Shining a Light on Health Inequities & Cancer
Kentucky is a beautiful state known for its rolling hills, horses, bourbon and basketball. But beneath those hallmarks lie some grim health numbers that the University of Kentucky College of Nursing is working hard to change. In tandem with UK HealthCare’s Markey Cancer Center, the College of Nursing is conducting research looking at health inequities and cancer in the state and finding ways to better reach underserved communities with prevention, screening and treatment interventions.
“We have some pretty dark statistics in Kentucky regarding a lot of things, but specifically cancer,” says Dr. Mark Evers, director of Markey Cancer Center. “Kentucky is No. 1 in the country for cancer incidences per population. It’s also No. 1 in the country for cancer mortality. And a lot of people don’t know that.”
While a lot of people might be unaware of those facts, they weigh heavily on the minds of the College’s nurse researchers, many of whom went on of economic indicators in the U.S. to earn their PhDs in an effort to discover the best ways to effect change and improve the health and lives of Kentuckians.
They are using evidence-based interventions to engage underserved Kentucky communities, many in Markey’s catchment area, from the inside out rather than the outside in. This means meeting with residents in places that are more convenient and comfortable, such as local churches, and involving key community members who can help build trust and maintain initiatives.
“We tailor interventions to meet the specific needs of underrepresented populations and to make sure there’s effective community engagement in these projects, so that the needs and the interests of the communities are being met and the research is not an investigator-driven process,” say Dr. Tom Kelly, associate dean for research at the UK College of Nursing. “And not only do we have to develop interventions that work in the clinics at the university, but we also have to understand what the barriers and challenges are of taking that evidence-based intervention and using it in, say, Hazard.”
Dr. Evers says taking these interventions into communities—particularly those in Appalachia, where cancer rates are even higher—is key.
“Many of the communities are very rural, and the terrain is not so conducive to folks getting in a vehicle and driving to Lexington,” he says, adding that 50 of the 54 counties in Eastern Kentucky are in the lowest 10% of economic indicators in the U.S.
“These are some of the poorest counties in the country, and some folks can’t afford the gas to get here. So, we have to figure out how best to take prevention and screenings to them. And that’s what we are doing, which I think is pretty unique, and it has certainly served as a model for other institutions around the country as well.”
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Dr. Lovoria Williams knew from her earliest moments that she wanted to be a nurse. Growing up in western Kentucky, she had watched her parents battle chronic illnesses and noted disparities even as a child. “I saw my mom suffer with diabetes and its complications and then die relatively early from colon cancer; my dad, had a long smoking history and eventually died from COPD. Also, growing up in the Black church, I noticed the high obesity prevalence and witnessed people become ill during worship due to having chronically poor health.”
As a nurse, she more distinctly recognized the role social determinants play in health disparities. “Where we live, work, and play are major health influencers and predictors of health status. We most often see these negative social determinants among marginalized communities, such as communities of color.
“That’s why I decided I wanted to earn my PhD, so that I could do community-based interventions to really work with communities to identify and address these health needs,” says Dr. Williams, who along, with doing diabetes research, has gone on to become Markey’s assistant director of cancer health equity. Her job, she says, is to make sure that Markey’s initiatives are approached with a health equity lens and attentive to the needs of all of Kentucky’s diverse populations.
“My role with Markey came from the research I’ve done in communities that suffer from health inequities,” she says. “One of the first things I did was examine Markey’s partnerships and projects through an equity lens, to ensure that all of the state’s varied populations are represented.
“A lot of our work has been in Appalachia due to the disparate population, but we also need to be sure that we are reaching the Latin community, migrant farmers, African Americans, rural black communities and rural white communities,” says Dr. Williams .
“I think that it starts with our leadership acknowledging that their perspective may not be as broad as it should be, and we do better by having diversity at the table,” Dr. Williams noted. “We need to be able to say: ‘We’re doing great in this area, but we’re really missing an opportunity here and how can we address it?’”
