Identifying health literacy and health system navigation needs among rural cancer patients: findings from the Rural Oncology Literacy Enhancement Study (ROLES)

Implementing the European code of cancer practice in rural settings

Existing evidence often indicates higher cancer incidence and mortality rates, later diagnosis, lower screening uptake and poorer long-term survival for people living in rural compared to more urbanised areas. Despite wide inequities and variation in cancer care and outcomes across Europe, much of the scientific literature explicitly exploring the impact of rurality on cancer continues to come from Australia and North America. The European Code of Cancer Practice or "The Code" is a citizen and patient-centred statement of the most salient requirements for good clinical cancer practice and has been extensively co-produced by cancer patients, cancer professionals and patient advocates. It contains 10 key overarching Rights that a cancer patient should expect from their healthcare system, regardless of where they live and has been strongly endorsed by professional and patient cancer organisations as well as the European Commission. In this article, we use these 10 fundamental Rights as a framework to argue that (i) the issues and needs identified in The Code are generally more profound for rural people with cancer; (ii) addressing these issues is also more challenging in rural contexts; (iii) interventions and support must explicitly account for the unique needs of rural residents living with and affected by cancer and (iv) new innovative approaches are urgently required to successfully overcome the challenges faced by rural people with cancer and their caregivers. Despite equitable healthcare being a key European policy focus, the needs of rural people living with cancer have largely been neglected.

Cancer Treatment Closer to the Patient Reduces Travel Burden, Time Toxicity, and Improves Patient Satisfaction, Results of 546 Consecutive Patients in a Northern Italian District

Background and Objectives: The distance to cancer facilities may cause disparities by creating barriers to oncologic diagnosis and treatment, and travel burden may cause time and financial toxicity. Materials and Methods: To relieve travel burden, a program to deliver oncologic treatment closer to the patient was initiated in the district of Piacenza (Northern Italy) several years ago. The oncologic activities are performed by oncologists and by nurses who travel from the oncologic ward of the city hospital to territorial centres to provide cancer patient management. This model is called Territorial Oncology Care (TOC): patients are managed near their home, in three territorial hospitals and in a health centre, named "Casa della Salute" (CDS). A retrospective study was performed and the records of patients with cancer managed in the TOC program were analysed. The primary endpoints were the km and time saved, the secondary endpoints: reduction of caregiver need for transport and patient satisfaction. Results: 546 cancer patients managed in the TOC program from 2 January 2021 to 30 June 2022 were included in this study. Primary endpoints: median km to reach the city hospital: 26 (range 11-79 km) median time: 44 min (range 32-116); median km to reach the territorial clinicians in the TOC program: 7 (range 1-35 km), median time: 16 minutes (range 6-54), p < 0.001. Secondary endpoints: 64.8% of patients who needed a caregiver for the city hospital could travel alone in the TOC program and 99.63% of patients were satisfied. Conclusions: The results of this retrospective study highlight the possibility of treating cancer patients near their residence, reducing travel burden and saving time.

Limited Health Literacy and Its Associated Health Outcomes Among Adults With at Least 2 Atopic Diseases

BACKGROUND

Health literacy (HL) is essential for patients with multiple atopic diseases to improve their health, given the complexity of their disease and treatment regimens.

OBJECTIVE

To estimate the proportion of adults with multiple atopic diseases (at least 2 of atopic dermatitis, asthma, allergic rhinitis, and food allergy) in the Dutch general population and to evaluate the prevalence of limited HL, and its association with socioeconomic status (SES), lifestyle factors, and health-related quality of life (HR-QoL) in this patient population.

METHODS

This cross-sectional study was conducted within the Lifelines Cohort Study via sending an add-on digital questionnaire, including (among others) questions on atopic dermatitis, to all adult participants (n = 135,950) between February and May 2020. Data on asthma, allergic rhinitis, lifestyle factors, HR-QoL, and SES were extracted from baseline assessment between 2006 and 2013. Functional, communicative, and critical HL were measured by validated items from Chew and the Dutch Functional Communicative and Critical Health Literacy questionnaires between 2012 and 2016. Food allergy was measured by the Food Allergy Questionnaire between 2014 and 2016.

RESULTS

In total, 11.8% of the overall study population reported ever having multiple atopic diseases; of those, 23.6% reported having limited functional HL, with a higher prevalence among those with a low SES. Limited functional HL showed positive associations with smoking, obesity, chronic stress, a low diet quality, and decreased HR-QoL among subjects with multiple atopic diseases.

CONCLUSIONS

We identified an HL deficit, and its association with a low SES and poor health outcomes among patients with multiple atopic diseases. Further research is warranted to utilize a more extensive assessment to measure HL and include more health outcomes, such as treatment adherence and disease control.

