The Relationship between Perceived Burden of Chronic Conditions and Colorectal Cancer Screening among Appalachian Residents

More than 1 in 5, or 72 million people, will be age 65 or older in the US by the year 2030.1 The unprecedented growth of the older population portends huge increases in the simultaneous occurrence of concurrent chronic health conditions, or multiple morbidity (MM),2 forcing providers and patients to face increasingly complex clinical and lifestyle decisions. These decisions include how to fit effective prevention efforts into disease management activities.3 Since those with MM are more likely than in years past to experience long life expectancy, there is utility in understanding the relationship between MM management and disease prevention. Insights on these relationships are particularly needed among traditionally underserved populations that face the highest rates of diseases and the lowest level of preventive care.4-6 This paper contributes to the emerging body of research by examining rural residents’ perceptions of their MM and the burdens of disease management in relation to colorectal cancer screening (CRCS). In general, rural residents tend to be older, poorer, less educated, are more likely to be uninsured, and suffer higher rates of disease and disability than their urban counterparts.4-6 Those who reside in rural Appalachia are particularly disadvantaged. Residents of Appalachian Kentucky (54 of 120 counties) are characterized by socioeconomic status indicators that are among the lowest in the United States.7-10 For example, in 2009, the per capita personal income in Appalachian Kentucky was $26,157 (compared to $39,635 nationally and $32,426 in the Appalachian region).7,8 The percentage of Appalachian Kentucky residents below poverty level was nearly double the national and Appalachian region averages (24% vs 14% and 16%, respectively),9 and 63% had graduated from high school compared to 82% in the US and 77% in the Appalachian region overall.10 There are fewer health care professionals, particularly specialists, in rural areas—yet many challenges exist, including transportation barriers, in rural locations.11,12 Consequently, Appalachian and rural residents often experience a more pernicious version of the nation’s health problems, including a higher MM incidence and colorectal cancer incidence and mortality.12-14 Based on the 2005 analyses of cancer registries of Kentucky, Pennsylvania, and West Virginia, the incidence of colon and rectal cancers in the Appalachian region was 44.1 and 17.6 per 100,000 population. The estimated local-stage colorectal cancer rate was low in comparison to the elevated colorectal cancer mortality rate in the region, suggesting modest utilization of CRCS among vulnerable rural and Appalachian residents.15 Thus, research efforts focused on this disadvantaged population are warranted given the combination of higher disease rates and fewer resources (on both individual and community levels) to manage existing conditions and prevent future disease. Research on etiology of the relationship between disease management and prevention, including CRCS, remains scant. On one hand, according to the surveillance hypothesis, individuals diagnosed with MM tend to have greater contact with the health care system and, consequently, an increased likelihood of being encouraged to receive a colorectal examination.16,17 Proponents of the competing demand hypothesis, on the other hand, speculate that MM competes for the time and focus of physicians and resources of the individual, thus undermining prevention efforts like cancer screening.18-20 Consistent with several observational studies,21-27 our recent study of this vulnerable population suggests that the overall presence of MM is associated with increased rates of CRCS.28 In this study, we aim to better understand the mechanisms that underlie CRCS among those with MM by examining individuals’ perceived burdens of chronic conditions, as proxies of their competing demands and coping abilities. We hypothesize that: (i) individuals’ perceptions are reflective of their actual MM burdens, and (ii) those who perceive their chronic conditions to constitute a burden may be less inclined to obtain screening.29