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Dr. Stacy Stanifer has been working with cancer patients throughout her career. “I’ve always loved cancer nursing,” she says, “but over time I’ve realized so many cancers could be prevented.”
This prompted her to return to the UK College of Nursing for her PhD and led to her interest in lung cancer and radon. “Most people don’t realize what a threat radon is. Radon is responsible for nearly 22,000 lung cancer deaths annually and is the leading cause of lung cancer among non-smokers. When you have exposure to both radon and tobacco, you have a 10-fold greater risk of developing lung cancer. Because of Kentucky’s radon risk potential, high smoking rates and lack of smoke-free laws, we have the perfect storm for the over-representation of lung cancer,” says Stanifer, a member of the UK College of Nursing’s BREATHE Team and Markey’s Cancer Prevention and Control Research Program and Lung Cancer Translational Research Group.
“Thankfully, there are ways to reduce exposure to radon. Yet many Kentuckians either can’t afford the cost of radon mitigation or don’t have access to certified radon mitigators,“ says Dr. Stanifer. “I’ve always loved cancer nursing, but over time I’ve realized so many cancers could be prevented.”
In an effort to reduce the incidence of lung cancer, she is reaching out to health care providers, particularly in underserved areas, to encourage practitioners to talk with patients about radon and recommend they test their homes.
In addition, the BREATHE team is working to identify opportunities that would make mitigation affordable and available for everyone.
For example, Dr. Stanifer received a grant to increase access to radon services for rural Kentuckians. The grant supports two home construction professionals in becoming certified in radon measurement and mitigation. The individuals were recruited from rural counties that are currently without radon mitigation services. The grant will evaluate how radon services were integrated into their current business plan and track mitigation efforts.
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As a psychiatric mental health nurse early in her career, Dr. Amanda Fallin-Bennett quickly noted the disproportionate number of smokers in residential substance abuse treatment programs.
Over time, she also came to realize that nicotine addiction often exacerbated patients’ issues, leaving them short on money for necessities and wreaking havoc on their health.
Dr. Fallin-Bennett is trying to change these negative outcomes through smoking cessation programs aimed at residential treatment programs. Similar to the general population, most people want to quit, she says, but in that stressful environment, evidence has shown a more tailored approach is necessary.
“It’s becoming more and more common and more recognized for smoking cessation to be offered during residential substance abuse treatment,” she says. “But for a long time, there were persistent myths that if you try to stop smoking while you’re in treatment, you might be more likely to return to use of substances. Through extensive research, we now know that’s not true. In fact, if anything, quitting smoking actually improves your likelihood for a long-term and sustained recovery.”
Dr. Fallin-Bennett also works with residents in rural areas that are more prone to smoking, such as LGBTQIA+ youth and in rural areas, especially in the South, which has been slower to adopt anti-smoking legislation and higher tobacco taxes, both of which have been proven to reduce smoking rates.
She helped write a grant that is comparing 50 rural municipalities across four Southern states, only half of which have smoke-free ordinances, to determine what factors lead to successfully enacting smoke-free laws. By using an evidence-based approach, she is hoping to help create a roadmap to more smoke-free communities, and in turn, better health.
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Dr. Ty Borders says throughout his career he has been particularly interested in the differences between how residents of cities and rural areas access health care.
“If we can figure out how to improve the organization and delivery of health care, we can improve the health of these populations,” he says.
Oftentimes, people assume residents of rural areas have a tougher time accessing health care. Dr. Borders notes that this is not always the case. Sometimes, difficulty finding care close to home may depend more on their specific condition, such as colon cancer, the third-leading cause of cancer-related deaths in the United States.
Dr. Borders is currently involved in a new research study with the American Board of Family Medicine on colorectal screening.
“We are looking at what kind of care people are receiving after they complete their cancer treatment, whether surgery and/or chemotherapy, because there are recommendations about continual follow-up services to monitor and protect patients and potentially detect whether cancer has returned, “he says. “And also to make sure people have adequate access to other types of services, such as those related to pain or psycho-social services related to their cancer or their cancer treatment.”
