As defined by the Appalachian Regional Commission (ARC), the US Appalachian region consists of 420 counties in 13 states stretching from the southern tier of New York through the hill country of northern Mississippi. This region is characterized by high poverty, low educational achievement, and a scarcity of health professionals. Rural areas in the Appalachian region have higher death rates for all cancers, lung cancer, and cervical cancer compared with US rates (1-3). A study of 3 Appalachian states (West Virginia, Pennsylvania, and Kentucky) reported that the incidence of cancers of the lung, colon, rectum, and cervix were significantly higher than the nationwide rate (4). In another multistate study of Appalachian populations, the Appalachia Community Cancer Network reported lower rates of cancer screening behaviors, higher cancer incidence and death rates, and a higher proportion of late-stage cancer diagnosis among Appalachian populations (5). In 2004, Halverson et al reported that cancer death rates in Appalachian counties were higher than in non-Appalachian counties in 10 of the 13 Appalachian states (6).

In an effort to address these cancer disparities, in 2006 a grant was awarded to East Tennessee State University (ETSU) through an interagency agreement between ARC and the Centers for Disease Control and Prevention (CDC) National Comprehensive Cancer Control Program (NCCCP). NCCCP supports state comprehensive cancer control (CCC) coalitions by providing grants to states, territories, and tribal organizations. CDC encourages the CCC coalitions to promote statewide cancer control activities by implementing state cancer plans. The goal of the CDC-ARC grant is to identify strategies that will increase involvement of Appalachian communities in the local implementation of CCC activities.

In October 2007, ETSU sponsored the Community Cancer Control in Appalachia Forum to develop a plan to implement the grant. We invited approximately 30 people, including leaders from CCC coalitions from the 13 Appalachian states and representatives from Appalachian community organizations who were recognized as providing outstanding local cancer control activities by the CCC coalitions, CDC, and ARC. These partners included local cancer patient support groups, organizations providing cancer education to the local community, and individuals and groups that raised funds to provide free cancer screenings to uninsured and underinsured people.

We created an agenda for the forum to ensure that attendees participated in several group process sessions designed to meet 3 objectives: 1) provide an opportunity for state leaders, CCC coalition members, and community groups in Appalachian states to develop cancer control activities cooperatively; 2) define state Appalachian cancer disparities; and 3) identify unique Appalachian cultural place-based characteristics that influence participation in statewide CCC coalitions. Presenters at the forum introduced Appalachian cultural cancer beliefs that included a strong sense of community, a mistrust of numbers (eg, cancer rates), and an individual involvement in cancer control activities only when encouraged through personal, not organizational, relationships (7,8).

On the basis of findings from the forum, a project advisory work group that included ARC, CDC, and CCC coalition representatives recommended a minigrant approach to promote partnerships between CCC coalitions and local Appalachian community cancer organizations. From this recommendation, we developed a request for proposals (RFP) strategy to provide funding for the following activities: 1) replicate the 2007 forum in local Appalachian communities and 2) conduct a shorter, data-driven roundtable to discuss cancer data in the local Appalachian community. This approach builds on coalition theory and lessons learned in promoting collaboration between communities and external resources (9,10).

In this article, we describe the minigrant model strategy that supported forums and roundtables. These events brought together state CCC coalitions with groups and individuals in Appalachian communities to learn about state cancer plans and encourage local implementation of cancer control activities.

ETSU released the RFPs for the forums and roundtables in March 2008, for a June 30 deadline, and re-released them in December 2008 on a first-come, first-served basis until all funds were allocated. The RFPs were distributed through the project advisory work group, NCCCP, CCC coalitions, consultants, the ARC Health Policy Advisory Council, and directly to all 13 states' CCC coalitions. Further circulation occurred by word of mouth. The RFPs were also posted to the project website. ETSU project staff reviewed all submitted proposals using guidelines agreed on by ETSU, NCCCP, and ARC. To receive financial support for a roundtable or forum, CCC coalitions and Appalachian community organizations were required to identify common interests, plan their cooperative events, and share minigrant resources. Forums were more formal and involved than roundtables (Box).

