Understanding rural caregivers' experiences of cancer care when accessing metropolitan cancer services: a qualitative study

North Carolina Caregiver Listening Study: Caregiver Experiences and Perspectives on Services and Supports in an Aging U.S. State

Family caregivers experience health, financial, and social burdens related to caregiving responsibilities. North Carolina has an estimated 1.3 million caregivers, equating to a value of $13.1 billion per year. Caregiving demands warrant additional understanding of the caregiver lived experiences. Our objective was to document these North Carolina caregiver experiences during the era of COVID-19 through focus groups. Participants were recruited through diverse community organizations. All 44 caregivers who completed interest solicitation surveys were invited to participate; 29 caregivers participated across 11 groups. Thematic analysis was used to code and synthesize transcripts from each participant using Dedoose software and guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ). Themes included: caregiver routines (caregiving as an all-encompassing role; dimensions of support); most challenging parts (exhaustion and defeat; lacking support; evolving relationships); most rewarding parts (care recipient resilience; quality time; sense of purpose); social service and healthcare system interactions (positive interactions; negative interactions; inaccessible services); COVID-19 impacts on caregiving (opportunities; challenges); and caregiver suggestions for system improvements (increasing financial support; improved coordination; ideological shifts). Caregivers shared unmet needs, challenges, and opportunities for improvement. Examining these needs and experience-informed recommendations can help advance additional caregiving research, policy-making, and program development.

"I'm not the one with cancer but it's affecting me just as much": A qualitative study of rural caregivers' experiences seeking and accessing support for their health and wellbeing while caring for someone with cancer

PURPOSE

Caregivers provide vital support to people with cancer but often report feeling unsupported themselves. This study investigated rural caregivers' experiences seeking support for their health and wellbeing while caring for someone with cancer.

METHODS

Through semi-structured interviews, 20 rural caregivers described their experiences seeking and accessing support for their own health and wellbeing while caring for someone with cancer, including what support was, or would have been, helpful. Interview transcripts were analysed using content analysis to identify the type and source of support sought and what aspects of the support were helpful or unhelpful.

RESULTS

Health and wellbeing support was sought across medical and psychosocial domains. Caregivers' responses reflected both facilitators and barriers to support-seeking and benefits and challenges of accessing support. Facilitators to support-seeking included telehealth options and being involved in patient care discussions, as this helped caregivers know what to expect in their role. Barriers included social isolation while travelling for treatment and caregivers' needs for support not being acknowledged or understood by medical staff or social networks. Benefits of accessing support included help with managing daily responsibilities and being linked with additional services. Challenges included delays in receiving support, inadequate duration of support, and lack of lived experience among care providers.

CONCLUSIONS

To optimise rural caregivers' access to support for their health and wellbeing, support services should be prompt and flexible in delivery, simple to navigate, integrated with patient care, improve caregivers' coping ability, provide access to additional supports, and reduce caregiver burden.

Rural-urban and regional variations in aspects of caregiving, support services and caregiver health in the USA: evidence from a national survey

OBJECTIVES

Due to substantial regional variability in available caregiving services and supports, culture and health status among informal caregivers in the USA, the study objective was to explore how rural-urban differences in aspects of caregiving-caregiving intensity, distance to care recipient, caregiver burden, caregiver health and caregiving support-vary by US Census region (Northeast, South, Midwest and West) after accounting for other social determinants of health.

DESIGN

This study was a secondary analysis of multiwave, cross-sectional study data.

SETTING

The data were collected on a representative sample of informal, unpaid caregivers to older adults.

PARTICIPANTS

A sample of n=3551 informal caregivers from the National Study of Caregiving identified by older adult care recipients from waves 1 (2011) and 5 (2015) of the National Health and Aging Trends Study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures were caregiving intensity (provided support for/with the number of activities of daily living (ADLs) and instrumental ADL (IADLs)) caregiver assisted with, hours of caregiving per month), caregiver burden (physical, emotional and financial), support services sought (types and total number), caregivers' self-reported health and health status (individual comorbidities and a total number of comorbidities). Analyses were stratified by US Census region and rural-urban status, as defined by the US Census Bureau, of census tract of caregiver residence.

RESULTS

Urban caregivers provided higher levels of ADL support in the Northeast (beta=0.19, 95% CI 0.03, 0.35) and West (beta=0.15, 95% CI 0.05,0.26) regions. Urban caregivers provided significantly higher levels of ADL support (p=0.020), IADL support (p=0.033) and total ADLs plus IADLs (p=0.013) than rural caregivers. Caregivers living in the South had higher amounts of monthly hours spent caregiving, ADL support, IADL support and combined ADLs plus IADLs and were more likely to have obesity, report poor or fair health, have heart conditions and experience emotional difficulty from caregiving (all p<0.001).

CONCLUSIONS

Study findings underscore caregiving's multifaceted and complex nature and identify important urban-rural and regional differences in caregiving in the USA. Healthcare providers and healthcare organisations can have an important role in identifying and mitigating the negative impacts of caregiving on caregivers' overall health. Interventions and support should be tailored to caregivers' demographic backgrounds, addressing regional differences.

People affected by cancer and their carers from gender and sexually diverse communities: their experiences and the role of smartphone applications

BACKGROUND

People living with cancer, or carers who are from lesbian, gay, bisexual, transgender, queer, intersex or asexual (LGBTQIA+) communities experience unique information and support needs. Accessible technology-based resources providing tailored support are required to promote wellbeing, however this is a growing area of research requiring further investigation. The purpose of this study was to explore the experiences of healthcare services among people living with cancer, and their carers, who belong to sexual or gender diverse communities (LGBTQIA+), and identify how smartphone applications (apps) could support people from LGBTQIA + communities.

