Video telehealth visits (VTV) have emerged as a critical tool for oncology care delivery, with potential to address longstanding access disparities. We examined the association between broadband internet availability, individual digital literacy factors, and VTV utilization among patients with cancer. In a retrospective cohort of 13,897 patients across a multi-site practice, VTV utilization was significantly lower in areas with ≤1 internet service provider (ISP) offering download speeds ≥25 Mbps (p = 0.0009). Validation in a regional cohort (n = 6665) confirmed lower VTV utilization in low-broadband areas. Among 1134 surveyed patients, higher digital literacy was the strongest predictor of VTV use (OR 2.5; p < 0.001), even where broadband was limited. This study demonstrates that while both broadband availability and digital literacy independently influence VTV utilization, individual digital skills can partially offset structural limitations, underscoring the need for concurrent investment in broadband infrastructure and targeted digital literacy initiatives to advance access to care.

PURPOSE:Limited access to high-speed internet (broadband [BB]) may pose challenges to video telehealth visit (VTV) utilization. This study explored barriers, facilitators, and attitudes toward VTV adoption in patients with cancer residing in low-BB settings. METHODS:We examined a cohort of patients with cancer receiving longitudinal care at Mayo Clinic Cancer Practice in the Upper Midwest. Eligible patients had ≥6 in-person visits during July 2020-October 2022, received oncology care at Mayo Clinic sites, were alive at sampling, and resided in low-BB areas defined by Federal Communications Commission data as 0 or 1 internet service provider offering <25 Mbps. We enrolled 24 participants stratified into two groups: (1) Transitioned users (TUs): adopted VTVs postpandemic (November 2022-December 2023); (2) persistent nonusers (PNUs): received exclusively in-person visits. Semistructured telephone interviews were conducted in June 2024 and thematically analyzed. RESULTS:The average age of participants was 71.3 years (range, 42-88), 50% was female, and all identified as White. Three themes emerged: (1) Structural and clinical constraints-physical examinations, laboratory testing, and chemotherapy administration were viewed as requiring in-person care, whereas VTVs were perceived acceptable for routine follow-ups; (2) Skills and experience-digital literacy was generally adequate, but confidence and direct exposure to VTV distinguished TU from PNU; (3) Motivations-both groups preferred in-person care for cancer-related emotional reassurance. TU cited weather, travel burden, and proactive provider offering as adoption triggers, whereas PNU reported that VTV was rarely offered. TU focused on system-level solutions, whereas PNUs preferred individual-level resources. CONCLUSION:Differential VTV adoption in low-BB settings reflected exposure, provider offering, and situational necessity rather than BB access alone. Oncology practices should consider normalizing the hybrid care model combining in-person and video appointment visits and provide tailored supports to advance equitable telemedicine. Expanding video care in oncology requires more than digital access and depends on patient experience, care context, and human connection inherent in oncology care.

Rural and low-socioeconomic status women face social determinants of health barriers leading to disproportionately low rates of breast cancer screening and markedly reduced participation in clinical trials. To address this gap, we developed the WeCARE (Women's Engagement for Cancer Awareness, Resources, and Education) intervention using a community-engaged approach. This paper describes how Community Advisory Board feedback informed the development of Mayo Clinic Health System's WeCARE intervention components. Their input was systematically analyzed using the Consolidated Framework for Implementation Research (CFIR 2.0) to identify determinants of acceptability, appropriateness, and feasibility and to guide actionable refinements to intervention content and delivery.

