Rural Survivors Research Articles

Time-site Differences In Cancer Survivors Ratings Of Distress Due To Covid-19 And Exercise Clinics Closure

PURPOSE: To determine differences and 6-month changes in Cancer survivor reported levels of distress relating to COVID-19 pandemic and closure of Cancer Exercise Rehabilitation Clinics at three sites: Pacific Island site (S 1, n = 50), Urban (S 2, n = 102) and Rural (S3, n = 14). METHODS: Cancer Survivors (n = 166; 89% female, 87% white, 46% Breast Cancer) who participated in structured exercise prior to the pandemic completed a modified NCCN Distress Thermometer in March 2020 (T1) and September 2020 (T2). COVID-19 and Exercise Clinic Concern categories were added to existing categories. Distress Ratings, identification of Problem Concerns, changes and correlations were determined. RESULTS: Sites S2 (4.38) S3 (4.77) met mean clinical distress levels (>4) while S1 did not (3.64). All ratings decreased slightly T1 (N = 50) to T2 (N = 115) with no significant site or time differences. Emotional (46%) and Exercise Clinic Closure (48%) were most frequently identified Problem Concerns. 2 X 2 ANOVA identified Site (F = 3.086 P = .048, df = 2) and Time (F = 7.521 P = .007, df = 1) differences in Physical Concerns, with Post-Hoc Tukey HSD differences in sites 1 vs 2, and 1 vs 3. Site differences (F = 6.987 P = .001, df = 2) in Exercise Concerns were noted with Post-Hoc Tukey HSD (2 vs 3). Time (F = 9.044 P = .003 df = 1,) differences in COVID-19 Concerns with no Post-hoc differences. A trend in Family Concerns (F = 2.267, P = .107, df = 2) noted post-Hoc differences sites 1 vs 2. Multiple Significant Site, Time correlations were noted with Distress. Exercise Concerns had no time, site Distress Correlations while COVID-19 Concerns had 2 site and 2-time correlations. Emotional Category Correlations occurred at all sites, most times and with all other categories CONCLUSIONS: Overall Rural (S3) survivors had higher ratings of distress (4.77) identified more concerns (avg 34%) vs Urban S2 (4.38; 26%) and Pacific Islanders S1 (22%) who also had the lowest distress rating (3.64), and warrants more investigation. Multi-factorial Contributions to Clinical levels of distress was confirmed with Emotional Concerns the primary contributor. Exercise Concern lack of Distress correlation suggests it contributes less to distress than expected. However, Emotion-Exercise associations suggests Exercise does contribute to well-being.

A Telemedicine-Delivered Nursing Intervention for Cancer-Related Distress in Rural Survivors.

To evaluate preliminary efficacy, fidelity, and integrity of data collection of a nurse-led, telemedicine-delivered video visit intervention aimed at improving management of rural survivors' cancer-related distress symptoms. 21 rural survivors participated in a nurse-led telemedicine intervention delivered six weeks after the end of active cancer treatment. Participants' symptom management was measured with the Short Form Survivor Unmet Needs Survey, a four-factor, 30-item instrument that measures the unmet needs of adult survivors. Data were collected preintervention and six weeks postintervention. The mean difference between pre- and postintervention survey scores was -0.24, representing an overall improvement in management of unmet needs. The unmet emotional needs domain had the highest mean preintervention score and the largest mean reduction. All effect sizes were small. A nurse-led, telemedicine-delivered video visit intervention may improve rural survivors' symptom management during early survivorship. Comparison with a control group using a sample size powered to detect clinically meaningful differences is an important next step to fully evaluate the impact of this model of care.

A comparison of survey incentive methods to recruit rural cancer survivors into cancer care delivery research studies.

Unconditional (upfront) incentives are proposed to improve acceptance of cancer research among underrepresented, racial/ethnic minority populations, but few studies have tested incentive strategies among rural cancer survivors. Descriptive statistics summarized demographic characteristics of survey respondents, and response rates by arm were compared using Chi-square tests. We compared upfront ($2) and response-based ($10 conditional) incentives in a mailed survey of adult post-treatment rural survivors. Individuals meeting eligibility criteria from the electronic medical record (n = 2,830) were randomized into two incentive arms (n = 1,414 for the upfront arm and n = 1,416 for the contingent arm). Of the total delivered, presumed eligible participants (n = 1,304 upfront arm; n = 1,317 contingent arm), 67.8% were aged 65y+, 49.8% were female, and 95.1% were non-Hispanic white. The response rate for all participants was 18.5%. We received eligible surveys from 281 rural survivors in the first arm (response rate: 21.5%); and 205 surveys in the second arm (response rate: 15.6%). Participants who received the upfront incentive had a higher response rate than those receiving a response-based incentive, X2 (1, 2,621) = 15.53, p < 0.0001. Incentivizing survey completion with an upfront $2 bill encouraged a higher survey response rate; other supplemental strategies are needed to achieve a higher response rate for this population.

