151
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Allen H, Wright B, Broffman L. The Impacts of Medicaid Expansion on Rural Low-Income Adults: Lessons From the Oregon Health Insurance Experiment. Med Care Res Rev 2017; 75:354-383. [PMID: 29148324 DOI: 10.1177/1077558716688793] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Medicaid expansions through the Affordable Care Act began in January 2014, but we have little information about what is happening in rural areas where provider access and patient resources might be more limited. In 2008, Oregon held a lottery for restricted access to its Medicaid program for uninsured low-income adults not otherwise eligible for public coverage. The Oregon Health Insurance Experiment used this opportunity to conduct the first randomized controlled study of a public insurance expansion. This analysis builds off of previous work by comparing rural and urban survey outcomes and adds qualitative interviews with 86 rural study participants for context. We examine health care access and use, personal finances, and self-reported health. While urban and rural populations have unique demographic profiles, rural populations appear to have benefited from Medicaid as much as urban. Qualitative interviews revealed the distinctive challenges still facing low-income uninsured and newly insured rural populations.
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Affiliation(s)
| | - Bill Wright
- 2 Providence Health & Services Center for Outcomes Research and Education, Portland, OR, USA
| | - Lauren Broffman
- 2 Providence Health & Services Center for Outcomes Research and Education, Portland, OR, USA
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152
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Kaul S, Avila JC, Mutambudzi M, Russell H, Kirchhoff AC, Schwartz CL. Mental distress and health care use among survivors of adolescent and young adult cancer: A cross-sectional analysis of the National Health Interview Survey. Cancer 2016; 123:869-878. [DOI: 10.1002/cncr.30417] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/04/2016] [Accepted: 10/05/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Sapna Kaul
- Preventive Medicine and Community Health; University of Texas Medical Branch; Galveston Texas
| | - Jaqueline C. Avila
- Preventive Medicine and Community Health; University of Texas Medical Branch; Galveston Texas
| | - Miriam Mutambudzi
- Preventive Medicine and Community Health; University of Texas Medical Branch; Galveston Texas
| | - Heidi Russell
- Section of Hematology-Oncology, Department of Pediatrics; Baylor College of Medicine; Houston Texas
| | - Anne C. Kirchhoff
- Cancer Control and Population Sciences Research Program, Huntsman Cancer Institute; University of Utah; Salt Lake City Utah
| | - Cindy L. Schwartz
- Division of Pediatrics, Department of Pediatrics Patient Care; The University of Texas MD Anderson Cancer Center; Houston Texas
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153
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Cohen SA, Cook SK, Kelley L, Foutz JD, Sando TA. A Closer Look at Rural-Urban Health Disparities: Associations Between Obesity and Rurality Vary by Geospatial and Sociodemographic Factors. J Rural Health 2016; 33:167-179. [PMID: 27557442 DOI: 10.1111/jrh.12207] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 05/10/2016] [Accepted: 07/05/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Obesity affects over one-third of older adults in the United States. Both aging and obesity contribute to an increased risk for chronic disease, early mortality, and additional health care utilization. Obesity rates are higher in rural areas than in urban areas, although findings are mixed. The objectives of this study are to assess potential nonlinearity in the association between rurality and obesity, and to evaluate the potential for socioeconomic status and geographic area to moderate the associations between rurality and obesity. METHODS Using a representative sample of adults aged 65 and above from the Behavioral Risk Factor Surveillance System, obesity (BMI ≥ 30 kg/m2 ) was modeled against the primary exposure of rural-urban status, as measured by the Index of Relative Rurality. Binary logistic regression models were used to estimate the odds of obesity by rurality both as a continuous variable and by decile of rurality. Models were then stratified by per-capita income and state to assess potential moderation by these factors. RESULTS The prevalence of obesity in older adults was highest in intermediate rurality areas (OR in rurality decile #5 1.134, 95% CI: 1.086-1.184) and lowest in the most rural and most urban areas. Obesity was highest in low- and middle-income areas, regardless of rural-urban status. In high-income areas, obesity among older adults was highest in areas of intermediate rurality and lowest in the most rural areas (OR 0.726, 95% CI: 0.606-0.870) and more urban areas, showing a J-shaped association. There were substantial differences in the associations between rurality and obesity in older adults among states. CONCLUSION Associations between rurality and obesity varied by degree of rurality, socioeconomic status, and geography. Therefore, traditional "one-size-fits-all" approaches to reducing rural-urban health disparities in older adults may be more effective if tailored to the area-specific rural-urban gradients in health.
