Where science and communities meet: A comparative case study of strategies to increase cancer screening among rural residents.

Background: Cancer accounts for one in every four deaths in the U.S. Screening to detect cancer at an early stage when more favorable treatment outcomes are possible can reduce morbidity and mortality from cancer. Rural populations have some of the highest cancer incidence and mortality rates in the nation but particularly low screening rates. Understanding which strategies are effective for increasing screening in rural areas is essential to reduce this disparity; however, there is little evidence of best practice strategies to increase cancer screening among rural residents. 

Purpose: The goal of this study was to assess and model best practice strategies for promoting cancer screening among rural populations. 

Methods: The study used a retrospective comparative case study design and mixed methods, guided by a conceptual framework based on Social Ecological Theory and the Community Partnership approach to health promotion to assess strategies for promoting breast, cervical, colorectal, prostate, and skin cancer screening during 2006-2008 and related outcomes. Key informant telephone interviews (n=40) were conducted with community-based cancer coalition members (n=23) in three Appalachian states and cancer center or university-based community outreach program staff (n= 17) in ten Appalachian states that serve rural populations. Key informants provided review and editing of their transcribed interview. Document review conducted of program websites, two existing program databases, and published literature was used to supplement the key informant data. Content analysis, pattern matching, and triangulation of qualitative data were conducted and descriptive statistics used for case descriptions and frequencies of screening strategies. The data were compared against evidence-based strategies recommended by the U.S. Preventive Services Task Force, Behavioral Risk Factor Surveillance System (BRFSS) cancer screening data, and the study's conceptual model. The findings were then used to construct a best practices model of rural cancer screening strategies. 

Results: Both cancer center-academic outreach programs and coalitions used strategies to address multiple physical (environmental), structural, sociocultural, individual, and programmatic barriers in their rural communities with demonstrated screening success. Coalitions used more evidence-informed approaches but were less cognizant of health behavior theories underlying such strategies; cancer center-academic programs used more theory- and evidence-based programs and described them by name. Other 'best screening practices' found include cancer screening education for the public, community involvement in program development and delivery, primary care clinics and mobile screening vans as intervention sites, 'piggy-backing' programs onto other community events, targeting multiple conditions in a health fair-type setting, and multiple component interventions. 

Conclusion:Cancer screening in rural communities can be increased by strategies that are evidence- and theory-based, involve community stakeholders in program development and implementation, and address multiple barriers to cancer screening. Areas for future practice and research include strategies and programs that aim to increase physician recommendation of screening; increased, ongoing dialog and feedback between community-based and cancer center/academic outreach programs; recognition and testing of strategies developed by coalitions shown to effectively increase screening; systematic integration of community-academic partnerships into the mission of medical/ academic institutions; sustained funding for rural cancer screening programs and mobile vans; and future study and analysis of power and class issues that persist in Appalachia.

Contributions:This research and the proposed best practices model help fill an important gap in rural cancer prevention and control, which may ultimately contribute to reducing cancer disparities in Appalachia and other rural areas.