Sociodemographic and Clinical Factors Associated With Radiation Treatment Nonadherence and Survival Among Rural and Nonrural Patients With Cancer

Cancer treatment nonadherence is associated with higher rates of cancer recurrence and decreased survival. Rural patients with cancer experience a 10% higher mortality rate compared with their nonrural counterparts; geographic differences in nonadherence may contribute to this increased mortality. The goal of this study was to assess for geographic disparities and determine sociodemographic and clinical factors associated with radiation therapy (RT) nonadherence and survival among rural and nonrural patients with cancer. We examined cancer registry, medical records, and billing claims data at a safety net academic medical center. Geographic residence was defined as rural versus nonrural by US Department of Agriculture 2013 Rural-Urban Continuum Codes. Other factors assessed were age, sex, race, marital status, insurance type, employment, area median household income, residential distance to cancer treatment center, clinical stage, cancer type, treatment modality, total radiation dose received, and radiation dose per fraction. We used Cox proportional hazards modeling to examine 7 ways of operationalizing nonadherence and selected the definition that resulted in the best model fit statistics and prediction of mortality. Overall survival rates were estimated with the Kaplan-Meier method. We then examined nonadherence as the main exposure along with additional covariates in least absolute shrinkage and selection operator penalized survival analyses and as the outcome in our multivariable generalized linear regression analyses predicting nonadherence. We considered 2-way interaction terms with the main exposure, geographic residence. We identified 3,077 patients with cancer who averaged 62 years old, were 59% female, 34% Black, and 14% rural. Twenty-two percent of patients missed at least 2 fractions and missed an average of 10% of their treatment plan. Rural patients experienced a higher mortality rate than nonrural patients (53% vs 42%, P < .0001). Survival was assessed through December 31, 2021, with a mean follow-up of 4.5 years. Proportion of missed fractions as the indicator of nonadherence provided the best model fit statistics and prediction of survival. Marital status, employment status, tumor, nodes, metastases stage, cancer type, and age at diagnosis significantly affected survival, in addition to a treatment delay by geographic residence interaction effect. Specifically, patients residing in rural areas who experienced a treatment delay were more than twice as likely to die as nonrural residents who also experienced a treatment delay, and nearly twice as likely to die as rural residents who did not experience a treatment delay. The 2-year survival rate was 76% for nonrural residents who did not experience a treatment delay versus 27% for rural residents who experienced a treatment delay. Patients who were widowed, had stage 4 cancer, or lung cancer were more likely to be nonadherent. Finally, patients residing in rural areas who experienced a treatment delay were more likely to subsequently be nonadherent. In a geographically and racially diverse population, RT nonadherence is a significant concern that affects survival, yet it is a modifiable risk factor. We demonstrated that rural residence was associated with both RT nonadherence and poorer overall survival. Rural patients with a treatment delay had the lowest overall survival, compared with both nonrural survivors and rural survivors without delay. Rural residents who are delayed in starting treatment are at heightened risk for poor outcomes and should receive targeted support to mitigate the observed disparities. Additional patient populations that may benefit from targeted treatment adherence support include widowed patients and those with stage 4 cancer or lung cancer.

Self-reliance, Social Norms, and Self-stigma as Barriers to Psychosocial Help-Seeking Among Rural Cancer Survivors With Cancer-Related Distress: Qualitative Interview Study.

BackgroundEven when technology allows rural cancer survivors to connect with supportive care providers from a distance, uptake of psychosocial referrals is low. Fewer than one-third of participants in a telemedicine intervention for identifying rural survivors with high distress and connecting them with care accepted psychosocial referral.ObjectiveThe purpose of this research was to examine the reasons for which rural cancer survivors did not accept a psychosocial referral.MethodsWe utilized a qualitative design to address the research purpose. We interviewed participants who had been offered psychosocial referral. Semistructured interviews were conducted 6 weeks later (n=14), and structured interviews were conducted 9 months later (n=6). Data were analyzed descriptively using an inductive approach.ResultsUltimately, none of the rural cancer survivors (0/14, 0%) engaged with a psychosocial care provider, including those who had originally accepted referrals (0/4, 0%) for further psychosocial care. When explaining their decisions, survivors minimized their distress, emphasizing their self-reliance and the need to handle distress on their own. They expressed a preference for dealing with distress via informal support networks, which was often limited to close family members. No survivors endorsed public stigma as a barrier to accepting psychosocial help, but several suggested that self-stigma associated with not being able to handle their own distress was a reason for not seeking care.ConclusionsRural cancer survivors’ willingness to accept a psychosocial referral may be mediated by the rural cultural norm of self-reliance and by self-stigma. Interventions to address referral uptake may benefit from further illumination of these relationships as well as a strength-based approach that emphasizes positive aspects of the rural community and individual self-affirmation.

