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Wang Z, Selvaggi K, Stein D. Survey Study of Awareness and Perception of Palliative and Hospice Care in a Cancer Center in Rural Pennsylvania. Palliat Med Rep 2022; 3:17-20. [PMID: 36262549 PMCID: PMC8900202 DOI: 10.1089/pmr.2020.0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose: Hospice and palliative medicine (HPM) have been gaining ground especially in large urban settings. However, less is known about their perception in small rural areas. This study assessed the awareness and perception of a rural oncology population of this field and the effects of prognosis on their awareness. Methods: Subjects were patients of the community cancer center in rural Clarion County, Pennsylvania, who volunteered to complete a short nine-question survey (supplemental figure). Results were analyzed based on completed surveys. Results: A total of 65 surveys were collected from the Cancer Center at the Clarion Hospital. Among these patients, 54% stated that they have heard of palliative and hospice medicine. When correlating patient-reported prognosis with their awareness of palliative and hospice care, 100% of the patients with poor prognosis were aware of palliative or hospice care, respectively. In contrast, only <20% of patients with reported good prognosis were aware of HPM. Conclusions: Our study has shown that the awareness of HPM in rural areas is improving. It was observed that more patients are aware of HPM is when their prognosis was poor as compared with those who reported good prognosis.
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Affiliation(s)
- Zhu Wang
- Department of Family Medicine, Clarion Hospital, Butler Health System, Clarion, Pennsylvania, USA
| | - Kathy Selvaggi
- Department of Palliative Care, Butler Memorial Hospital, Butler, Pennsylvania, USA
| | - Dillon Stein
- Department of Palliative Care, Butler Memorial Hospital, Butler, Pennsylvania, USA
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2
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Ratcliff CG, Torres D, Tullos EA, Geng Y, Lu Q. A systematic review of behavioral interventions for rural breast cancer survivors. J Behav Med 2020; 44:467-483. [PMID: 32813192 DOI: 10.1007/s10865-020-00174-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 08/06/2020] [Indexed: 12/21/2022]
Abstract
Rural breast cancer survivors (RBCS) are at greater risk for poorer health outcomes and face greater treatment barriers compared to their urban counterparts, necessitating behavioral interventions tailored for the unique needs of RBCS. A systematic review of studies examining behavioral interventions delivered to RBCS living in the United States from 2000 to 2020 was conducted following PRIMSA guidelines. Nineteen unique studies were included: eight randomized controlled trials, two matched-control studies, six pre-post intervention feasibility studies, and three post-intervention satisfaction studies. Thirteen interventions aimed to improve psychosocial support, three to improve weight management, and three to improve education. Results indicate interventions' feasibility and acceptability. Six out of eight intervention conditions reported favorable outcomes compared to control conditions, suggesting promise for efficacy. However, variability in intervention objective, duration, delivery, and follow-up timing, and small sample sizes prevent overarching conclusions. Research involving larger sample sizes, higher quality control groups, and longer follow-up data is needed.
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Affiliation(s)
- Chelsea G Ratcliff
- Department of Psychology, Sam Houston State University, Campus Box 2447, Huntsville, TX, 77341-2447, USA. .,Baylor College of Medicine, Houston, TX, USA.
| | - Debbie Torres
- Department of Psychology, Sam Houston State University, Campus Box 2447, Huntsville, TX, 77341-2447, USA
| | - Emily A Tullos
- Department of Psychology, Sam Houston State University, Campus Box 2447, Huntsville, TX, 77341-2447, USA
| | - Yimin Geng
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Qian Lu
- Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Hughes PM, Ingleton MC, Noble B, Clark D. Providing Cancer and Palliative Care in Rural Areas: A Review of Patient and Carer Needs. J Palliat Care 2019. [DOI: 10.1177/082585970402000109] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Bill Noble
- Academic Palliative Medicine Unit, University of Sheffield
| | - David Clark
- Institute for Health Research, Lancaster University
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4
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Raque-Bogdan TL, Lamphere B, Kostiuk M, Gissen M, Beranek M. Unpacking the layers: a meta-ethnography of cancer survivors' loneliness. J Cancer Surviv 2018; 13:21-33. [PMID: 30414079 DOI: 10.1007/s11764-018-0724-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 10/20/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To review the empirical qualitative literature on cancer survivor's experiences with loneliness to inform assessments and interventions for improving cancer survivors' social well-being. METHODS A rigorous systematic review of qualitative studies published in five databases between 1993 and 2016 was conducted. Three coders reviewed 285 titles and abstracts and, after applying a critical review process, 20 manuscripts were synthesized using meta-ethnography. RESULTS The synthesis of the 20 studies provided a framework for understanding survivors' layers of loneliness at the level of the individual, their social support system, the healthcare system, and society. Internally, survivors described loneliness resulting from feelings of inauthenticity, of being alone in their cancer experience, and of lack of control. In their social networks, survivors attributed loneliness to others' avoidance, misperceptions of cancer, and others' failure to recognize the effects of cancer after active treatment. Unmet needs after treatment contributed to feelings of loneliness within the healthcare system. Further, societal stigma around cancer and pressures to experience growth after cancer created another layer of loneliness. The results suggest the need to move beyond an individual level perspective in assessing and treating loneliness in cancer survivors. CONCLUSIONS This meta-ethnography presents an integrated framework of loneliness in cancer survivors as a multi-layered experience. Implications for Cancer Survivors Conceptualizing loneliness from a systemic perspective adds missing pieces to the loneliness puzzle by encouraging assessment and intervention at interacting levels of functioning; considering how individuals respond to and are affected by their social systems can deepen our understanding of cancer survivorship.