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Affiliation(s)
- Steven A Cohen
- Health Studies Program, Department of Kinesiology, University of Rhode Island, Kingston, Rhode Island
| | - Sarah K Cook
- Center on Society and Health, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Lauren Kelley
- Center on Society and Health, Virginia Commonwealth University School of Medicine, Richmond, Virginia.,Division of Epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Julia D Foutz
- Division of Epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Trisha A Sando
- Division of Epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
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154
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Hall AE, Sanson-Fisher RW, Carey ML, Paul C, Williamson A, Bradstock K, Campbell HS. Prevalence and associates of psychological distress in haematological cancer survivors. Support Care Cancer 2016; 24:4413-22. [DOI: 10.1007/s00520-016-3282-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/16/2016] [Indexed: 10/21/2022]
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155
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Andrykowski MA, Steffens RF, Bush HM, Tucker TC. Posttraumatic growth and benefit-finding in lung cancer survivors: The benefit of rural residence? J Health Psychol 2015; 22:896-905. [PMID: 26657018 DOI: 10.1177/1359105315617820] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Rural cancer survivors report more distress than non-rural survivors. Little research has examined whether rural residence might also be linked to positive psychological outcomes. Rural ( n = 117) and non-rural ( n = 76) lung cancer survivors completed measures of posttraumatic growth, benefit-finding, and distress. Rural survivors reported more posttraumatic growth than urban survivors. There were no differences in benefit-finding. Mediation analyses indicated distress mediated the relationship between rural residence and posttraumatic growth. Findings suggest rural residence might be beneficial with regard to potential for posttraumatic growth among cancer survivors. Consistent with trauma theory, distress mediated the relationship between rural residence and posttraumatic growth.
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156
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Lee Smith J, Hall IJ. Advancing Health Equity in Cancer Survivorship: Opportunities for Public Health. Am J Prev Med 2015; 49:S477-82. [PMID: 26590642 PMCID: PMC4658651 DOI: 10.1016/j.amepre.2015.08.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 08/03/2015] [Accepted: 08/13/2015] [Indexed: 01/18/2023]
Affiliation(s)
- Judith Lee Smith
- Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia.
| | - Ingrid J Hall
- Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
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157
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Cohen SA, Kelley L, Bell AE. Spatiotemporal Discordance in Five Common Measures of Rurality for US Counties and Applications for Health Disparities Research in Older Adults. Front Public Health 2015; 3:267. [PMID: 26636064 PMCID: PMC4658471 DOI: 10.3389/fpubh.2015.00267] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 11/10/2015] [Indexed: 11/13/2022] Open
Abstract
Introduction Rural populations face numerous barriers to health, including poorer health care infrastructure, access to care, and other sociodemographic factors largely associated with rurality. Multiple measures of rurality used in the biomedical and public health literature can help assess rural–urban health disparities and may impact the observed associations between rurality and health. Furthermore, understanding what makes a place truly “rural” versus “urban” may vary from region to region in the US. Purpose The objectives of this study are to compare and contrast five common measures of rurality and determine how well-correlated these measures are at the national, regional, and divisional level, as well as to assess patterns in the correlations between the prevalence of obesity in the population aged 60+ and each of the five measures of rurality at the regional and divisional level. Methods Five measures of rurality were abstracted from the US Census and US Department of Agriculture (USDA) to characterize US counties. Obesity data in the population aged 60+ were abstracted from the Behavioral Risk Factor Surveillance System (BRFSS). Spearman’s rank correlations were used to quantify the associations among the five rurality measurements at the national, regional, and divisional level, as defined by the US Census Bureau. Geographic information systems were used to visually illustrate temporal, spatial, and regional variability. Results Overall, Spearman’s rank correlations among the five measures ranged from 0.521 (percent urban–urban influence code) to 0.917 (rural–urban continuum code–urban influence code). Notable discrepancies existed in these associations by Census region and by division. The associations between measures of rurality and obesity in the 60+ population varied by rurality measure used and by region. Conclusion This study is among the first to systematically assess the spatial, temporal, and regional differences and similarities among five commonly used measures of rurality in the US. There are important, quantifiable distinctions in defining what it means to be a rural county depending on both the geographic region and the measurement used. These findings highlight the importance of developing and selecting an appropriate rurality metric in health research.
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Affiliation(s)
- Steven A Cohen
- Department of Family Medicine and Population Health, Virginia Commonwealth University , Richmond, VA , USA
| | - Lauren Kelley
- Department of Family Medicine and Population Health, Virginia Commonwealth University , Richmond, VA , USA
| | - Allison E Bell
- Department of Internal Medicine, Virginia Commonwealth University , Richmond, VA , USA
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158
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Choi KM. Investigation of cancer mortality inequalities between rural and urban areas in South Korea. Aust J Rural Health 2015; 24:61-6. [PMID: 26123204 DOI: 10.1111/ajr.12216] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2015] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Little is known about rural-urban cancer disparities, particularly in South Korea, and this study is to identify cancer-specific mortality inequalities between the rural and urban areas of the country. DESIGN, SETTING, AND PARTICIPANTS For 11 specific cancer sites, age-standardised mortality rates were analysed for the rural and urban administrative districts of South Korea during 2006-2011. MAIN OUTCOME MEASURES The Poisson log linear regression models were employed to estimate cancer-specific mortality rates, and Bonferroni comparison method was used to identify rural-urban disparities. RESULTS There were significant rural-urban disparities observed for all cancer sites except prostate, pancreas and leukaemia. The mortality rates of lung, liver and stomach cancers, the three most common cancers in the country, were observed to be significantly higher in rural areas than in metropolitan areas. In contrast, the reverse relationship was observed for the reproductive system (breast and uterus) and colon cancers. Central nervous system cancer mortality was observed to be significantly higher in rural areas than in non-metro urban areas. CONCLUSIONS For the first time ever, significant rural-urban disparity patterns in cancer mortality rates in South Korea have been identified in this paper. Future investigations on cancer risk factors for the country should address these disparity patterns.