Rural-Urban Disparities in Cancer Outcomes: Opportunities for Future Research

Cancer care disparities among rural populations are increasingly documented and may be worsening, likely because of the impact of rurality on access to state-of-the-art cancer prevention, diagnosis, and treatment services, as well as higher rates of risk factors such as smoking and obesity. In 2018, the American Society of Clinical Oncology undertook an initiative to understand and address factors contributing to rural cancer care disparities. A key pillar of this initiative was to identify knowledge gaps and promote the research needed to understand the magnitude of difference in outcomes in rural vs nonrural settings, the drivers of those differences, and interventions to address them. The purpose of this review is to describe continued knowledge gaps and areas of priority research to address them. We conducted a comprehensive literature review by searching the PubMed (Medline), Embase, Web of Science, and Cochrane Library databases for studies published in English between 1971 and 2021 and restricted to primary reports from populations in the United States and abstracted data to synthesize current evidence and identify continued gaps in knowledge. Our review identified continuing gaps in the literature regarding the underlying causes of rural-urban disparities in cancer outcomes. Rapid advances in cancer care will worsen existing disparities in outcomes for rural patients without directed effort to understand and address barriers to high-quality care in these areas. Research should be prioritized to address ongoing knowledge gaps about the drivers of rurality-based disparities and preventative and corrective interventions.

Consequences of Structural Urbanism: Urban-Rural Differences in Cancer Patients' Use and Perceived Importance of Supportive Care Services from a 2017-2018 Midwestern Survey

BACKGROUND

Structural inequities, in part, undergird urban-rural differences in cancer care. The current study aims to understand the potential consequences of structural inequities on rural and urban cancer patients' access to and perceived importance of supportive cancer care resources.

METHODS

We used data collected from November 2017 to May 2018 from a larger cross-sectional needs assessment about patients' support needs, use of services, and perceptions at a Midwestern United States cancer center. Oncology patients received a study packet during their outpatient clinic visit, and interested patients consented and completed the questionnaires.

RESULTS

Among the sample of 326 patients, 27% of the sample was rural. In adjusted logistic regression models, rural patients were less likely to report using any secondary support services (15% vs. 27%; OR = 0.43, 95%CI [0.22, 0.85], p = 0.02) and less likely than urban counterparts to perceive secondary support services as very important (51% vs. 64%; OR = 0.57, 95%CI [0.33, 0.94], p = 0.03).

CONCLUSION

Structural inequities likely have implications on the reduced access to and importance of supportive care services observed for rural cancer patients. To eliminate persistent urban-rural disparities in cancer care, rural residents must have programs and policies that address cancer care and structural inequities.

Perspectives of cancer prevention and control resources from stakeholders in rural southern Illinois

PURPOSE

Rural residents have a higher cancer burden than urban residents, which is likely related to multiple socioecological factors. This study sought to investigate the perspectives of a diverse set of rural stakeholders regarding access to cancer prevention and control resources in rural southern Illinois.

METHODS

Stakeholders were recruited from counties in southern Illinois and included residents (cancer survivors or caregivers), leaders of community-based organizations with health-related missions, and health care providers. Individual interviews and focus groups assessed recommended cancer prevention, control, and treatment resources; helpfulness of regional resources; and needed resources. The research team used an iterative approach to thematic analysis wherein codes were derived inductively and refined repeatedly to reveal overarching themes.

FINDINGS

Forty-four stakeholders reported challenges to health care access (eg, travel distance, financial burdens, and poor quality of care) and limited access to supportive care services (lack of caregiver support and "spotty" area resources). To mitigate these barriers, local residents used a combination of individual (self-reliance and adaptive measures) and organizational (patient navigation and financial services) approaches. Finally, stakeholders reported multiple forms of cancer control and prevention communication, including formal discussions with health care providers and various types of informal social support (eg, friends and family).

CONCLUSIONS

Stakeholders experienced barriers to cancer prevention and control often mitigated by a reliance on personal adaptations, nonclinical organizational supports, and informal support systems. While resources remain minimal in southern Illinois, researchers and practitioners must make efforts to leverage existing community organizations and social networks to improve cancer outcomes in this region.

The role of health literacy in cancer care: A mixed studies systematic review

BACKGROUND

Patients diagnosed with cancer face many challenges and need a good understanding of their diagnosis and proposed treatments to make informed decisions about their care. Health literacy plays an important role in this and low health literacy has been associated with poorer outcomes. The aims of this review are to identify which outcomes relate to health literacy in patients with cancer, and to combine this through a mixed studies approach with the patient experience as described through qualitative studies.

METHODS

Four electronic databases were searched in January 2021 to identify records relating to health literacy and patients with cancer. Records were independently screened then assessed for inclusion by two reviewers according to the following criteria: patients aged ≥18 years with cancer, English language publication AND health literacy measured with validated tool and measured outcome associated with health literacy OR qualitative study exploring the role of health literacy as patients make decisions about health. Quality was independently assessed by two reviewers. A narrative synthesis was performed, and findings integrated through concept mapping. This systematic review was registered with PROSPERO, entry CRD42020166454.