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Affiliation(s)
- Trisha L Raque-Bogdan
- Department of Counseling Psychology, Morgridge College of Education, University of Denver, 1999 E. Evans Avenue, Denver, CO, USA.
| | - Brooke Lamphere
- Department of Counseling Psychology, Morgridge College of Education, University of Denver, 1999 E. Evans Avenue, Denver, CO, USA
| | - Marisa Kostiuk
- Department of Counseling Psychology, Morgridge College of Education, University of Denver, 1999 E. Evans Avenue, Denver, CO, USA
| | - Maura Gissen
- Department of Counseling Psychology, Morgridge College of Education, University of Denver, 1999 E. Evans Avenue, Denver, CO, USA
| | - Megan Beranek
- Department of Counseling Psychology, Morgridge College of Education, University of Denver, 1999 E. Evans Avenue, Denver, CO, USA
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5
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Lashbrook M, Bernardes CM, Kirshbaum MN, Valery PC. Physical functioning and psychological morbidity among regional and rural cancer survivors: A report from a regional cancer centre. Aust J Rural Health 2018; 26:211-219. [PMID: 29799149 DOI: 10.1111/ajr.12419] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To identify factors associated with psychosocial, physical and practical difficulties of daily living and distress among cancer survivors from a regional area in Australia. DESIGN Cross-sectional study. SETTING Riverina region of southern New South Wales. PARTICIPANTS The sample included 134 patients who completed treatment for breast, colorectal, lung or cancer at the Riverina Cancer Care Centre. MAIN OUTCOME MEASURES Distress was assessed by the Distress Thermometer. Psychosocial, physical and practical difficulties of daily living were assessed by the Patient-Reported Outcomes Measurement Information System questionnaires. RESULTS A high proportion of cancer survivors had abnormal scores for physical function, sleep disturbance, satisfaction with role, fatigue and pain interference, with many also displaying abnormal scores for anxiety, depression and distress. Survivors living in rural areas and those who had undergone surgery had higher odds of having abnormal scores for sleep disturbance than their counterparts. Living without a partner increased the odds of anxiety and depression. Having advanced disease increased the odds of anxiety and pain. Colorectal cancer and higher education were associated with depression. CONCLUSION Monitoring for abnormal physical and psychosocial issues after cancer treatment is essential to maintain or improve psychosocial well-being during survivorship. When developing survivorship care plans for patients residing in regional centres, health professionals should consider availability of high-quality and accessible support services in regional areas of Australia.
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Affiliation(s)
- Mari Lashbrook
- The Riverina Cancer Care Centre, Wagga Wagga, New South Wales, Australia.,QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Christina M Bernardes
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Marilynne N Kirshbaum
- School of Health (Nursing), Charles Darwin University, Darwin, Northern Territory, Australia
| | - Patricia C Valery
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
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Cockle SG, Ogden J. The 'radiation vacation': Parents' experiences of travelling to have their children's brain tumours treated with proton beam therapy. Health Psychol Open 2016; 3:2055102916649767. [PMID: 28070403 PMCID: PMC5193290 DOI: 10.1177/2055102916649767] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Proton beam therapy is a new form of radiotherapy. Little is known about patients' experiences of proton beam therapy and less about parents' experiences of children receiving treatment. Semi-structured interviews explored 10 parents' experiences of travelling from the United Kingdom to the United States to have their children's brain tumours treated with proton beam therapy. Thematic analysis uncovered themes of 'adjusting to the PBT routine', 'finding benefit in the situation' and 'readjusting upon returning home'. Parents' initial worries were elevated by travel, but they found benefit in their experiences, describing them positively. The periods before and after treatment were most difficult, illustrating a cycle from upset to calm, back to upset upon their return home.
