Hollows as sampling units for community-based participatory research in appalachia: The mountain air project

Background: In rural Appalachia, numerous geographical, historical, and socioeconomic barriers undermine health. We describe a community/academic partnership that leveraged local assets to implement an on-the-ground enumeration approach to enrolling participants, ultimately achieving an 82.1% response rate in a cross-sectional study of adult respiratory disease. We sought to discuss challenges addressed while establishing an accurate sample frame and a broadly accepted data collection procedure. Methods: Innovative and established epidemiologic methods (household enumeration) were combined within a community-based participatory research (CBPR) framework. Community members partnered with researchers to identify an appropriate, novel sampling unit: hollows. Members of two community advisory boards (CABs) provided extensive guidance, and community health workers (CHWs) administered surveys and spirometry from randomly selected households. Results: Most hollows (28/40) had participation rates of more than 80%. The sample (N = 972) was representative of the study area. Conclusions: Investigators seeking to recruit hard-to-reach populations may consider on-the-ground enumeration guided by community partners.