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Affiliation(s)
- Kyung-Mee Choi
- Ansan Hospital, Institute of Human Genomic Study, Korea University College of Medicine, Gyeonggi-do, South Korea
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159
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Wong SF, Matheson L, Morrissy K, Pitson G, Ashley DM, Khasraw M, Lorgelly PK, Henry MJ. Retrospective analysis of cancer survival across South-Western Victoria in Australia. Aust J Rural Health 2015; 24:79-84. [DOI: 10.1111/ajr.12203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2015] [Indexed: 11/29/2022] Open
Affiliation(s)
- Shu Fen Wong
- Department of Medicine; Barwon Health; Deakin University; Geelong Victoria Australia
- Andrew Love Cancer Centre; Barwon Health; Geelong Victoria Australia
| | - Leigh Matheson
- Barwon South Western Regional Integrated Cancer Services; Geelong Victoria Australia
| | - Kate Morrissy
- Barwon South Western Regional Integrated Cancer Services; Geelong Victoria Australia
| | - Graham Pitson
- Andrew Love Cancer Centre; Barwon Health; Geelong Victoria Australia
- Barwon South Western Regional Integrated Cancer Services; Geelong Victoria Australia
| | - David M. Ashley
- Department of Medicine; Barwon Health; Deakin University; Geelong Victoria Australia
- Andrew Love Cancer Centre; Barwon Health; Geelong Victoria Australia
- Barwon South Western Regional Integrated Cancer Services; Geelong Victoria Australia
| | - Mustafa Khasraw
- Andrew Love Cancer Centre; Barwon Health; Geelong Victoria Australia
| | - Paula K. Lorgelly
- Centre of Health Economics; Monash University; Melbourne Victoria Australia
| | - Margaret J. Henry
- Barwon South Western Regional Integrated Cancer Services; Geelong Victoria Australia
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160
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"When everything changes:" Parent perspectives on the challenges of accessing care for a child with a disability. Disabil Health J 2015. [PMID: 26215893 DOI: 10.1016/j.dhjo.2015.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Health disparities exist among individuals living in rural and urban contexts in terms of access to health care and overall mortality. These disparities are typically greater for youth with disabilities living in rural areas, who face additional barriers in receiving health and support services specific to their disability. Parents are typically the ones responsible for coordinating the care needed by children with a disability; however, with numerous barriers present families are not provided adequate support to care for a child with disabilities. OBJECTIVE The purpose of this study was to examine barriers and facilitators to accessing health and support services among urban and rural families of children with disabilities. METHODS In-depth interviews were conducted with parents who provide care for an adolescent with a disability. The sample was comprised of parents from one rural county (N = 9) and one urban county (N = 10) in Georgia. Parental interviews were conducted face to face by a trained researcher. Each interview was audio-recorded. The recordings were transcribed and content analysis used to create codes and identify emerging themes. RESULTS The common themes found during the analysis include accessibility of health and support resources, transitions, and social isolation. CONCLUSIONS When comparing urban and rural areas, barriers to access do differ in terms of availability, but analysis revealed more similarities existed among parents from both contexts. Efforts must be made to increase opportunities for youth with disabilities to become connected with the local community in order to improve quality of life for families.
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161
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Shim HY, Shin JY, Kim JH, Kim SY, Yang HK, Park JH. Negative Public Attitudes Towards Cancer Survivors Returning to Work: A Nationwide Survey in Korea. Cancer Res Treat 2015; 48:815-24. [PMID: 26044157 PMCID: PMC4843714 DOI: 10.4143/crt.2015.094] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 04/22/2015] [Indexed: 11/26/2022] Open
Abstract
Purpose Early diagnosis and an improved survival rate have emerged as important issues for cancer survivors returning to work during the prime of their working life. This study investigated the attitudes of the general public towards cancer survivors returning to work in Korea and attempted to identify the factors influencing this negative attitude. Materials and Methods A general public perception survey regarding cancer survivors returning to work, targeting 2,000 individuals between 40-70 years of age, was conducted as face-to-face home visit. Results The public expressed a negative attitude towards cancer survivors returning to work, in terms of both perception and acceptance. Negative perception was higher among those in metropolitan areas compared with urban/rural areas (odds ratio [OR], 1.71), with monthly incomes < $2,000 compared with > $4,000 (OR, 1.54), and with patient care experience compared with those without (OR, 1.41). Negative acceptance was higher among those with monthly incomes < $2,000 compared with > $4,000 (OR, 1.71) and those with patient care experience compared with those without (OR, 1.54). The common factors between acceptance and perception that influenced negative attitude included area of residence, patient care experience, and monthly income. Conclusion This study identified negative attitudes towards cancer survivors returning to work in South Korea and the factors influencing the reintegration of cancer survivors into society. It is necessary to promote community awareness and intervention activities to enable access to community, social, and individual units for the social reintegration of cancer survivors.
