Journal of Health Care for the Poor and Underserved

Brief communication COMMUNITY CANCER CONTROL IN A RURAL, UNDERSERVED POPULATION: THE APPALACHIAN LEADERSHIP INITIATIVE ON CANCER PROJECT Despite decreasing U.S. cancer mortality rates, progress toward meeting the Healthy People 2010 Goals for Cancer is being hampered by the nation's inability to deal effectively with the greater cancer burden being borne by certain vulnerable populations. These "special populations," defined as population groups at a higher-than-average risk of death, disease, and disability , include people with low incomes, older Americans, African Americans , Hispanics, Native Americans, and other ethnic populations. In recognition of the cancer risk among African Americans and Hispanics, the National Cancer Institute (NCI) took steps over the last two decades to improve cancer detection, treatment, and survival rates in these populations by establishing the National Black Leadership Initiative on Cancer (NBLIC) in 1986 and the National Hispanic Leadership Initiative on Cancer (NHLIC) in 1991. Both of these initiatives were developed to address the barriers to cancer prevention and control associated with race and ethnicity. At the same time, it was recognized that the relatively high rate of poverty in these populations was perhaps the most important barrier to their participation in cancer control activities.1"3 The NCI has stated that it also considers rural residents to constitute a "special population."4 Rural Americans tend to be older, poorer, less educated, and more likely to be uninsured than their urban/suburban counterparts.5 Rural communities have higher rates of chronic illness and disability and report poorer overall health status than their urban counterparts. Residents of rural areas generally have less contact and fewer visits with physicians and, in general , lower levels of preventive care.6 In addition to factors related to rural health status and practices, there are systemic factors related to rural life in general, for example, lack of public transportation and lower levels of other community services, that may also contribute to less-than-optimal cancer control . All of these risk factors are particularly evident in the largely rural and predominantly white population of Appalachia. Overview of the region Appalachia, as defined by the Appalachian Regional Commission, includes 399 counties in 13 states.7 According to the 1990 census, 20.7 million people, 8 percent of the U.S. population, live in Appalachia. Approximately 92 Journal ofHealth Care for the Poor and Underserved · Vol. 12,No. 1 · 2001 6 Appalachian Leadership Initiative on Cancer TABLE 1 SELECTED DEMOGRAPHIC CHARACTERISTICS AND HEALTH STATUS OF ALL APPALACHIA, RURAL APPALACHIA, AND THE UNITED STATES TOTAL TOTAL RURAL CHARACTERISTIC UNITED STATES APPALACHIA APPALACHIA Demographic and socioeconomic Census population, 1990 248,799,500 20,701,400 6,606,600 Per capita income, 1990 $18,746 $15,331 $13,077 Percentage unemployed, 1990 5.5 6.2 7.6 Percentage below poverty, 1989 12.8 14.8 18.7 Percentage of population with a high school diploma, 1990 75.2 68.4 60.0 Health status AU causes mortality, 1988 871.7 1,006.3 1,024.9 Heart disease mortality, 1988 204.9 245.5 256.2 Malignant neoplasms mortality, 1988 195.0 219.6 217.4 Population per patient care physician, 1990 516.4 680.8 1,144.6 Source: Couto RA, Simpson NK, Harris G, eds. Sowing seeds in the mountains: Communitybased coalitions for cancer prevention and control. Washington, DC: National Cancer Institute, 1994. (DHHS Pub. No. (NIH) 94-3779.) percent of the population is white, 1 percent Native American, and 7 percent African American. Of the 399 counties, 266 (67 percent) are categorized as rural, and a majority of these counties have been designated by the federal government as health professional shortage areas. In many of these counties, a significant segment of the population is poor, less educated, older, and less healthy than the national average. The level of literacy, roughly indicated by the grade of formal schooling completed, is generally lower in Appalachia than in most of the rest of the country.7 These socioeconomic problems are reflected in a variety of health care indices , including higher overall mortality, higher mortality from heart disease and cancer, and higher infant mortality, as shown in Table 1. Although Appalachian 1950-to-1980 breast cancer mortality rates are comparable...