Perspectives of major traumatic injury survivors on accessibility and quality of rehabilitation services in rural Australia

Purpose For the 30% of Australians who live in rural areas, access to rehabilitation services after sustaining a major traumatic injury can be challenging. This study aimed to explore the experience of rural major traumatic injury survivors accessing rehabilitation services. Materials and methods Semi-structured interviews were conducted with 21 rural major traumatic injury survivors (Mage = 47.86; SD = 11.35; Range: 21–61) who were an average of seven years post-injury (SD = 3.10; Range: 3.25–13.01). Transcribed interviews were thematically analysed. Results Four themes were identified: (1) Managing the transition back to local services, (2) Independence and determination to get better, (3) Rehabilitation is an ongoing process, and (4) Limited service access and quality. While injury-related symptoms persisted for many participants, they expressed strong determination for independence and self-management of their recovery. Barriers to accessing rehabilitation services included poor knowledge of local services, travel burden, financial costs, and a lack of local practitioners experienced in major traumatic injury rehabilitation. Facilitating factors included financial, psychological, community, and informal supports. Conclusions To support recovery, future rural service models should improve consideration of factors resulting from living at a distance to services and harness independence to self-manage. IMPLICATIONS FOR REHABILITATION Rural major traumatic injury survivors need support to navigate numerous barriers to accessing rehabilitation services. Rural participants expressed their preference for greater involvement in planning their transition back home following hospitalisation and help to link with available services in their local area. Specialist training and support for rural rehabilitation practitioners is needed, to effectively treat impairments related to major traumatic injury, particularly psychological and cognitive difficulties. Future service delivery models should incorporate methods to locate rural services; facilitate telehealth access and client self-management; and provide financial and mental health support to both rural survivors of major traumatic injury and their carers.

Telehealth Availability and Use of Related Technologies Among Medicare-Enrolled Cancer Survivors: Cross-sectional Findings From the Onset of the COVID-19 Pandemic.

BackgroundThere has been rapid integration of telehealth into care delivery during the COVID-19 pandemic. However, little is known about technology ownership, internet access and use for communication, and telehealth availability among cancer survivors, particularly those enrolled in Medicare.ObjectiveThis study aims to identify sociodemographic associations with technology ownership, internet access and use for communication, and telehealth availability in a population-based sample of Medicare-enrolled cancer survivors.MethodsData are from the Medicare Current Beneficiary Survey COVID-19 Summer 2020 Supplement administered between June 10 and July 15, 2020. Analyses were restricted to beneficiaries who reported a prior (nonskin) cancer diagnosis and a usual source of care (N=2044). Dichotomous outcomes included technology ownership, internet access, internet use for communication, and telehealth availability from providers. Sociodemographic correlates included sex, age, race/ethnicity, Medicare/Medicaid dual enrollment, rurality, census region, and self-reported comorbidities.ResultsOver half (957/2044, 53%) of cancer survivors reported using the internet for communication purposes, and 62% (1218/2044) reported that their usual provider had telehealth services available. Using the internet for communication purposes was reported less frequently for rural compared to urban survivors (adjusted probability of 28% vs 46%; P<.001) and for Hispanic and Black survivors compared to non-Hispanic White survivors (29%, 31%, and 44%, respectively; all P<.01). Rural survivors reported lower telehealth availability (53% vs 63%; P<.001); no significant differences in telehealth availability were identified by race/ethnicity.ConclusionsDuring the COVID-19 pandemic, study findings highlight a complex digital divide among Medicare beneficiaries with a history of cancer related to device ownership necessary for telehealth, internet access and use for communication, and reports of providers having telehealth available. Multilevel approaches are needed to increase equitable telehealth availability and use for cancer survivors. Suggested strategies include increasing broadband internet access to providers and patients in at-risk communities, supporting telehealth implementation among providers that serve populations with known health disparities, raising awareness of providers’ available telehealth services among patients, and screening for technology use and provision of telehealth-related technical assistance among older and historically underserved cancer survivors.

