Publication Date
2025
Document Type
Dissertation/Thesis
First Advisor
Hughes, M. Courtney
Degree Name
Ph.D. (Doctor of Philosophy)
Legacy Department
School of Health Studies
Abstract
Background: Cancer remains a significant public health challenge in the United States, with persistent disparities in incidence, morbidity, mortality, and survival across socioeconomic, racial and ethnic, and geographic lines. Social determinants of health (SDOH) substantially influence these disparate health outcomes. Factors such as poverty, lack of health insurance, rural residence, and limited access to quality healthcare contribute to later-stage diagnoses and poorer outcomes. Robust measures like the CDC's Social Vulnerability Index can help quantify community-level disadvantages. Geographic disparities, particularly between urban and rural areas, further compound these challenges, with rural populations often experiencing a higher incidence of preventable cancers and greater overall cancer mortality due to barriers like distance to care and specialist shortages. Disparities also extend to end-of-life care, where preferences for dying at home are often unmet, especially for minority and rural cancer patient populations, and to specific cancer types like liver cancer, where multifactorial, socially patterned risk factors necessitate population-level assessment tools.
Purpose: This dissertation sought to explore a thorough understanding of how socioeconomic vulnerabilities, geographic contexts (urban versus rural), and demographic factors drive cancer disparities across multiple points of the care continuum, including risk, incidence, mortality, and end-of-life experiences, and to develop actionable, data-driven tools to guide effective and targeted public health interventions.
Methods: This research utilized a sequence of three quantitative studies. Study 1, an ecological cross-sectional study, analyzed national county-level cancer outcomes and SDOH using multivariable regression to examine the association between social vulnerability, geographic location (urban/rural), and overall cancer incidence, mortality, and mortality-to-incidence ratios (MIR). Study 2, a retrospective study of individual-level national death certificate data (National Vital Statistics System), employed descriptive statistics and logistic regression to identify geographic and racial/ethnic differences in the place of death among cancer patients. Study 3, a Liver Cancer Population Risk Index (LC-PRI), was developed by synthesizing evidence on modifiable risk factors through literature reviews and meta-analyses, integrating county-level prevalence data, and validating the index by correlating LC-PRI scores with observed county-level liver cancer incidence and mortality rates.
Results: Study 1 found a significant association between higher county-level social vulnerability and adverse cancer outcomes, particularly increased MIR, with rural areas generally exhibiting poorer outcomes. Study 2 revealed geographic and racial/ethnic disparities in place of death; notably, rural residents and certain minority groups had lower utilization of hospice facilities and differing patterns of hospital versus home deaths compared to urban and White populations, respectively. Study 3 successfully developed and validated the LC-PRI, demonstrating its ability to identify geographic areas with higher cumulative risk for liver cancer, which correlated significantly with observed county-level liver cancer incidence and mortality rates.
Conclusion: This dissertation provides compelling evidence that socioeconomic vulnerabilities and geographic context are profound drivers of cancer disparities across the continuum, from risk and incidence to mortality and end-of-life experiences. The findings underscore the need to address upstream SDOH, utilize vulnerability and risk assessment tools like the SVI and the novel LC-PRI for targeted resource allocation and interventions, strengthen rural and underserved healthcare infrastructure, and promote culturally competent, fair, and accessible end-of-life care. An integrated, multilevel approach that translates comprehensive disparity understanding into actionable public health strategies is crucial for achieving improved health outcomes for all and reducing health disparities.
Recommended Citation
Guo, Lei Raymond, "Where You Live and How You Die: Social Vulnerability, Geography, and Inequities in Cancer in the United States" (2025). Graduate Research Theses & Dissertations. 8115.
https://huskiecommons.lib.niu.edu/allgraduate-thesesdissertations/8115
Extent
176 pages
Language
en
Publisher
Northern Illinois University
Rights Statement
In Copyright
Rights Statement 2
NIU theses are protected by copyright. They may be viewed from Huskie Commons for any purpose, but reproduction or distribution in any format is prohibited without the written permission of the authors.
Media Type
Text