Mayo Clinic addresses community health needs by integrating community expertise and collaboratively identifying and responding to community health priorities. Community-engaged research (CEnR), encompassing a continuum of engagement from raising awareness to co-ownership of research efforts, helps operationalize this commitment. Mayo Clinic's CEnR efforts are guided by principles that emphasize community context, sustained partnerships, integration of community perspectives across the research process, and evaluation of community-centered outcomes. The CEnR Program at Mayo Clinic is coordinated through the Center for Clinical and Translational Science (CCaTS), an enterprise-wide hub supporting education, career development, and translational research. It is also implemented in collaboration with Community Outreach and Engagement Research Services (COERS), a shared resource coordinated by the CCaTS and the Mayo Clinic Comprehensive Cancer Center. The CCaTS supports CEnR through community advisory boards, community health needs assessments, and an awards program; COERS advances engagement through Community Engagement Studios, a Community Scientist Program, and related outreach activities. In 2023-2024, we devised and refined a strategic framework for CEnR, bringing together a multidisciplinary group of academic and community partners and informed by a multisite evaluation. The evaluation identified key facilitators of and barriers to academic-community partnerships and generated actionable recommendations. These efforts culminated in the Mayo Clinic CEnR logic model, integrating national guidelines, institutional commitments, and evaluation findings. This logic model serves as a framework for current and future CEnR initiatives within Mayo Clinic and may inform similar efforts nationally. We describe the key elements required to establish and sustain a cross-location CEnR program within a values-based health care institution.

Importance:Rural-urban disparities in chronic disease prevalence are well established; however, the extent to which individual-level socioeconomic status (SES) contributes to these disparities remains unclear. Objective:To examine the associations of rurality and SES with the prevalence of five most burdensome chronic diseases among adults. Design:We conducted a retrospective cross-sectional study of adults across 27 Upper Midwest counties using the Expanded Rochester Epidemiology Project (E-REP) medical record data linkage system to evaluate associations between rurality, SES and chronic disease prevalence. Prevalence of clinically diagnosed asthma, diabetes, hypertension, coronary heart disease, and mood disorders was identified from International Classification of Diseases ICD9/10 codes over a five-year period (2014-2019). Setting:Population based. Participants:Adults over 18 years residing in the 27 E-REP counties, excluding those missing rural-urban residence status. Exposure:HOUSES index, an individual-level measure of SES, served as the primary measure, while rurality based on Rural Urban Commuting Area (RUCA) codes 4-10 was the secondary measure. Main Outcome:Prevalence of the five clinically diagnosed chronic diseases was identified using ICD9/10 codes from 2014-2019. Mixed effect logistic regression models were used and adjusted for demographics and general medical examination receipt, to assess rural-urban and SES differences for prevalence of each chronic disease. Results:Among 455,802 adults with available HOUSES index, 42.8% lived in rural areas, 53.8% were female and 87.4% were non-Hispanic White. In the unadjusted analysis, rural and urban populations showed comparable asthma and CHD prevalence, while mood disorders, hypertension, and diabetes were more common in urban areas. After adjusting for demographic factors and healthcare utilization, rural-urban differences were no longer statistically significant, whereas SES remained strongly associated with all diseases in a dose response manner (e.g., adjusted Odds Ratio for hypertension (ref: HOUSES index Q4): 1.14, 1.27, and 1.42 for HOUSES index Q3, Q2, and Q1, respectively). Conclusions and Relevance:Individual-level SES measured by the HOUSES index, was more strongly associated with chronic disease prevalence than rurality, supporting its integration into population health assessment and risk stratification.