Abstract PO-206: Community conversations on cancer: Creating and implementing a community engagement strategy for the 2022-2027 Illinois Comprehensive Cancer Control Plan through an academic – state public health department partnership

Abstract Background: Comprehensive cancer control (CCC) plans are region-specific blueprints that identify cancer priorities and health equity informed strategies to address cancer burden and are supported by the National Comprehensive Cancer Control Program through the Centers for Disease Control and Prevention (CDC). Although CCC plans are created by stakeholder coalitions, few have focused on community engaged approaches, which may diminish their applicability for community members. Thus, in preparation for its forthcoming 2022-2027 CCC plan, the Illinois Comprehensive Cancer Control Program collaborated with the University of Illinois Cancer Center's Community Engagement and Health Equity office to implement a community engagement strategy to address cancer burden. Objective: To describe the development and implementation of a community engagement strategy for the 2022-2027 Illinois CCC plan. Method: The goal of the community engagement strategy was to identify barriers, facilitating factors and recommendations related to cancer burden and equity in Illinois by engaging diverse community stakeholders. A statewide town hall and focus groups (FGs) were implemented in early 2021. The development and analysis of the community engagement strategy were guided by the Model for Analysis of Population Health and Health Disparities, CDC's CHANGE Action Guide, and the Community ToolBox. Semi-structured guides included questions about fundamental causes of health, social and physical contexts, individual demographics and risk factors, and biologic responses and pathways. The town hall was open to Illinoisians over 18 years of age. FG participants were selected using purposive sampling to maximize group heterogeneity. Eight FGs were held, one each for: rural residents, survivors, young survivors, caregivers, and Spanish speakers, and three that were a mix of community members. Town hall notes and FGs were analyzed using content analysis. Results were synthesized and a final report was included in the forthcoming plan. Results: Town hall and FG (n=8) participants (n=115) included cancer survivors (36%), caregivers (27%), Latinos (17%), African Americans (23%), and rural residents (14%). Throughout the development of the plan, data were continuously reviewed with the coalition developing the CCC Plan. The final report described multi-level factors that contribute to cancer disparities among Illinoisians, proposed recommendations to improve health across the cancer continuum across multiple levels, funding priorities, and the impact of COVID-19 on cancer care. Participant quotes supported strategies throughout the plan. Conclusion: A robust community engagement strategy for the forthcoming 2022-2027 Illinois CCC Plan was implemented through a successful academic–state public health department partnership. This strategy ensures that the plan reflects the expertise and voices of Illinoisians impacted by cancer. This engagement strategy, framed around health determinants that impact cancer risk and outcomes, may be replicated by other coalitions creating CCC plans. Citation Format: Leslie R Carnahan, Jennifer Newsome, Sarah Christian, Colleen Hallock, Brenda Soto, Yohana Ghdey, Linda Kasebier, Manorama Khare, Erica Martinez, Vida Henderson. Community conversations on cancer: Creating and implementing a community engagement strategy for the 2022-2027 Illinois Comprehensive Cancer Control Plan through an academic – state public health department partnership [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-206.

Abstract 10308: Rural-Urban Differences in Health Characteristics and Health Behaviors in 14,955 US Stroke Survivors

Introduction: Rural residence is associated with increased CVD risk, including incident stroke. Less is known about the association of rurality on health characteristics and health behaviors among stroke survivors. The purpose of this study was to determine the presence and magnitude of rural/urban differences in health characteristics and health behaviors among stroke survivors. Methods: Data from 14,599 stroke survivors were available from the 2017 &amp; 2019 Behavioral Risk Factor Surveillance System, an annual health survey of non-institutionalized US adults. Inclusion criteria included history of self-reported stroke and age ≥65 years. Respondents with missing data regarding rural vs. urban dwelling status were excluded from analysis. Respondents provided self-reported data on sociodemographics (sex, race, marital status, education, and income), health characteristics, and health behaviors (see table for characteristics and behaviors). Logistic regression was used to compute odds ratios and 95% CI’s to examine the association among rural/urban status and health characteristics and health behaviors. Results: Prevalence of health characteristics and health behaviors, and computed adjusted odds ratios, are presented in the table. Although the prevalence of disability, poor general health, and insufficient physical activity were higher among rural-dwelling stroke survivors, odds ratios adjusted for sociodemographic and health characteristics demonstrated no association among rurality, health characteristics, and health behaviors. Conclusions: Although no differences in health characteristics and behaviors were found between rural and urban-dwelling stroke survivors, prevalences of many CVD risk factors were high, which increase risk for recurrent stroke, secondary conditions, and chronic disease. Interventions for improving risk factors and health behaviors in this health disparate population are needed.

Features That Middle-aged and Older Cancer Survivors Want in Web-Based Healthy Lifestyle Interventions: Qualitative Descriptive Study.