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Youl PH, Dasgupta P, Youlden D, Aitken JF, Garvey G, Zorbas H, Chynoweth J, Wallington I, Baade PD. A systematic review of inequalities in psychosocial outcomes for women with breast cancer according to residential location and Indigenous status in Australia. Psychooncology 2016; 25:1157-1167. [DOI: 10.1002/pon.4124] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/29/2015] [Accepted: 02/22/2016] [Indexed: 12/26/2022]
Affiliation(s)
- PH Youl
- Cancer Research Centre; Cancer Council Queensland; Brisbane Australia
- Menzies Health Institute Queensland; Griffith University, Gold Coast Campus; Southport Australia
- School of Public Health and Social Work; Queensland University of Technology; Kelvin Grove Australia
| | - P Dasgupta
- Cancer Research Centre; Cancer Council Queensland; Brisbane Australia
| | - D Youlden
- Cancer Research Centre; Cancer Council Queensland; Brisbane Australia
| | - JF Aitken
- Cancer Research Centre; Cancer Council Queensland; Brisbane Australia
- School of Public Health and Social Work; Queensland University of Technology; Kelvin Grove Australia
- School of Population Health; University of Queensland; Brisbane Australia
| | - G Garvey
- Menzies School of Health Research; Charles Darwin University; Brisbane Australia
| | - H Zorbas
- Cancer Australia; Sydney New South Wales Australia
| | - J Chynoweth
- Cancer Australia; Sydney New South Wales Australia
| | - I Wallington
- Cancer Australia; Sydney New South Wales Australia
| | - PD Baade
- Cancer Research Centre; Cancer Council Queensland; Brisbane Australia
- Menzies Health Institute Queensland; Griffith University, Gold Coast Campus; Southport Australia
- School of Public Health and Social Work; Queensland University of Technology; Kelvin Grove Australia
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8
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“Undressing” distress among cancer patients living in urban, regional, and remote locations in Western Australia. Support Care Cancer 2015; 24:1963-1973. [DOI: 10.1007/s00520-015-2982-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 10/05/2015] [Indexed: 02/07/2023]
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Olson RA, Howard F, Turnbull K, Munroe D, Zirul C, Manji R, Tobin P, Ward A. Prospective evaluation of unmet needs of rural and aboriginal cancer survivors in Northern British Columbia. ACTA ACUST UNITED AC 2014; 21:e179-85. [PMID: 24764702 DOI: 10.3747/co.21.1729] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The unmet needs of cancer survivors in rural, remote, and aboriginal communities are largely unexplored. We explored potential differences between rural survivors (rss) in 4 general population (gp) and 4 First Nations (fn) communities. METHODS We approached 4 gp and 4 fn rs communities to participate in a mixed-methods project. Participants completed the Hospital Anxiety and Depression Scale (hads) and the Survivor Unmet Needs Survey (suns) and provided demographic information. Each question on the suns can be scored from 0 to 4, with 0 representing "no unmet need" and 4 representing "very high unmet need." A directed approach to content analysis of focus group and interview data was used to triangulate the hads and suns results. RESULTS We prospectively accrued 23 fn rss and 56 gp rss for this study. More fn rss had borderline or abnormal anxiety (5% vs. 21%, p = 0.02). Compared with gp rss, fn rss had higher unmet needs scores in all categories: Information (2.29 vs. 0.8, p < 0.001), Work and Financial (1.66 vs. 0.5, p < 0.001), Access and Continuity of Health Care (1.83 vs. 0.44, p < 0.001), Coping and Sharing (2.22 vs. 0.62, p < 0.001), and Emotional (2.12 vs. 0.63, p < 0.001). The qualitative findings provided examples and insight into the unmet needs experienced by rss. CONCLUSIONS First Nations rss had significantly higher anxiety and unmet needs compared with their gp rs counterparts. In addition, different qualitative themes were identified in the groups. Our findings support the development of tailored approaches to survivorship for these populations.
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Affiliation(s)
- R A Olson
- BC Cancer Agency Centre for the North, Prince George, BC. ; University of British Columbia, Vancouver, BC. ; University of Northern British Columbia, Prince George, BC
| | - F Howard
- University of British Columbia, Vancouver, BC
| | - K Turnbull
- University of British Columbia, Vancouver, BC
| | - D Munroe
- BC Cancer Agency Vancouver Centre, Vancouver, BC
| | - C Zirul
- University of Northern British Columbia, Prince George, BC
| | - R Manji
- University of British Columbia, Vancouver, BC
| | - P Tobin
- BC Cancer Agency Centre for the North, Prince George, BC
| | - A Ward
- University of British Columbia, Vancouver, BC
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10
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Fuchsia Howard A, Smillie K, Turnbull K, Zirul C, Munroe D, Ward A, Tobin P, Kazanjian A, Olson R. Access to medical and supportive care for rural and remote cancer survivors in northern British Columbia. J Rural Health 2014; 30:311-21. [PMID: 24483272 DOI: 10.1111/jrh.12064] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Rural cancer survivors (RCS) potentially have unique medical and supportive care experiences when they return to their communities posttreatment because of the availability and accessibility of health services. However, there is a limited understanding of cancer survivorship in rural communities. PURPOSE The purpose of this study is to describe RCS experiences accessing medical and supportive care postcancer treatment. METHODS Interviews and focus groups were conducted with 52 RCS residing in northern British Columbia, Canada. The data were analyzed using qualitative content analysis methods. RESULTS General Population RCS and First Nations RCS experienced challenges accessing timely medical care close to home, resulting in unmet medical needs. Emotional support services were rarely available, and, if they did exist, were difficult to access or not tailored to cancer survivors. Travel and distance were barriers to medical and psychological support and services, not only in terms of the cost of travel, but also the toll this took on family members. Many of the RCS lacked access to trusted and useful information. Financial assistance, for follow-up care and rehabilitation services, was rarely available, as was appropriate employment assistance. CONCLUSION Medical and supportive care can be inaccessible, unavailable, and unaffordable for cancer survivors living in rural northern communities.