RESULTS

4441 records were retrieved. Following de-duplication, 2496 titles and abstracts were screened and full texts of 405 papers were reviewed for eligibility. 66 papers relating to 60 studies met the eligibility criteria. Lower health literacy was associated with greater difficulties understanding and processing cancer related information, poorer quality of life and poorer experience of care. Personal and situational influences contributed to how participants processed information and reached decisions about their care.

CONCLUSION

This review highlights the important role of health literacy for patients with cancer. Outcomes are poorer for those who experience difficulties with health literacy. Further efforts should be made to facilitate understanding, develop health literacy and support patients to become more involved in their care.

Outcomes and Critical Factors for Successful Implementation of Organizational Health Literacy Interventions: A Scoping Review

Organizational health literacy (OHL)-interventions can reduce inequality and demands in health care encountered by patients. However, an overview of their impact and critical factors for organization-wide implementation is lacking. The aim of this scoping review is to summarize the evidence on: (1) the outcomes of OHL-interventions at patient, professional and organizational levels; and (2) the factors and strategies that affect implementation and outcomes of OHL-interventions. We reviewed empirical studies following the five-stage framework of Arksey and O'Malley. The databases Scopus, PubMed, PsychInfo and CINAHL were searched from 1 January 2010 to 31 December 2019, focusing on OHL-interventions using terms related to "health literacy", "health care organization" and "intervention characteristics". After a full-text review, we selected 24 descriptive stu-dies. Of these, 23 studies reported health literacy problems in relation to OHL-assessment tools. Nine out of thirteen studies reported that the use of interventions resulted in positive changes on OHL-domains regarding comprehensible communication, professionals' competencies and practices, and strategic organizational changes. Organization-wide OHL-interventions resulted in some improvement of patient outcomes but evidence was scarce. Critical factors for organization-wide implementation of OHL-interventions were leadership support, top-down and bottom-up approaches, a change champion, and staff commitment. Organization-wide interventions lead to more positive change on OHL-domains, but evidence regarding OHL-outcomes needs strengthening.

What Are the Perceptions and Experiences of Care Delivery Among Faith Community Nurses? A Systematic Review

OBJECTIVE

This systematic review set out to identify the unique perceptions and experiences of care delivery among faith community nurses (FCNs).

DATA SOURCES

This review was conducted and has been reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was conducted using the following databases, Medline (OVID), EmCare for Nurses (OVID), PsycINFO (OVID), CINAHL (EBSCO), Cochrane, and PubMed. The search strategies included the use of truncations, adjacency search parameters, and Boolean operators using a range of key search terms. Predetermined eligibility criteria were applied to all studies. The review process was managed using Covidence systematic review software. Data extraction and quality assessment was conducted across all included studies. Data were analyzed using a narrative synthesis approach.

CONCLUSION

This review has made an important contribution by identifying the role that FCNs play in care delivery as trusted members of their communities who act as a conduit at the intersect of faith and health care. Irrespective of the location or faith denomination, what was common to FCNs was that they delivered care to address the physical, psychological, spiritual, congregational, communication, health system, and family-related needs of those in their care.

IMPLICATIONS FOR NURSING PRACTICE

The nurses represented in the included studies expressed concerns that patients experienced unmet supportive care needs because of a fragmented and highly complex existing health care system. Often, FCNs provided a valuable contribution in supporting patients in their care pathways and facilitated continuity of care among people who lived with preexisting comorbidities and who had complex health care needs. Further research is needed to understand the role that faith community nursing models might have in cancer care from the perspective of patients and other members of the multidisciplinary team across different international contexts.

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

Purpose

To summarise what is currently known about the psychosocial morbidity, experiences, and needs of people with cancer and their informal caregivers, who live in rural or regional areas of developed countries.

Methods

Eligible studies dating from August 2010 until May 2021 were identified through several online databases, including MEDLINE, EMBASE, PsychINFO, and RURAL (Rural and Remote Health Database). Results were reported according to the PRISMA guidelines and the protocol was registered on PROSPERO (CRD42020171764).

Results

Sixty-five studies were included in this review, including 20 qualitative studies, 41 quantitative studies, and 4 mixed methods studies. Qualitative research demonstrated that many unique psychosocial needs of rural people remain unmet, particularly relating to finances, travel, and accessing care. However, most (9/19) quantitative studies that compared rural and urban groups reported no significant differences in psychosocial needs, morbidity, or quality of life (QOL). Five quantitative studies reported poorer psychosocial outcomes (social and emotional functioning) in urban cancer survivors, while three highlighted poorer outcomes (physical functioning, role functioning, and self-reported mental health outcomes) in the rural group.

Conclusion

Recent research shows that rural people affected by cancer have unique unmet psychosocial needs relating to rurality. However, there was little evidence that rural cancer survivors report greater unmet needs than their urban counterparts. This contrasts to the findings from a 2011 systematic review that found rural survivors consistently reported worse psychosocial outcomes. More population-based research is needed to establish whether uniquely rural unmet needs are due to general or cancer-specific factors.