METHODS

This was a qualitative descriptive study where people living with cancer or carers from LGBTQIA + communities participated in phone interviews. Participants were recruited across Australia via social media advertisements, LGBTQIA + medical practices, and cancer advocacy groups. Participants were asked questions about their experiences, and were provided with screenshots of an existing app and asked to provide feedback on content and inclusiveness. Transcripts were coded and codes grouped together to form similar and concepts. Inductive and deductive analyses were used to create themes.

RESULTS

13 patients (mean age 56 (SD:13)), and three carers (mean age 64 (SD:19)) completed phone interviews. The majority of participants identified their gender as female (patients n = 9, carers 3), and their sexuality as gay or lesbian (patients n = 10, carers n = 3). Four themes were created: (1) navigating disclosure in healthcare, described emotional challenges surrounding disclosure; (2) the power of positive experiences with clinicians, described positive interactions and gaps in care from clinicians; (3) impact of gender and sexuality on informal support, outlined support received from informal network and gaps in support, and; (4) opportunities to increase inclusivity in smartphone apps, generated ideas on how apps can be tailored to meet needs identified.

CONCLUSION

Disclosure of gender or sexuality, and interactions with clinicians had the potential to impact participants' experience of cancer care. Gaps in informal networks pointed at how to better support LGBTQIA + communities, and identified opportunities for inclusion in an app that will be tailored and trialled for this community. Future work should focus on addressing systems-level processes in acknowledging and supporting priority groups affected by cancer.

Exploring dietitians' practice and perspectives on the role of dietary patterns during cancer treatment: A qualitative study

BACKGROUND

Dietitians are nutrition professionals equipped with specialised skills required to prevent and treat malnutrition in cancer. Optimisation of dietary intake is recommended as the primary nutrition strategy for the treatment of cancer-related malnutrition. However, it is unclear whether dietary patterns, described as the combination, quantity, and frequency of food consumption, are considered. This study examined dietitians' current food-based management of malnutrition; explored dietitians' awareness of dietary patterns and assessed barriers and enablers to the use of dietary patterns in clinical practice.

METHODS

This qualitative study consisted of semi-structured interviews with oncology dietitians. Dietitians were recruited through national nutrition societies, social media, and professional networks. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis.

RESULTS

Fourteen oncology dietitians from across four Australian states and territories participated. Three themes were identified: (i) principles to guide nutritional care, (ii) dietary patterns as a gap in knowledge and practice, and (iii) opportunities for better care with systems as both a barrier and enabler. Dietetic practice was food-focussed, encouraging energy and protein-rich foods consistent with nutrient-focussed evidence-based guidelines. Dietitians encouraged one of two nutrition-related approaches, either encouraging intake of 'any tolerated food' or 'foods supportive on longer-term health'. Dietitians were generally unaware of dietary patterns and questioned their relevance in certain clinical situations. A multidisciplinary team approach, adequate food service and dissemination of dietary patterns research and education were identified as opportunities for better patient care.

CONCLUSIONS

Recommendations for the treatment of malnutrition vary between oncology dietitians and uncertainty exists regarding dietary patterns and their relevance in clinical practice. Further exploration into the role of dietary patterns to treat cancer-related malnutrition and education for dietitians are required prior to implementation of a dietary patterns approach into clinical practice.

Soins de soutien au Nouveau-Brunswick (Canada): analyse de l’environnement

Le diagnostic et le traitement du cancer laissent rarement les survivants et leurs proches physiquement et psychologiquement indemnes. Les services dont ils ont besoin dépassent le seul traitement médical, c’est-à-dire qu’il leur faut une variété de soins de soutien répondant à leurs besoins physiques, sociaux, informationnels et émotionnels. La présente étude a pour objectif de répertorier les services de soutien destinés aux survivants du cancer, aux membres de leur famille et à leurs proches aidants qui sont disponibles dans la province du Nouveau-Brunswick, au Canada. Pour ce faire, nous avons procédé à une analyse de l’environnement, ce qui nous a permis de constater que les services disponibles dans la province ne sont pas facilement repérables ou accessibles. On a observé tout particulièrement des lacunes dans les services aux survivants, à leur famille et à leurs proches, en phase post-traitement.

Supportive care services in New Brunswick, Canada: An environmental scan

Cancer diagnosis and treatment often have significant physical and psychological implications for both the survivor and their family/caregivers. Necessary services extend beyond medical treatment and include a variety of supportive care services (SCS) that address individuals' physical, social, educational, and emotional needs. This study seeks to map the SCS available in the province of New Brunswick (NB), Canada, for cancer survivors, their families, and their caregivers. An environmental scan was conducted to assess current SCS available in NB. While some SCS exist in NB, they are not always easily accessible or identifiable, and gaps in services were prevalent. In particular, a gap in services was found for individuals who are no longer actively receiving cancer treatment, as well as for family members and caregivers.

Travelling overseas for proton beam therapy: A retrospective interview study

INTRODUCTION

Travelling for cancer treatment comes with unique challenges, particularly for a young patient and his or her family. The aims of this study were to (1) gain an understanding of the experiences of families and patients who travelled overseas (OS) from Australia for proton beam therapy (PBT) and (2) identify the supportive care needs patients and their families require when living away from home, while having PBT.

METHODS

This was a retrospective, qualitative study using semi-structured interviews, conducted with participants aged under 25 years and their families who travelled OS for PBT between 2017 and 2020. Data were analysed using Microsoft Excel Software, where key themes were identified and coded based on their responses. A total of 17 participants were included in interviews from seven Australian families who travelled to America or Europe for PBT.