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Affiliation(s)
- A Fuchsia Howard
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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11
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Zucca A, Boyes A, Newling G, Hall A, Girgis A. Travelling all over the countryside: Travel-related burden and financial difficulties reported by cancer patients in New South Wales and Victoria. Aust J Rural Health 2011; 19:298-305. [DOI: 10.1111/j.1440-1584.2011.01232.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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12
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Butow PN, Phillips F, Schweder J, White K, Underhill C, Goldstein D. Psychosocial well-being and supportive care needs of cancer patients living in urban and rural/regional areas: a systematic review. Support Care Cancer 2011; 20:1-22. [PMID: 21956760 DOI: 10.1007/s00520-011-1270-1] [Citation(s) in RCA: 166] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Accepted: 09/06/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study was to describe what is known about levels of morbidity and the experience and needs of people with cancer, and their informal caregivers, living in rural areas. METHODS A search of online databases for English language papers describing or assessing the prevalence of psychosocial morbidity or needs in a population of rural or regional cancer patients was employed. The following were excluded: intervention studies, discussion of service delivery, effectiveness of support groups or support via videoconferencing, concentrated on medical outcomes or survival rates, reported differences in the uptake of cancer screening or concentrated on health attitudes or treatment decision making. RESULTS There were 37 studies in the review, including 25 quantitative studies (all surveys), 11 of which included a control group of urban patients and 12 qualitative studies. Until recently, most studies had methodological shortcomings. Only two prospective studies were identified, most studies focused on breast cancer and few addressed psychological morbidity. The majority of controlled studies reported worse outcomes for rural patients, who appear to have higher needs in the domains of physical/daily living. This may reflect more limited access to resources, a more self-sufficient lifestyle and personal characteristics, for example, being more stoical and less likely to ask for help. The need to travel for treatment caused many practical, emotional and financial problems for patients and burdened them with additional worry concerning family and work commitments. Some patients reported benefits in sharing experiences with others also forced to stay away from home, but most agreed that staying at home was preferable. CONCLUSION This review highlights that whilst we are beginning to get some insight into the needs of people with cancer in rural areas, much is still unknown. Population-based, prospective studies including people with heterogeneous cancers from rural and urban settings are needed.
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Affiliation(s)
- Phyllis N Butow
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, Australia.
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13
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Befort CA, Austin H, Klemp JR. Weight control needs and experiences among rural breast cancer survivors. Psychooncology 2010; 20:1069-75. [PMID: 20734339 DOI: 10.1002/pon.1828] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 06/25/2010] [Accepted: 07/03/2010] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Rural women are understudied in research on weight control among breast cancer survivors despite having higher obesity rates than their urban counterparts placing them at higher risk for recurrence. The purpose of this survey study was to describe weight status and methods used for weight control in rural breast cancer survivors and to examine psychosocial factors in this population associated with weight change since breast cancer diagnosis. METHODS Women treated for breast cancer within the past 6 years at one of three rural Cancer Centers were mailed a survey with a cover letter from their oncology provider. RESULTS Survey respondents (n=918, 83% response rate) were 96% White non-Hispanic, on average 3.2 years from treatment, and 11% reported metastatic disease. Among respondents without known metastatic disease, 68% were overweight or obese, 37% were obese, and 25% reported a weight gain exceeding 5 kg since diagnosis. Among the overweight/obese women, 61% were currently attempting weight loss, and the most common weight loss method was dieting on one's own without assistance. Psychosocial factors associated with weight gain since diagnosis included depression, fear of cancer recurrence, diminished physical strength, body image concerns, relationship changes, and financial stressors. CONCLUSIONS The high response rate indicates a general interest in body weight issues among rural BrCa survivors, and the findings highlight the need for weight control programs in this population. Findings also indicate that factors related to poor adjustment to breast cancer are associated with weight gain among rural women.