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Affiliation(s)
- Hye-Young Shim
- National Cancer Control Institute, National Cancer Center, Goyang, Korea
| | - Ji-Yeon Shin
- Department of Preventive Medicine, Eulji University School of Medicine, Daejeon, Korea
| | - Jong Heun Kim
- National Cancer Control Institute, National Cancer Center, Goyang, Korea
| | - So-Young Kim
- College of Medicine/Graduate School of Health Science Business Convergence, Chungbuk National University, Cheongju, Korea
| | - Hyung-Kook Yang
- National Cancer Control Institute, National Cancer Center, Goyang, Korea
| | - Jong-Hyock Park
- College of Medicine/Graduate School of Health Science Business Convergence, Chungbuk National University, Cheongju, Korea
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162
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Logan HL, Guo Y, Emanuel AS, Shepperd JA, Dodd VJ, Marks JG, Muller KE, Riley JL. Determinants of First-Time Cancer Examinations in a Rural Community: A Mechanism for Behavior Change. Am J Public Health 2015; 105:1424-31. [PMID: 25973820 DOI: 10.2105/ajph.2014.302516] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES After conducting a media campaign focusing on the importance of oral and pharyngeal cancer (OPC) examinations, we assessed mechanisms of behavior change among individuals receiving an OPC examination for the first time. METHODS We used data from 2 waves of telephone surveys of individuals residing in 36 rural census tracts in northern Florida (n = 806). The second survey occurred after our media intervention. We developed media messages and modes of message delivery with community members via focus groups and intercept interviews. We performed a mediation analysis to examine behavior change mechanisms. RESULTS Greater exposure to media messages corresponded with heightened concern about OPC. Heightened concern, in turn, predicted receipt of a first-time OPC examination, but only among men. CONCLUSIONS We extended earlier studies by measuring an outcome behavior (receipt of an OPC examination) and demonstrating that the putative mechanism of action (concern about the disease) explained the link between a media intervention and engaging in the target behavior. Improving the quality of media campaigns by engaging community stakeholders in selecting messages and delivery methods is an effective strategy in building public health interventions aimed at changing behaviors.
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Affiliation(s)
- Henrietta L Logan
- At the time of the study, Henrietta L. Logan, Amber S. Emanuel, Virginia J. Dodd, John G. Marks, and Joseph L. Riley III were with the Department of Community Dentistry and Behavioral Science, College of Dentistry, University of Florida, Gainesville. Yi Guo and Keith E. Muller were with the Department of Health Outcomes and Policy, College of Medicine, University of Florida. James A. Shepperd was with the Department of Psychology, College of Liberal Arts and Science, University of Florida
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163
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McNulty JA, Nail L. Cancer Survivorship in Rural and Urban Adults: A Descriptive and Mixed Methods Study. J Rural Health 2015; 31:282-91. [PMID: 25599984 DOI: 10.1111/jrh.12106] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Rural-dwelling cancer survivors (CSs) are at risk for decrements in health and well-being due to decreased access to health care and support resources. This study compares the impact of cancer in rural- and urban-dwelling adult CSs living in 2 regions of the Pacific Northwest. METHODS A convenience sample of posttreatment adult CSs (N = 132) completed the Impact of Cancer version 2 (IOCv2) and the Memorial Symptom Assessment Scale-short form. High and low scorers on the IOCv2 participated in an in-depth interview (n = 19). FINDINGS The sample was predominantly middle-aged (mean age 58) and female (84%). Mean time since treatment completion was 6.7 years. Cancer diagnoses represented included breast (56%), gynecologic (9%), lymphoma (8%), head and neck (6%), and colorectal (5%). Comparisons across geographic regions show statistically significant differences in body concerns, worry, negative impact, and employment concerns. Rural-urban differences from interview data include access to health care, care coordination, connecting/community, thinking about death and dying, public/private journey, and advocacy. CONCLUSION The insights into the differences and similarities between rural and urban CSs challenge the prevalent assumptions about rural-dwelling CSs and their risk for negative outcomes. A common theme across the study findings was community. Access to health care may not be the driver of the survivorship experience. Findings can influence health care providers and survivorship program development, building on the strengths of both rural and urban living and the engagement of the survivorship community.
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Affiliation(s)
- Julie A McNulty
- Arizona State University, College of Nursing and Health Innovation, Phoenix, Arizona
| | - Lillian Nail
- Oregon Health and Science University, School of Nursing, Portland, Oregon
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164
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Warner EL, Kirchhoff AC, Nam GE, Fluchel M. Financial Burden of Pediatric Cancer for Patients and Their Families. J Oncol Pract 2015; 11:12-8. [PMID: 25316026 PMCID: PMC4295420 DOI: 10.1200/jop.2014.001495] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cancer treatment may cause financial stress for pediatric oncology patients and their families. We evaluated pediatric cancer caregivers' perceived financial burden related to socioeconomic factors (eg, parental employment) and health care use factors (eg, unexpected hospitalizations). METHODS A single-site, cross-sectional survey of primary caretakers of patients with childhood cancer was performed from July 2010 to July 2012. Eligible patients were treated at a pediatric cancer hospital, diagnosed at age ≤ 21 years and were ≤ 5 years from diagnosis (N = 254). Financial burden was rated on a visual analog scale of 0 to 100. Multivariable linear regression models were used to calculate coefficients and 95% CIs of financial burden by time since diagnosis. RESULTS Mean age at diagnosis was 6.8 years (SD = 5.5 years), and average time since diagnosis was 1.6 years (SD = 1.4 years). The most common diagnosis was leukemia (41.9%). When adjusted for sex, age at diagnosis, insurance status, and rural residence, caregivers whose child was 1 to 5 years from diagnosis with ≥ 5 unexpected hospitalizations experienced 24.9 (95% CI, 9.1 to 40.7; P < .01) points higher financial burden than those with no unexpected hospitalizations. In addition, when compared with families without employment disruptions, families of children 1 to 5 years from diagnosis in which a caregiver had quit or changed jobs reported 13.4 (95% CI, 3.2 to 23.6; P = .01) points higher financial burden. CONCLUSIONS Efforts to reduce unexpected hospitalizations and employment disruptions by providing more comprehensive supportive care for pediatric patients with cancer could help ease families' financial burden.