BackgroundWith the increasing number of older cancer survivors, it is imperative to optimize the reach of interventions that promote healthy lifestyles. Web-based delivery holds promise for increasing the reach of such interventions with the rapid increase in internet use among older adults. However, few studies have explored the views of middle-aged and older cancer survivors on this approach and potential variations in these views by gender or rural and urban residence.ObjectiveThe aim of this study was to explore the views of middle-aged and older cancer survivors regarding the features of web-based healthy lifestyle programs to inform the development of a web-based diet and exercise intervention.MethodsUsing a qualitative descriptive approach, we conducted 10 focus groups with 57 cancer survivors recruited from hospital cancer registries in 1 southeastern US state. Data were analyzed using inductive thematic and content analyses with NVivo (version 12.5, QSR International).ResultsA total of 29 male and 28 female urban and rural dwelling Black and White survivors, with a mean age of 65 (SD 8.27) years, shared their views about a web-based healthy lifestyle program for cancer survivors. Five themes emerged related to program content, design, delivery, participation, technology training, and receiving feedback. Cancer survivors felt that web-based healthy lifestyle programs for cancer survivors must deliver credible, high-quality, and individually tailored information, as recommended by health care professionals or content experts. Urban survivors were more concerned about information reliability, whereas women were more likely to trust physicians’ recommendations. Male and rural survivors wanted information to be tailored to the cancer type and age group. Privacy, usability, interaction frequency, and session length were important factors for engaging cancer survivors with a web-based program. Female and rural participants liked the interactive nature and visual appeal of the e-learning sessions. Learning from experts, an attractive design, flexible schedule, and opportunity to interact with other cancer survivors in Facebook closed groups emerged as factors promoting program participation. Low computer literacy, lack of experience with web program features, and concerns about Facebook group privacy were important concerns influencing cancer survivors’ potential participation. Participants noted the importance of technology training, preferring individualized help to standardized computer classes. More rural cancer survivors acknowledged the need to learn how to use computers. The receipt of regular feedback about progress was noted as encouragement toward goal achievement, whereas women were particularly interested in receiving immediate feedback to stay motivated.ConclusionsImportant considerations for designing web-based healthy lifestyle interventions for middle-aged and older cancer survivors include program quality, participants’ privacy, ease of use, attractive design, and the prominent role of health care providers and content experts. Cancer survivors’ preferences based on gender and residence should be considered to promote program participation.

Characterizing the Exercise Behaviour, Preferences, Barriers, and Facilitators of Cancer Survivors in a Rural Canadian Community: A Cross-Sectional Survey.

Barriers, facilitators, and motivators to exercise for cancer survivors living in urban settings are well described in the literature. However, there is a lack of comparable information for cancer survivors living in rural communities. We describe the exercise behaviours, barriers, facilitators, and motivators to exercise participation of cancer survivors living in a rural Canadian community. Adult cancer survivors with a primary address in a rural region of Ontario, Canada, who had visited a community hospital in the previous five years were mailed a cross-sectional survey assessing current exercise volume (minutes of moderate-to-vigorous aerobic and resistance exercise), as well as exercise preferences, barriers, and facilitators. Seventy-two survivors (mean age 65 years) completed the survey (16% response rate). A majority of respondents were diagnosed with breast cancer (49%) in the last 5 years (61%). Aerobic- and resistance-training guidelines for cancer survivors were met by 38% and 10% of respondents, respectively. Physical side effects were the most common barrier to exercise during treatment (65%) and post-treatment (35%). Being unaware of available exercise programs, time for exercise, distance to exercise services, and cost were commonly reported barriers during and post-treatment (reported by 10–22%). Respondents reported needing information from a qualified exercise professional (46%), access to a gym (33%) and exercise equipment (26%), and social support (25%) to facilitate exercise participation. Consistent with urban-based cancer survivors, most rural survivors surveyed in this study were not meeting the physical-activity guidelines and reported numerous exercise barriers. These findings can serve as a resource for this and similar rural communities when developing community-based exercise-support services for cancer survivors.

Psychosocial well-being and supportive care needs of cancer patients and survivors living in rural or regional areas: a systematic review from 2010 to 2021.