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DiSipio T, Hayes SC, Newman B, Aitken J, Janda M. Does quality of life among breast cancer survivors one year after diagnosis differ depending on urban and non-urban residence? A comparative study. Health Qual Life Outcomes 2010; 8:3. [PMID: 20059768 PMCID: PMC2821367 DOI: 10.1186/1477-7525-8-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Accepted: 01/07/2010] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study examined the quality of life (QOL), measured by the Functional Assessment of Cancer Therapy (FACT) questionnaire, among urban (n = 277) and non-urban (n = 323) breast cancer survivors and women from the general population (n = 1140) in Queensland, Australia. METHODS Population-based samples of breast cancer survivors aged < 75 years who were 12 months post-diagnosis and similarly-aged women from the general population were recruited between 2002 and 2007. RESULTS Age-adjusted QOL among urban and non-urban breast cancer survivors was similar, although QOL related to breast cancer concerns was the weakest domain and was lower among non-urban survivors than their urban counterparts (36.8 versus 40.4, P < 0.01). Irrespective of residence, breast cancer survivors, on average, reported comparable scores on most QOL scales as their general population peers, although physical well-being was significantly lower among non-urban survivors (versus the general population, P < 0.01). Overall, around 20%-33% of survivors experienced lower QOL than peers without the disease. The odds of reporting QOL below normative levels were increased more than two-fold for those who experienced complications following surgery, reported upper-body problems, had higher perceived stress levels and/or a poor perception of handling stress (P < 0.01 for all). CONCLUSIONS Results can be used to identify subgroups of women at risk of low QOL and to inform components of tailored recovery interventions to optimize QOL for these women following cancer treatment.
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Affiliation(s)
- Tracey DiSipio
- School of Public Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Queensland, 4059, Australia.
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16
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Schlegel RJ, Talley AE, Molix LA, Bettencourt BA. Rural breast cancer patients, coping and depressive symptoms: A prospective comparison study. Psychol Health 2009; 24:933-48. [DOI: 10.1080/08870440802254613] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bettencourt BA, Talley AE, Molix L, Schlegel R, Westgate SJ. Rural and urban breast cancer patients: health locus of control and psychological adjustment. Psychooncology 2008; 17:932-9. [PMID: 18098346 DOI: 10.1002/pon.1315] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study examines the moderating influence of rural residence on the associations between health locus of control (HLC) beliefs and psychological well-being. METHOD Two hundred and twenty-four breast cancer patients were surveyed. RESULTS The results revealed that rurality interacted with HLC beliefs in predicting psychological adjustment. The pattern indicated that, whereas endorsing external forms of locus of control can be detrimental to the psychological well-being of urban breast cancer patients, the same is not true for rural breast cancer patients. For rural breast cancer patients, powerful others locus of control was beneficial for and chance locus of control was unrelated to well-being. CONCLUSIONS Implications for future research and medical care are discussed.
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Affiliation(s)
- B Ann Bettencourt
- Psychological Sciences, University of Missouri, Columbia, MO 65211, USA.
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18
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Baldwin AE, Usher K. Going the distance--experiences of women with gynaecological cancer residing in rural remote north Queensland. Int J Nurs Pract 2008; 14:322-8. [PMID: 18715395 DOI: 10.1111/j.1440-172x.2008.00705.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Women who are diagnosed with gynaecological cancer face a difficult journey. For women residing in areas geographically removed from major health providers the journey can be much more difficult. While they 'make do' and 'struggle on', their lived experiences can provide valuable insight into the complex issues surrounding a cancer diagnosis in rural areas. This study aimed to understand their experiences through the women's stories and sought to identify the major themes impacting on these stories. This qualitative phenomenological study undertook interviews with seven women with gynaecological cancer who reside in rural and remote north Queensland. Analysis of the data collected revealed three themes: seeking answers at a distance; sharing information within a small community; and experiences of navigating the health system. The results show the inherent difficulties in accessing support in rural areas and the difficulties associated with travelling considerable distances to undergo treatment.
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Affiliation(s)
- Adele E Baldwin
- School of Nursing,, Midwifery and Nutrition, James Cook University, Townsville, Queensland, Australia.
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Kremser T, Evans A, Moore A, Luxford K, Begbie S, Bensoussan A, Marigliani R, Zorbas H. Use of complementary therapies by Australian women with breast cancer. Breast 2008; 17:387-94. [DOI: 10.1016/j.breast.2007.12.006] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Revised: 11/08/2007] [Accepted: 12/04/2007] [Indexed: 11/30/2022] Open
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Clavarino AM, Lowe JB, Carmont SA, Balanda K. THE NEEDS OF CANCER PATIENTS AND THEIR FAMILIES FROM RURAL AND REMOTE AREAS OF QUEENSLAND. Aust J Rural Health 2008. [DOI: 10.1111/j.1440-1584.2002.tb00031.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Minstrell M, Winzenberg T, Rankin N, Hughes C, Walker J. Supportive care of rural women with breast cancer in Tasmania, Australia: changing needs over time. Psychooncology 2008; 17:58-65. [PMID: 17410518 DOI: 10.1002/pon.1174] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Providing for patients' psychosocial needs is a potential means of minimising cancer morbidity. Needs assessments can guide responsive patient-centred care. A longitudinal survey of women with early breast cancer consulting a breast nurse in a primarily rural state of Australia was undertaken to measure unmet supportive care needs, identify changes in unmet needs across time and compare results with previous studies. Needs assessments were completed with the Supportive Care Needs Survey (SCNS) at 1 month (n = 74) and 3 months (n = 83) post-diagnosis. Access to services was also examined. High levels of psychological and health system and information needs were identified at 1 month post-diagnosis, but these decreased significantly at 3 months post-diagnosis. Sexuality domain needs increased significantly during the same time. Compared to a previous SCNS study of rural women with breast cancer, unmet supportive care needs in this study were significantly lower than previously reported, although assistance with energy levels (i.e. fatigue) continues to be an unmet need for women with breast cancer. Results suggest there have been positive cultural changes within healthcare systems, specifically in better informing patients and providing support. Although services appear to be more responsive to breast cancer patients, significant unmet needs still exist.