RESULTS

The majority of participants reported a lack of coordination with travel and treatment arrangements prior to arrival OS. Families who stayed in hotel accommodation while OS reported greater feelings of isolation compared with those who stayed in share house-style accommodation. The acuity of cancer diagnosis played a significant part in patient experience, with those patients requiring the greatest amount of supportive care and availability of service provision at stand-alone centres reporting a lack of appropriate care provision.

CONCLUSIONS

This study has identified services, accommodation provisions and care coordination requirements that are largely missing from the travel and treatment experience in patients travelling OS for PBT. Future use of consumer-led working groups or committees in creating models of care for families travelling for PBT treatment could be advantageous, with many families willing to share their experiences and provide support to others who are travelling for PBT.

Implementation Costs of Technology-Enhanced Transitional Palliative Care for Rural Caregivers

OBJECTIVES

Compared to urban family caregivers (FCG), rural FCG experience greater burdens accessing coordinated care for their loved ones during and after hospitalization. The impact of technology-enhanced transitional palliative care (TPC) on caregiver outcomes is currently being evaluated in a randomized control trial. This study evaluates resource use and health system costs of this FCG-focused TPC intervention and potential Medicare reimbursement mechanisms.

METHODS

Rural caregivers of hospitalized patients were randomized into an 8-week intervention consisting of video visits conducted by a registered nurse certified in palliative care, supplemented with phone calls and texts (n = 215), or attentional control. Labor costs were estimated for a registered nurse and compared to scenario analyses using a nurse practitioner or social worker wages. Medicare reimbursement scenarios included Transitional Care Management (TCM) and Chronic Care Management (CCM) CPT codes.

RESULTS

In the base case, TPC cost was $395 per FCG facilitated by a registered nurse, compared to $337 and $585 if facilitated by a social worker or nurse practitioner, respectively. Mean Medicare reimbursement in the TCM-only scenario was $322 and $260 for high or moderate complexity patients, respectively. Reimbursement in the CCM only scenario was $348 and $274 for complex and non-complex patients, respectively. Reimbursement in the TCM+CCM scenario was $496 and $397, for high/complex and moderate/non-complex patients, respectively.

CONCLUSION

TPC is a feasible, low cost and sustainable strategy to enhance FCG support in rural areas. Potential reimbursement mechanisms are available to offset the costs to the health system for providing transitional palliative care to caregivers of patients recently hospitalized.

The experience of bereaved cancer carers in rural and regional areas: The impact of the COVID-19 pandemic and the potential of peer support

BACKGROUND

Caring for someone with cancer during end of life care can be a challenging and complex experience. Those living in rural and regional areas are less likely to have local healthcare services and may be physically isolated. Even where support services such as respite do exist, they may be less likely to be accessed due to the time burden in travelling to services. This was compounded by the COVID-19 pandemic.

AIM

To understand the potential benefits of peer support for bereaved carers of people with cancer from rural and regional locations during the COVID-19 period.

METHODS

Phone interviews were conducted with bereaved cancer carers living in rural and regional areas in Victoria. Semi-structured interviews were used, and participants were asked about their experience as a carer, bereavement and the potential for peer support. Interviews were audio recorded and transcribed verbatim; transcripts were coded and a thematic analysis was conducted.

FINDINGS

12 interviews were conducted. Carers were mostly female (85%) and were on average 58 years of age (range 42-71). Interviews lasted an average of 58 minutes (range 53-91 minutes). Three themes were derived from the data; 1) Supportive care needs while caring and the impact of COVID-19; 2) Isolation during bereavement compounded by the COVID-19 pandemic; and 3) Peer support requires flexibility to meet diverse needs.

CONCLUSION

Peer support has potential to assist bereaved carers of people with cancer. A co-design approach may be beneficial for developing a flexible model for supporting and linking carers together.

Social determinants of health, psychological distress, and caregiver burden among informal cancer caregivers of cancer survivors during treatment

OBJECTIVE

This study compared three ethnic/racial groups of informal cancer caregivers on social determinants of health and tested social determinants of health as predictors of psychological distress and caregiver burden.

METHODS

This study was a secondary analysis of baseline data of a sequential multiple assignment randomized trial (SMART) testing symptom management interventions with caregiver-survivor dyads. Caregivers completed baseline measures of social determinants of health (SDoH), functional limitations, psychological distress, and caregiver burden. Hispanic, non-Hispanic White, and non-Hispanic other races caregivers were compared on these variables. Multivariate tests of associations between SDoH and caregiver burden and psychological distress were conducted in structural equation modeling with caregiver burden and psychological distress as latent variables.

RESULTS

Hispanic caregivers reported significantly higher caregiver burden, specifically for finances, family, and schedules. Caregiver burden was significantly predicted by having income barely or not meeting needs, being female, socially isolated, married, Hispanic, and having poor physical functioning. Significant predictors of caregivers' psychological distress: being female, being socially isolated, and having poor physical functioning.

CONCLUSION

Hispanic caregivers experience significant challenges associated with caregiver burden, especially if they are female, socially isolated, and have poor physical functioning. Assessment of these SDoH is important in caregiver health to provide supportive care during caregiving.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03743415 www.clinicaltrials.gov.

Inequities Among Cancer Caregivers with Diverse Identities: A Review of the Literature and Future Directions

PURPOSE OF REVIEW

The number of older adults with cancer relying on support from caregivers continues to increase. Health disparities in older adults with cancer often extend to their caregivers. This review aims to assess the state of cancer caregiving research in historically underrepresented diverse populations and provide recommendations for future research and policy.

