‘Rural-urban gap’ for cancer screening exists among women seen at community health centers
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Key takeaways:
- English proficiency key factor in urban community health centers screening for cervical cancer more than rural ones.
- The rural-urban disparity gap would have been larger had insurance types been equal.
English proficiency, income and insurance type could factor into why women cared for at rural community health centers screen for cervical less than those who receive health care services at urban community health centers.
Urban community health centers (CHCs) had a nearly 5% higher screening rate than rural CHCs before the COVID-19 pandemic, and the disparity increased during it, according to study results published in Cancer.
“Various factors contributed to the rural-urban gap in cervical cancer screening,” Hyunjung Lee, PhD, MS, MPP, MBA, principal scientist at the American Cancer Society, told Healio. “The top two contributors were proportions of patients with limited English proficiency and insurance coverage. The other factors included racial/ethnic composition of patients and the proportion of females aged 21 to 64 years, patients experiencing homelessness, and patients with incomes below the federal poverty level at the CHC level, as well as unemployment rate and primary care physician density in the CHC's catchment area.”
Background and methodology
Approximately 1,400 CHCs operated in the U.S. in 2019 and served roughly 30 million individuals, according to background information provided by researchers.
“CHCs mainly serve historically marginalized populations,” Lee said, including people of color, low-income populations and those who use Medicare or have no insurance.
Researchers wanted to determine if differences existed in cervical cancer screenings between urban CHCs and rural ones and, if so, the factors that contributed to them.
“Previous studies found that the prevalence of cervical cancer screening has been lower in rural areas compared to urban areas,” Lee said. “Little information is available on differences in cervical cancer screening between rural and urban CHCs over time.”
Lee and colleagues used the Uniform Data System to gather information on CHCs operational from 2014-2021 across the nation and the American Community Survey 5-year estimation (2014-2018) for sociodemographic characteristics. They defined the catchment area as a 20-minute driving distance.
Rural CHCs served a higher proportion of white (greater than 30%) and privately insured (nearly 10%) women. More than 40% of the patients that went to rural CHCs resided in the South, whereas urban CHCs had populations above 20% in the Northeast, South, Midwest and West.
Urban CHCs served a higher proportion of women aged 21-64 years, college graduates (more than 10% higher than rural) and more affluent areas (incomes more than $13,000 above rural).
Results and next steps
Rural and urban CHCs had similar cervical cancer screening numbers in 2014 and 2015 but shifted in favor of urban areas after that.
From 2014-2019, urban CHCs had up-to-date screenings rates of 43% vs. 38.2% for rural CHCs (P < .001).
“In 2016, the proportion of females up to date for cervical cancer screening was 36.2% in rural CHCs and 40.4% in urban CHCs,” Lee said. “In 2019, the percentage points difference was 5.5 — 46.3% in rural CHCs and 51.8% in urban CHCs.”
Screening dropped for both urban and rural CHCs during the COVID-19 pandemic, but the gap increased in 2021 (43.8% for rural vs. 50.1% for urban), Lee said.
A decomposition analysis determined English proficiency to be the primary factor for the disparity, accounting for 55.9% of the deficit from 2014-2019 and 65.6% in 2020-2021.
“A possible explanation for this finding might be greater access to language translation services in urban CHCs, as clinics serving a greater proportion of racial and ethnic minority groups are more likely to provide better translation services,” Lee said. “Increasing access to language translation services or adaptation of patient navigator interventions might improve completion and timeliness of cancer screening in CHCs and among patients with limited English proficiency, especially in rural CHCs. Insufficient funding remains a challenge to initiate and manage these activities, particularly in rural CHCs.”
Other factors that contributed to the disparity included the proportion of women aged 21-64 years (9.8% in 2014-2019; 38.1% in 2020-2021), race/ethnicity (24.6%; 43.2%) and patients with private insurance (14.8%; 76.9%).
The gap would have been greater had it not been for urban CHCs serving a higher proportion of uninsured patients and those insured through Medicaid.
That “counterbalanced” the gaps, Lee said.
“We also found that rural-urban differences in CHC cancer screening partly stemmed from catchment area-level characteristics, including lower primary care physician density, higher unemployment rate, and lower educational attainment (only before the pandemic) in rural areas, which could result in inadequate access to health care and misperceptions or limited awareness about cancer screening,” she added.
Study limitations included excluding a small percentage of CHCs due to missing data, not including other potential factors such as CHC practice size, proximity to the CHC, and using 2014-2018 catchment characteristics before and during the COVID-19 pandemic.
“Further research is needed to identify the factors that contributed to [the] larger drop and faster recovery of cervical cancer screening in urban CHCs compared to rural CHCs during the pandemic and widening of disparities in cervical cancer screening between rural and urban CHCs,” Lee said.
It would also be useful to evaluate long-term trends for disparities in cancer screening between rural and urban CHCs, she continued.
“More research is also needed on associations between race and ethnicity, immigration status, and cancer screening disparities at rural and urban CHCs using individual-level data, given the increased contribution of race and ethnicity and English language proficiency to these disparities at the CHC-level during the pandemic, Lee said. “The prevalence of cervical cancer screening in CHCs is generally lower than in the general population, underscoring the need for improving the utilization of cancer screening in both rural and urban CHCs.”
For more information:
Hyunjung Lee, PhD, MS, MPP, MBA, can be reached at hyunjung.lee@cancer.org.
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