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Affiliation(s)
- Melinda Minstrell
- University Department of Rural Health, Faculty of Health Science, University of Tasmania, Hobart, Australia.
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22
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Bettencourt BA, Schlegel RJ, Talley AE, Molix LA. The breast cancer experience of rural women: a literature review. Psychooncology 2008; 16:875-87. [PMID: 17611958 DOI: 10.1002/pon.1235] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This report is a review of studies that focus on rural breast cancer survivorship. It includes a total of 14 studies using large databases and 27 other studies using qualitative and quantitative methods. In our review of this literature, we identified four broad themes, including access to treatment and treatment type, medical providers and health information, psychosocial adjustment and coping, and social support and psychological support services. We review the findings of the rural breast cancer survivorship studies within each of these broad themes. A few of the findings of the review include that rural and urban women receive different primary treatments for breast cancer, that rural women may have greater difficulty negotiating their traditional gender roles during and after treatment, that rural women desire greater health-related information about their breast cancer, and that rural women have less access to mental health therapy. The review discusses the implications of these findings as well as the weakness in the literature.
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Affiliation(s)
- B Ann Bettencourt
- Department of Psychological Sciences, University of Missouri, Columbia, MO 65203, USA.
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23
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Abstract
End of life throws up significant mental health challenges. A high proportion of people in the terminal stages of illness experience depressive symptoms. This paper integrates a theory of hierarchy of human needs and empirical research describing experiences of grief and depression in terminal illness, to develop a model of care aimed at reducing depression and suffering. This care attends to physical, psychological, social and spiritual aspects, taking into account the concerns of patients and their families. Professional help can be offered to patients to restore dignity and hope, strengthen their ways of coping, and encourage social connections. To offer this, a well-resourced and coordinated, multidisciplinary and skilled workforce is needed.
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Affiliation(s)
- David M Clarke
- Discipline of Psychological Medicine, Monash University, Melbourne, Victoria, Australia.
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Burns CM, Broom DH, Smith WT, Dear K, Craft PS. Fluctuating awareness of treatment goals among patients and their caregivers: a longitudinal study of a dynamic process. Support Care Cancer 2006; 15:187-96. [PMID: 16953423 DOI: 10.1007/s00520-006-0116-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2006] [Accepted: 06/21/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Because increasing numbers of people now survive for months or years with advanced cancer, communication between patients, service providers, and family caregivers often continues over long periods. Hence, understanding of the goals of medical treatment may develop and change as time elapses and disease progresses. This understanding is closely related to the "awareness of dying," which has been studied in both qualitative and quantitative research. However, when both a patient and family caregiver are involved, the question of "awareness" becomes more complex. A recent longitudinal study reported on patient and caregiver knowledge of treatment goals, but no comparison of such knowledge using matched interview schedules and paired data analysis has been provided. This report examines patterns of awareness and factors associated with these patterns. MATERIALS AND METHODS One hundred sixty-three patients with incurable cancer and their nominated principal family caregivers (136) were recruited from The Canberra Hospital Oncology Services. Participants' understanding of the treatment goals were measured by interview questions at weeks 1 and 12. RESULTS One-third of both patients and caregivers understood that the treatment goal was not curative; however, not all patient and caregiver pairs had the same understanding. In 15% of pairs, both patient and caregiver believed that the goal of treatment was curative, while another 13% said that they did not know the aim of the treatment. Thirty-nine percent of pairs registered incongruent responses in which only one member of the pair understood that the treatment was not intended to cure the disease. Over time, a few respondents changed their perception of the treatment goals toward accurate clarification. Bivariate analysis using an awareness variable, constructed for the purpose, showed that in 6 months before death, at least one person in 89% of pairs understood that the treatment was noncurative. Time-to-death, gender, and place of residence were also important predictors of knowledge. CONCLUSIONS Discrepancies between patients and their caregivers may complicate the delivery of effective care when patients are seriously ill. Misunderstanding or uncertainty about treatment goals will obstruct proper informed consent. Health professionals providing care for families dealing with advanced cancer must recognize that the discussion of treatment goals is a dynamic process, which may require them to extend their communication skills.
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Affiliation(s)
- Catherine M Burns
- School of Social Administration and Social Work, Flinders University, GPO Box 2100, Adelaide, 5001, South Australia.
