U.S. Rural-Urban Breast Cancer Screening Inequities: Leveraging Contextual Heterogeneity to Identify Solutions

Abstract

Breast cancer screening is a critical tool for early detection and prevention, yet rural populations in the U.S. face persistent inequities in access and uptake. Existing research often treats rural communities as a monolith, overlooking contextual differences that may shape health outcomes. This dissertation unpacks rural settings' multidimensional characteristics to better understand and address inequities in breast cancer screening. Drawing on the Community Capitals Framework and guided by Public Health Critical Race Praxis, this mixed-methods dissertation examines how varying rural contexts influence health behaviors and aims to develop tools for identifying place- and equity-centered intervention pathways. The first paper addresses the limitations of standard rural definitions by developing a novel typology of rurality at the census tract level using latent class analysis (LCA). To do so, we compiled nationally representative data across seven domains of community capital — natural, cultural, human, social, political, financial, and built — for all rural census tracts in the U.S. (n=15,643). The LCA identified four distinct rural typologies: Outlying, Developed, Well-Resourced, and Adaptable Rural. These rural types varied in community capital profiles and social vulnerability, underscoring the need for more nuanced definitions in population health. Paper two builds from these findings using qualitative methods to explore how contextual heterogeneity shapes screening behaviors in two rural types, Outlying and Well-Resourced, in South-Central Washington State. Community focus groups identified how barriers such as gender norms, seasonal labor, geographic isolation, and uneven resource distribution emerge across community capitals. Though both rural types reported barriers, their underlying mechanisms differed. Four key themes emerged: seasonality and resource prioritization; distance as a resource-dependent barrier; gender roles and healthcare access; and race and place shaping resource distribution. These findings suggest that targeting barriers that cut across mechanisms, such as cultural and social barriers, may lead to larger impacts than uniform interventions. The third paper introduces a prototype agent-based model (ABM) simulating breast cancer screening behavior across the four rural types identified in Paper 1, using qualitative findings from Paper 2 to inform model rules and contextual parameters. Simulated agents represent screening-eligible women with four characteristics: remoteness, racial identity, poverty status, and insurance status. We found that screening behavior evolves based on these attributes and social network influence. Results show that insurance, poverty, and social connectivity most strongly shape outcomes. Social connectivity improved screening across all groups but had a more pronounced impact among insured and higher-income agents, suggesting connectivity may amplify access where structural barriers are lower. As a theory-building tool, the model clarifies which contextual factors may influence screening and provides a platform to test targeted multilevel interventions before implementation. Together, these studies challenge the notion of rurality as a singular category and propose an equity-centered framework for understanding how place-based differences shape health. By integrating quantitative, qualitative, and simulation methods, this dissertation advances efforts to design interventions aligned with the unique strengths and needs of diverse rural communities. These findings highlight the importance of context-specific, justice-oriented approaches to achieving health equity in cancer prevention and control.Population Health Science