INTRODUCTION:Women residing in rural areas or belonging to lower socioeconomic status (SES) strata experience disproportionately low rates of breast cancer screening, contributing to delayed diagnoses and poorer prognoses. In addition, their participation in clinical trials remains markedly limited, reducing opportunities to access preventive and screening interventions. Promoting research preparedness among women before disease onset may empower them to make informed decisions regarding their health and willingness to participate in clinical research with fewer emotional and logistical barriers. METHODS AND ANALYSIS:This project applies a community-based participatory research approach to develop and refine the WeCARE (Women's Engagement for Cancer Awareness, Resources and Education) intervention for women aged 50-74 years who have either never undergone breast cancer screening or have not received screening in the past 5 years and who reside in rural areas or belong to low SES groups. The intervention consists of two components. Component 1 is a single-day, in-person community forum that includes (a) an educational seminar led by an oncologist to address breast cancer risk and screening guidelines, (b) survivor storytelling to enhance emotional engagement and cultural resonance and (c) facilitated navigation to breast cancer screening and future research participation. Component 2 involves structured post-forum follow-up through multiple touchpoints (phone calls and mailed boosters) to reinforce knowledge, address barriers and support screening completion and research enrolment. Quantitative data (eg, screening completion, satisfaction and follow-up engagement) will be summarised using descriptive statistics to assess feasibility and reach on 50 participants. Qualitative feedback from participants will undergo thematic analysis to identify barriers, facilitators and perceived cultural relevance. Integrated mixed-method interpretation will inform iterative refinement of the WeCARE intervention and guide design of subsequent larger trials. ETHICS AND DISSEMINATION:Approved by the Mayo Clinic Institutional Review Board (IRB #25-008934). All participants will provide informed consent. Procedures ensure confidentiality, cultural sensitivity and participant safety. Data will be stored in REDCap and disseminated through publications, conferences, local town halls and community reports.

Background Immigrants to the United States often face challenges from limited healthcare access and less healthy environments which contribute to rising obesity and cardiovascular risk. Purpose To assess the feasibility and effectiveness of a community-based social network intervention for cardiovascular risk reduction among Hispanic and Somali adults. Methods A social network-informed, community-based participatory research-derived health promotion intervention was delivered by Hispanic and Somali lay health promoters (HPs) to members of their social networks over 1 year (12 biweekly sessions in months 0-6; 12 biweekly check-ins in months 7-12). Using a closed-cohort stepped wedge cluster randomized design, social networks were randomly assigned to receive the intervention immediately or after a delay of 1 year. Measurements at baseline, 6 months, and 12 months were derived from 6 of the American Heart Association's "Life's Simple 7": BMI, blood pressure, fasting glucose, cholesterol, physical activity and dietary quality (range 0-12, with higher values indicating lower cardiovascular risk). Waist circumference and proportion of participants who achieved >5% body weight loss were also assessed. Results Four hundred seventy-five participants were enrolled among 51 HPs (29 Hispanic; 22 Somali). There was a statistically significant improvement in cardiovascular risk in the intervention group (n = 246) compared with controls (n = 229) at 6 months (0.4 [1.8] vs. -0.1 [1.7]; P = .03) that was not sustained at 12 months (0.5 [1.9] vs. 0.3 [1.8]; P = .38). There was a statistically significant higher proportion of participants who lost >5% of body weight in the intervention group compared with controls at 12 months (37% [15] vs. 18% [7.9]; P = .02). Reductions in weight and waist circumference in the intervention group compared with controls did not achieve statistical significance. Conclusion A social network intervention, delivered by lay HPs was feasible and resulted in a modest improvement of cardiovascular risk and clinically significant weight loss.Clinical Trial Identification Number NCT05136339.

BACKGROUND:Plasma ceramides are recognized biomarkers of cardiovascular risk; however, racial and ethnic differences in their levels, as well as their association with cardiovascular health (CVH) among African-American populations, remain insufficiently studied. OBJECTIVES:This study aimed to assess the association between ceramide scores and CVH, as well as atherosclerotic cardiovascular disease (ASCVD) risk, among African-American adults, and to compare ceramide scores between African-American and White adults. MATERIAL AND METHODS:We conducted a secondary analysis of 2 U.S. studies including African-American and White adults. Collected data encompassed demographics, behavioral factors (e.g., diet) and clinical measures (e.g., plasma ceramide levels). Atherosclerotic cardiovascular disease risk was assessed using the American College of Cardiology/American Heart Association (ACC/AHA) 10-year pooled cohort equations, while CVH was evaluated using the American Heart Association (AHA) Life's Essential 8 (LE8) scoring system. RESULTS:Fifty-eight African-American adults (mean age: 54.6 years; 67.2% women) and 1,103 White adults (mean age: 64.5 years; 52.1% women) were included. Compared with White participants, African-Americans had significantly higher prevalence of obesity, hypertension, diabetes, and hyperlipidemia, but similar ASCVD risk (12.8% vs 12.6%; p = 0.65). No significant associations were observed between ceramide scores and either LE8 or ASCVD risk in African-Americans. Ceramide levels differed by race/ethnicity, with African-Americans showing lower concentrations of 18:0 (0.08 vs 0.10 μmol/L) and 24:1 (0.91 vs 1.17 μmol/L) species compared with White adults (both p < 0.001). CONCLUSION:No association was observed between ceramide scores and CVH or ASCVD risk in African-American adults. Despite having a less favorable cardiometabolic profile, African-Americans exhibited lower ceramide levels than White adults. These findings suggest that ceramide scores may not accurately reflect cardiovascular risk in African-American populations.

