Social Risks and Unmet Needs in Individuals With Cancer Living in Metropolitan and Nonmetropolitan Areas

Abstract

OBJECTIVES

To identify social risks and unmet needs in individuals with cancer and to compare differences between those living in metropolitan and nonmetropolitan areas.

SAMPLE & SETTING

900 individuals with cancer who completed the Health Information National Trends Survey.

METHODS & VARIABLES

Data from the Health Information National Trends Survey were used. Descriptive statistics, t tests, and chi-square analyses were conducted.

RESULTS

Of 900 individuals with cancer, 16% resided in nonmetropolitan areas. In the past year, 9% experienced food insecurity, 9% experienced housing instability, and 8% lacked transportation, and more than 30% felt uncomfortable sharing these issues with healthcare providers. Nonmetropolitan residents had lower health literacy, income, and education.

IMPLICATIONS FOR NURSING

Nonmetropolitan residents had higher social risks, but their unmet needs did not differ from metropolitan residents. Building open communication and trust between individuals and healthcare providers is crucial for ensuring effective support and personalized care.

About 46 million people (15% of the U.S. population) reside in nonmetropolitan areas (U.S. Department of Agriculture [USDA], 2025). These areas include urban populations of less than 5,000, 5,000–20,000, and more than 20,000, each categorized by their proximity to metropolitan areas (adjacent or not adjacent). Residing in nonmetropolitan areas may pose additional challenges for individuals with cancer. For example, the infrastructure required for cancer diagnostic procedures and treatments, along with the necessary human resources for optimal care delivery, is concentrated in metropolitan areas (Bhatia et al., 2022). People from nonmetropolitan areas often face limited access to care or services because of the need to travel long distances for care, leading to geography-associated disparities in cancer outcomes (Bhatia et al., 2022; van der Kruk et al., 2022).

In addition to geographic challenges, social risks and unmet needs may also play a significant role in hindering the physical and psychological well-being of individuals with cancer. Social risks and unmet needs (e.g., education, income, health literacy, insurance, food, housing, transportation), which fall under the umbrella of social determinants of health, affect individuals with cancer and their ability to access adequate resources they need, potentially contributing to their health outcomes (Green & Zook, 2019; Papadakos et al., 2018; Wallace et al., 2020). Residents in nonmetropolitan areas often have lower rates of commercial insurance, with higher rates of Medicaid coverage or being uninsured compared to those in metropolitan areas (Agarwal et al., 2019).

Few studies have explored and compared the social risks and unmet needs of individuals with cancer living in metropolitan versus nonmetropolitan areas. The purpose of this study is to identify the social risks and unmet needs of individuals with cancer and compare the differences between those living in metropolitan and nonmetropolitan areas.

Methods

Cross-sectional data from the National Cancer Institute’s Health Information National Trends Survey collected from March 7 to November 8, 2022, were used. A total of 900 individuals with cancer were included in this study. A post hoc power analysis using G*Power, version 3.1, for an independent t test (medium effect size, d = 0.5, α = 0.05) with sample sizes of 141 and 759 for groups 1 (nonmetropolitan) and 2 (metropolitan), respectively, showed the study achieved a power of 0.99.

Rural-Urban Continuum Codes, developed by the USDA (2025), were used to categorize counties based on population size, degree of urbanization, and proximity to metropolitan areas using zip codes. The nine categories are grouped into two classifications as follows: metropolitan (with three categories) and nonmetropolitan (with six categories).

Sociodemographic characteristics and social risk factors included age, gender, race/ethnicity, employment status, education level, annual household income, insurance coverage, and health literacy. Unmet needs variables included food insecurity, housing instability, and lack of transportation. In addition, individuals’ comfort level in sharing unmet needs with their healthcare providers was assessed. Questions and response options are presented in Figure 1.

FIGURE 1.

Questions and Response Options

IBM SPSS Statistics, version 29.0, was used for analyses. Descriptive statistics, t tests, and chi-square analyses were conducted to describe the sample and identify differences in social risks and unmet needs between individuals with cancer living in metropolitan and nonmetropolitan areas.