Assessing the Readability of Online Patient Education Resources Related to Gynecomastia

BACKGROUND

The Internet has a plethora of online patient education resources for many symptoms and diseases. National medical governing bodies recommend that patient education materials are written at or below the eighth-grade level, and the literature suggests that health literacy has been linked to increased adherence to treatment regimens and improved outcomes. The primary aim of the study is to assess the readability of online patient materials relating to gynecomastia and ascertain the availability of patient materials in non-English languages.

METHODS

The readability of patient education materials relating to gynecomastia for academic-based websites and nonacademic websites was assessed using the Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), and Simple Measure of Gobbledygook (SMOG). The prevalence of non-English patient education materials was assessed for both academic-based and nonacademic websites.

RESULTS

Fifty-eight documents were collected across academic websites. Overall median values were 10.7 for the FKGL, 47.0 for the FRE, and 11.4 for the SMOG. For the 10 nonacademic institutions, the overall median values were 10.6 for the FKGL, 45.2 for the FRE, and 10.8 for the SMOG. No appreciable differences were observed for readability when stratified by region or source. The prevalence of non-English patient materials was 19.1% across institutions. None of the noninstitutional materials had information in non-English languages.

CONCLUSIONS

The readability of patient education materials related to gynecomastia is at higher levels than recommended by national organizations. There are limited non-English patient education materials. Future efforts should focus on improving the readability and accessibility of patient materials.

Feasibility and acceptability of a telehealth behavior change intervention for promoting physical activity and fruit and vegetable consumption among rural-living young adult cancer survivors

Purpose: We assessed the feasibility and acceptability of a 12-week telehealth behavior change intervention to promote physical activity and fruit and vegetable consumption among rural-living young adult cancer survivors.Methods: Participants met with a health coach once a week for 60 minutes for 12 weeks. Feasibility measures included rates of recruitment, enrollment, attrition, retention, adherence, and missing data. Acceptability was assessed using semi-structured interviews.Findings: Over 1-year, 18 individuals self-referred, 9 were eligible and consented to participate, and 2 dropped out. Retention was 74% and adherence was 95%. Participants considered the length of the intervention, synchronous communication with the health coach, and the distance-based delivery mode to be acceptable. Moreover, participants described key behavior change techniques and recommended minor changes.Implications: Findings provide information that can help refine future trials seeking to increase access to behavior change interventions and optimize participation in health-promoting behaviors for underserved populations.Trial registration: ClinicalTrials.gov. NCT03691545. Registered on October 1, 2018.

Health Literacy in Adult Oncology: An Integrative Review

PROBLEM IDENTIFICATION

Patients with cancer face high expectations for performing health literacy activities necessary for self-management and decision making, but only 12% of adults in the United States are proficient in health literacy. This review explores evidence regarding what is known about functional, interactive, and critical health literacy in adult oncology populations.

LITERATURE SEARCH

The review was conducted by searching extensively in the CINAHL® Plus database.

DATA EVALUATION

Of 614 articles retrieved from the literature search, 22 were included in the final sample. Most were cross-sectional, descriptive, correlational studies.

SYNTHESIS

Health literacy research in the United States focuses primarily on functional health literacy, but studies that include interactive and/or critical health literacy indicate their applicability in adult oncology populations.

IMPLICATIONS FOR RESEARCH

Additional research is needed to clarify the role of health literacy in cancer care to develop effective interventions that facilitate self-management and decision making.

Barriers to Quality of Care for Cancer Patients in Rural Areas: A Study from the Faroe Islands

Introduction

Research has indicated that cancer patients living in rural areas receive poorer quality of treatment and care than their urban counterparts. With a population of approximately 51,000, the Faroe Islands may be characterized as a small-scale, rural society. Due to the geographical location and size of the Faroe Islands, patients who live there often receive part of their treatment abroad. Although a shift in the focus of cancer care from a disease-focused approach to a person-centered approach has been successfully implemented elsewhere, legal and structural conditions unique to the Faroe Islands might prohibit the realization of this paradigmatic shift in the Faroe Islands. The aim of this qualitative study was to examine how Faroese cancer patients have experienced their disease, treatment, and care and provide additional knowledge on cancer patients living in small-scale and rural societies.

Methods

Five men and three women who had been through a cancer treatment course with a good prognosis volunteered to be interviewed. Their ages varied from 40 to 80 years. “Active interviewing”, a constructionist approach to qualitative interviewing and latent thematic analysis, was applied.

Results

Three overlapping themes were identified from the categories: sense of coherence, resources and challenges in everyday life, and trust in the system. The analysis uncovered multiple factors related to legal and structural conditions that were barriers to ensuring the quality of cancer care for patients, for instance, shifting consultants, a lack of coherence in treatment, information loss and insufficient contact with cancer nurse specialists.

Discussion

This study is based on a limited number of participants. However, the findings from this study provide insight into the special conditions of cancer patients living in a small-scale, rural society and help explain disparities in the quality of cancer treatment and care between urban and rural areas.