PurposeTo summarise what is currently known about the psychosocial morbidity, experiences, and needs of people with cancer and their informal caregivers, who live in rural or regional areas of developed countries.MethodsEligible studies dating from August 2010 until May 2021 were identified through several online databases, including MEDLINE, EMBASE, PsychINFO, and RURAL (Rural and Remote Health Database). Results were reported according to the PRISMA guidelines and the protocol was registered on PROSPERO (CRD42020171764).ResultsSixty-five studies were included in this review, including 20 qualitative studies, 41 quantitative studies, and 4 mixed methods studies. Qualitative research demonstrated that many unique psychosocial needs of rural people remain unmet, particularly relating to finances, travel, and accessing care. However, most (9/19) quantitative studies that compared rural and urban groups reported no significant differences in psychosocial needs, morbidity, or quality of life (QOL). Five quantitative studies reported poorer psychosocial outcomes (social and emotional functioning) in urban cancer survivors, while three highlighted poorer outcomes (physical functioning, role functioning, and self-reported mental health outcomes) in the rural group.ConclusionRecent research shows that rural people affected by cancer have unique unmet psychosocial needs relating to rurality. However, there was little evidence that rural cancer survivors report greater unmet needs than their urban counterparts. This contrasts to the findings from a 2011 systematic review that found rural survivors consistently reported worse psychosocial outcomes. More population-based research is needed to establish whether uniquely rural unmet needs are due to general or cancer-specific factors.

When Housing and Communities Were Delivered: A Case Study of Post-Wenchuan Earthquake Rural Reconstruction and Recovery

This study contributes to an in-depth examination of how Wenchuan earthquake disaster survivors utilize intensive built environment reconstruction outcomes (housing and infrastructural systems) to facilitate their long-term social and economic recovery and sustainable rural development. Post-disaster recovery administered via top-down disaster management systems usually consists of two phases: a short-term, government-led reconstruction (STGLR) of the built environment and a long-term, survivor-led recovery (LTSLR) of human and social settings. However, current studies have been inadequate in examining how rural disaster survivors have adapted to their new government-provided housing or how communities conducted their long-term recovery efforts. This qualitative case study invited sixty rural disaster survivors to examine their place-making activities utilizing government-delivered, urban-style residential communities to support their long-term recovery. This study discovered that rural residents’ recovery activities successfully perpetuated their original rural lives and rebuilt social connections and networks both individually and collectively. However, they were only able to manage their agriculture-based livelihood recovery temporarily. This research suggests that engaging rural inhabitants’ place-making expertise and providing opportunities to improve their housing and communities would advance the long-term grassroots recovery of lives and livelihoods, achieving sustainable development.

Rurality as Concordance: Mental Health Service Delivery for Rural Survivors of Intimate Partner Violence

This manuscript examines how a shared sociospatial or “rural” identity may uniquely facilitate mental health care delivery. In particular, we consider the significant but largely unexplored role that domestic violence center staff, whom we term “Reputational Provider-Experts” or RPEs, play in addressing the mental health needs of rural women who have experienced intimate partner violence. Using data collected through semi-structured individual and focus group interviews with RPEs across 12 counties and four tribal reservations in northern Wisconsin ( N = 15), we detail the sociospatial commonalities that enable RPEs to provide trusted, sustained mental health support to rural women. Because these advocates are rural community members whose approach implicitly appeals to local norms and values, we argue that they represent rurally concordant providers. In this way, rurality emerges as a meaningful and novel form of patient-provider concordance, one with critical relevance to addressing the rural mental health crisis in the United States.

Examination of a distress screening intervention for rural cancer survivors reveals low uptake of psychosocial referrals.

PurposeTo determine the impact of a telemedicine-delivered intervention aimed at identifying unmet needs and cancer-related distress (CRD) following the end of active treatment on supportive care referral patterns.MethodsWe used a quasi-experimental design to compare supportive care referral patterns between a group of rural cancer survivors receiving the intervention and a control group (N = 60). We evaluated the impact of the intervention on the number and type of referrals offered and whether or not the participant accepted the referral. CRD was measured using a modified version of the National Comprehensive Cancer Network Distress Thermometer and Problem List.ResultsOverall, 30% of participants received a referral for further post-treatment supportive care. Supporting the benefits of the intervention, the odds of being offered a referral were 13 times higher for those who received the intervention than those in the control group. However, even among the intervention group, only 28.6% of participants who were offered a referral for further psychosocial care accepted.ConclusionsA nursing telemedicine visit was successful in identifying areas of high distress and increasing referrals. However, referral uptake was low, particularly for psychosocial support. Distance to care and stigma associated with seeking psychosocial care may be factors. Further study to improve referral uptake is warranted.Implications for Cancer SurvivorsScreening for CRD may be inadequate for cancer survivors unless patients can be successfully referred to further supportive care. Strategies to improve uptake of psychosocial referrals is of high importance for rural survivors, who are at higher risk of CRD.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11764-021-01052-4.

Improving Survivors' Quality of Life Post-Treatment: The Perspectives of Rural Australian Cancer Survivors and Their Carers.

