Unpacking rural Heterogeneity: A proof-of-concept study of how varying rural contexts shape breast cancer screening behaviors.

Purpose: Rural women in the U.S. experience persistent inequities in breast cancer (BrCa) screening access, yet rural populations are often treated as a monolith in research and practice. This study serves as a proof of concept by examining how contextual heterogeneity across rural settings in South-Central Washington shapes screening behaviors and access, emphasizing the intersection of structural, cultural, and environmental factors through a community-informed lens. Methods: Guided by the Community Capitals Framework, we conducted focus groups with women in two demographically and economically distinct rural communities in South-Central Washington. Participants discussed how barriers to BrCa screening manifest across seven domains of community capital-natural, cultural, human, social, political, financial, and built-offering a multidimensional understanding of health access in context. Findings: Participants across both rural settings identified overlapping community barriers, but also revealed unique, context-specific barriers. Four emergent themes captured these dynamics: (1) seasonality and competing resource demands; (2) distance as a resource-dependent constraint; (3) gendered expectations shaping care access; and (4) race and place influencing resource distribution. These findings illustrate how overlapping systems of power and community assets interact to shape health behavior and access. Conclusions: Addressing rural BrCa screening inequities requires more than generic rural interventions; this study demonstrates that inequities may manifest differently across rural types, with distinct underlying dynamics shaping barriers. By showing how contextual variation influences health behaviors, this proof-of-concept study underscores the importance of disaggregating rural populations in health research and tailoring interventions to the specific mechanisms and resources operating within each context.