Cigarette smoking is associated with numerous adverse pregnancy outcomes, due in part to polycyclic aromatic hydrocarbons and free radicals produced by combustion. Less is known about the impact of smokeless tobacco (ST) use during pregnancy. Alaska Native women report higher rates of cigarette and ST use during pregnancy than non-Native women. We investigated oxidative stress and hypoxia pathways in term placentae from Alaska Native women who did (commercial or iqmik; n = 10) or did not (n = 18) use ST during pregnancy. Despite substantial maternal exposure to nicotine, placentae of women who used ST had similar mRNA levels of antioxidant enzymes and markers of hypoxia compared to those who did not use tobacco. Although mRNA levels of angiogenesis markers vegf and vegfr2 were similar between groups, vegfr1 mRNA levels are increased in placentae of women using ST compared to women who did not use tobacco. Together these results suggest that, while ST use may not have as significant an effect on oxidative stress pathways in the placenta as cigarette smoking, an effect is present. It is not clear what this limited effect may have on the developing fetus.

ABSTRACT: Importance: Rural urban disparities in chronic disease prevalence are well established; however, the extent to which individual level socioeconomic status (SES) contributes to these disparities remains unclear. Objective: To examine the associations of rurality and SES with the prevalence of five most burdensome chronic diseases among adults. Design: We conducted a retrospective cross sectional study of adults across 27 Upper Midwest counties using the Expanded Rochester Epidemiology Project (E REP) medical record data linkage system to evaluate associations between rurality, SES and chronic disease prevalence. Prevalence of clinically diagnosed asthma, diabetes, hypertension, coronary heart disease, and mood disorders was identified from International Classification of Diseases ICD9/10 codes over a five-year period (2014 to 2019). Setting: Population based Participants: Adults over 18 years residing in the 27 E REP counties, excluding those missing rural urban residence status. Exposure: HOUSES index, an individual level measure of SES, served as the primary measure, while rurality based on Rural Urban Commuting Area (RUCA) codes 4-10 was the secondary measure. Main Outcome: Prevalence of the five clinically diagnosed chronic diseases was identified using ICD9/10 codes from 2014 to 2019. Mixed effect logistic regression models were used and adjusted for demographics and general medical examination receipt, to assess rural urban and SES differences for prevalence of each chronic disease. Results: Among 455,802 adults with available HOUSES index, 42.8% lived in rural areas, 53.8% were female and 87.4% were non-Hispanic White. In the unadjusted analysis, rural and urban populations showed comparable asthma and CHD prevalence, while mood disorders, hypertension, and diabetes were more common in urban areas. After adjusting for demographic factors and healthcare utilization, rural urban differences were no longer statistically significant, whereas SES remained strongly associated with all diseases in a dose response manner (e.g., adjusted Odds Ratio for hypertension (ref: HOUSES index Q4): 1.14, 1.27, and 1.42 for HOUSES index Q3, Q2, and Q1, respectively). Conclusions and Relevance: Individual level SES measured by the HOUSES index, was more strongly associated with chronic disease prevalence than rurality, supporting its integration into population health assessment and risk stratification. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was funded by NIH grant AG65639 and NIH grant R21HD 51902-2. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Institutional Review Board of Mayo Clinic gave ethical approval for this work. (Approval number:06-009617) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript

Although alcohol-related morbidity and mortality have increased disproportionately among U.S. women, utilization of evidence-based alcohol treatment (EBAT) remains lower among women compared with men. Rural women face additional barriers to treatment access, including stigma, caregiving responsibilities, geographic isolation, and limited availability of services. Social media platforms such as Facebook may offer a sustainable approach to delivering peer support and EBAT access to rural women. This study aimed to describe the development and community-engaged refinement of Women-Peer Supported Alcohol Treatment and Liaison (Women-PALS), a peer-supported Facebook intervention to promote alcohol use reduction and evidence-based alcohol treatment uptake among rural females with mild-to-moderate alcohol use disorder. Intervention content (Facebook moderator postings) was created and adapted from existing evidence-based resources. The development and refinement were informed by rural females with lived experience and other stakeholder feedback through a Community Engagement Studio (n=9) and a rural Community Advisory Board (n=12). Feedback was sought on message clarity, cultural relevance, inclusivity, and acceptability of intervention postings. Six posts were reviewed during the CE Studio; after incorporating CE Studio feedback, four were subsequently reviewed at the CAB meeting to elicit more in-depth feedback. Across both review stages, members consistently called for shorter, scannable content; authentic rural and demographically diverse imagery; reduced reliance on statistics or prevention-style messaging; and language that did not assume a specific parenting status, abstinence goal, or recovery stage. Content and imagery changed considerably across the two review stages. Members favored short, action-oriented posts and peer-voiced language over statistics and top-down framing. They also asked that treatment goals not presuppose abstinence, that content avoid assumptions about parenthood and family structure, and that imagery balance local authenticity against participant privacy. These preferences have not been tested against outcomes and require further testing. Next steps include pilot testing of feasibility, acceptability, and preliminary efficacy.

[This corrects the article DOI: 10.3389/fpubh.2025.1622237.].

Rural residents who smoke tobacco face higher smoking prevalence and unique barriers to cessation support, including limited access to evidence-based treatments and digital health resources. The transition to digital smoking cessation interventions offers potential solutions but may exacerbate health disparities without a clear understanding of digital equity barriers in these populations. This formative evaluation study aimed to examine the barriers rural adults face in accessing digital smoking cessation interventions and to map these barriers to a digital health equity framework, to inform strategies for equitable program design. We conducted in-depth, semi-structured telephone interviews between January and April 2023 with 30 rural adults who smoke cigarettes. Participants, who resided in the Midwest (Minnesota, Wisconsin, Iowa) were recruited from a three-arm randomized pilot trial of digital smoking cessation interventions. Interview topics included rural living experiences, healthcare access, and efforts to quit smoking. Data were analyzed using inductive thematic analysis, then mapped to Richardson et al.’s Digital Health Equity framework to identify multilevel barriers and opportunities for intervention. All 30 interview respondents were White, 67% were female, and the mean age was 51.9 years (SD 14.3). Three primary themes emerged: rural living conditions, healthcare access and navigation, and smoking cessation experiences. Major barriers to digital cessation support included unreliable internet connectivity, transportation and economic constraints, digital literacy challenges, lack of program personalization, social isolation, privacy concerns, and unaddressed mental health needs. Mapping to the digital health equity framework revealed nine modifiable barrier domains: digital infrastructure, economic inequities, transportation, digital literacy, adoption readiness, social isolation, privacy, integration of behavioral health, and navigation of government resources. Rural adults encounter multiple, intersecting barriers to digital smoking cessation interventions that span structural, psychosocial, and individual domains. Addressing these inequities will require comprehensive solutions, including broadband investment, integrated mental health support, hybrid (digital and in-person) program delivery, targeted digital literacy training, and policy changes to ensure affordable access to telehealth cessation services. Clinical Trials Registry (NCT05209451)

