthors on Extension publications and peer-reviewed journal publications. Through this coauthorship, they are learning skills of literature review, editing, data analysis and interpretation, and writing for research journals and the public. Graduate students have been involved in data collection, management, and analysis and publishing of posters, reports, and journal articles. How have the results been disseminated to communities of interest?The project director and co-project directors disseminated information about the project to other Extension, academic, and health professionals at the National Health Outreach Conferences in 2018 and 2019, 2019 Society for Nutrition Education and Behavior Annual Conference, and the 2019 International Federation for Home Economics (Trinidad, West Indies). In addition, posters were presented at the Georgia Clinical Translational Science Alliance Conference, Georgia Extension Association of Family and Consumer Sciences Annual Meeting and the Epsilon Sigma Phi, Georgia Chapter meeting.An abstract has been submitted for presentation at the International Federation of Home Economics in 2020 in Atlanta, GA. We have submitted to the National Extension Association of Family and Consumer Sciences to present two webinars to share with others results of the study and the programs we have to share. Lastly, we have three manuscripts in preparation from the data for publication in peer-reviewed journals and several more planned. In addition to planned activities, this project has provided opportunities for new partnerships and programs in the areas of cancer prevention, management, and Extension that should ultimately impact our communities.Connecting with the American Cancer Society on this project, helped open the door to including radon as a cause of lung cancer in the Georgia Cancer Plan. Dr. Turner, who directs the UGA radon education program, was invited to join the Georgia Lung Cancer Roundtable and contribute to the new cancer plan for the state of Georgia. In addition, presenting our work at national conferences has opened doors to partnering with other land grant universities and Extension to explore opportunities for Extension programming and research on financial toxicity during cancer diagnosis and treatment. What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? Provide the program in rural counties statewide and selected Texas counties. Accomplishments: During the grant period, 113Cooking for a Lifetime of Cancer Prevention Cooking School (C4L) programs have taken place in 30rural Georgia counties and 3 rural Texascounties reaching more than 1400 people. The programs in Georgia have been provided in all four Extension regions in the state (Northeast, Northwest, Southeast, and Southwest). Seventy-six follow-up programs have taken place in 30 rural Georgia counties and 3 rural Texas counties reaching more than 1000 people. Some follow-up programs have included people from more than one county. Importantly, the C4L program was so well accepted by program participants and Extension agents that Prairie View A&M university has now incorporated the C4L Program into their regular Family and Consumer Sciences healthExtension programming lead by collaborators and Co-PDs Dawn Burton and Jacquelyn White. Thus, the program should sustain in both Georgia and Texas and continue to improve cancer prevention behaviors among our citizens. Improve C4L participant intention to engage in breast, cervical, and colorectal cancer screenings and nutrition and physical activity behaviors for cancer prevention. Accomplishments: While data are still being analyzed, preliminary analyses suggest that after the program, participants were significantly (p < 0.001) more likely to intend to implement all cancer preventive nutrition and physical activity behaviors discussed (achieve and maintain a healthy weight, exercise at least 30 minutes 5 days per week, fill half their plate with fruits and vegetables, make at least half of their grains whole grains, limit red and avoid processed meat, limit alcohol) than before the program. Preliminary analyses also indicate that following the program, at least 70% of participants who met the age and gender guidelines for cervical, breast, and colorectal cancer screenings said they were "Definitely" going to get the recommended screenings (cervical: 85%, breast: 88%, colorectal: 72%). Assess the health insurance literacy needs of C4L participants related to cancer screening and preventative care. Accomplishments: Preliminary analyses of participants attending cancer prevention programs and follow-up programs indicate that approximately 30% indicate they feel they are "Not at all confident" or "A little confident" that they "Know most of the things [they] need to know about using health insurance." Similarly, about 30% report that they are "Not at all confident" or "A little confident" that they "know how to find out what is and is not covered before" receiving a health care service. While data are still being collected and analyzed, this suggests that people in Georgia and Texas who attend Extension programs may have low health insurance literacy and are in need of education related to using health insurance. Assess C4L impact on sustained behavior change and cancer screening. Accomplishments: Data are still being analyzed. However, preliminary analyses suggest, of participants who provided data at both the cancer prevention program and follow-up and who were age and gender eligible (n = 436), 137 women received a PAP between the time of the cancer prevention program and the follow-up event. Rather, these women were not in compliance with cervical cancer screening guidelines at the time of the C4L program and did get a cervical cancer screening (PAP) between the time of the program and follow-up event. Similarly, 166 (36%) of program attendees who provided data at both the C4L program and follow-up (n = 459) received a mammogram between the time of the cancer prevention program and the follow-up event. Rather, these women were not in compliance with breast cancer screening guidelines at the time of the C4L program and did get a breast cancer screening (mammogram) between the time of the program and follow-up event. Lastly, 185 people (37%) received a colonoscopy between the time of the cancer prevention program and the follow-up event. Rather, these men and women were not in compliance with colon cancer screening guidelines at the time of the C4L program and did get a colon cancer screening (colonoscopy) between the time of the program and follow-up event. Again, this is preliminary data analyses, but shows that participants are being motivated by attending the C4L program to obtain recommended cancer screenings for their age and sex. At follow-up, there was also a trend for greater mammogram compliance among C4L participants compared to those who only attended a follow-up (C4L non-participants)(p=0.059); and C4L participants reported significantly greater intention to get a colonoscopy thanthose who only attended a follow-up (C4L non-participants)(p=0.001). Moreover, preliminary analyses also suggests that of those participants who attended both a cancer prevention program and a follow-up event, intentions remained significantly higher at follow-up than they were at baseline (p< 0.001 for all behaviors), indicating that the one time workshop resulted in sustained increases in intention to follow these nutrition and physical activity behaviors for cancer prevention. Assess the health insurance literacy needs across the southern region related to preventative health care. Accomplishments: While the initial intent of this project was to only survey the southern Extension region, we expanded our survey to reach Extension specialists, administrators and educators nationally (n = 87). Importantly, 46% of respondents indicate that their Extension organization does not offer a health insurance education program and 59% indicated that rural communities in their state would be interested in such a program. This, combined with the fact that 1/3 of our participants reported little confidence in understanding their health insurance suggests there may be a need for programs to address health insurance literacy across the nation through Extension. Data will be further analyzed and the intent is to publish results. Provide follow up education and/or resources to meet those needs. Accomplishments: A preventative health care Extension bulletin has been developed and provided to Georgia FACS Extension Agents. This publication is available to the public on the UGA Extension website. Furthermore, a press release was written to increase awareness of preventative health care benefits and distributed through news media channels at UGA. This press release has been shared with Extension agents for them to publish in local papers and media outlets. We have submitted to the National Extension Association of Family and Consumer Sciences to present one webinar and one application is in preparation to share with others the program and the results of the study. Importantly, the Cooking for a Lifetime of Cancer Prevention Program (C4L) was recently identified as a research-tested, evidence-based intervention for inclusion in the SNAP-Ed national toolkit (https://snapedtoolkit.org/interventions/programs/cooking-for-a-lifetime-of-cancer-prevention/). Inclusion in the toolkit should enhance dissemination and implementation of the program in Extension and other SNAP-Ed implementing agencies and the target audience, hopefully increasing cancer prevention awareness and behaviors. Additional education and/or resources will be developed and provided after the data from items 3, 4, and 5 have been analyzed and published.