Twenty-eight events in 10 Appalachian states were conducted between September 2008 and June 2010. A total of 622 people attended these events; 82% of attendees classified themselves as Appalachian residents. Only 22% were members of the state's CCC coalition.

The ARC-CDC interagency agreement funding, the first to focus on CCC activities in the Appalachian substate regions, had several strengths and limitations. A strength of the minigrant program was the determination that much can be accomplished with a small investment. The minigrant process offered small budgets but produced a long list of outcomes. Most events required substantially less money than was estimated in the proposals. This finding suggests that seed money can promote a successful process leading to collaboration between state CCC coalitions and Appalachian community leaders and organizations to conduct cancer control activities.

Another strength was the prescriptive forum agendas and roundtable engagement process. Several organizers reported strong approval of the established methods and reported that having these methods in place was a key aspect of their success.

As anticipated, CCC coalitions indicated an increase in membership and in speakers and participants for subsequent events. Participants from the Appalachian substate regions left the events with new information and ideas that they were able to share with their communities.

Perhaps the most important acknowledged strength of these events was the networking that occurred. We were reminded of the importance of getting people together face-to-face. Similarly, the importance of local Appalachian community cancer partners meeting state CCC coalition personnel in their own communities cannot be overstated. CCC coalition personnel had renewed respect for the disparities faced by people living in Appalachia. Holding events in recognized Appalachian sites was important.

The successful best practices that were presented at the forums were required to be from the Appalachian region. A few states were able to identify successful local programs in their substate Appalachian region, and others identified state programs that are locally implemented. Some states presented state programs that were not implemented in the Appalachian region but for which more Appalachian visibility and participation were desired. Although participation in the forums provided state and Appalachian regional visibility, states fell short of the original goal of searching for and highlighting local successful cancer control programs. Minigrant recipients who developed new partnerships in the Appalachian substate region were able to identify successful cancer control programs with which they had been unfamiliar, and we hope that this exercise improved state awareness.

The initial time frame for responding to the RFP and conducting the roundtables and forums was during the states' annual NCCCP program reporting and grant revewal submission deadlines. Programs found it difficult to respond to the RFP and subsequently conduct the roundtables and forums. However, CDC and ARC allowed a second announcement of the RFP that better accommodated the NCCCP state program schedule. For future minigrant projects, we intend to release the RFP announcement to accommodate the program deadlines of the NCCCP state programs, which will also allow the respondents to incorporate the minigrant plans into their fiscal year schedule and provide more time between the announcement and expected start dates of the events.

In addition, staff turnover in local Appalachian community organizations created difficulties with implementation of some events, even after grant awards were made. In particular, the timing of this process coincided with tightened budgets and reduced staff nationwide for many cancer organizations.

Presentation of data excites local communities, invites comparison, and focuses the question "Why are we different?" However, several roundtables did not allot sufficient time in their agendas to identify differences in local cancer prevention and treatment resources that were perceived to affect cancer outcomes. The use of data prepared from regional and state sources had mixed results. Some grantees attempted to locate more up-to-date state data but were unsuccessful. However, some states were able to analyze their state's cancer data to compare Appalachian with non-Appalachian regions for the first time. The roundtable guidelines were less prescriptive than the forum guidelines and allowed for greater local creativity in agenda development and use of state or other cancer data. This flexibility resulted in some roundtables allotting too little time for a sufficient cancer data presentation and discussion. Future efforts should more specifically require discussion and participant interaction in response to the presentation of data.

Allowing local grantees to fully manage the event did not ensure administration of evaluations. Not all evaluation forms were completed. The best return rates were at events that used small incentives or reminders, or where event staff stood at the door collecting evaluations as people left.

The CCC coalitions were able to find willing, eligible applicants to be fiscally responsible and accountable for these grants. However, there was no uniform manner in which the coalitions and their partners became applicants for the minigrants, which resulted in some delays and confusion about sponsorship. Therefore, it is important to be aware of contractual requirements when designing a minigrant process.