Demographic and psychosocial factors associated with limited health literacy in a community-based sample of older Black Americans

OBJECTIVES

Individuals with limited health literacy often experience suboptimal health outcomes. This study examined the frequency of limited health literacy and demographic and psychosocial factors associated with limited health literacy in a sample of older Black Americans.

METHODS

Participants (n = 330) enrolled in a community-based intervention to promote colorectal cancer (CRC) screening completed baseline surveys assessing health literacy with the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) test, CRC awareness, cancer fatalism, Preventive Health Model (PHM) constructs, and demographics.

RESULTS

Approximately 52% of participants had limited health literacy, the REALM-R score was 5.4 (SD = 2.7). Univariable correlates of limited health literacy were gender, employment, income, prior screening, cancer fatalism, CRC awareness, and PHM constructs (religious beliefs, salience/coherence, perceived susceptibility). Multivariable correlates of limited health literacy were male gender (OR = 2.3, CI = 1.4-3.8), unable to work (OR = 2.8, CI = 1.3-6.1), lower household income (OR = 3.0, CI = 1.6, 5.5), and higher PHM religious beliefs (OR = 1.1, CI = 1.0-1.2).

CONCLUSION

Limited health literacy was associated with multiple complex factors. Interventions should incorporate patient health literacy and low-literacy materials that can be delivered through multiple channels.

PRACTICE IMPLICATIONS

Future studies are needed to understand the role of health literacy in an individual's health behavior and the provision of effective healthcare.

Carers as System Navigators: Exploring Sources, Processes and Outcomes of Structural Burden

BACKGROUND AND OBJECTIVES

Structural features of formal care systems influence the amount, difficulty, and complexity of what carers do as they interface with those systems. In this study, we explored how carers navigate health and social care systems, and their experiences of structural burden related to features such as complexity and fragmentation.

RESEARCH DESIGN AND METHODS

This qualitative descriptive inquiry drew on data from in-person interviews with 32 carers of older adults, which were analyzed first using inductive thematic analysis and then using structural burden as a conceptual lens.

RESULTS

Participant accounts revealed how navigating formal systems on behalf of older adult family members can exact considerable demands on carers in terms of time investment and emotional energy. In this way, care systems exacerbate the stress and structural burden experienced by carers, even when formal services alleviate other forms of carer burden.

DISCUSSION AND IMPLICATIONS

Our findings contribute to knowledge of how the structural context of formal services shapes carer experiences and outcomes. To promote equity and prevent burden, system navigation work should be considered as a public, structural issue, rather than an individual-level problem of skills and learning.

Health literacy: Impact on quality of life in head and neck cancer survivors

OBJECTIVES

Although inadequate health literacy has been shown to impact health outcomes in other cancers, little is known about its impact in head and neck cancer (HNC). This study aimed to determine the prevalence and predictors of inadequate health literacy and evaluate the association between health literacy and quality of life (QOL) in HNC survivors.

METHODS

We conducted a retrospective analysis of HNC survivors evaluated in a multidisciplinary HNC survivorship clinic. Survivors had to be ≥1-year postcompletion of treatment to be included in the analysis. Health literacy was assessed via self-report with the Brief Health Literacy Screen (score <10 indicating inadequate health literacy), and QOL was measured using the University of Washington QOL questionnaire. Linear regression with robust standard errors was utilized to evaluate the association between health literacy and QOL.

RESULTS

Of the 218 survivors evaluated, 13.8% (n = 30) demonstrated inadequate health literacy. After adjusting for age, marital status, site, stage, treatment modality, and years since treatment completion, social-emotional QOL scores for survivors with adequate health literacy were estimated to be 10.67 points higher than those with inadequate health literacy (P = .013). Health literacy was not significantly associated with physical QOL after adjusting for covariates (P = .130).

CONCLUSION

Inadequate health literacy is associated with a lower social QOL in HNC survivors, and among those with inadequate health literacy, interventions to ameliorate the impact on QOL are needed.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2354-2359, 2020.

Patient Perspectives to Inform a Health Literacy Educational Program: A Systematic Review and Thematic Synthesis of Qualitative Studies

Patient-centred care is tailored to the needs of patients and is necessary for better health outcomes, especially for individuals with limited health literacy (LHL). However, its implementation remains challenging. The key to effectively address patient-centred care is to include perspectives of patients with LHL within the curricula of (future) healthcare providers (HCP). This systematic review aimed to explore and synthesize evidence on the needs, experiences and preferences of patients with LHL and to inform an existing educational framework. We searched three databases: PsychInfo, Medline and Cinahl, and extracted 798 articles. One-hundred and three articles met the inclusion criteria. After data extraction and thematic synthesis, key themes were identified. Patients with LHL and chronic diseases encounter multiple problems in the care process, which are often related to a lack of person-centeredness. Patient perspectives were categorized into four key themes: (1) Support system; (2) Patient self-management; (3) Capacities of HCPs; (4) Barriers in healthcare systems. "Cultural sensitivity" and "eHealth" were identified as recurring themes. A set of learning outcomes for (future) HCPs was developed based on our findings. The perspectives of patients with LHL provided valuable input for a comprehensive and person-centred educational framework that can enhance the relevance and quality of education for (future) HCPs, and contribute to better person-centred care for patients with LHL.