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Affiliation(s)
- Echo L Warner
- Huntsman Cancer Institute; and University of Utah, Salt Lake City, UT
| | - Anne C Kirchhoff
- Huntsman Cancer Institute; and University of Utah, Salt Lake City, UT
| | - Gina E Nam
- Huntsman Cancer Institute; and University of Utah, Salt Lake City, UT
| | - Mark Fluchel
- Huntsman Cancer Institute; and University of Utah, Salt Lake City, UT
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165
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Pedro LW, Schmiege SJ. Rural living as context: a study of disparities in long-term cancer survivors. Oncol Nurs Forum 2014; 41:E211-9. [PMID: 24769604 DOI: 10.1188/14.onf.e211-e219] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To explore the impact of rurality on health-related quality-of-life (HRQOL) disparities in rural long-term cancer survivors. DESIGN Cross-sectional survey. SETTING Rural-Urban Continuum Codes (RUCC) 7, 8, and 9. SAMPLE 91 adults at least five years post-treatment. METHODS Mailed surveys measured HRQOL, self-esteem, and social support. Regression models were estimated to isolate (from self-esteem and social support) the effect of level of rurality on HRQOL. MAIN RESEARCH VARIABLES HRQOL, self-esteem, social support, and rurality. FINDINGS No differences in demographic characteristics existed among RUCCs. Survivors residing in RUCCs 7 or 8 tended to be similar in several dimensions of HRQOL. Survivors living in RUCC 7 reported significantly lower social function and greater financial difficulty and number of symptoms compared to survivors in RUCC 9 (the most remote). Self-esteem and social support strongly correlated with HRQOL. CONCLUSIONS The significant impact of rurality on HRQOL beyond self-esteem and social support suggests its role in explaining cancer survivorship disparities and directing practice. Until additional exploration can identify mechanisms behind rurality's impact, consideration of level of rurality as a potential factor in evaluating survivors' HRQOL outcomes is reasonable. IMPLICATIONS FOR NURSING Survivor context (e.g., level of rurality) influences HRQOL outcomes. Context or culture-relevant risk minimization and HRQOL optimization nursing practices are indicated.
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Affiliation(s)
- Leli W Pedro
- College of Nursing, University of Colorado in Denver
| | - Sarah J Schmiege
- Department of Biostatistics and Informatics, University of Colorado in Denver
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166
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Blanch-Hartigan D, Viswanath K. Socioeconomic and sociodemographic predictors of cancer-related information sources used by cancer survivors. JOURNAL OF HEALTH COMMUNICATION 2014; 20:204-210. [PMID: 25495027 DOI: 10.1080/10810730.2014.921742] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
With 14 million cancer survivors in the United States, identifying and categorizing their use of sources of cancer-related information is vital for targeting effective communications to this growing population. In addition, recognizing socioeconomic and sociodemographic differences in the use of cancer-related information sources is a potential mechanism for reducing health disparities in survivorship. Fourteen sources of information survivors (N = 519) used for cancer-related information were factor-analyzed to create a taxonomy of source use. The association between social determinants and use of these source types was analyzed in regression models. Factor analysis revealed 5 categories of information source use (mass media; Internet and print; support organizations; family and friends; health care providers), and use varied based on sociodemographic and socioeconomic characteristics. Higher education predicted increased use of all source categories except mass media. African American cancer survivors turned to health care providers as a source for cancer-related information less often than did White survivors. Social determinants predicted differences in the type of cancer-related information sources used. Providers and health communicators should target communication platforms based on the demographic profile of specific survivor audiences.
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Affiliation(s)
- Danielle Blanch-Hartigan
- a Department of Natural and Applied Sciences , Bentley University , Waltham , Massachusetts , USA
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167
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Naughton MJ, Weaver KE. Physical and mental health among cancer survivors: considerations for long-term care and quality of life. N C Med J 2014; 75:283-6. [PMID: 25046097 PMCID: PMC4503227 DOI: 10.18043/ncm.75.4.283] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The physical and mental health of cancer patients needs to be addressed not only during active treatment but also throughout the continuum of survivorship care. This commentary provides an overview of issues pertinent to cancer survivors, with an emphasis on mental health issues and recommendations for annual clinical screening and monitoring using recently published guidelines from the American Society of Clinical Oncology.