“If we can figure out how to improve the organization and delivery of health care, we can improve the health of these populations.”
“They have a very unique data set in which they collect information from several hundred family physician practices across the nation about their patients receiving recommended services, including colorectal screening,” he says. “So we’re currently working with ABFM to examine rural and urban differences in whether patients receive recommended colorectal screening.”
The focus is on family practices. “We didn’t really have very good information from actual family care practices about the degree to which their patients are receiving recommended cancer screenings,” he said.
Dr. Borders is also involved in research on follow-up care among cancer survivors and whether there is a difference between that care in rural and urban areas.
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When Dr. Jean Edward immigrated to the United States as a 17-year-old from Sri Lanka, she envisioned “a rosy, free world where everyone was kind to one another and got along.” But she quickly realized how inequity permeated the fabric of American life, starting with skin color and reaching into many aspects of society.
After she started her career as a nurse in critical care, Dr. Edward saw how these inequities affected the health care system, especially access to care and affordability, and she wanted to do something about it. She noted the particular difficulties faced by cancer patients, who often must undergo long, expensive treatment and frequently have to stop working or cut back on their hours. The same is often true for their caregivers.
“There’s a direct link between financial hardships and mortality that is seen more frequently among our cancer patients compared to those with other chronic illnesses, because cancer is one of the costliest diseases to deal with,” says Dr. Edward. “It’s a concept called financial toxicity, and we need to do more about it.”
Dr. Edward, who is also a member of the College’s CHANGE research team, is currently working on implementing two different financial navigation programs for hematology oncology pediatric patients at the Kentucky Children’s Hospital DanceBlue clinic and adult patients at Markey Cancer Center.
“Our DanceBlue clinic program also incorporates a medical-legal partnership, which allows us to help address financial, social and legal needs of our patients and their families,” she says. “Both of these programs allow us to see the immediate impact our social, financial and legal services will have on patient lives. And there’s nothing more rewarding than that.”
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Growing up in Nigeria, Dr. Adebola Adegboyega saw a lot of disparity rooted in social, economic and educational status. These disparities were further driven home when she became a medical lab scientist involved in HIV prevention, screening and counseling.
“There was a lack of access even to basic infrastructure among the population that I worked with,” she says.
When Dr. Adegboyega came to the United States to study nursing, she noted similar societal disparities, “Many people don’t have what they need to attain their full health potential.”
Her research is focused on trying to change that. She is on the UK College of Nursing’s CHANGE Team and a member of the Cancer Prevention and Control Research Program at Markey, as well as a mentee member of the Translation on Research Interventions into Practice, Population and Policy Leadership (TRIPPLe) Team Alliance.
She is currently looking at cultural attitudes and behaviors related to cancer screening in an effort to understand how to best reach underserved populations with cancer screening and prevention tools. “Many people don’t have what they need to attain their full health potential.”
Dr. Adegboyega is researching attitudes, knowledge and behaviors around HPV vaccination in a pilot study in Lexington, Kentucky among young adult African American and African immigrant populations. “It is difficult for these populations to get vaccinated when many of them don’t know about it in the first place,” she says.
HPV is the most common sexually transmitted disease and can lead to several different kinds of cancer, including cervical cancer, the rates of which are higher in Kentucky and among African Americans than the national average. The goal is to use this information and work within communities to increase awareness, education and HPV vaccination rates. “I’m trying to find out things that are missing so we can try and create programs to fill those gaps,” she says.
Dr. Adegboyega is also studying attitudes toward cancer screenings and prevention among African American and sub-Saharan African women in Kentucky, which will help in developing a strategy to approach cervical cancer screening. Part of that strategy will include training women within these communities to provide support to their peers to encourage regular screenings.
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This story appeared in the UK College of Nursing's Fall 2021 edition of Engagement magazine.