566 Background: Video telemedicine visits (VTVs) have the potential to overcome disparities in access to cancer care for many socially, geographically, and economically disadvantaged populations. Internet connectivity, digital literacy, and socioeconomic factors are traditionally cited as influencing VTV utilization. However, digital diffusion has occurred rapidly across several sectors, including healthcare, since the onset of the COVID-19 pandemic, and less is known about how these factors have evolved to influence VTV utilization behavior over this time. Through a qualitative approach, we aimed to: (1) explore the lived experiences of cancer patients who transitioned to VTV use as compared to those who persistently did not, and (2) identify similarities and differences between these two groups that could inform targeted interventions to support access and patient acceptance of VTVs in the setting of cancer care. Methods: During June 2024, we conducted semi-structured interviews with 24 patients (Mean age 71.3 years, range 42-88; female 50%) receiving ongoing, longitudinal cancer care at our academic medical center since July 2021 who had not used VTVs through at least October 2022. Using purposeful sampling, patients were equally divided according to VTV utilization behaviors defined as “transitioned users” (TU; i.e. those who transitioned to VTV utilization after October 2022) and “persistent non-users” (PNU). Transcripts were analyzed using a combined deductive–inductive thematic approach and categorized into themes of barriers and facilitators across three domains consistent with the COM-B model: capabilities (C), opportunities (O), and motivations (M). Results: TU patients frequently cited a reduction in travel and logistical considerations as a primary reason for uptake of VTVs. PNU patients frequently reported digital literacy barriers, particularly among older patients, as primary reasons for lack of VTV utilization. TU patients reported more experience and comfort in technical skills as compared to PNU participants. PNU patients also reported less frequent offering of VTV as an option by their care teams over time, implying they may have transitioned to VTV utilization if it had been offered with more regularity. Both study groups desired improved internet access and technical support to enhance (or, in the case of PNU patients, enable) VTV utilization. Conclusions: These findings suggest that multi-modal care delivery may best serve current patient populations, not requiring, yet offering VTV services as an adjunct to in-person care. Longer term, individual barriers to VTV use will also need to be addressed to further optimize access for patients who desire to incorporate this care modality.

Objectives: Modifiable lifestyle factors are associated with morbidity and mortality in hematopoietic stem cell transplant (HSCT) survivors. The aims of the study were to examine: (a) receipt of provider advice to change behaviors, (b) health behavior change, and (c) how modifiable lifestyle factors might cluster together. Methods: Patients within a large HSCT program completed a survey ( N =870) of lifestyle factors at pre-HSCT evaluation. The survey assessed self-reported adherence to American Cancer Society and HSCT guidelines for cancer survivorship in the year prior to a pre-HSCT evaluation. Lifestyle factors of interest were physical activity, fruit and vegetable consumption, tobacco use, alcohol use, and height/weight to calculate Body Mass Index (BMI). Results: Among patients not meeting all five guidelines (98%), 31% received provider advice to change. Between 10% and 42% reported healthy behavior change since diagnosis. Physical activity, fruit and vegetable consumption, and BMI were the most commonly clustered lifestyle behaviors. Conclusions: A considerable proportion of patients did not meet national guidelines for lifestyle factors. Results highlight an immediate opportunity to improve health care delivery and transplant outcomes via pre-HSCT lifestyle screening and implementation of effective health behavior change interventions.

Self-efficacy theory proposes that confidence to engage in a health behavior is associated with engaging in that specific behavior. Most research examining self-efficacy has been conducted with white young adult populations. This cross-sectional analysis examined the association of self-efficacy (i.e., confidence) for healthy eating and physical activity in two immigrant communities. At enrollment into the Healthy Immigrant Community study, a clinical weight management and cardiovascular risk reduction intervention set in southeastern Minnesota, 475 participants completed assessments about their confidence for healthy eating and physical activity. Measurements also included self-reports of dietary quality and intake, physical activity, quality of life, and biometric assessments. Study materials were available in English, Spanish, and Somali. In total, 450 adults (Hispanic/Latinx = 267; Somali = 183) completed measures at baseline and were included for analysis. Their average age was 45 years (range 18–87) and 59