New Hampshire and Vermont Cancer Center Catchment Area Population Health Needs Assessment

Problem: From 2011 to 2015, the cancer incidence rates in New Hampshire (479.7 new cases per 100,000) and Vermont (449.0 per 100,000) exceeded the national average 441.2 per 100,000.^1,2 Mortality rates also exceeded the national average.¹ In addition, cancer death rates in rural areas are higher than in urban areas, with barriers such as a lack of broadband internet connectivity and a lower concentration of physicians potentially limiting access to information and services related to cancer prevention, early detection, and treatment. Prior to this initiative, access issues specific to New Hampshire and Vermont had not been documented. 

¹National Cancer Institute and Centers for Disease Control and Prevention. (2019a). State Cancer Profiles. Retrieved from https://bit.ly/2OvwAfy. 

²National Cancer Institute and Centers for Disease Control and Prevention. (2019b). State Cancer Profiles. Retrieved from  https://bit.ly/2KcApRA.

PSE Change Solution: The catchment area of the Dartmouth-Hitchcock Norris Cotton Cancer Center (Norris Cotton), located in Lebanon, New Hampshire, includes New Hampshire and Vermont, with about 40% of the catchment area’s population living in rural areas. Norris Cotton conducted a survey-based population health needs assessment to identify the cancer prevention and control needs of its catchment area, and to determine whether needs varied significantly between rural and urban residents. Different versions of the same survey were conducted via phone and online and assessed residents’ cancer-related attitudes, beliefs, and knowledge; access to cancer care and other health services; whether and how they access cancer-related information; and whether and how they’d like to receive cancer-related information. 

Main findings were that (1) while most survey participants reported their understanding that preventive measures can be taken to reduce their risk of developing cancer, most also indicated that it is hard to know what those preventive measures are; and (2) when hen survey participants were asked to identify information channels that they would be ‘extremely likely’ or ‘likely’ to use to access cancer-related information, the top ranked source for participants from all four Rural-Urban Community Areas (RUCAs)* was “doctor”. This regional survey of cancer communications, beliefs, and knowledge can help target outreach, education, and intervention activities related to cancer prevention and control in New Hampshire and Vermont 

*Geographic areas were classified into four RUCA categories: Urban, Large Rural, Small Rural and Isolated Rural (University of Washington Rural Health Research Center). 

Read the Entire Example

Problem 

For the five-year period 2011-2015, New Hampshire’s cancer incidence rate of 479.7 new cases per 100,000 significantly exceeded the national average of 441.2 per 100,000 (National Cancer Institute [NCI] and Centers for Disease Control and Prevention [CDC], 2019a). For the same period, the cancer incidence in Vermont was 449.0 per 100,000 (NCI and CDC, 2019b). 

From 2011-2015, New Hampshire experienced 164.9 cancer deaths per 100,000 (NCI and CDC, 2019a), while Vermont’s mortality rate was 167.6 per 100,000 (NCI and CDC, 2019b). The rate in both states exceeded the national average of 163.5 deaths per 100,000 (NCI and CDC, 2019a). 

Generally, people living in rural areas experience lower rates of new cancer cases than urban areas, but the rural cancer death rate is higher (CDC, 2018a). New cases of lung cancer, colorectal cancer and cervical cancer occur more frequently in rural counties (CDC, 2018b). 

In the U.S., some rural areas still lack broadband internet connectivity (Greenberg-Worisek et al., 2019) and have a lower concentration of primary care (Rabinowitz, Diamond, Markham, & Paynter, 2001) and cancer specialists (Kirkwood, Bruinooge, Goldstein, Bajorin, & Kosty, 2014). Therefore, rural residents may have limited access to information and services related to cancer prevention, early detection, and treatment. However, recent research reviewing the impact of rurality on cancer screening, cancer treatment and follow-up, and outcomes found inconsistent results (Charlton, Schlichting, Chioreso, Ward, & Vikas, 2015). 

Specific access issues in Vermont and New Hampshire had not been previously documented, however. 

PSE Solution 

During 2017 and 2018, the Dartmouth-Hitchcock Norris Cotton Cancer Center (Norris Cotton), an NCI-Designated Comprehensive Cancer Center, conducted a survey-based population health needs assessment to identify the cancer prevention and control needs of its catchment area of New Hampshire and Vermont. Because about 40% of the catchment area’s population lives in rural areas, the needs assessment also sought to understand whether needs varied significantly between rural and urban residents and whether information about cancer should be distributed using different communication channels to reach each audience (United States Census Bureau, 2018; University of Washington Rural Health Research Center, n.d.). 

To thoroughly understand the cancer-related needs of Vermont and New Hampshire residents and identify opportunities to address those needs, the Norris Cotton research team developed two versions of the same survey – one focused question set conducted over the phone and another longer question set conducted online. A total of 1,717 adults from New Hampshire and Vermont participated in the survey, with about 46% of the participants being from rural communities. 

Actions/Results 

Actions 

The needs assessment objectives for the one-year project period were to: 

1. Collect data on health information communication, access/utilization of health care, and cancer prevention and control within the catchment area; 

2. Examine whether rurality of residence modifies effective modes of information delivery related to cancer prevention and control; and 

3. Quantify and characterize variation in cancer control needs based on rurality of residence to identify actionable areas. 