Evaluating and providing quality health information for adolescents and young adults with cancer

Adolescents and young adults (AYAs, 15-39 years old) are an ideal population to benefit from the ever-expanding number and variety of cancer information and health resources available via the Internet and other digital platforms. However, the ability of individual AYAs to fully utilize such resources depends on their degree of health literacy. Across the trajectory of cancer care, an important role for the oncology clinician is assisting AYAs and caregivers in accessing quality health information consistent with their level of health literacy. Working from the premise that all AYAs with cancer and their caregivers deserve to be empowered with maximal knowledge about their condition, this review provides information to assist oncology clinicians in (1) understanding the variety of contemporary online resources that are currently available, including their strengths and limitations; (2) evaluating the quality of health information; and (3) recommending specific health information resources to their AYA patients.

How formal navigators interpret their roles supporting families

Purpose

The purpose of this paper is to examine how formal navigators interpret their roles supporting families of older adults.

Design/methodology/approach

This study was an interpretive inquiry informed by critical gerontology and discourse analytic methods. Interview data were collected and analyzed from 22 formal service providers who helped older adults and their families navigate health and social care resources in one Western Canadian city.

Findings

Although acknowledging structural barriers to service access, participants emphasized individual empowerment as their dominant strategy, interpreting their roles as providing information and education about services. In part, these interpretations may reflect the limited nature of their ability to help broker access or advocate; in part, they may also reflect the broader political and economic discourses surrounding care in Canada.

Research limitations/implications

When providers position navigation and access to care as individual problems, this can obscure structural burden as well as potential inequities among older adults. Future research should examine whether navigational role interpretations are similar or different to those of navigators in other regions. Navigators in other health and social care contexts may enact differing meanings in their work.

Practical implications

Although formal public navigators can play an important role, approaches that go beyond providing information may better meet families’ needs for support.

Originality/value

This is one of the first studies focused specifically on providers’ interpretations of the meaning of navigational work in health and social care for older adults, and to extend a critical gerontological gaze toward the issue of system navigation.

Association Between Rurality and Lung Cancer Treatment Characteristics and Timeliness

BACKGROUND

Lung cancer is the leading cause of cancer-related mortality in the United States, and rural states bear a greater burden of disease.

METHODS

We analyzed tumor registry data to examine relationships between rurality and lung cancer stage at diagnosis and treatment. Cases were from the Maine Cancer Registry from 2012 to 2015, and rurality was defined using rural-urban commuting areas. Multivariable models were used to examine the relationships between rurality and treatment, adjusting for age, sex, poverty, education, insurance status, and cancer stage.

RESULTS

We identified 5,338 adults with incident lung cancer; 3,429 (64.2%) were diagnosed at a late stage (III or IV). Rurality was not associated with stage at diagnosis. For patients with early-stage disease (I or II), rurality was not associated with receipt of treatment. However, for patients with late-stage disease, residents of large rural areas received more surgery (10%) compared with metropolitan (9%) or small/isolated rural areas (6%), P = .01. In multivariable analyses, patients in large rural areas received more chemotherapy (OR 1.48; 95% CI: 1.08-2.02) than those in metropolitan areas. Patients with early-stage disease residing in small/ isolated rural areas had delays in treatment (median time to first treatment = 43 days, interquartile range [IQR] 22-68) compared with large rural (34 days, IQR 17-55) and metropolitan areas (35 days, IQR 17-60), P = .0009.

CONCLUSION

Rurality is associated with differences in receipt of specific lung cancer treatments and in timeliness of treatment.

Digital Health in Melanoma Posttreatment Care in Rural and Remote Australia: Systematic Review

Background

The melanoma incidence and mortality rates in rural and remote communities are exponentially higher than in urban areas. Digital health could be used to close the urban/rural gap for melanoma and improve access to posttreatment and support care services.

Objective

The aim of this review was to understand how digital health is currently used for melanoma posttreatment care and determine the benefits for Australian rural and remote areas.

Methods

A systematic search of PubMed, Medline, PsycINFO, and Scopus was conducted in March 2018. Findings were clustered per type of intervention and related direct outcomes.

Results

Five studies met the inclusion criteria, but none investigated the benefits of digital health for melanoma posttreatment care in rural and remote areas of Australia. Some empirical studies demonstrated consumers’ acceptance of digital intervention for posttreatment care. The findings did not take into consideration individual, psychological, and socioeconomic factors, even though studies show their significant impacts on melanoma quality of aftercare.

