Project Summary / Abstract A rural/urban disparity in mortality of 8% has been observed for lung, colorectal, prostate, breast, and cervical cancers. Physical inactivity is a modifiable cancer risk factor; physical activity (PA) is associated with risk reductions between 10-20% for breast, colon, and 6 other cancers. Further, rural residents report approximately 24% lower PA compared to urban residents. Primary care providers are a trusted source of health advice and they are in an ideal position to assess PA and advise patients regarding becoming and staying physically active. It is estimated that 84.3% of adults had an appointment with a primary health care professional in 2018. Thus, primary care encounters provide an opportunity to promote PA among the majority of rural adults, particularly among those with chronic disease profiles placing them at elevated cancer risk (e.g., overweight, obesity, diabetes). There is substantial evidence demonstrating the success of primary care providers promoting PA. Advice from providers is most effective in creating sustainable increases in PA when followed by phone or community-based support. The first challenge to implementing this type of approach in rural settings is the need for a methodology to train rural primary care providers to promote PA. We propose to apply the well validated ECHO Model to train providers toward the goal of communicating the health benefits of PA to patients, making clear recommendations, and connecting them to PA resources. Additional challenges to promoting PA in rural residents are provision of behavioral support and ensuring adequate opportunities for PA. These activities are beyond the scope of practice for primary care providers. We propose to partner with the Harrisburg YMCA to create a ‘MoveLine’ – logistically, the PA equivalent to the highly successful smoking cessation ‘QuitLine’. Providers will refer patients to the MoveLine, who will then counsel and connect patients to PA options available in their communities. Study staff and a community advisory board (CAB), in collaboration with the YMCA, Penn State Extension, and Penn State (PSU) faculty will work to identify existing PA options and to expand them as well. While intervening on the built environment is beyond the scope of this application, we acknowledge the import of environment on PA by rigorously evaluating its impact on outcomes. We propose a multi-level group randomized trial, including provider advice (patient), coaching and MoveLine (patient, social), and educating and promoting community PA opportunities and programs (community). We also evaluate the impact of the built environment on PA outcomes. We propose this work in collaboration with the Primary Health Network (8 Federally Qualified Health Clinics serving rural Pennsylvania), Penn State Health (8 clinics serving rural Pennsylvania), the Harrisburg YMCA, and Penn State Extension to increase PA levels in rural Pennsylvanians, toward the goal of reducing cancer risk. A total of 16 clinics will be randomized to the immediate or delayed treatment condition (2-3 providers nested within each clinic and 20 patients nested within each provider; 800 patients in total).

Public Narrative. Given the rural/urban disparity in cancer incidence and mortality and matching disparity in physical inactivity, the goal of the PA Moves Trial is to increase physical activity among rural Pennsylvanians. A multi-level intervention will address physical inactivity at the level of organizations (health care systems), communities (with assessment and promotion of community resources), and individuals (counseling from a physician and from a community source). This group randomized trial will partner with rural primary care clinics, the YMCA, and Penn State Extension to increase physical activity in rural Pennsylvania.