Developing and deploying the population health needs assessment required several steps, including: 

1. Eliciting input from community stakeholders about what topic areas to prioritize in the assessment (Step 2: Scan); 

2. Identifying and/or developing survey questions in alignment with the prioritized topics; 

3. Partnering with a university’s survey call center to conduct the telephone survey with residents from both rural and urban communities (Step 1: Engage); 

4. Deploying the survey online and ensuring adequate participation from both rural and urban communities; 

5. Analyzing the data to identify cancer prevention and control needs of the catchment area; and 

6. Engaging community stakeholders in developing a plan to address cancer prevention and control needs. 

Results 

The two main findings from the needs assessment were: 

1. While most survey participants reported their understanding that preventive measures can be taken to reduce their risk of developing cancer, most participants also indicated that it is hard to know what those preventive measures are. 

2. When survey participants were asked to identify information channels that they would be ‘extremely likely’ or ‘likely’ to use to access cancer-related information if they needed it, the top ranked source for participants from all four Rural-Urban Community Areas (RUCAs)¹ was “doctor”. In addition, the top five sources of information ranked by all participants were: “doctor”, “internet”, “cancer treatment facility”, “cancer research facility”, and “cancer organization” though there were differences in the order of these rankings for each RUCA. 

¹Geographic areas were classified into four RUCA categories: Urban, Large Rural, Small Rural and Isolated Rural (University of Washington Rural Health Research Center). 

Success Factors and Key Questions Addressed 

What data were needed to support your position on the issue(s)? 

The surveys included questions to assess residents’ cancer-related attitudes, beliefs, and knowledge; access to cancer care and other health services; whether and how they access cancer-related information; and whether and how they’d like to receive cancer-related information. 

What kind of data did you obtain (qualitative, quantitative, peer-reviewed journals, trusted sources, etc.)? 

Most of the data requested from participants were quantitative in nature (e.g., multiple-choice questions, ‘check all that apply’ questions). Where feasible, previously validated questions were used or modified to assess the prioritized topic areas. 

What were your SMART (specific, measurable, attainable, relevant and time-bound) goals and objectives? 

Norris Cotton has recently begun planning their approach aimed at addressing the findings from the needs assessment. SMART objectives, strategies, activities and metrics will be developed accordingly. 

Next Steps 

This regional survey of cancer communications, beliefs, and knowledge can help target outreach, education, and intervention activities related to cancer prevention and control in New Hampshire and Vermont. Further analysis may point to specific subgroups that require tailored responses by health officials – such as rural residents, the elderly, young adults, and racial/ethnic minorities. Norris Cotton’s team will be working with its Community Advisory Board and community partners, such as Vermont’s comprehensive cancer collaboration, to develop plans to address disparities identified in this assessment. 

Related Resources 

For more information about Norris Cotton’s needs assessment, please see Cancer Information Seeking, Beliefs, and Knowledge in the Information Age: A Snapshot of New Hampshire through a Cancer Control Lens. To read more about trends in health communications and information technology, see Health Information National Trends Survey (HINTS). Finally, in 2016, the National Cancer Institute provided funding for many NCI-designated cancer centers to conduct research to better characterize their catchment areas. Read more about this initiative here. 

To learn about designing and implementing evidence-based communication campaigns, see the GW Cancer Center’s Communication Training for Comprehensive Cancer Control Professionals 102: Making Communication Campaigns Evidence-Based. 

REFERENCES 

Centers for Disease Control and Prevention. (2018a). Rural Health. Cancer Policy Brief. Retrieved from https://www.cdc.gov/ruralhealth/cancer/policybrief.html. 

Centers for Disease Control and Prevention. (2018b). Rural Health. Cancer in Rural America. Retrieved from https://www.cdc.gov/ruralhealth/cancer.html. 

Charlton, M., Schlichting, J., Chioreso, C., Ward, M., & Vikas, P. (2015). Challenges of rural cancer care in the United States. Oncology, 29(9), 633-640. 

Greenberg-Worisek, A. J., Kurani, S., Rutten, L. J. F., Blake, K.D., Moser, R. P., & Hesse, B. W. (2019) Tracking Healthy People 2020 internet, broadband, and mobile device access goals: An update using data from the Health Information National Trends Survey. Journal of Medical Internet Research, 21(6), 3133000. doi: 10.2196/13300 

Kirkwood, M. K., Bruinooge, S. S., Goldstein, M. A., Bajorin, D. F., & Kosty, M. P. (2014). Enhancing the American Society of Clinical Oncology workforce information system with geographic distribution of oncologists and comparison of data sources for the number of practicing oncologists. Journal of Oncology Practice, 10(1), 32-38. doi: 10.1200/JOP.2013.001311 

National Cancer Institute and Centers for Disease Control and Prevention. (2019a). State Cancer Profiles. Retrieved from https://bit.ly/2OvwAfy. 

National Cancer Institute and Centers for Disease Control and Prevention. (2019b). State Cancer Profiles. Retrieved from https://bit.ly/2KcApRA. 

Rabinowitz, H. K., Diamond, J. J., Markham, F. W., & Paynter, N. P. 2001. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA 286(9), 1041-1048. 

United States Census Bureau. (2018). Geography Program. List of Population, Land Area, and Percent Urban and Rural in 2010 and Changes from 2000 to 2010. Retrieved from https://www.census.gov/programs-surveys/geography/guidance/geo-areas/urban-rural/2010-urban-rural.html. 

University of Washington Rural Health Research Center. ZIP Code RUCA Approximation.  http://depts.washington.edu/uwruca/ruca-approx.php. Accessed 8/18/2018.