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Affiliation(s)
- Michelle J Naughton
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
| | - Kathryn E Weaver
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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McDougall GJ, Oliver JS, Scogin F. Memory and cancer: a review of the literature. Arch Psychiatr Nurs 2014; 28:180-6. [PMID: 24856270 PMCID: PMC4033831 DOI: 10.1016/j.apnu.2013.12.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 12/30/2013] [Indexed: 12/31/2022]
Abstract
The mental health of cancer survivors has not always been the primary emphasis of treatment protocols since physical health outcomes have taken precedence. Older cancer survivors experience a double jeopardy since they are at risk for memory impairments and mild cognitive impairment and because they are greater than 55 years of age. Of the 9.6 million cancer survivors in the US who have completed active treatment, many report cognitive difficulties, with labels such as "chemo brain," "not as sharp," "woolly-headedness," or the "mind does not work as quickly". To date, most of our knowledge of cognitive impairment in cancer survivors comes from female breast cancer survivors. Studies indicate that these survivors have diminished executive function, verbal memory, and motor function. Cancer survivors want to live independently in the community for as long as possible however, these cognitive deficits may prevent this desired lifestyle. To broaden our understanding this paper reviews the literature on the cognitive impairment and memory deficits experienced by three groups of cancer survivors breast, colorectal, and prostate cancer, that make up 60% of all survivors nationally. Even though mental health declined after a cancer diagnosis, the long-term outcomes of cancer survivors did not differ from persons without cancer in depression or cognitive function.
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Affiliation(s)
| | - JoAnn S Oliver
- The University of Alabama, Capstone College of Nursing, Tuscaloosa, AL
| | - Forrest Scogin
- The University of Alabama, Department of Psychology, Tuscaloosa, AL
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169
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Quality of life and disparities among long-term cervical cancer survivors. J Cancer Surviv 2014; 8:419-26. [PMID: 24706363 DOI: 10.1007/s11764-014-0352-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 02/13/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE Little population-based research has been done on social, economic, and environmental factors affecting quality of life (QOL) among long-term cancer survivors. This research assesses the impact of disease and nondisease factors on QOL among long-term survivors of cervical cancer. METHODS In a collaborative, observational study, data were obtained from cancer registries, interviews, and self-administered questionnaires. Comparisons of QOL were made between women with cervical cancer histories and women from the general population. A total of 715 women 4-28 years postdiagnosis were identified from cancer registries in Connecticut (N = 208), Detroit Metropolitan Area (N = 211), New Mexico (N = 197), and Hawaii (N = 99). QOL was measured according to four SF-36 dimensions-physical functioning, social functioning, bodily pain, and general health status. RESULTS Means on SF-36 measures among women with cervical cancer histories were close to or higher than women in the general population. In a multiple regression analysis, economic disadvantage negatively predicted physical functioning (B = -13.4, SE = 2.1), social functioning (B = -13.2, SE = 2.4), bodily pain (B = -12.6, SE = 2.5), and general health (B = -12.8, SE = 2.1). Residence in New Mexico negatively predicted several QOL dimensions. No impact of race was detected when income was controlled. Disease stage did not predict QOL. CONCLUSIONS Cervical cancer does not generally reduce QOL among long-term survivors. Economic disadvantage and residential location affect QOL through mechanisms yet to be determined. IMPLICATIONS FOR CANCER SURVIVORS Women diagnosed with cervical cancer have good prospects for high quality of life; socioeconomic status strongly affects quality of life over the long term.
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170
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Frensham LJ, Zarnowiecki DM, Parfitt G, King S, Dollman J. The experiences of participants in an innovative online resource designed to increase regular walking among rural cancer survivors: a qualitative pilot feasibility study. Support Care Cancer 2014; 22:1923-9. [PMID: 24573604 DOI: 10.1007/s00520-014-2177-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 02/17/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE Physical activity has been associated with improved outcomes for cancer survivors. Compared to their urban counterparts, rural Australians experience a health disadvantage, including poorer survival rates after diagnosis of cancer. The aim of this pilot feasibility study was to gain insight into the experiences of rural cancer survivors engaging in an online resource designed to increase regular walking. METHODS A 6-week online lifestyle intervention was implemented among eight cancer survivors living in three rural regions of South Australia. Participants used a pedometer to monitor daily steps taken, reported daily steps using a specially designed website and were provided with daily step goals based on their affective state. Participants took part in semi-structured face-to-face interviews to gauge their impressions of the program. Data were analysed using qualitative description and content analysis to derive major themes from the interviews. RESULTS The program motivated participants to increase their walking and resulted in improvements in several self-reported physical and quality of life outcomes. The resource was clear and easy to navigate. The three-tiered step goal system reduced feelings of guilt if participants were unable to reach a goal. The step log and graph allowed participants to self-monitor their progress. The forum fostered social support; however, more interaction with intervention personnel was suggested. CONCLUSIONS This online pedometer-based walking intervention is feasible and effectively increases motivation for walking and enhances health-related quality of life in South Australian rural cancer survivors. A randomized controlled trial of this intervention is warranted.
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Affiliation(s)
- Lauren J Frensham
- Sansom Institute for Health Research, School of Health Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia,
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171
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Christopher KL, Wiggins AT, Van Meter EM, Means RT, Hayslip JW, Roach JP. Differences in vitamin D nutritional status between newly diagnosed cancer patients from rural or urban settings in Kentucky. Nutr Cancer 2014; 65:653-8. [PMID: 23859032 DOI: 10.1080/01635581.2013.789117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Although poor nutritional status and weight loss in cancer patients is known to affect outcomes, little is known about malnutrition differences based on geographic location. We investigated nutritional and inflammatory status of 220 newly diagnosed adults with solid tumors at the University of Kentucky's Markey Cancer Center during December 2008 through October 2011. Chi-square tests were used to determine any associations between suboptimal nutritional levels and rural-urban areas of residence. Out of the 13 lab values collected, the only significant difference between rural and urban participants was found for vitamin D resulting in more rural subjects (67.4%) having a suboptimal vitamin D status as compared to those residing in urban areas (53.3%, P = 0.04). Controlling for baseline demographics including age, race, sex, body mass index, nutritional status, and type of cancer, logistic regression analyses concluded those in rural areas had nearly a twofold increase in the odds of having a suboptimal vitamin D level compared to those in urban areas (odd's ratio = 1.97; 95% confidence interval = 1.04, 3.74). Further investigation into the rural-urban differences in vitamin D needs to be investigated in order to improve outcomes during cancer treatment.
