Bruce Behringer

Cancer mortality rates in Appalachia: descriptive epidemiology and an approach to explaining differences in outcomes.

Cancer is a leading cause of death in the Appalachian region of the United States. Existing studies compare regional mortality rates to those of the entire nation. We compare cancer mortality rates in Appalachia to those of the nation, with additional comparisons of Appalachian and non-Appalachian counties within the 13 states that contain the Appalachian region. Lung/bronchus, colorectal, female breast and cervical cancers, as well as all cancers combined, are included in analysis. Linear regression is used to identify independent associations between ecological socioeconomic and demographic variables and county-level cancer mortality outcomes. There is a pattern of high cancer mortality rates in the 13 states containing Appalachia compared to the rest of the United States. Mortality rate differences exist between Appalachian and non-Appalachian counties within the 13 states, but these are not consistent. Lung cancer is a major problem in Appalachia; most Appalachian counties within the 13 states have significantly higher mortality rates than in-state, non-Appalachian counterparts. Mortality rates from all cancers combined also appear to be worse overall within Appalachia, but part of this disparity is likely driven by lung cancer. Education and income are generally associated with cancer mortality, but differences in the strength and direction of these associations exist depending on location and cancer type. Improving high school graduation rates in Appalachia could result in a meaningful long term reduction in lung cancer mortality. The relative importance of household income level to cancer outcomes may be greater outside the Appalachian regions within these states.

Understanding the role of religion in cancer care in Appalachia.

Religion and spirituality may influence outcomes in cancer prevention and therapy and contribute to cancer disparities in deeply religious communities like the Appalachian region of the United States. Finding a method to bridge this division is essential to reduce cancer health disparities in this population. Religious beliefs may lead patients to seek less aggressive medical care, influence them to believe that the diagnosis of cancer is a mandate from God and cannot be managed by the healthcare system, ultimately compromising outcomes and contributing to disparities in healthcare in such communities. The significant role of religion and spirituality in decision making relevant to cancer care has been reinforced through clinical experience and conversations with Appalachian focus groups. The influence needs to be recognized, emphasized and handled appropriately by healthcare providers. Physicians in practice need to be able to relate to this dimension and work with local spiritual support systems to provide both a medical and spiritual prescription for the individuals journey through cancer care or prevention approaches.

Models for local implementation of comprehensive cancer control: meeting local cancer control needs through community collaboration.

The comprehensive cancer control approach is used by state, tribes, tribal organizations, territorial and Pacific Island Jurisdiction cancer coalitions to spur local implementation of cancer plans to reduce the burden of cancer in jurisdictions across the country. There is a rich diversity of models and approaches to the development of relationships and scope of planning for cancer control activities between coalitions and advocates in local communities. The national comprehensive cancer control philosophy provides an operational framework while support from the Centers for Disease Control and Prevention enables coalitions to act as catalysts to bring local partners together to combat cancer in communities. This manuscript describes multiple characteristics of cancer coalitions and how they are organized. Two models of how coalitions and local partners collaborate are described. A case study method was used to identify how five different state and tribal coalitions use the two models to organize their collaborations with local communities that result in local implementation of cancer plan priorities. Conclusions support the use of multiple organizing models to ensure involvement of diverse interests and sensitivity to local cancer issues that encourages implementation of cancer control activities.

The Tennessee Department of Health workshops on use of secondary data for community health assessment, 2012.

Community health assessment is a core function of public health departments, a standard for accreditation of public health departments, and a core competency for public health professionals. The Tennessee Department of Health developed a statewide initiative to improve the processes for engaging county health departments in assessing their community’s health status through the collection and analysis of secondary data. One aim of the Tennessee Department of Health was to position county public health departments as trusted leaders in providing population data and engaging community stakeholders in assessments. The Tennessee Department of Health’s Division of Policy, Planning, and Assessment conducted regional 2-day training workshops to explain and guide completion of computer spreadsheets on 12 health topics. Participants from 93 counties extracted data from multiple and diverse sources to quantify county demographics, health status, and resources and wrote problem statements based on the data examined. The workshops included additional staff development through integration of short lessons on data analysis, epidemiology, and social-behavior theory. Participants reported in post-workshop surveys higher degrees of comfort in interpreting data and writing about their findings on county health issues, and they shared their findings with health, hospital, school, and government leaders (including county health council members) in their counties. Completion of the assessments enabled counties and the Tennessee Department of Health to address performance-improvement goals and assist counties in preparing to meet public health accreditation prerequisites. The methods developed for using secondary data for community health assessment are Tennessee’s first-phase response to counties’ request for a statewide structure for conducting such assessments.

Evaluation of a Community Approach to Address Substance Abuse in Appalachia

The purpose of this study was to evaluate a conference based program designed to enable 26 Appalachian teams to create intervention plans to address substance abuse in their communities. In March 2006, 26 Appalachian teams attended a conference to address substance abuse in their region. Teams of four to seven stakeholders generated community plans. The teams were evaluated 8 months later using a framework based on an adaptation of the Health Belief Model. Team leaders participated in structured telephone interviews. Results of this study found that the most common benefit to promulgating plans was community support. The most indicated barrier was time. The majority of teams believed that their community was susceptible to substance abuse problems. The cues that were most responsible for action were public awareness campaigns that emphasized the problems associated with substance abuse. The common denominator for team success was the ability to recruit key stakeholders and the ability to integrate with other organizations. The results of this study suggest that substance abuse is a threat to the health of the region. More effort on the part of communities will be needed to solve this problem. It will not be solved by a single agency, philosophy or program strategy, but must include multiple stakeholder participation.