Conclusions

Digital interventions may be used as an adjunct service by clinicians during melanoma posttreatment care, especially in regions that are less-resourced by practitioners and health infrastructure, such as rural and remote Australia. Technology could be used to reduce the disparity in melanoma incidence, mortality rates, and accessibility to posttreatment care management between urban and rural/remote populations.

Effects of program scale-up on time to resolution for patients with abnormal screening mammography results

PURPOSE

Effects of geographic program expansion to rural areas on screening program outcomes are understudied. We sought to determine whether time-to-resolution (TTR) varied significantly by service delivery time period, location, and participant characteristics across 19 North Texas counties.

METHODS

We calculated proportions undergoing diagnostic follow-up and resolved ≤ 60 days. We calculated median TTR for each time period and abnormal result BI-RADS 0, 4, 5. Cox proportional hazards regressions estimated time period and patient characteristic effects on TTR. Wilcoxon rank sum tests evaluated whether TTR differed between women who did or did not transfer between counties for services.

RESULTS

TTR ranged from 14 to 17 days for BI-RADs 0, 4, and 5; 12.4% transferred to a different county, resulting in longer median TTR (26 vs. 16 days; p < .001). Of those completing follow-up, 92% were resolved ≤ 60 days (median 15 days). For BI-RAD 3, TTR was 208 days (including required 180 day waiting period). Follow-up was significantly lower for women with BI-RAD 3 (59% vs. 96%; p < .0001).

CONCLUSION

Expansion maintained timely service delivery, increasing access to screening among rural, uninsured women. Policies adding a separate quality metric for BI-RAD 3 could encourage follow-up monitoring to address lower completion and longer TTR among women with this result.

Effectiveness of a patient navigator on patient satisfaction in adult patients in an ambulatory care setting: a systematic review

BACKGROUND

One approach to overcoming healthcare system barriers and facilitating timely access to quality care and patient satisfaction is with a patient navigator. A patient navigator is a trained person who individually assists patients, families and caregivers navigate the healthcare system barriers efficiently and effectively at any point along the care continuum, improving patient care at all levels of an organization.

OBJECTIVES

To synthesize the best available evidence on the effectiveness of a patient navigator on patient satisfaction in adult patients 18 years and older in ambulatory care settings.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

This review considered studies that involved adults of any ethnicity, race or gender, aged 18 years or older, regardless of diagnoses, stage of illness, whether the illness is acute or chronic or previous treatment, who had been receiving care in an ambulatory care setting.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

This review considered studies on the use of a patient navigator as an additional intervention to usual care for promoting patient satisfaction for adult patients in an ambulatory care setting. Usual care without a patient navigator was considered as a comparator.

TYPES OF STUDIES

This review considered experimental and observational studies.

OUTCOMES

The outcome considered was patient satisfaction.

SEARCH STRATEGY

The literature search included published and unpublished studies in the English Language from 1990 through July 2015. A search of PubMed, CINAHL, Excerpta Medica Database (EMBASE), Academic Search Premier, Cochrane Library, PsycINFO and Health Source: Nursing/Academic Edition, Social Work Abstracts and Web of Science was conducted. A search for gray literature and electronic hand searching of relevant journals was also performed.

METHODOLOGICAL QUALITY

Two reviewers independently evaluated the included studies for methodological quality utilizing standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Standardized data extraction tools from Joanna Briggs Institute were used by two independent reviewers for data extraction.

DATA SYNTHESIS

A statistical meta-analysis was not possible due to heterogeneity between the included studies. Results are presented in a narrative form.

RESULTS

Four studies were included in this review, two were randomized controlled trials (RCTs), one was a quasi-experimental pre-post-test design study and one was a cohort study. The four studies showed that a patient navigator had clinical benefit for patient satisfaction, care coordination and patient access to timely healthcare services. One RCT reported a mean satisfaction score of 4.3 for navigated patients and 2.9 for non-navigated patients; P < 0.001. A second RCT showed an odds ratio 1.29; 95% confidence interval 0.92-1.82 for navigated versus non-navigated patients. The quasi-experimental pre-test-post-test study showed navigated patient satisfaction with a mean = 11.45 (standard deviation [SD], 3.69) in comparison with the non-navigated patient (mean, 14.95; SD, 1.69) (F = 11.85; P = 0.000). The cohort study demonstrated a mean satisfaction score of 90.7 for navigated patients and 85.5 for non-navigated patients; P = 0.03. The four studies showed no clinically significant results; however, the patient navigator role may promote relationships among the healthcare team, reducing barriers for patient-centered care and enhanced patient satisfaction.

CONCLUSION

There is a paucity of evidence on the effectiveness of a patient navigator on patient satisfaction. In the four studies selected for inclusion, a patient navigator had a positive effect on patient satisfaction, although none of the studies demonstrated statistical significance with a patient navigator on patient satisfaction. The effect of a patient navigator remains questionable with differences in perceptions on the best individual for the role and the expected role perception and performance. A standardized approach to the role of the patient navigator may maximize health outcomes and positively affect the quality of life for all patients.