Simple SummaryExisting programs to support cancer survivors post-treatment tend to be delivered face-to-face, reducing their accessibility to those living in rural and remote locations. Additionally, little is known about the acceptability of urban-developed survivorship care programs among rural cancer survivors who may have unique values and different attitudes towards help-seeking. The purpose of this study was to explore the experiences of cancer survivors who return to their rural communities upon completion of active treatment, and to identify the challenges these survivors experience in engaging with quality of life-related support services. The findings of this study will inform the design and development of new interventions, or modification of existing interventions, to better meet the preferences and needs of rural survivors. Identifying the specific challenges and intervention preferences of rural cancer survivors will help to ensure they benefit as much as urban survivors, from efforts to improve post-treatment quality of life.The transition from urban centres back to rural and remote communities can be challenging for rural cancer survivors after treatment. This study aimed to (a) provide deeper understanding of the experiences of rural survivors who have completed active cancer treatment and returned to their rural communities, and (b) determine strategies to re-orient existing services or develop new interventions to more appropriately meet rural survivors’ service preferences and needs. Semi-structured interviews were conducted with 22 adults (64% female) who lived outside of a metropolitan area and had completed active cancer treatment (n = 13), were the carer for a rural/remote cancer survivor (n = 6), or were both a survivor and carer (n = 3). Thematic analysis was conducted to identify dominant themes in the qualitative data. A range of physical, psychological and practical challenges that impact quality of life among rural survivors post-treatment were found. These challenges appeared to be compounded by a lack of trust in local rural healthcare services and a lack of clear post-treatment pathways to quality of life-enhancing support services. Acceptable strategies to overcome barriers included nurse-led, telephone-based, or face-to-face interventions, initiated and continued by the same service provider, and that included support to manage emotional challenges associated with post-treatment survivorship. The findings will inform the design of interventions to better meet rural cancer survivors’ post-treatment support needs.

Abstract P872: Persistent Inequities in Intravenous Thrombolysis for Acute Ischemic Stroke in the United States: Results From the Nationwide Inpatient Sample

Background: Intravenous thrombolysis (IVT) was approved for acute ischemic stroke (AIS) 25 yrs ago, yet few AIS patients receive it, with inequities by race/ethnicity, sex, and geography. With expanding evidence-based programs, we hypothesized increases in IVT utilization and reduction in inequities. Methods: Using the Nationwide Inpatient Sample (NIS), we assessed temporal trends from 2002 to 2015 in IVT for AIS (weighted N=6,694,081) by sex, race/ethnicity, age, insurance, and hospital location/teaching status strata using survey - weighted logistic regression. Covariates included socio-demographics, comorbidities, and hospital characteristics. We calculated odds ratios for IVT by each category in 2002-2008 and 2009-2015. Results: IVT for AIS increased from 1.0% in 2002 to 6.8% in 2015, with an overall adjusted annual relative ratio (AARR) of 1.15 (CI 1.14-1.16). Individuals 18-44 yrs had the highest rate of IVT in 2015. The very elderly (≥85 yrs) had the most pronounced increase in IVT (AARR 1.18, CI 1.17-1.19). The sex disparity in IVT improved, but in 2009-2015, women were still 6% less likely to receive IVT than men (Fig 1). Individuals 18-44 yrs were ~3-fold more likely to receive IVT than the very elderly. IVT inequities for black and Hispanic stroke survivors lessened, but blacks remained ~20% less likely than whites to receive IVT. Government-insured patients were ~25% less likely to receive IVT compared to privately insured. Urban AIS patients were up to 4-fold more likely to receive IVT than rural dwellers. Conclusion: From 2002 through 2015, IVT for AIS in the U.S. increased regardless of race/ethnicity, sex, and age among ≥18 yrs, with the most pronounced increase among the very elderly. Despite encouraging trends, only 1 in 15 AIS patients received IVT and persistent inequities remain for blacks, women, government-insured, and rural stroke survivors, highlighting the need for intensifying stroke literacy and preparedness and enhancing systems of care.

The impact of breast cancer-related lymphedema on rural and small-town Survivors’ return-to-work and quality of life: A multiple-case study