Results

Among 900 individuals with cancer, 759 (84%) and 141 (16%) resided in metropolitan and nonmetropolitan areas, respectively. In the overall sample, individuals were aged on average 68.56 years, and the majority were non-Hispanic White (n = 625, 75%), did not have a college degree (n = 475, 54%), had health insurance (n = 879, 98%), had an annual household income of $50,000 or more (n = 469, 57%), and were more than 11 years after diagnosis (n = 432, 50%) (percentages were calculated using adjusted N values to account for missing data). Overall, about 14% (n = 122) reported feeling not at all or a little confident in filling out medical forms, and 27% (n = 239) found it hard or very hard to understand medical statistics. In the past 12 months, 83 (9%), 77 (9%), and 73 (8%) experienced food insecurity, housing instability, and lack of transportation, respectively. More than 30% (n = 304, 312, and 263 for food insecurity, housing instability, and lack of transportation, respectively) reported feeling uncomfortable sharing information about their social risks and unmet needs with their healthcare providers for the purpose of providing treatment. There were no differences in comfort levels for individuals with cancer sharing unmet needs between metropolitan and nonmetropolitan areas.

The differences in demographic variables and other variables between individuals with cancer living in metropolitan and nonmetropolitan areas are detailed in Table 1. Individuals with cancer living in nonmetropolitan areas had lower health literacy (t [degrees of freedom = 894] = 3.07; p = 0.002), were more likely to have lower household income (χ² [degrees of freedom = 4, N = 821] = 16.65; p = 0.002), and had less education (χ² [degrees of freedom = 3, N = 887] = 23.9; p < 0.001) compared to those in metropolitan areas. There were no statistical differences in food insecurity, housing instability, lack of transportation, and insurance coverage between individuals in metropolitan and nonmetropolitan areas.

TABLE 1.

Difference Between Metropolitan and Nonmetropolitan Individuals

Characteristic	Overall (N = 900)		Metropolitan (N = 759)		Nonmetropolitan (N = 141)		p
	X̄	SD	X̄	SD	X̄	SD
Age (years)	68.56	12.19	68.7	12.41	67.76	10.94	0.404
Health literacy	3.43	0.84	3.47	0.82	3.23	0.94	0.002
Characteristic	n	%	n	%	n	%	p
Annual household income ($) (N = 821)							0.002
Less than 20,000	128	16	98	14	30	23
20,000–34,999	113	14	89	13	24	19
35,000–49,999	111	14	97	14	14	11
50,000–74,999	151	18	124	18	27	21
75,000 or more	318	39	285	41	33	26
Education (N = 887)							< 0.001
Less than high school	55	6	44	6	11	8
High school	151	17	113	15	38	27
Some college	269	30	219	29	50	36
College graduate or higher	412	46	372	50	40	29
Insurance (N = 895)							0.084
Yes	879	98	740	98	139	100
No	16	2	16	2	–	–
Race/ethnicity (N = 829)							< 0.001
Asian	18	2	18	3	–	–
Black or African American	92	11	85	12	7	6
Hispanic	71	9	69	10	2	2
Non-Hispanic White	625	75	517	73	108	88
Other	23	3	17	2	6	5
Gender assigned at birth (N = 888)							0.839
Female	527	59	445	60	82	59
Male	361	41	303	41	58	41
Food insecurity (N = 890)							0.538
No	807	91	682	91	125	89
Yes	83	9	68	9	15	11
Housing instability (N = 888)							0.5
No	811	91	682	91	129	93
Yes	77	9	67	9	10	7
Lack of transportation (N = 890)							0.133
No	817	92	684	91	133	95
Yes	73	8	66	9	7	5
Comfort level in sharing food insecurity (N = 855)							0.799
Comfortable	551	64	464	64	87	65
Uncomfortable	304	36	258	36	46	35
Comfort level in sharing housing instability (N = 849)							0.622
Comfortable	537	63	451	63	86	65
Uncomfortable	312	37	266	37	46	35
Comfort level in sharing lack of transportation (N = 855)							0.696
Comfortable	592	69	498	69	94	71
Uncomfortable	263	31	224	31	39	29

Note. Because of rounding, percentages may not total 100.

Note. Questions measuring health literacy, food insecurity, housing instability, and lack of transportation can be found in Figure 1. Health literacy was measured on a 4-point scale ranging from 1 (not at all confident) to 4 (very confident).

Note. N values listed with each characteristic reflect item responses for the overall group. Percentages were calculated using adjusted N values to account for missing data, which resulted from item nonresponse.