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25
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Stewart GD, Long G, Tulloh BR. Surgical service centralisation in Australia versus choice and quality of life for rural patients. Med J Aust 2006; 185:162-3. [PMID: 16893360 DOI: 10.5694/j.1326-5377.2006.tb00507.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 05/07/2006] [Indexed: 11/17/2022]
Abstract
High patient volume for both hospitals and surgeons is an important determinant of operative mortality and outcome for complex and infrequently performed operations. The 13% of Australia's population who live in rural and remote areas often choose to have surgery close to home and support networks despite the potentially higher operative mortality and morbidity. Rural patients should be able to make an informed choice about having their surgery locally. Rural and metropolitan surgeons should discuss and reach mutual agreement on where each patient is best treated. A balance must be struck between quality of services that can be provided locally and geographic convenience.
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Affiliation(s)
- Grant D Stewart
- Department of Clinical and Surgical Services (Surgery), Edinburgh University, Edinburgh, United Kingdom.
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26
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McGrath P. Exploring Aboriginal peoples’ experience of relocation for treatment during end-of-life care. Int J Palliat Nurs 2006; 12:102-8. [PMID: 16628174 DOI: 10.12968/ijpn.2006.12.3.20692] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM to explore indigenous peoples' experience of relocation for medical treatment during end-of-life care. METHODS the data were collected from 72 qualitative interviews conducted throughout the regional, rural and remote areas of the Northern Territory, Australia, with Aboriginal patients and carers and the health professionals who cared for them. RESULTS relocation for indigenous peoples is a frightening experience. There are a myriad of fears including: the fear of leaving home, especially for people who had never been away from their home lands; the fear of dis-empowerment associated with leaving the support of family networks; fears about hospital environments and 'high-tech' treatments; fear of cultural alienation for familiar foods and ways of being; fear of travel; fear of loneliness; fear of language and communication barriers; financial fears; and fear of dying away from the homeland. CONCLUSION the findings demonstrate the strong need for building-up local palliative care services and raise significant questions about the cultural appropriateness of the Western biomedical rationale for relocation during end-of-life care.
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Affiliation(s)
- Pam McGrath
- International Programme for Psycho-social Health Research, Central Queensland University, Brisbane Office, PO Box 1307, Kenmore, Brisbane, Queensland 4069, Australia.
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27
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Turner J, Zapart S, Pedersen K, Rankin N, Luxford K, Fletcher J. Clinical practice guidelines for the psychosocial care of adults with cancer. Psychooncology 2005; 14:159-73. [PMID: 15669019 DOI: 10.1002/pon.897] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Clinical practice guidelines are increasingly being developed in medical settings to provide evidence-based recommendations to guide the clinical care of patients. The development of Clinical practice guidelines for the psychosocial care of patients with medical illness is a newer initiative, and more complex as the target audience includes health care professionals from diverse backgrounds. In Australia, the National Breast Cancer Centre and National Cancer Control Initiative have collaborated to develop Clinical practice guidelines for the psychosocial care of adults with cancer, funded by the Australian Government Department of Health and Ageing. This paper outlines the development of these guidelines in the international context, gives an overview of their content, and describes strategies for their implementation and evaluation.
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Affiliation(s)
- Jane Turner
- Department of Psychiatry, Mental Health Centre, University of Queensland, Australia.
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Gray RE, James P, Manthorne J, Gould J, Fitch MI. A consultation with Canadian rural women with breast cancer. Health Expect 2004; 7:40-50. [PMID: 14982498 PMCID: PMC5060207 DOI: 10.1046/j.1369-6513.2003.00248.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Relatively little research has been carried out on the health and supportive care needs of rural women living with breast cancer. In this study, results from a Canadian focus group study are used to highlight issues of importance to rural women. SETTING AND PARTICIPANTS A total of 276 rural women with breast cancer divided into 17 focus groups participated in the study conducted across Canada. A standardized protocol for discussion was employed. Issues of access to information, support and services were discussed, with women describing their experiences in trying to find appropriate programmes and services. MAIN RESULTS The major theme identified through analysis of qualitative data was 'becoming aware of and/or gaining access to health care information, support and services.' Other major themes included: (1) dealing with isolation; (2) having to travel; (3) feeling the financial burden and (4) coping with changing work. CONCLUSIONS Rural women with breast cancer have supportive care challenges related to their circumstances. A series of recommendations were generated through the consultation process which are contributing to the development of a national strategy focusing on the development and extension of programmes for rural women with breast cancer. Although the research on the project was not to specified standards, and suffered from less attention than community capacity building and advocacy, it proved to be of worth and revealed potential benefits from collaborations between researchers and community organizations.
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Affiliation(s)
- Ross E Gray
- Ontario Breast Cancer Community Research Initiative, Sunnybrook & Women's Health Sciences Centre, Toronto, Ontario, Canada.