Publications

• Type: Conference Papers and Presentations Status: Published Year Published: 2019 Citation: Berg A, Rafie C. Food and Physical Activity Choices for Cancer Prevention: an opportunity for nutrition educators. Oral session, Society for Nutrition Education and Behavior, Orlando, FL, Jul 30, 2019.
• Type: Conference Papers and Presentations Status: Published Year Published: 2019 Citation: Berg A, Turner P, Chatterjee S, Koonce J, Wilson H. Cancer Prevention and Health Insurance Education Needs Assessment of Extension Professionals. Oral session, National Health Outreach Conference 2019, Fort Worth, TX, May 2, 2019.
• Type: Conference Papers and Presentations Status: Published Year Published: 2019 Citation: Berg A, Turner P, Koonce J, Chatterjee S, Wilson H, Burton D. Innovative Two-Stage Program to Increase Cancer Awareness and Screenings in Rural Communities. Paper presentation, International Federation for Home Economics Conference, University of the West Indies Resource Centre, Trinidad, W.I., March 22, 2019.
• Type: Conference Papers and Presentations Status: Published Year Published: 2019 Citation: Wilson H*, Chatterjee S, Koonce J, Turner P, Burton D, Aguirre M&Berg A. Community-based Nutrition Education Intervention Increases Likelihood of Cancer Preventative Lifestyle Behaviors. Society for Nutrition Education and Behavior, Jul 2019, Orlando, FL. Abstract: Journal of Nutrition Education and Behavior, 51(7):102. https://doi.org/10.1016/j.jneb.2019.05.531
• Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Wilson H, Bentley R, Chatterjee S, Cook G, Davis S, Dekle M, Holland K, Hubbard R, Koonce J, Selph E, Smith L, Stewart R, Turner P, Berg A. Nutrition Education for Cancer Prevention in Rural Georgia Counties: Barriers and facilitators. Georgia Academy of Nutrition and Dietetics Annual Conference and Exhibition, Mar 2018.
• Type: Conference Papers and Presentations Status: Submitted Year Published: 2020 Citation: Berg A, Wilson H, Chatterjee S, Koonce, J, Turner P. Cooperative Extension Cancer Prevention Education Program Increases Cancer Screening and Intention to be Screened for Cancer Among Rural Georgians. International Federation for Home Economics World Congress 2020, Atlanta, GA.