RECENT FINDINGS

Research on caregivers of older adults with cancer from diverse backgrounds has primarily been descriptive. Health disparities for historically underrepresented caregivers (LGBTQ + , BIPOC, rural, young adults, youth) exist across several dimensions (e.g., financial, mental, and physical health, and access to caregiver support). Few published studies have closely examined the unique experiences of these caregivers nor provided culturally appropriate tailored interventions. Health equity research within caregiving populations is in its infancy. Priorities for future work should focus on identifying modifiable targets for intervention, changing systems-level processes in acknowledging and supporting caregivers, and creating policies that reduce financial inequities of caregiving.

Rural resilience during COVID-19: the lived experience of North Carolinian rural-dwelling cancer caregivers

PURPOSE

To illuminate the lived experience of resilience in rural-dwelling North Carolinian cancer caregivers at the intersection of cancer and the COVID-19 pandemic.

METHODS

In spring, 2020, we recruited self-identified primary caregivers (CGs) for a relative/friend with cancer living in a rural area. We conducted cross-sectional semi-structured interviews and then thematically analyzed transcripts to identify and categorize instances of stressors and benefit-finding.

RESULTS

Of the 24 participants, 29% were < 50 years old, 42% identified as non-Hispanic Black, 75% were women, and 58% were spousal CGs. Most care recipients (CRs) had stage IV cancer (n = 20) and cancer types varied. Participants played a variety of roles in caregiving and experienced stressors related to caregiving demands (e.g., conflicts with other responsibilities), rurality (e.g., transportation), and the COVID-19 pandemic (e.g., new visitor policy at hospital). Despite stressful experiences, participants also identified many positive aspects of their caregiving. Five domains of benefit-finding were identified: appreciation (e.g., gratitude toward their ability to care for CRs), CG-CR dyad relationship dynamics (e.g., increased closeness), interpersonal relationship dynamics (e.g., perceived peer support), faith (e.g., ability to cope through praying), and personal growth (e.g., new skills learned from caregiving).

CONCLUSION

Rural-dwelling cancer caregivers from mixed sociodemographic backgrounds identified a diverse range of benefits from caregiving, despite experiencing multiple stressors, including emergent stressors from the COVID-19 pandemic. Healthcare delivery serving rural communities may consider expanding transportation assistance and boosting benefit-finding to ameliorate stress in cancer caregivers.

Geospatial analysis of patients' social determinants of health for health systems science and disparity research

Social context matters for health, healthcare processes/quality and patient outcomes. The social status and circumstances we are born into, grow up in and live under, are called social determinants of health; they drive our health, and how we access and experience care; they are the fundamental causes of disease outcomes. Such circumstances are influenced heavily by our location through neighborhood context, which relates to support networks. Geography can influence proximity to resources and is an important dimension of social determinants of health, which also encompass race/ethnicity, language, health literacy, gender identity, social capital, wealth and income. Beginning with an explanation of social determinants, we explore the use of Geospatial Analysis methods and geocoding, including the importance of collaborating with geography experts, the pitfalls of geocoding, and how geographic analysis can help us to understand patient populations within the context of Social Determinants of Health. We then explain mechanisms and methods of geospatial analysis with two examples: (1) Bayesian hierarchical regression with crossed random effects and (2) discontinuity regression i.e., change point analysis. We leveraged the local University of Utah and Yale cohorts of the Multicenter Perioperative Outcomes Group (MPOG.org ), a perioperative electronic health registry; we enriched the Utah cohort with US-census tract level social determinants of health after geocoding patient addresses and extracting social determinants of health from the National Neighborhood Database (NaNDA). We explain how to investigate the impact of US-census tract level community deprivation indices and racial/ethnic composition on (1) individual clinicians’ administration of risk-adjusted perioperative antiemetic prophylaxis, (2) patients’ decisions to defer cataract surgery at the cusp of Medicare eligibility and finally (3) methods to further characterize patient populations at risk through publicly available datasets in the context of public transit access. Our examples are not rigorous analyses, and our preliminary inferences should not be taken at face value, but rather seen as illustration of geospatial analysis processes and methods. Our worked examples show the potential utility of geospatial analysis, and in particular the power of geocoding patient addresses to extract US-census level social determinants of health from publicly available databases to enrich electronic health registries for healthcare disparity research and targeted health system level countermeasures.

Differences in Distress Between Rural and Non-rural Appalachian Breast Cancer Patient/Caregiver Dyads During the First Year of Treatment

Introduction

Breast cancer patients and their caregivers living in rural Appalachia face substantial health disparities compared to their non-rural Appalachian counterparts. However, there is limited research on how these specific health disparities in rural Appalachian communities may impact patient psychological distress and caregiver strain during the first year of breast cancer treatment.

Purpose

The purpose of the current study was to assess differences in patient psychological distress (depression and anxiety) and caregiver strain between rural non-rural Appalachian breast-cancer-affected dyads (patients and their caregivers) during the first year of treatment.

Methods

A total of 48 Appalachian breast cancer patients (with a Stage I through Stage III diagnosis) and their identified caregiver (together, 'dyads') were identified from The University of Tennessee Medical Center across 2019 to 2020. Dyads completed follow-up surveys throughout the first year of treatment. In this prospective pilot study, measures on anxiety, depression and caregiver strain were self-reported and then analyzed using RM-ANOVA.

Results

There was a statistically significant higher number of reports of patient depression and caregiver strain in rural-residing dyads compared to non-rural-residing dyads. However, there was not a statistically significant difference between rural and non-rural Appalachian dyads for patient-reported anxiety during the first year of treatment.

