Cancer disparities in the context of rurality: risk factors and screening across various U.S. rural classification codes

Kelly A. Hirko, Huiwen Xu, Laura Q. Rogers, Michelle Y. Martin, Siddhartha Roy, Kimberly M. Kelly, Shannon M. Christy, Kimlin Tam Ashing, Jean C. Yi, Marquita W. Lewis-Thames, Cathy D. Meade, Qian Lu, Clement K. Gwede, Julianna Nemeth, Rachel M. Ceballos, Usha Menon, Katie Cueva, Karen Yeary, Lisa M. Klesges, Monica L. BaskinKassandra I. Alcaraz, Sabrina Ford

Research output: Contribution to journalArticlepeer-review

16 Scopus citations


Purpose: Prior cancer research is limited by inconsistencies in defining rurality. The purpose of this study was to describe the prevalence of cancer risk factors and cancer screening behaviors across various county-based rural classification codes, including measures reflecting a continuum, to inform our understanding of cancer disparities according to the extent of rurality. Methods: Using an ecological cross-sectional design, we examined differences in cancer risk factors and cancer screening behaviors from the Behavioral Risk Factor Surveillance System and National Health Interview Survey (2008–2013) across rural counties and between rural and urban counties using four rural–urban classification codes for counties and county-equivalents in 2013: U.S. Office of Management and Budget, National Center for Health Statistics, USDA Economic Research Service’s rural–urban continuum codes, and Urban Influence Codes. Results: Although a rural-to-urban gradient was not consistently evident across all classification codes, the prevalence of smoking, obesity, physical inactivity, and binge alcohol use increased (all ptrend < 0.03), while colorectal, cervical and breast cancer screening decreased (all ptrend < 0.001) with increasing rurality. Differences in the prevalence of risk factors and screening behaviors across rural areas were greater than differences between rural and urban counties for obesity (2.4% vs. 1.5%), physical activity (2.9% vs. 2.5%), binge alcohol use (3.4% vs. 0.4%), cervical cancer screening (6.8% vs. 4.0%), and colorectal cancer screening (4.4% vs. 3.8%). Conclusions: Rural cancer disparities persist across multiple rural–urban classification codes, with marked variation in cancer risk factors and screening evident within rural regions. Focusing only on a rural–urban dichotomy may not sufficiently capture subpopulations of rural residents at greater risk for cancer and cancer-related mortality.

Original languageEnglish
Pages (from-to)1095-1105
Number of pages11
JournalCancer Causes and Control
Issue number8
StatePublished - Aug 2022


  • Alcohol
  • Cancer screening
  • Health disparities
  • Obesity
  • Physical activity
  • Risk factors
  • Rural
  • Smoking


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