Progress 09/01/17 to 08/31/18

Outputs
Target Audience:Sixty-nineCooking for a Lifetime of Cancer Prevention Cooking School programs have taken place in 26rural Georgia counties and 3 rural Texascounties. These programs havereached 879 people (779 in Georgia and 100 in Texas)of which 791 provided evaluation data.Participants are primarily middle aged (53.3 ±19 y, range: 12 to 96, n = 739) and approximately 87% female, 56% White, 42% Black, and 12% Hispanic. A little less than half of participants (39.5%) had a high school education or less and 21% were college graduates. Approximately 12% had no health insurance; 17% had Medicare only; 7% had Medicaid only; 38% had private insurance; and the rest had some other combination. Fifty-six follow-up programs have taken place in 22 rural Georgia counties and 3 rural Texas counties. These programs have reached 730 people (654 in Georgia and 76 in Texas) of which 653 submitted evaluation data.Participants are primarily middle aged (54.1 ±19 y, range: 18 to 94, n = 636) andapproximately 85% female, 56% White, 43% Black, and 10% Hispanic. A little less than half of participants (36.8%) had ahigh school education or less and 22% were college graduates. Approximately 9% had no health insurance; 15% had Medicare only; 4% had Medicaid only; 43% had private insurance; and the rest had some other combination. Changes/Problems:Hurricane Michael (Georgia) has slowed implementation and caused some problems with scheduling follow-up events during the intended implementation timeframe. In addition, long-term recovery from Hurricane Harvey (Texas) and significant personal health problems among some of the project staff at Prairie View A&M University have also slowed implementation and caused problems with the follow-up timeframes. With the awarded no cost extension, we do not anticipate any issues with completing the total number of programs proposed. We may, however, have a lower number of participants with valid data than expected, particularly in the follow-up events as many of these were cancelled or did not occur in the specified timeline. After data collection is complete and during the remainder of the project, the Co-PDs will assess the situation and determine the best way to evaluate follow-up event data. What opportunities for training and professional development has the project provided?Students and Family and Consumer Sciences Extension Agents have been provided training and professional development on evidence-based cancer prevention strategies related to screening, nutrition, and physical activity. Their experience implementing the program has helped them improve their skills in communicating these principles to their community. Thus, they will be better able to educate their community on cancer prevention beyond the life of the project. FACS Extension agents have also received training and professional development on the research process including human subjects research training, informed consent, and evaluation procedures. Through the production of conference presentations and posters, agents have learned about data analysis and reporting.Students and Family and Consumer Sciences Extension Agents have been provided training and professional development on evidence-based cancer prevention strategies related to screening, nutrition, and physical activity. Their experience implementing the program has helped them improve their skills in communicating these principles to their community. Thus, they will be better able to educate their community on cancer prevention beyond the life of the project. FACS Extension agents have also received training and professional development on the research process including human subjects research training, informed consent, and evaluation procedures. Through the production of conference presentations and posters, agents have learned about data analysis and reporting. How have the results been disseminated to communities of interest?The project director and co-project directors disseminated information about the project to other Extension, academic, and health professionals at the National Health Outreach Conference. In addition, posters were presented at the Georgia Clinical Translational Science Alliance Conference, Georgia Extension Association of Family and Consumer Sciences Annual Meeting and the Epsilon Sigma Phi, Georgia Chapter meeting. What do you plan to do during the next reporting period to accomplish the goals?We will continue to conduct our cancer prevention education programs and follow-up programs as outlined in our grant proposal/initiation report. Some follow-up programs will occur outside the intended timeline as cancellations and rescheduling occurred as a result of the impact of hurricanes in Texas and Georgia and due to personal issues with Extension agents implementing the program. See next section "Changes/Problems." We are optimistic that we will still be able to meet our intended numbers of programs. We will continue analyzing our survey data and creating all training and resources following completion of data collection as outlined in the proposal and initiation report.