Discussion

The findings indicate that individuals with cancer residing in nonmetropolitan areas face greater social risks, including lower levels of education, annual household income, and health literacy compared to those in metropolitan areas. These results are consistent with national reports. According to the USDA, 14% of individuals living in nonmetropolitan areas fall below the federal poverty level, compared to 10.7% in metropolitan areas (Farrigan et al., 2024). The USDA (2017) Rural Education at a Glance report highlighted that 15% of individuals in nonmetropolitan areas had less than a high school diploma, compared to 13% in metropolitan areas. In addition, only 19% of individuals in nonmetropolitan areas attained a bachelor’s degree or higher, compared to 33% in metropolitan areas; this gap has been widening since 2000 (USDA, 2017). The current study found that individuals residing in nonmetropolitan areas had lower health literacy, which is supported by a previous study showing that individuals with cancer living in rural areas were 33% more likely to have lower levels of health literacy (Halverson et al., 2013). These disparities may exacerbate challenges in accessing high-quality cancer care and resources, making informed decisions, maintaining healthy behaviors, and sustaining overall well-being, thereby further exacerbating health outcome inequity in addition to geographic disparities (Fan et al., 2021; Holden et al., 2021; O’Connor et al., 2018). Therefore, targeted interventions and policies are needed to address these disparities in nonmetropolitan populations with a comprehensive understanding of the unique socioeconomic and geographic challenges. In clinical settings, it is essential to implement tailored education programs that consider patients’ levels of education and health literacy while ensuring access to adequate financial resources for cancer care.

About 10% of individuals in the current study living with cancer reported experiencing food insecurity, housing instability, and a lack of transportation, with no significant differences observed between those in metropolitan and nonmetropolitan areas. However, considering that about 30% expressed discomfort with sharing information about their unmet needs to their healthcare providers for treatment purposes, the actual prevalence of these challenges is likely higher. This reluctance to disclose to providers may impede effective social needs screening in clinical settings, potentially leading to insufficient support for patients. This highlights the importance of building trust while integrating social risks and unmet needs screening into care practices. Future research is needed to explore the reasons behind this discomfort and to identify effective strategies to foster open discussion about social risks and unmet social needs. In addition, future research should investigate why nonmetropolitan residents face greater risks yet report no differences in unmet needs. Possible factors include reluctance to disclose unmet needs or geographic influences such as affordability, and research should focus on identifying alternative ways to meet these needs.

Limitations

The limitations of this study include the reliance on self-reported information, which may introduce social desirability bias. In addition, because the Health Information National Trends Survey collected data through mail and online surveys, certain subgroups such as individuals without stable housing may be underrepresented, limiting the generalizability of the findings. In addition, the question regarding health insurance captured only a general “yes” or “no” response, and answer options did not provide detailed information about coverage type or provider access.

Implications for Nursing

There are several implications for nursing. First, it is essential to incorporate screening for social risks and unmet needs into routine nursing assessments on a regular basis, normalizing these assessments throughout the cancer care continuum because patients’ circumstances may change. Second, building a trusted relationship with patients is fundamental to assessing needs, communicating effectively, connecting at-risk patients to appropriate resources, and obtaining positive outcomes (Ozaras & Abaan, 2018). In addition, maintaining confidentiality and creating a supportive environment for open communication are crucial.

Conclusion

There are differences in social risks (e.g., low income, education, and health literacy) but no differences in unmet needs between individuals with cancer living in metropolitan and nonmetropolitan areas. Addressing disparities for populations in nonmetropolitan areas will likely involve focusing on education and health literacy. Fostering open communication and trust between individuals and healthcare providers is crucial for ensuring effective support and personalized care.

KNOWLEDGE TRANSLATION.

• ■ There are elevated social risks for nonmetropolitan residents with cancer, emphasizing the need for targeted interventions to mitigate these risks despite reported similarities in unmet needs compared to metropolitan residents.

• ■ It is crucial to foster open communication and trust among individuals with cancer and healthcare providers to encourage the disclosure of unmet needs to provide adequate support.

• ■ Geographic factors, including affordability and alternative support mechanisms, play a role in addressing unmet needs, underscoring the necessity of geographically tailored strategies to better serve nonmetropolitan populations.

Funding Statement

Park’s contribution to this research was supported, in part, by the University of Utah College of Nursing Burton Foundation and Family Caregiving Collaborative Fellowship.