Rural Health Disparities in Skin Cancer Amplified Among Skin of Color

June 2024 | Volume 23 | Issue 6 | 480 | Copyright © June 2024


Published online May 10, 2024

doi:10.36849/JDD.8094

Rachel R. Lin BSa, Juwon Lee BSa, Andrea D. Maderal MDb, Scott A. Elman MDb

aUniversity of Miami Miller School of Medicine, Miami, FL 
bDr. Phillip Frost Department of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine, Miami, FL

Abstract
Limited studies explore the role social determinants of health have on urban-rural health disparities, particularly for Skin of Color. To further evaluate this relationship, a cross-sectional study was conducted on data from five states using the 2018 to 2021 Behavior Risk Factor Surveillance Survey, a national state-run health survey. Prevalence of skin cancer history and urban/rural status were evaluated across these social determinants of health: sex, age, race, insurance status, number of personal healthcare providers, and household income. Overall, rural counterparts were significantly more likely to have a positive skin cancer history across most social determinants of health. Rural populations had a higher prevalence of skin cancer history across all races (P<.001). Rural non-Hispanic Whites had greater odds than their urban counterparts (OR=1.40; 95% CI 1.34 - 1.46). The odds were approximately twice as high for rural Black (OR=1.74; 95% CI 1.14 - 2.65), Hispanic (OR=2.31; 95% CI 1.56 - 3.41), and Other Race, non-Hispanic (OR=1.99; 95% CI 1.51 - 2.61), and twenty times higher for Asians (OR=20.46; 95% CI 8.63 - 48.54), although no significant difference was seen for American Indian/Alaskan Native (OR=1.5; 95% CI 0.99 - 2.28). However, when household income exceeded $100,000 no significant difference in prevalence or odds was seen between urban and rural settings. Despite increasing awareness of metropolitan-based health inequity, urban-rural disparities in skin cancer prevalence continue to persist and may be magnified by social determinants such as income and race.

J Drugs Dermatol. 2024;23(6):480-484.    doi:10.36849/JDD.8094

INTRODUCTION

While urban-rural health disparities in skin cancer prognosis have been well-described, few studies evaluate the role of social determinants of health (SDOH) on urban-rural health disparities.1 Even fewer studies examine the impact of urban-rural differences on skin cancer prevalence among skin of color (SOC) patients. Among skin cancer research, more recent studies have shown that rural populations are more likely to present with later-stage melanoma in the vulnerable head and neck region.2 In addition to this, patients of color have an increased risk of mortality for both melanoma and non-melanoma skin cancers.3,4 The intersection of rural health disparities and SOC is an important but understudied frontier. Increasing awareness of skin cancer prevention and screening has significant health implications because the delay in skin cancer diagnosis, particularly for SOC patients, can lead to increased morbidity and mortality from a condition that has an excellent prognosis with early diagnosis and treatment. Therefore, we sought to examine the association between urban-rural status and skin cancer prevalence across the following SDOHs: sex, age, race, insurance status, number of personal health care providers (PHCP), and income.

MATERIALS AND METHODS

We conducted a cross-sectional study on the 2018 to 2021 data from the Behavioral Risk Factor Surveillance Survey (BRFSS). The BRFSS is an annual, telephone-based health survey in which adult participants are randomly selected to voluntarily participate through random digit dialing either through landline or mobile phone. Questions included in the BRFSS have been validated as moderately or highly reliable, and the survey provides an accurate and timely sample of individual health behaviors by state.5 Due to the participant selection process, the BRFSS does not distinguish by citizenship and includes answers from undocumented residents, legal residents, and U.S citizens. We selected data from California, Florida, Georgia, Michigan, and Tennessee as states with high numbers of agricultural workers per the United States Bureau of Labor Statistics.6  These states were chosen to ensure a fair distribution of urban and rural workers that may compromise the sample, and reflect a generalizable sample selected from different regions of the country.

The outcome of positive skin cancer history was determined by the answer "Yes" to the survey question "(Ever told) you had 
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