Impacts
What was accomplished under these goals? Data is still being collected and analyzed, and some parts of the project have yet to be implemented. It is too early to comment on accomplishment of overall goals of the project. Accomplishments during the reporting period by objective are as follows: Provide the program in rural counties statewide and selected Texas counties. Accomplishments: During the reporting period, 69Cooking for a Lifetime of Cancer Prevention Cooking School programs have taken place in 26rural Georgia counties and 3 rural Texascounties. The programs in Georgia have been provided in all four Extension regions in the state (Northeast, Northwest, Southeast, and Southwest). Fifty-six follow-up programs have taken place in 22 rural Georgia counties and 3 rural Texas counties. Some follow-up programs have included people from more than one county. Improve C4L participant intention to engage in breast, cervical, and colorectal cancer screenings and nutrition and physical activity behaviors for cancer prevention. Accomplishments: Within the Cancer prevention cooking school programs conducted during the reporting period, preliminary analyses suggest that after the program, participants were significantly (p < 0.001) more likely to intend to implement all cancer preventive nutrition and physical activity behaviors discussed (achieve and maintain a healthy weight, exercise at least 30 minutes 5 days per week, fill half their plate with fruits and vegetables, make at least half of their grains whole grains, limit red and avoid processed meat, limit alcohol) than before the program. Preliminary analyses also indicate that following the program, at least 70% of participants who met the age and gender guidelines for cervical, breast, and colorectal cancer screenings said they were "Definitely" going to get the recommended screenings (cervical: 87%, breast: 89%, colorectal: 73%). Assess the health insurance literacy needs of C4L participants related to cancer screening and preventative care. Accomplishments: Preliminary analyses of participants attending cancer prevention programs and follow-up programs indicate that approximately 30% indicate they feel they are "Not at all confident" or "A little confident" that they "Know most of the things [they] need to know about using health insurance." Similarly, about 30% report that they are "Not at all confident" or "A little confident" that they "know how to find out what is and is not covered before" receiving a health care service. While data are still being collected and analyzed, this suggests that people in Georgia and Texas who attend Extension programs may have low health insurance literacy and are in need of education related to using health insurance. Assess C4L impact on sustained behavior change and cancer screening. Accomplishments: Data are still being analyzed and a few programs and follow-up events to cancer prevention programs have yet to occur. However, preliminary analyses of current data suggests that of those participants who attended both a cancer prevention program and a follow-up event, their intention to engage in the cancer preventive nutrition and physical activity behaviors at the time of follow-up program remains higher than before they came to the cancer prevention program. Thus, participant motivation to follow cancer prevention nutrition and physical activity behaviors is being maintained overtime. However, further analyses are needed to confirm. Analyses are still ongoing to determine if participants who were out of compliance with cancer screenings at the time of the cancer prevention program are in compliance by the time of the follow-up program. Assess the health insurance literacy needs across the southern region related to preventative health care. Accomplishments: Preliminary analyses suggest that at least 30% of program participants lack confidence in understanding health insurance (see goal 3 accomplishments). The survey to collect data from Southern Region Extension specialists and other faculty is complete and data are being analyzed. Preliminary analyses show that 46% of respondents indicate that their Extension organization does not offer a health insurance education program and 59% indicated that rural communities in their state would be interested in such a program. Thus, there may be a need for programs to address health insurance literacy in the Southern Region. Data will be further analyzed and the intent is to publish results. Provide follow up education and/or resources to meet those needs. Accomplishments: A preventative health care Extension bulletin has been developed and provided to Georgia FACS Extension Agents. This publication may be distributed regionally as determined appropriate following further data collection and analysis. Additional education and/or resources will be developed and provided after the data from items 3, 4, and 5 have been collected and analyzed

Publications

• Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Conference Presentation: Berg AC, Burton D, Chatterjee S, Koonce J, Turner P, White J, Wilson H. Cancer Prevention: Promoting a Culture of Health in the Rural South Through the C4L Program. Role: author, presenter. Presented at National Health Outreach Conference, Bloomington, MN, May 3, 2018.
• Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Conference presentation: Beltran I, Aaron LA, Bentley R, Black T, Booth C, Campbell C, Centner A, Chatterjee S, Collins B, Cook G, Culpepper S, Dallas J, Davis S, Dekle M, English B, Eubank J, Everson D, Faulk K, Holland K, Hornbeck MB, Howell K, Howington S, Hubbard R, Koonce J, Moore J, Moore S, Ogden J, Parker M, Poston E, Roberts A, Scarrow A, Smith L, Soltanmammedova Z, Stewart R, Sumpter K, Sweda C, Thomas K, Turner P, Walker B, Wall K. Williams B, Wilson H, Worley B, Jimenez Olga, Berg A. UGA Extension: Committed to saving lives through cancer prevention education. Poster presented at 1) 2018 Annual Meeting of the Epsilon Sigma Phi Alpha Beta Chapter, September 7, 2018, Athens, GA. Second place winner, category: Family and Consumer Sciences Extension, and 2) the 2018 Annual Meeting of the Georgia Extension Association for Family and Consumer Sciences, August 28-30, 2018, Madison, GA.
• Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Conference presentation: Berg A, Chatterjee S, Wilson H, Koonce J, Turner P. Community-based educational intervention may improve cancer screening compliance in rural. Poster presented at the Georgia Clinical and Translational Science Alliance Inaugural Conference, Brasleton, GA, February 23, 2018