BackgroundBreast cancer-related lymphedema (BCRL) is a lifelong condition. Millions who develop breast cancer are younger than retirement age and at a lifetime risk for developing BCRL. Rural and small-town survivors may face unique challenges in terms of access to health care and BCRL/survivorship resources. This multiple-case study describes how BCRL influences the work experiences and quality of life (QoL) of survivors living in rural and small towns in Missouri. Methods and MaterialsThirteen survivors from rural and small towns in Missouri completed semi-structured interviews and a standardized QoL instrument. Cases were analyzed using in-vivo and open-coding techniques and constant cross-case comparative methods. Twelve of the 13 participants’ data are synthesized into themes to represent an illustrative case. The 13th case is presented as a contradictory (rival) case. ResultsFour themes are represented within the illustrative case – multiple medical encounters; the development of self-care routines; the reciprocity of work/live activities, triggers, and adjustments; and rural/small-town cultural impact. Upon BCRL diagnosis, survivors received intensive treatments, eventually establishing self-care routines. Survivors identified strategies for working around their BCRL when completing work and home responsibilities. The contradictory (rival) case was more recently diagnosed and, as such, had not established self-care and coping mechanisms in the same way. Conclusions and implicationsSurvivors alleviate BCRL symptoms and improve their QoL by establishing self-care strategies. This provides guidance for client-centered survivorship care-planning and occupational rehabilitation of rural survivors with BCRL. This study provides the foundation for developing information for rural survivors that supports mental preparation and coping skills for BCRL self-management.

Abstract PO-078: Delaying and forgoing care due to cost among rural cancer survivors

Abstract Purpose: Financial hardship, including delaying/forgoing services because of cost, is reported by approximately 30% of an estimated 16.9 million cancer survivors. However, hardship is poorly assessed and interventions sporadically implemented for survivors. The objective of this study is to assess factors associated with delaying and forgoing care services due to cost to inform a patient navigation program for rural cancer survivors. Methods: Adults with a cancer diagnosis who were 6 months or more post-definitive treatment or were receiving on-going maintenance therapy were identified for a cross-sectional mailed survey through the electronic medical record. Participants were predominately residents of one of eight priority rural counties in Northwest North Carolina (all resided in a zip-code defined by a Rural- Urban Commuting Area [RUCA] code of 4-10). Items from the 2019 National Health Information Survey (NHIS) assessed delayed/foregone medical care. Univariate statistics described the sample distribution and prevalence of delaying/forgoing care. Participants were randomized into two incentive groups ($2 bill with the survey mailing vs a $10 gift card upon completion). Chi-square tests examined the factors associated with delaying/forgoing services by demographic and cancer characteristics. Results: The survey response rate was 22.0%; 451 complete surveys were included in the present analyses. Enrolled survivors (49.7% female) were predominately non-Hispanic white (96.2%), with a mean age of 69 years, and 69.0% were 5 years or more post diagnosis. The most common cancer sites were prostate (21.5%), breast (19.7%), and colorectal (7.3%). Delayed medical care was reported by 16.2% of the sample. The prevalence of forgoing care due to cost was 6.4% for medical care, 12.3% for medications, 6.4% for mental health, and 7.0% for medical tests. Chi-square tests found significant differences by age, gender, and radiation treatment status (yes/no), with higher prevalence of delaying care among survivors aged 41-64 vs younger and older survivors (34.1% vs 27.2% and 8.8%, P&amp;lt;0.001), females vs males (22.4% vs 10.4%, P&amp;lt;0.001), and those treated with radiation therapy compared to those who were not (21.0% vs 13.2%, P=0.03). Survivors aged 18-40 compared to older survivors (18.8% vs 13.4% [aged 41-64] and 3.2% [aged 65+], P&amp;lt;0.001), and females vs male survivors (10.7% vs 3.2%, P=0.006) were also more likely to report forgoing care due to cost. Discussion: A minority of post- treatment rural cancer survivors report delaying and forgoing medical care because of cost. Patient navigation programs should prioritize ongoing screening efforts for financial hardship among younger and female rural survivors after initial treatment completion. Citation Format: Derek S. Falk, Karen E. Winkfield, Janet A. Tooze, Kelsey Shore, Carla Strom, Kathryn E. Weaver. Delaying and forgoing care due to cost among rural cancer survivors [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-078.

Age-varying associations between physical activity and psychological outcomes among rural cancer survivors.

We examined the prevalence of psychological outcomes (i.e., symptoms of depression and anxiety) by age and age-varying associations between physical activity and psychological outcomes among rural cancer survivors. Participants (N = 219; ages 22-93) completed sociodemographic, psychological, and physical activity questionnaires. Time-varying effect models estimated the prevalence of psychological outcomes and assessed associations between physical activity and psychological outcomes as a flexible function of age. Depression and anxiety symptoms decreased with age among cancer survivors aged 22-40years and were relatively stable across age among those > 40years. Positive associations between vigorous physical activity and psychological outcomes in those aged 22-40years were identified. In those > 70-80years, there were negative associations between vigorous physical activity and psychological outcomes. Results suggest there is variation across age in the associations between physical activity and psychological outcomes among rural survivors. Future research should further explore these age-varying relationships to identify important intervention targets.