Implications

The higher reported patient depression and caregiver strain among rural-residing Appalachian patients may indicate the need for implementing remote (e.g., telehealth) Cognitive Behavioral Therapy (CBT) to address the psychological needs of rural-residing dyads. Additionally, greater education from physicians to rural dyads on what to expect during treatment could alleviate caregiver strain.

Australian Rural Caregivers' Experiences in Supporting Patients With Kidney Failure to Access Dialysis and Kidney Transplantation: A Qualitative Study

RATIONALE & OBJECTIVE

Caregivers of patients with chronic kidney disease from rural communities play a crucial role in access to dialysis and transplantation, but they face many challenges including geographical distance, financial hardship, and limited support. This study aimed to inform strategies to overcome these challenges by describing the experiences of caregivers of patients with kidney failure from rural Australian communities in accessing kidney replacement therapy.

STUDY DESIGN

Qualitative study.

SETTING & PARTICIPANTS

18 adult caregivers of Australian rural patients with kidney failure treated with dialysis or kidney transplantation.

ANALYTICAL APPROACH

Semistructured interviews were conducted. Interview transcripts were thematically analyzed.

RESULTS

The 18 participants were aged 20 to 78 years; 13 (72%) were female, and 13 (72%) were the spouse/partner of the patient. We identified 5 themes: devastating social isolation (difficult periods of separation, exclusion from peers, forced relocation); financial dependency and sacrifice (burgeoning out-of-pocket costs, disruption to work life, foregoing autonomy); ongoing psychological trauma (concern for neglect and stress on children, long-term emotional distress); overwhelmed by multifaceted roles and expectations (patient advocacy, uncertainty in navigating multiple health systems); and persistent burden of responsibility (loss of self-identity, ongoing travel requirements, scarcity of psychosocial support, unpreparedness for treatment regime).

LIMITATIONS

The study was conducted in a high-income, English-speaking country with universal health insurance, which may limit the transferability of the findings.

CONCLUSIONS

Australian rural caregivers of people with kidney failure treated by maintenance dialysis or transplantation experience an exhausting physical, financial, and psychological burden. Strategies to address these profound challenges are needed.

PLAIN-LANGUAGE SUMMARY

This interview-based study elicited the challenges faced by people and family members who care for patients from rural towns who are receiving dialysis or kidney transplantation. The barriers and difficulties reported included traveling long distances, needing to move to larger towns and leaving their homes, feeling concerned for the long-term effects on their children, physical exhaustion, and financial issues. Additional efforts are needed to identify the means by which caregivers and their families in rural towns can obtain support to care for those with kidney failure.

"If I wasn't in a rural area, I would definitely have more support": social needs identified by rural cancer caregivers and hospital staff

BACKGROUND

The social needs of rural families facing cancer warrant investigation to inform psychosocial care planning and policy development.

METHODS

Using purposive sampling, we interviewed 24 rural caregivers and 17 hospital staff from an academic cancer center in the U.S. South. Social needs were defined as the support needed to effectively provide informal caregiving across economic, physical, interpersonal, and service domains. We used the framework method to code and synthesize findings.

FINDINGS

Caregiver economic and physical needs were interconnected and most pressing, including common examples of distance to care and transportation barriers. Caregivers desired additional support from the health system, insurance providers, and community resources. Staff identified similar need patterns and gaps in health system capacity.

CONCLUSIONS

Rural cancer caregivers experience multiple unmet social needs. Supportive interventions for this population will benefit from flexible implementation and multilevel, multisector approaches. In particular, interventions that address financial hardship and limited internet access are needed.

Being away from home for cancer treatment: a qualitative study of patient experience and supportive care needs during radiation therapy

INTRODUCTION

Supportive care needs (SCN) refer to support required by patients and their families to better cope with cancer. Many rural radiation therapy (RT) patients stay away from home for significant periods, which can lead to the negative effects of both social isolation and cultural disparity. They may demonstrate complex SCN. This study aimed to explore experiences of being away from home by considering patient perspectives of their own SCN. The objectives were to provide a deeper understanding of how these patients think and feel and present a foundation of patient-centred insights for further research.

METHODS

Thirteen patients participated in semi-structured interviews; all stayed away from home for RT at the North Coast Cancer Institute for >3 days a week for >3 weeks. The data were subject to interpretive phenomenological analysis: a thorough process of understanding and analysis that is accompanied by reflection to improve researcher transparency.

RESULTS

Two themes influenced patient experiences of their care: values and identity, and expectations. Patients discussed the value they place on rural life, community connections and health care and referred to information for managing expectations. SCN discussed fell into practical, physical and psycho-social needs.

CONCLUSIONS

Experiences of culturally appropriate patient-centred supportive care improve control and confidence. Patient well-being is influenced by compassionate, caring and respectful connections with others. Several practical ways of managing expectations and promoting the psycho-social well-being of patients are discussed, for example, tailored packing lists and easy access to green spaces. Future research can be shaped by lived experiences.

The quality of life of regional and remote cancer caregivers in Australia

Objective

This study compares the well‐being of rural caregivers with that of the general population and explores the potential drivers of poorer outcomes.

Method

Patient–caregiver dyads (n = 241) residing in regional or remote Queensland, Australia, reported on QoL, chronic illness, caregiver burden, depression, anxiety and stress. Caregiver outcomes were compared with population norms and patient outcomes. Multiple regressions were conducted to identify factors associated with poorer caregiver outcomes.

Results

Caregivers reported lower mental health‐related QoL (M = 0.436, 95% CI = 0.410–0.462) in comparison with age‐matched population norms (M = 0.556, 95% CI = 0.532–0.580). No differences existed between caregiver and population norms for anxiety, stress and depression. Caregiver chronic illness and higher burden were associated with poorer mental and physical QoL, depression, anxiety and stress (η²s ranging from 0.03 to 0.30). These associations were slightly stronger for male caregivers when compared with female caregivers (η²s ranging from 0.03 to 0.08).

