Rural adults’ perceptions of nutrition recommendations for cancer prevention: Contradictory and conflicting messages

Figures & data

Figure 1. The virtual health assistant prototype. Can be customized to user preferences on features like race, gender, voice and appearance.

Table 1. Participant demographics.

Variable	n	%
Gender
Men	24	50%
Women	24	50%
Race
Black	31	65%
White	17	35%
Primary language
English	47	100%
Marital status
Single	12	25%
Married	23	48%
Divorced/separated	9	19%
Widowed	3	6%
Missing data	1	2%
Education completed
Grade 1–8	1	2%
High school graduate, technical college, some college	24	50%
College	11	23%
Postgraduate training	11	23%
Missing data	1	2%
Household Income
<$11,000	7	14%
$11,000–$30,000	9	19%
$30,001–$75,000	14	29%
$75,001+	10	21%
Missing data/prefer not to answer	8	17%
Health insurance coverage
Yes	48	100%
No	0	0%
Total	48	100

Table 2. Inter-rater reliability of all themes coded.

Theme	Kappa	% Agreement
Contradictory recommendations	1.00	100.00
Reactions to nutrition messages	0.81	99.14
Information gaps	0.78	97.67

Table 3. Themes, subthemes, and definitions.

Theme	Definition	Subtheme
Contradictory recommendations	Users perceive differences between colorectal cancer nutrition guidelines and nutrition information related to other health needs or conditions.	Contradicting health conditions. Nutrition recommendations for one health condition (e.g. heart disease) may contradict recommendations for a different condition (e.g. colorectal cancer).
		Contradicting sources. One source (e.g. a health care provider) provides nutrition information that is different from the information provided by a different source (e.g. a trusted relative).
		Contradicting cultural or dietary preferences. Nutrition recommendations contradict cultural ways of being and/or cultural norms or dietary intake preferences.
Reactions to nutrition messages	Comments show discomfort with messages prompting avoidance of certain behaviors (drinking alcohol, eating red/processed meat) or alternatively endorsing this framing.	Aversion to prohibitive recommendations. Reactance to cancer prevention nutrition messages prohibiting intake of specific foods or beverages, regarding potential negative impacts on credibility and/or behavior.
		Appreciation for guidance. Stated preferences for avoidance messages and/or expressed appreciation for a message that clearly said what behavior they should take (e.g. avoid alcohol, avoid processed meat, limit red meat) for colorectal cancer prevention.
		Desire for a balance of risk messages and positive messages. Stated preferences for positive messaging (e.g. risk-reduction or health promotion vs. avoidance) for cancer prevention or suggestions to insert positive messages.
Information gaps	Comments on missing information or information needed to understand colorectal cancer – specific risks, understanding nutritional health, or engaging in promoted behaviors.	Gaps in nutrition information. Requests for more nutrition information beyond the three colorectal cancer risk factors discussed by the virtual agent.
		Gaps in statistics and numbers. Requests for statistics related to colorectal cancer risk.
		Gaps in screening information. Requests for more information on colorectal cancer screening, risks, and modalities.

Table 4. Expansion of major themes and subthemes.