How rural and urban patients in Australia with colorectal or breast cancer experience choice of treatment provider: A qualitative study

Modern healthcare systems promote patient choice of cancer treatment provider, but little is known about how place of residence influences decision-making. This research explored how rural and urban patients with breast or colorectal cancer experience choice of cancer treatment provider in Victoria, Australia. Realist thematic analysis of 43 semi-structured telephone interviews identified little active participation in decision-making regardless of area of residence or cancer diagnosis. Perceptions of choice were impacted by urgency for treatment, insurance status and access to providers, a key issue for rural patients. All patients wanted high quality care, but needed to trust health professional's recommendations. Rural patients experienced more complex decision-making, balancing a range of social factors with perceptions about quality of accessible care. Further research into variation in quality of care and complex cancer pathways for rural and urban cancer patients is warranted to inform choices and enhance patient-centred care.

Designing health-literate health care organization: A literature review

Health literacy is usually described as a silent epidemic, which is challenging the sustainability of health care systems all over the world. The scientific literature has discussed the drawbacks of marginal health literacy on the functioning of the health care organizations. In particular, limited health literacy has been associated with: poorer ability of patients to comprehend health information, deficient medication adherence, insufficient use of prevention services, higher hospitalization rates, and greater health service utilization. In most of the cases, health literacy has been understood as an individual trait, which ultimately concerns the patients’ ability to obtain, process, and understand health information to navigate the health system. Alternatively, poor attention has been paid to the health literacy of the organizations operating within the health system, that is to say “organizational health literacy”. Indeed, neither the scholars nor the practitioners have adequately addressed the role played by the health care organizations to meet the needs of patients who live with limited health literacy. To contribute in filling such a gap, this study discusses the design and the structure of health-literate health care organizations. For this purpose, a systematic literature review was performed, involving 69 articles indexed in Scopus-Elsevier, Pub-Med, and Google Scholar to point out how the health care organizations face health literacy issues and to discuss what tools are used by the health care organizations to meet the information needs of people living with limited health literacy. Health-literate health care organizations turn out to be crucial to enhance patient engagement and improve health outcomes.

Health Literacy and Health-Related Quality of Life Among a Population-Based Sample of Cancer Patients

Health-related quality of life is an important outcome in cancer care. A few studies indicate that health literacy influences cancer patients' health-related quality of life, but additional investigation is needed. The authors examined the relation between health literacy and health-related quality of life among cancer patients. A cross-sectional survey was conducted with cancer patients in Wisconsin during 2006-2007. Data on sociodemographics, clinical characteristics, health-related quality of life, and health literacy were obtained from the state's cancer registry and a mailed questionnaire. Regression analyses were used to characterize the association between health-related quality of life and health literacy. The study sample included 1,841 adults, newly diagnosed with lung, breast, colorectal, or prostate cancer in 2004 (response rate = 68%). Health-related quality of life was measured with the Functional Assessment of Cancer Therapy-General. Adjusting for confounders, higher health literacy was associated with greater health-related quality of life (p < .0001). Controlling for covariates, we found significant differences between those in the highest and lowest health literacy categories (p < .0001) and in the physical (p < .0001), functional (p < .0001), emotional (p < .0001), and social (p = .0007) well-being subscales. These associations exceeded the minimally important difference threshold for overall health-related quality of life and functional well-being. Health literacy is positively and independently associated with health-related quality of life among cancer patients. These findings support adoption of health literacy best practices by cancer care systems.

Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults

PURPOSE

In recent years, colorectal cancer (CRC) screening rates have increased steadily in the USA, though racial and ethnic disparities persist. In a community-based randomized controlled trial, we investigated the effect of patient navigation on increasing CRC screening adherence among older African Americans.

METHODS

Participants in the Cancer Prevention and Treatment Demonstration were randomized to either the control group, receiving only printed educational materials (PEM), or the intervention arm where they were assigned a patient navigator in addition to PEM. Navigators assisted participants with identifying and overcoming screening barriers. Logistic regression analyses were used to assess the effect of patient navigation on CRC screening adherence. Up-to-date with screening was defined as self-reported receipt of colonoscopy/sigmoidoscopy in the previous 10 years or fecal occult blood testing (FOBT) in the year prior to the exit interview.

RESULTS

Compared with controls, the intervention group was more likely to report being up-to-date with CRC screening at the exit interview (OR 1.55, 95 % CI 1.07-2.23), after adjusting for select demographics. When examining the screening modalities separately, the patient navigator increased screening for colonoscopy/sigmoidoscopy (OR 1.53, 95 % CI 1.07-2.19), but not FOBT screening. Analyses of moderation revealed stronger effects of navigation among participants 65-69 years and those with an adequate health literacy level.

CONCLUSIONS

In a population of older African Americans adults, patient navigation was effective in increasing the likelihood of CRC screening. However, more intensive navigation may be necessary for adults over 70 years and individuals with low literacy levels.