Conclusion

It is vital that efforts are made to improve rural caregivers' mental and emotional well‐being. Interventions that support caregivers with chronic conditions reduce caregiver burden and take into consideration the unique experience of male caregivers will go some way to addressing this. Future research is needed to identify other drivers of health outcomes in this group.

Gender differences in the association between unmet support service needs and mental health among American cancer caregivers

PURPOSE

Cancer caregiving can be distressing, and many caregivers have support service needs. Given the role gender has played in shaping norms around caring, gender may influence caregiving experiences. Using Behavioral Risk Factor Surveillance System data, 2015-2018, we aimed to examine gender as an effect modifier of the unmet support service needs and mental health association among cancer caregivers.

METHODS

Our n = 5814 sample represented approximately 4.8 million caregivers. Mental health was operationalized as number of mentally unhealthy days over the past 30 (MUDs) and Frequent Mental Distress (FMD, MUDs ± 14 days). Unmet supportive care needs included endorsement of needing but not receiving caregiving classes, help accessing services, support groups, counseling, and respite care. We conducted zero-inflated negative binomial (ZINB) and logistic regression analyses to examine the associations between unmet needs with MUDs and FMD and then tested gender as an effect modifier.

RESULTS

Cancer caregivers reported an average of 6 MUDs. Approximately 20% of caregivers reported FMD, and 17% reported having any unmet needs. Gender moderated the unmet needs and FMD association. Among female caregivers, those with unmet needs were more likely to report FMD (aOR: 2.167; 95%CI: 1.447, 3.243); among male caregivers, no association was found (aOR: 0.970; 95%CI: 0.471, 2.001). In the ZINB model of MUDs, no significant moderation effect of gender was found.

CONCLUSION

Though distress does not appear to vary by gender, having unmet support needs may negatively affect mental health in female cancer caregivers. Studies on gendered experiences can inform strategies to meet caregiver needs.

Strategies for Improving Access to Cancer Services in Rural Communities: A Pre-implementation Study

Background

Implementation science is defined as the scientific study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners. Failure of implementation is more common in resource-limited settings and may contribute to health disparities between rural and urban communities. In this pre-implementation study, we aimed to (1) evaluate barriers and facilitators for implementation of guideline-concordant healthcare services for cancer patients in rural communities in Upstate New York and (2) identify key strategies for successful implementation of cancer services and supportive programs in resource-poor settings.

Methods

The mixed methods study was guided by the Consolidated Framework for Implementation Research (CFIR). Using engagement approaches from Community-Based Participatory Research, we collected qualitative and quantitative data to assess barriers and facilitators to implementation of rural cancer survivorship services (three focus groups, n = 43, survey n = 120). Information was collected using both in-person and web-based approaches and assessed attitude and preferences for various models of cancer care organization and delivery in rural communities. Stakeholders included cancer survivors, their families and caregivers, local public services administrators, health providers, and allied health-care professionals from rural and remote communities in Upstate New York. Data was analyzed using grounded theory.

Results

Responders reported preferences for cross-region team-based cancer care delivery and emphasized the importance of connecting local providers with cancer care networks and multidisciplinary teams at large urban cancer centers. The main reported barriers to rural cancer program implementation included regional variation in infrastructure and services delivery practices, inadequate number of providers/specialists, lack of integration among oncology, primary care and supportive services within the regions, and misalignment between clinical guideline recommendations and current reimbursement policies.

Conclusions

Our findings revealed a unique combination of community, socio-economic, financial, and workforce barriers to implementation of guideline-concordant healthcare services for cancer patients in rural communities. One strategy to overcome these barriers is to improve provider cross-region collaboration and care coordination by means of teamwork and facilitation. Augmenting implementation framework with provider team-building strategies across and within regions could improve rural provider confidence and performance, minimize chances of implementation failure, and improve continuity of care for cancer patients living in rural areas.

Experiences of People with Cancer from Rural and Remote Areas of Western Australia Using Supported Accommodation in Perth While Undergoing Treatment

The aim of the study was to explore the lived experiences of people diagnosed with cancer from rural and remote areas of Western Australia, who utilise supported accommodation services whilst undergoing treatment in the capital city (Perth). Methods A qualitative phenomenological approach was used in this study. Ten participants were recruited using purposive sampling, who were aged between 35–65 years, were diagnosed with cancer within the previous three months and used accommodation services within the past 12 months. Semi-structured in-depth interviews were conducted with a duration of approximately 45–60 min via Zoom, FaceTime or phone call. Interview data was transcribed, thematically analysed and coded into relevant themes. Results: Three overarching themes were derived from the interviews–“It’s harder to have cancer when you have to relocate for treatment,” “The paradoxical experience of staying at the accommodation,” and “Feeling grateful for the support offered’. Conclusions: People diagnosed with cancer who have to relocate during treatment require emotional, logistical, and social supports. Cancer accommodation services are essential in enabling individuals to continue engaging in meaningful occupations and maintain their quality of life. Our study highlights the need for cancer accommodation services to consider the complex needs of individuals completing treatment for cancer in locations away from their usual homes.

Caring for someone with cancer in rural Australia

PURPOSE

To explore the experiences of people caring for someone with cancer, while living in rural Australia, and the impact of the cancer-caring role on their well-being.

METHOD

Eighteen adults in regional or remote ('rural') Australia who cared for a person with cancer took part in semi-structured telephone interviews. Participants were aged 32-77 years and mainly female (66%). Data were analysed using thematic analysis and an essentialist approach.