Progress 09/01/16 to 08/31/17

Outputs
Target Audience:Thirty Extension Cancer Prevention Cooking School programs have taken place in 15 rural Georgia counties and 3 Texas counties. These programs have reached 362 rural Georgians and 56 rural Texans with education on cancer prevention through screening, nutrition, and physical activity. Participants are primarily middle aged (57.4 ± 16.4 y, n = 347) and approximately 74% female, 60% White, 25% Black, and 10% Hispanic. A little less than half of participants (45.6%) had a high school education or less and 22% were college graduates. Ten Extension follow-up programs have been conducted in 9 rural Georgia Counties. These programs have reached 163 rural Georgians and have covered topics such as health insurance basics, prostate cancer prevention, physical activity promotion, and green cleaning. Participants at follow-up programs have been primarily middle aged (56.7 ± 16.4 y, n = 142), approximately 73% female, 60% White, 30% Black, and 1% Hispanic. Approximately half of participants attending follow-up events had a high school education or less and 20% were college graduates. Changes/Problems:Hurricanes Irma (Georgia) and Harvey (Texas) have slowed implementation and caused some problems with scheduling follow-up events during the intended implementation timeframe. As we have already applied for and been granted the no cost extension, we do not anticipate any issues with completing the programs in the timeline allotted. We may, however, have a lower number of participants with valid data than expected, particularly in the follow-up events as many of these were cancelled or did not occur in the specified timeline. As the project progresses, the Co-PDs will assess the situation and determine the best way to evaluate follow-up event data. What opportunities for training and professional development has the project provided?Students and Family and Consumer Sciences Extension Agents have been provided training and professional development on evidence-based cancer prevention strategies related to screening, nutrition, and physical activity. The individuals have also received training and professional development on the research process including human subjects research training, informed consent, and evaluation procedures. How have the results been disseminated to communities of interest? Nothing Reported What do you plan to do during the next reporting period to accomplish the goals?We will continue to conduct our cancer prevention education programs and follow-up programs as outlined in our grant proposal/initiation report. Some follow-up programs will occur outside the intended timeline as cancellations and reschedulings occurred during Hurricanes Irma and Harvey. See next section "Changes/Problems." We are optimistic that we will still be able to meet our intended numbers of contacts. We will continue with collecting our survey data and creating all training and resources following completion of data collection as outlined in the proposal andinitaition report.

Impacts
What was accomplished under these goals? Data is still being collected and analyzed, and some parts of the project have yet to be implemented. It is too early to comment on accomplishment of overallgoals of the project. Accomplishments during the reporting period by objective are as follows: Provide the program in rural counties statewide and selected Texas counties.Accomplishments: Thirty cancer prevention programs have been provided in 15 rural counties in Georgia and 3 rural counties in Texas. Ten follow-up events and programs have been provided in 9 rural counties in Georgia Improve C4L participant intention to engage in breast, cervical, and colorectal cancer screenings and nutrition and physical activity behaviors for cancer prevention.Accomplishments: Preliminary analysis suggests positive results, however data is still being collected and analyzed. Assess the health insurance literacy needs of C4L participants related to cancer screening and preventative care.Accomplishments: Data is still being collected, so we do not have anything to report for this period. Assess C4L impact on sustained behavior change and cancer screening.Accomplishments: Data is still being collected and many follow-up events to cancer prevention programs have yet to occur. Nothing to report for this period. Assess the health insurance literacy needs across the southern region related to preventative health care. Accomplishments:Data is still being collected through evaluations at cancer prevention cooking school programs and follow-up events. Additional survey to collect data from Southern Region Extension specialists and other faculty is currently open to response. Provide follow up education and/or resources to meet those needs.Accomplishments: Nothing to report. This will occur after the data from items 3, 4, and 5 have been collected and evaluated

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