Explaining place-based colorectal cancer health disparities: Evidence from a rural context Kirsten M.M. Beyer a, * , Sara Comstock b , Renea Seagren c , Gerard Rushton d a Medical College of Wisconsin, Institute for Health and Society, 8701 Watertown Plank Road, Milwaukee, WI 53226, United States b Iowa Consortium for Comprehensive Cancer Control, IA, United States c United Community Health Center, Storm Lake, IA, United States d Department of Geography, University of Iowa, IA, United States article info Article history: Available online 8 October 2010 Keywords: Health disparities Cancer Place Environment Rurality Concept mapping Participatory research USA Rural Risk abstract A growing body of work examines geographical setting as a source of health disparity, hypothesizing individual as well as larger, environmental sources of risk. However, mechanisms by which this influence operates, especially in rural settings, are not well understood. This study investigates the problem of colorectal cancer in a rural US community through the lens of geographical setting. Statewide maps of colorectal cancer burdens show a place-based disparity in colorectal cancer in the region surrounding a small, diverse Iowa community. Within a research partnership framework, we use these maps to engage community residents in discussions of high colorectal cancer rates. We ask how a rural community experiencing higher than expected rates of colorectal cancer late-stage diagnosis and mortality perceives and explains their increased risk, interpreting available epidemiological evidence based on their lived experience. We use concept mapping to organize these perceptions and situate our findings in the context of previous work. Our findings reveal a complex understanding of risk that should be taken into account in crafting effective public health interventions and messages. Our work informs the growing literature on how context influences individual experiences of health problems, with specific relevance for rural populations. Ó 2010 Elsevier Ltd. All rights reserved. Introduction Health disparities are a growing focus of research and their elimination is a public health imperative. A growing body of work examines geographical setting as a source of disparity, including a growing literature that seeks to incorporate geographical context into investigations of individual health outcomes, hypothesizing individual as well as larger, environmental sources of risk (Bernard et al., 2007; Evans & Stoddart, 1990). Diverse researchers have discussed the influence of “community,”“neighborhood,”“place” and “social space” on health (e.g. Behringer & Friedell, 2006; Brown, McLafferty, & Moon, 2010; Curtis & Jones,1998; Groleau, Souliere, & Kirmayer, 2006; Minkler & Wallerstein, 2003; Schulz, Parker, Israel, & Fisher, 2001). Prominent in the use of these constructs in the health literature is the nature of experience and its relevance in understanding the community context in which health related decisions are made, including the importance of the measurable characteristics of an individual’s immediate environment in affecting health outcomes (examples from the US include: Diez- Roux, 2002; Krieger et al., 2002; Leung, Yen, & Minkler, 2004; Sampson, Morenoff, & Gannon-Rowley, 2002; Srinivasan, O’Fallon, & Dearry, 2003). Recent work from the US has contributed to the international literature on neighborhood deprivation indices (Messer et al., 2006), has included an increasing focus on the built environment (Srinivasan et al., 2003), and has responded to the critique that previous work in the US has been aspatial in nature (Caughy, Hayslett-McCall, & O’Campo, 2007; Subramanian, 2004). Researchers have hypothesized several pathways by which place context may influence health outcomes, including environmental contaminants, psychosocial stress, social isolation, disruption in social networks or social capital, and the likelihood for informal social control, or collective efficacy (Burke, O’Campo, & Peak, 2006; Marmot & Wilkinson, 2001; Sampson et al., 2002). However, a conceptual understanding of these influences remains incom- plete (Macintyre, Ellaway, & Cummins, 2002), which limits the impact of work on health related place effects. More research is needed to adequately conceptualize the effects of place context on health, including (1) an increased focus on non- urban experiences, and (2) an increased focus on community * Corresponding author. Tel.: þ1 414 955 7530; fax: þ1 414 955 6529. E-mail address: kbeyer@mcw.edu (K.M.M. Beyer). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed 0277-9536/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2010.09.017 Social Science & Medicine 72 (2011) 373e382