RESULTS

Eight themes were identified: (1) travel is hard, but supports are available; (2) frustration with systems that do not demonstrate understanding of the rural context; (3) the importance of lay and peer support; (4) the impact of access to trusted, local health care services; (5) the importance of access to rurally relevant information (particularly on relevant services and what to expect); (6) living with uncertainty and balancing loss with hope; (7) reluctance to seek or accept psychological support; and (8) the gendered nature of care.

CONCLUSION

Rural cancer carers' roles can be made easier by improving health systems and coordination to ease the burden of travel, providing information about available support and what to expect throughout cancer treatment that is relevant to the rural context, and increasing access to quality health, community, and support services, including palliative care, in rural areas. More training on the specific needs of rural patients and their carers is needed for urban health care professionals. Peer support groups may have particular value for cancer carers in rural settings, where there are known to be multiple barriers to accessing professional sources of psychosocial support.

Living in Rural Areas and Receiving Cancer Treatment Away From Home: A Qualitative Study Foregrounding Temporality

We used explorative interviews to gauge (inter)personal, physiological, and emotional challenges of seven rural cancer patients who traveled long distances to cancer treatment centers. After a thematic analysis, we foregrounded experiences of temporality by using a phenomenologically inspired approach. The analysis resulted in three themes: (a) An epiphany of “what really matters in life”—time gains new meaning, (b) Feeling out of sync with others and own body—striving for coherence and simultaneity, and (c) Being torn between benefits of home and treatments site—time and distance as a tangible aspect of traveling and being away. Under these themes, 13 meaning units were generated, which reflected changes in temporality. During treatment, life primarily revolved around repeating circles of travel arrangements, staying on top of treatment schedule, and synchronizing a home life with a life away from home. Nurses should provide comprehensive care to enhance stability in cancer patients’ temporal experiences.

Codesigning a supportive online resource for Australian cancer carers: a thematic analysis of informal carers' and healthcare professionals' perspectives about carers' responsibilities and content needs

OBJECTIVE

To gather preliminary qualitative data that will assist in the codesign and development of a new informational and supportive website to assist informal cancer carers in Australia.

DESIGN AND SETTING

Utilising a previously tested codesign process, informal carers' experiences and perspectives, including those of healthcare professionals', were examined via focus groups and/or interviews. Data were analysed via thematic analysis.

PARTICIPANTS

Rural (n=9) and urban (n=11) carers', and healthcare professionals' (n=8) perspectives were collected. Carers participated in a focus group (n=9) or telephone interview (n=11). Healthcare professionals completed an interview (n=6) or online survey (n=2).

RESULTS

Rural and urban carers typically felt ill prepared for their multitudinal caregiving responsibilities. Supporting patient-to-healthcare professional liaisons could especially challenge. Carers' biopsychosocial and fiscal strains were affected by patients' hardships and available informal supports. Rural carers described greater social support than urban carers. Both rural and urban carers also described discontentment related to a carer neglecting healthcare system. Both carers and healthcare professionals endorsed the need for a user-friendly, carer-specific website encompassing practical information and resources, peer-driven advice and evidence-based illness information, tailored to the Australian context.

CONCLUSIONS

Carers and healthcare professionals recognise the pressing need for an Australian, cancer carer-specific online resource. Findings will inform the next phase, where a resource will be designed, developed and tested.

The Supportive Care Needs of Regional and Remote Cancer Caregivers

Objective: As cancer survival rates continue to increase, so will the demand for care from family and friends, particularly in more isolated settings. This study aims to examine the needs of cancer caregivers in regional and remote Australia. Methods: A total of 239 informal (i.e., non-professional) cancer caregivers (e.g., family/friends) from regional and remote Queensland, Australia, completed the Comprehensive Needs Assessment Tool for Cancer Caregivers (CNAT-C). The frequencies of individuals reporting specific needs were calculated. Logistic regression analyses assessed the association between unmet needs and demographic characteristics and cancer type. Results: The most frequently endorsed needs were lodging near hospital (77%), information about the disease (74%), and tests and treatment (74%). The most frequent unmet needs were treatment near home (37%), help with economic burden (32%), and concerns about the person being cared for (32%). Younger and female caregivers were significantly more likely to report unmet needs overall (OR = 2.12; OR = 0.58), and unmet healthcare staff needs (OR = 0.35; OR = 1.99, respectively). Unmet family and social support needs were also significantly more likely among younger caregivers (OR = 0.35). Caregivers of breast cancer patients (OR = 0.43) and older caregivers (OR = 0.53) were significantly less likely to report unmet health and psychology needs. Proportions of participants reporting needs were largely similar across demographic groups and cancer type with some exceptions. Conclusions: Caregiver health, practical issues associated with travel, and emotional strain are all areas where regional and remote caregivers require more support. Caregivers’ age and gender, time since diagnosis and patient cancer type should be considered when determining the most appropriate supportive care.

Preparing for partnerships in cancer care: an explorative analysis of the role of family-based caregivers

BACKGROUND

Family-based 'informal' caregivers are critical to enable sustainable cancer care that produces optimal health outcomes but also gives rise to psychological burdens on caregivers. Evidence of psychosocial support for caregivers does not currently address the impacts of their role in providing clinical and health-related care for their loved ones. The present study sought to address this gap including with those from priority populations.

METHODS

Qualitative data was collected using focus group and interview methods. We purposively sampled caregivers identified as having a high burden of responsibility for providing clinical care including those from ethnic minority backgrounds, parental caregivers and those living rurally. Transcripts were subject to thematic analysis utilising a team-based approach.