Theme	Subtheme	Exemplar
Contradictory recommendations	Contradicting health conditions	“I have different health issues … I’m not supposed to do a lot of seafood because I had breast cancer and I had chemo and radiation. I’m not supposed to eat a lot of things that I can’t peel, whether they’re fruits or vegetables. And then I may have a flare-up with that. I have lymphedema. So, there’s other things that I can’t eat that are really salty. My diet is limited to a lot of different things, so I don’t have many choices. So, like they [my doctors] said, eat the lunch meat, but don’t get it too salty.” (P2118, TA1, BF, prototype 3) “Just thinking about the alcohol, the other health issues are saying, like a glass of wine or beer a day is like good for like cardiac issues or something. So, it’s like. What do you want to focus on improving?” (P9916, WF, TA7, Prototype 3)
	Contradicting sources	“I love to eat liver because they say that’s high in iron, so I’m like, how could they say liver is high in iron and is red meat and you can get colon cancer from red meat?” … [This] made me question my, my inner self of eating liver now because it’s red, and I don’t want to get colon cancer. But I know my doctor says liver is good for you to eat, so I want to learn more about the liver. Why do they say that liver is red meat and why is it bad for us to eat it because of the colon, and why do they say it’s good for us to eat because it’s high in iron? (P2948, BF, FG12, prototype 2)
	Contradicting cultural or dietary preferences	“You know, I didn’t see the point about the wine being a problem, but I don’t see it as a problem. It’s biblical, Jesus drinks wine and it’s, it’s just, if you don’t do it in excess, then it’s supposed to be good for you. It’s good for your blood circulation. So, I don’t see it really as a problem, I would have to really research that and find out for myself is it, that doesn’t sound like correct, like correct information … You know, I’m probably wrong, but not as far as biblical, I’m, I’m not wrong.” (P7930, WW, FG3, Prototype 1)
Reactions to nutrition messages	Aversion	“It came across as, if you want to avoid colorectal cancer, you better not ever have another drink in your life. And you probably should never have another piece of red meat or processed meat. It seemed very one or the other … for people that do enjoy a cocktail from time to time, I think it may be a little off-putting that they’re gonna say, wow. Not me. I’m not going to go get screened. If one drink is going to do for me, I don’t want to know.” (P5533, WM, FG7, prototype 1) “When I heard him say don’t drink it at all … You’ve got to enjoy life. And yes, you can drink it. Drinking wine has nothing to do with getting colorectal cancer. Drinking a large amount of wine increases the risk, but it can’t give you colorectal cancer. It’s like saying don’t go outside because something might fall on your head. It’s extreme advice given that people have to enjoy their lives and yet try to live as long as they can.” (P3963, WM, TA5, prototype 3)
	Appreciation	“[limit red meat to] three servings a week? Hmm. Okay. Well, that’s nice to know. Thanks, Alex, that’s good information. That’s nice and encouraging. Four ounces of meat, huh. A deck of cards. Okay.” (TA13, BM, Prototype 4)
	Balance with positive	“Me personally, anything for my health. I don’t care who I talk to as long as it’s positive. It doesn’t bother me. I’m used to stuff like that. I don’t really care as long as it’s benefiting me because nobody can judge me.” (P464, WM, TA2, prototype 3)
Information gaps	Nutrition information	“I thought there would be some kind of, … pathway to resources for a dietary sample of a meal plan or something, what things you could [eat]. We know what things we couldn’t [eat], shouldn’t [eat], but it wasn’t explained, ‘eat more vegetables, have more fiber,’ … that type of thing, I thought would have been included.” (P9163, BF, FG13, prototype 2) “There are things that I might look it up on my own now that the issue has been raised or the question has been raised. Like, I didn’t know about pork. And again, I wondered, you know about, we don’t eat it, that much, but I wonder, you know if there was a way to eat it without the danger of it being contaminated by, or preserved, you know. Obviously, ham has a lot of salt in it, but I’m aware of preservatives.” (P6736, WF, TA9, prototype 3)
	Statistics and numbers	“Well, from my perspective, it might be interesting to see something along the lines of the relation between red meat or alcohol and the number of cases. Whether it’s a line graph or a bar graph, or something of that nature, just showing the relationship or interrelationship between the foods, the alcohol, and the number of cases that are diagnosed.” (P5533, WM, FG7, prototype 1)
	Screening information	“What I, what I think is missing is showing where colon cancer can start … is it the large intestine, the colon is at the small intestine? Might be useful to show where they go with a colonoscopy.” (P5533, WM, FG7, prototype 1) “So, I’m asking, oh, how often should I discuss this [screening] with my doctor?” (P7466, WM, TA14, prototype 4) “I would mention that there’s a change [in the screening age] because you’re more likely to get the person to listen to what you’re saying.” (P7466, WM, TA14, prototype 4)