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Affiliation(s)
- K L Christopher
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky 40536, USA
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172
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Sowden M, Vacek P, Geller BM. The impact of cancer diagnosis on employment: is there a difference between rural and urban populations? J Cancer Surviv 2013; 8:213-7. [PMID: 24337871 DOI: 10.1007/s11764-013-0317-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 10/04/2013] [Indexed: 12/01/2022]
Abstract
PURPOSE To determine if living in a rural or urban area influences the impact of cancer diagnosis on employment. METHOD Surveys that asked about changes in employment status related to a cancer diagnosis or treatment were sent to 2,005 cancer survivors enrolled in the Vermont Cancer Survivor Surveillance Registry. Data on cancers were obtained from hospital cancer registries. Respondents indicating that they were working at the time of diagnosis were included in this study for a total of 1,155 participants. Associations between rural or urban residence and changes in employment were assessed by chi-square tests and logistic regression. RESULTS There were no statistically significant differences in the proportions of rural and urban survivors working fewer hours, experiencing a career change or unable to work. However, a larger proportion of rural than urban patients retired early after their diagnosis (11.1 vs. 7.2%, p = 0.031). There were also fewer rural patients that reported that they went on paid disability during cancer treatment (12.3 vs. 17.0%, p = 0.030). CONCLUSIONS While many patients will return to work after treatment for a cancer diagnosis, it appears that rural patients may be less likely to receive paid disability and more likely to retire early. It is possible that rural populations engage in more physically demanding jobs that they are unable to continue after their cancer treatment. Additionally the types of manual labor available in rural areas rarely offer disability benefits, increasing the impact of cancer diagnosis for this population. IMPLICATIONS FOR CANCER SURVIVORS A cancer diagnosis may have a greater impact on employment among rural residents. Cancer programs should recognize this disparity and enhance return to work and disability counseling in patients from rural areas.
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173
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Andrykowski MA, Steffens RF, Bush HM, Tucker TC. Disparities in mental health outcomes among lung cancer survivors associated with ruralness of residence. Psychooncology 2013; 23:428-36. [DOI: 10.1002/pon.3440] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 09/20/2013] [Accepted: 10/04/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Michael A. Andrykowski
- Department of Behavioral Science; University of Kentucky College of Medicine; Lexington KY USA
| | - Rachel F. Steffens
- Department of Behavioral Science; University of Kentucky College of Medicine; Lexington KY USA
| | - Heather M. Bush
- Department of Biostatistics; University of Kentucky College of Public Health; Lexington KY USA
| | - Thomas C. Tucker
- Department of Epidemiology; University of Kentucky College of Public Health; Lexington KY USA
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174
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Palmer NRA, Geiger AM, Lu L, Case LD, Weaver KE. Impact of rural residence on forgoing healthcare after cancer because of cost. Cancer Epidemiol Biomarkers Prev 2013; 22:1668-76. [PMID: 24097196 PMCID: PMC3833446 DOI: 10.1158/1055-9965.epi-13-0421] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Routine follow-up care is recommended to promote the well-being of cancer survivors, but financial difficulties may interfere. Rural-urban disparities in forgoing healthcare due to cost have been observed in the general population; however, it is unknown whether this disparity persists among survivors. The purpose of this study was to examine rural-urban disparities in forgoing healthcare after cancer due to cost. METHODS We analyzed data from 7,804 cancer survivors in the 2006 to 2010 National Health Interview Survey. Logistic regression models, adjusting for sociodemographic and clinical characteristics, were used to assess rural-urban disparities in forgoing medical care, prescription medications, and dental care due to cost, stratified by age (younger: 18-64, older: 65+). RESULTS Compared with urban survivors, younger rural survivors were more likely to forgo medical care (P < 0.001) and prescription medications (P < 0.001) due to cost; older rural survivors were more likely to forgo medical (P < 0.001) and dental care (P = 0.05). Rural-urban disparities did not persist among younger survivors in adjusted analyses; however, older rural survivors remained more likely to forgo medical [OR = 1.66, 95% confidence interval (CI) = 1.11-2.48] and dental care (OR = 1.54, 95%CI = 1.08-2.20). CONCLUSIONS Adjustment for health insurance and other sociodemographic characteristics attenuates rural-urban disparities in forgoing healthcare among younger survivors, but not older survivors. Financial factors relating to healthcare use among rural survivors should be a topic of continued investigation. IMPACT Addressing out-of-pocket costs may be an important step in reducing rural-urban disparities in healthcare, especially for older survivors. It will be important to monitor how healthcare reform efforts impact disparities observed in this vulnerable population.