RESULTS

Family-based caregivers included spouses (11), parents (7), children (1), siblings (1). Ten participants were from ethnic minority backgrounds and five participants were from regional or rural locations. Four resulting inter-related themes were; 1) Dual burden of providing clinical care and managing personal emotional distress; 2) Navigating healthcare partnership dynamics; 3) Developing a caregiving skillset, and 4) Unique supportive needs and barriers to access. These data provide evidence of the unique challenge of providing clinical care as part of family-based caregiving for a loved one with cancer, and the absence of support for caregivers to take up this role.

CONCLUSION

Our findings highlight the substantial contribution of family-based caregivers to the provision of cancer care in contemporary health systems. Inadequate support for caregivers is apparent with regard to their role in providing clinical aspects of care such as medication administration and management. Support programs to prepare caregivers to provide clinical care while building capacity to manage their stressors and emotions through this challenging period may be valuable towards sustainable, person-centred care.

A prospective study monitoring carer distress during (chemo)radiotherapy for head and neck cancer via an electronic platform

INTRODUCTION

Research has shown that electronic platforms can assist data capture of patient-reported outcome measures (PROMs) to guide clinical care. In comparison, routine collection of carer-reported outcome measures (CROMs) to support the patient-carer dyad during cancer treatment has had limited attention. The current study utilised a novel electronic CROM (eCROM) system, ScreenIT Carer, to monitor the prevalence and nature of distress in carers of patients undergoing (chemo)radiotherapy ((C)RT) for head/neck cancer (HNC), and explore factors associated with carer distress.

METHODS

Carers completed ScreenIT Carer weekly when attending patients' (C)RT treatment sessions from planning to 2 weeks post-treatment. ScreenIT Carer included the Distress Thermometer (DT) and Problem List, and a purpose-built Mealtime-Specific DT and Problem list. Data were first examined descriptively, then associations between demographic/treatment-related factors and distress severity were analysed using mixed-effects general linear modelling.

RESULTS

135 carers provided 434 ScreenIT Carer entries during the study period (mean entries = three/carer; yielding average adherence rate of 41% (range 11-100%)). A high prevalence of general (59%) and mealtime-specific distress (46%) was reported by carers. Nature of distress was multifactorial, with emotional problems and the patients' physical condition/symptoms common contributing factors. Based on multivariate analysis, tumour site, geographical location of residence and time during (C)RT when ScreenIT Carer was completed were significant predictors of carer distress severity.

CONCLUSIONS

Carer distress is prevalent and multifactorial during (C)RT. This study highlights the feasibility of utilising eCROM platforms such as ScreenIT Carer, to monitor carer wellbeing and guide supportive care services as part of a holistic care pathway.

The psychosocial experiences and supportive care preferences of organ transplant recipients and their carers who live in regional Australia

BACKGROUND

There is no evidence that being a rural or regional organ transplant recipient has adverse physical health outcomes post-surgery compared with those experienced by people living in cities, but the impact of living remotely from transplant centres on psychosocial outcomes has not been explored.

OBJECTIVE

To identify the social, emotional, psychological, spiritual, informational and practical issues associated with being a regionally based organ transplant recipient or carer and determine how support services could be improved for this group.

DESIGN/ SETTING/ PARTICIPANTS

Twenty-two purposively sampled adult Australians who lived outside metropolitan centres and had received an organ transplant (n = 15) or were the primary carer of someone who had received one (n = 7), participated in semi-structured, telephone interviews. Qualitative data were collected until data saturation was reached and were analysed using thematic analysis.

RESULTS

Five key themes (plus subthemes) were identified: (a) travelling for specialist transplant care takes a toll, (b) unique transplant-related psychological and emotional issues experienced before and after transplants, (c) caring for transplant recipients is a demanding role, (d) lay, peer and professional support, including rural general practitioners and accommodation facilities, help ease the burden, but (e) significant barriers to accessing transplant-focused psychosocial support exist.

CONCLUSION

Novel methods of delivering targeted, transplant-specific information and psychosocial care to rural transplant recipients and their carers, employers and rural health professionals require development and evaluation. Strategies might be delivered by peers or professionals via telehealth, telephone, social media or websites for example, depending on preferences and level of need.

Coping with fear of cancer recurrence among ovarian cancer survivors living in small urban and rural settings: A qualitative descriptive study

PURPOSE

Fear of cancer recurrence (FCR) is a paramount concern among ovarian cancer survivors. Evidence shows that cancer survivors living in regional or rural areas have higher psychological morbidity; however, no known studies have explored how ovarian cancer survivors living in small urban and rural areas cope with FCR.

METHODS

In this qualitative descriptive study, a semi-structured questioning process was developed in accordance with Carver et al.'s conceptualization of coping. Focus groups or 1:1 telephone interviews were used to collect data from a convenience sample of ovarian cancer survivors. Participants completed a demographic form and the Fear of Cancer Recurrence Inventory, and clinical information was extracted from hospital charts.

RESULTS

The average age of participants (n = 15) was 62.8 years (Range 51-76 years) and the average time since diagnosis was 2.7 years (Range 1-19 years). Most women had elevated levels of FCR. Five themes for coping were expressed by all women: 1) health care provider support; 2) knowing, trusting, and prioritizing self; 3) finding what works; 4) uniqueness and belonging; and 5) redirecting thoughts and actions. One additional theme was expressed by most women (n = 11): 6) preparing for the future.

CONCLUSION

Fear of cancer recurrence was a concern for most ovarian cancer survivors who used a variety of ways to cope. Results can be used to guide nurses' discussions with post-treatment ovarian cancer survivors or be used to inform refinement and development of resources to assist ovarian cancer survivors living in small urban and rural settings to cope with FCR.