Cancer Disparities in Rural Areas: The Impact of Social Determinants of Health and Access Challenges

In a Pharmacy Times^®, interview, Nathan Vanderford, PhD, MBA, Associate Professor of Toxicology and Cancer Biology in the College of Medicine at the University of Kentucky, discussed cancer disparities and social determinants of health experienced by patients with cancer in rural communities, using his home state of Kentucky as a case study. He sheds light on the various factors, such as limited institutions and resources, that prevent health care professionals from providing the care that many patients need.

Pharmacy Times: Can you shed some light on your session at the NCODA Fall Summit?

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Nathan Vanderford, PhD, MBA: My session is, in general, about cancer disparities and the social determinants of health that drive those disparities. But more specifically, I'm going to touch on the cancer disparities that exist in Kentucky as sort of a case study for those cancer disparities that exist in rural populations.

Pharmacy Times: How prevalent is the issue of cancer disparity and who is most affected?

Vanderford: Cancer disparities are a lot more common than I think people realize so I would go so far as to say that that many of us exist in populations or groups that experience some level of cancer disparity. So most prevalent, I would say black populations in the US have significant cancer disparities, they have much higher rates of cancer than other populations. Beyond that, Native Americans, Alaskan natives, have higher rates of cancer. And then, of course, rural populations and then gender minorities have higher rates of cancers. Also men have higher rates of cancer than do women. So, men exist in some regard in a cancer disparity group, so they're highly prevalent.

Pharmacy Times: What barriers do rural populations, both patients and medical institutions or practitioners, face in regard to cancer care access?

Vanderford: What comes immediately to mind in terms of the barriers that rural patients face is the access to care. There's just not as many health care facilities in rural populations. You can't drive down the road as easily to get to a health care facility and a rural population. And then beyond that, there's transportation and distance barriers if you think about how far patients from rural communities have to go to get care. In terms of transportation, it might be an issue of, maybe people don't have a reliable mode of transportation to drive an hour or an hour plus to take care.

Beyond that, there's often financial constraints. People that live in rural populations often have higher rates of poverty or they're uninsured or underinsured, and so that creates barriers. There's also limited awareness of cancer risk factors, health behaviors, the social determinants of health and how that relates to cancer risk those that awareness is lower in rural populations. Then there are cultural factors. There are aspects of people's culture, that while important to the culture, beautiful to the culture, it can put people at higher risk for getting cancer.

If you think about institutional level, there's barriers in terms of facilities and infrastructure that exist in rural populations. There are shortages of health care providers? There are some communities in rural areas, Kentucky being an example, where there are zero primary care doctors in some of these communities. So, there's significant healthcare shortages, and then that relates to limited services. If you, if you have fewer health care providers, you just don't have specialty services, for example. And then there's a lot of pressure and constraint on the health care workers that are there. There are few providers for a good number of people that are there, so they're really stretched in terms of the time that they spend with the patients that they do have. So, there's a number of barriers that exist that really put rural patients at greater risk.

Pharmacy Times: Many medical students leave their rural communities for larger, more accredited educational institutions and never return. What impact does this have?

Vanderford: As part of my talk, I'm going to address this a bit. So, I direct a cancer training program that's specific to students, undergraduate and high school students from Eastern Kentucky. And Eastern Kentucky is where there are very high rates of cancer, significantly higher than the rest of the state. So, in 2016, I developed a cancer training program to help address this issue. The goal is to recruit students from the area, get them motivated, prepared to pursue cancer careers, and then hopefully they either go back to their communities in Eastern Kentucky, or they practice somewhere like Lexington, which is in central Kentucky, and they are connected with their communities, and help can help care for patients from those communities, and patients from those communities would be better connected with them, have more trust understanding of them, because they're from those areas. We've had great outcomes. I'm going to present some outcomes at the conference, but there's still a way to go in terms of getting those students fully trained and ready to be practicing health care providers.

Pharmacy Times:How can advocacy help overcome the social determinants of health preventing patients from receiving care?

Vanderford: Advocacy can do a number of things. One thing that immediately comes to my mind is raising awareness and providing more education to individuals that live in rural communities. So, in terms of awareness, it's awareness and education specifically on that population and helping those people better understand cancer risk and modify modifiable behaviors, those types of things. But then it's also awareness and education to people outside of those communities so that they can understand those problem, and then if they're in a position of power and have means to help address those problems they can.

One of those might be policy makers, right? So, there's opportunities for lawmakers to work on policies at the local, regional, state, even national level, to help address some of these issues that rural communities experience. Advocacy could also help in terms of partnerships, in terms of private, public partnerships or innovative community-based partnerships that could help transportation as an example. So, if you have community partners that could help provide transportation to rural patients who struggle with not having transportation that can help address the issue of getting them to locations where they can't get themselves. And then there's a lot of a lot of individual empowerment that can come with advocacy, in terms of empowering patients to help address their own needs and the needs that they see for cancer patients like them. So, I think advocacy can play a big role.

Pharmacy Times: What is needed to expand cancer care access in rural communities?

Vanderford: This question on what is needed to expand cancer care, it ties in a lot with the other questions that you've asked. So, I think there needs to be more infrastructure in rural communities, more hospitals, more clinics, more primary care. And that's challenging, because it's an issue of there's just not as many people so in terms of cost benefit. It's unfortunate that you have to think about the cost benefit of having specialty physicians or special specialty healthcare providers in rural communities, but certainly it's greatly needed and could help address many of these issues.

Some help could be more innovation. There could be more leveraging of telehealth for rural populations that could really help address the transportation barriers and the distance that people have to travel. So, if they don't absolutely have to travel an hour and a half to a clinic, they could just do a telehealth appointment and get a lot of the same benefits.

And then, there's a lot of work that could be done in terms of workforce development. So, programs that could really help focus training healthcare providers to specifically go to rural areas, specifically understand the issues that exist in rural areas.

There are opportunities for the government policy level changes or initiatives that could help in terms of work. First, workforce development, specifically focused and rural areas. And then, the community within could also play a role in community-based approaches. Community based participatory research has really found several different ways that the community can really be involved in change, and so there are some evidence-based practices that could be put into place so that could be leveraged to help rural populations.