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Affiliation(s)
- Nynikka R A Palmer
- Authors' Affiliations: Social Science and Health Policy, Epidemiology and Prevention, Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina; Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Science, National Cancer Institute, Rockville, Maryland
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175
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Schootman M, Homan S, Weaver KE, Jeffe DB, Yun S. The health and welfare of rural and urban cancer survivors in Missouri. Prev Chronic Dis 2013; 10:E152. [PMID: 24028832 PMCID: PMC3775393 DOI: 10.5888/pcd10.130052] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION An estimated 2.8 million cancer survivors reside in rural areas in the United States. We compared the risk behaviors, psychosocial factors, health outcomes, quality of life, and follow-up care of rural and urban cancer survivors in Missouri. METHODS We used 2009-2010 Missouri Behavioral Risk Factor Surveillance System data to examine various health outcomes, behaviors, and psychosocial factors among rural and urban cancer survivors and their respective rural and urban counterparts without a cancer history. Cancer survivors also were asked about receipt of survivorship care plan components. Sociodemographic factors, access to medical care, and chronic conditions were examined as potential explanatory factors for differences among the 4 groups. RESULTS An estimated 9.4% of rural and 7.9% of urban Missourians aged 18 years or older reported a cancer history. Rural survivors reported the highest rates of poor self-reported health, physical distress, and activity limitation; however differences between rural and urban survivors were attributable largely to sociodemographic differences. Both rural and urban cancer survivors reported more fatigue than their respective counterparts without a cancer history. Rural survivors also were less likely to meet Centers for Disease Control and Prevention recommendations for physical activity than their rural controls. The prevalence of smoking among rural survivors was higher than among urban survivors. Only 62% of rural survivors versus 78% of urban survivors reported receiving advice about cancer follow-up care. CONCLUSION Rural cancer survivors face many health challenges. Interventions to improve quality of life and health behaviors should be adapted to meet the needs of rural cancer survivors.
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Affiliation(s)
- Mario Schootman
- Washington University School of Medicine, Department of Medicine, Division of Health Behavior Research, 4444 Forest Park Ave, Saint Louis, MO 63108, USA.
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176
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Martinez-Donate AP, Halverson J, Simon NJ, Strickland JS, Trentham-Dietz A, Smith PD, Linskens R, Wang X. Identifying health literacy and health system navigation needs among rural cancer patients: findings from the Rural Oncology Literacy Enhancement Study (ROLES). JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2013; 28:573-81. [PMID: 23813542 PMCID: PMC3755018 DOI: 10.1007/s13187-013-0505-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Rural residence is associated with disparities in cancer-related outcomes. Guided by the Chronic Care Model (CCM), the Rural Oncology Literacy Enhancement Study (ROLES) assessed health literacy and patient navigation needs among rural cancer patients. A mixed methods (qualitative and quantitative) approach was used, including: in-depth interviews, health literacy assessments, and phone surveys with cancer patients (N = 53) from 5 oncology clinics in rural Wisconsin; focus groups and self-administered surveys with staff (N = 41) in these clinics. Within four dimensions of the CCM (community resources, self-management support, delivery system design, and decision support), this study uncovered multiple unmet navigation needs, health literacy limitations, and barriers to quality cancer care. System-level implementation of patient navigation and health literacy best practices could contribute to improved cancer care and patient outcomes among rural populations. Further research identifying effective interventions that reduce cancer disparities among rural cancer patients is necessary.
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177
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Weaver KE, Palmer N, Lu L, Case LD, Geiger AM. Rural-urban differences in health behaviors and implications for health status among US cancer survivors. Cancer Causes Control 2013; 24:1481-90. [PMID: 23677333 DOI: 10.1007/s10552-013-0225-x] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 05/04/2013] [Indexed: 12/19/2022]
Abstract
PURPOSE Rural US adults have increased risk of poor outcomes after cancer, including increased cancer mortality. Rural-urban differences in health behaviors have been identified in the general population and may contribute to cancer health disparities, but have not yet been examined among US survivors. We examined rural-urban differences in health behaviors among cancer survivors and associations with self-reported health and health-related unemployment. METHODS We identified rural (n = 1,642) and urban (n = 6,162) survivors from the cross-sectional National Health Interview Survey (2006-2010) and calculated the prevalence of smoking, physical activity, overweight/obesity, and alcohol consumption. Multivariable models were used to examine the associations of fair/poor health and health-related unemployment with health behaviors and rural-urban residence. RESULTS The prevalence of fair/poor health (rural 36.7 %, urban 26.6 %), health-related unemployment (rural 18.5 %, urban 10.6 %), smoking (rural 25.3 %, urban 15.8 %), and physical inactivity (rural 50.7 %, urban 38.7 %) was significantly higher in rural survivors (all p < .05); alcohol consumption was lower (rural 46.3 %, urban 58.6 %), and there were no significant differences in overweight/obesity (rural 65.4 %, urban 62.6 %). All health behaviors were significantly associated with fair/poor health and health-related unemployment in both univariate and multivariable models. After adjustment for behaviors, rural survivors remained more likely than urban survivors to report fair/poor health (OR = 1.21, 95 % CI 1.03-1.43) and health-related unemployment (OR = 1.49, 95 % CI 1.18-1.88). CONCLUSIONS Rural survivors may need tailored, accessible health promotion interventions to address health-compromising behaviors and improve outcomes after cancer.
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Affiliation(s)
- Kathryn E Weaver
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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