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Martin-McDonald K, Rogers-Clark C, Hegney D, McCarthy A, Pearce S. Experiences of regional and rural people with cancer being treated with radiotherapy in a metropolitan centre. Int J Nurs Pract 2003; 9:176-82. [PMID: 12801249 DOI: 10.1046/j.1440-172x.2003.00421.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This paper explores the issues related to rural people with cancer whose choice of radiotherapy treatment necessitated travel and accommodation in a metropolitan centre. Semi-structured interviews with 46 participants, from the Toowoomba and Darling Downs region of Queensland, Australia, were conducted and the data thematically analysed. The specific themes identified were: being away from loved ones, maintaining responsibilities whilst undergoing treatment, emotional stress, burden on significant others, choice about radiotherapy as a treatment, travel and accommodation, and financial burden. This study supports the need for a radiotherapy centre in the location of Toowoomba as a way of providing some equity and access to such treatment for the rural people of Queensland.
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Affiliation(s)
- Kristine Martin-McDonald
- Centre of Rural and Remote Area Health, University of Southern Queensland, Toowoomba, Queensland, Australia.
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30
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Davis C, Williams P, Redman S, White K, King E. Assessing the practical and psychosocial needs of rural women with early breast cancer in Australia. SOCIAL WORK IN HEALTH CARE 2003; 36:25-36. [PMID: 12564650 DOI: 10.1300/j010v36n03_02] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The purpose of the current study was to assess the practical and psychosocial needs of rural women with early breast cancer in Australia and recommend strategies to ensure equity in availability and access to cancer treatment for all women. A random sample of 204 rural women diagnosed with early breast cancer was recruited to participate in a telephone survey via state and territory cancer registries. Although the majority of women were satisfied with their provision of information overall, less than a third of participants were provided with specific information on assistance for rural women. Findings also revealed that only 47% of the women who had to travel for treatment received financial assistance, and 13% of these women had difficulty organizing or claiming financial assistance. Furthermore, only 10% of women found social workers to be a source of support.
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31
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Fitch MI, Gray RE, McGowan T, Brunskill I, Steggles S, Sellick S, Bezjak A, McLeese D. Travelling for radiation cancer treatment: Patient perspectives. Psychooncology 2003; 12:664-74. [PMID: 14502591 DOI: 10.1002/pon.682] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Radiation treatment for cancer requires patients to receive frequent administrations and attend the treatment facility on a daily basis for several weeks. Travelling for radiation treatment has the potential to add to the distress an individual may be feeling. This study utilized in-depth interviews to capture 118 patients' perspectives about travelling for cancer treatment. Four themes emerged during the analysis of the data: (1) waiting was the most difficult part of the experience; (2) the idea of travelling for treatment was distressing; (3) travelling for treatment was tiring and posed difficulties for patients; and (4) being away from home had both benefits and drawbacks. Given the inevitability of travelling for radiation treatment, and the issues that arises for patients, supportive strategies need to be designed and implemented.
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Affiliation(s)
- Margaret I Fitch
- Psychosocial and Behavioral Research Unit, Toronto Sunnybrook Regional Cancer Centre, Toronto, Canada.
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32
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Clavarino AM, Lowe JB, Carmont SA, Balanda K. The needs of cancer patients and their families from rural and remote areas of Queensland. Aust J Rural Health 2002; 10:188-95. [PMID: 12121408 DOI: 10.1046/j.1440-1584.2002.00436.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study examines the impact of travelling for treatment on cancer patients and their families. Twenty-eight consecutive cancer patients, who were receiving radiation therapy treatment and 19 family carers, completed a structured needs assessment questionnaire and an in-depth interview. Both patients and carers reported moderate to high levels of unmet psychological need. Carers were found to have higher levels of anxiety than patients, although both groups had higher anxiety levels than the general population. Taking more responsibility for household tasks and organising new living arrangements for the family were the most frequently identified demands of a dual burden of caring. Nearly 40% of carers reported some disruption to their schedule and half reported experiencing financial difficulties. The qualitative interviews highlight the disruption that parents and children experience under the present system, particularly in relation to the demands of family life and the need to maintain some level of continuity and security for children.
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Affiliation(s)
- Alexandra M Clavarino
- Centre for Health Promotion and Cancer Prevention Research, School of Population Health, University of Queensland Medical School, Herston, Queensland, Australia.
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McGrath P. Returning home after specialist treatment for hematological malignancies: an Australian study. FAMILY & COMMUNITY HEALTH 2001; 24:36-48. [PMID: 11373165 DOI: 10.1097/00003727-200107000-00007] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The technologically advanced and specialist nature of the treatments for patients with hematological malignancies necessitate that they are carried out in major metropolitan treating hospitals. Consequently, patients from regional, rural, and remote areas in Queensland, Australia, must relocate, often for lengthy periods of time, for treatment. To date, there has been scant research carried out on what happens to these patients and their families when they return home after such intensive treatments in the metropolitan centers. This article documents recent, seminal work in this area. The findings indicate that these families have many emotional, medical, and practical needs. These needs change over time, depending on the trajectory of the illness.
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Affiliation(s)
- P McGrath
- Center for Palliative Care Research and Education, Brisbane, Australia
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Girgis A, Boyes A, Sanson-Fisher RW, Burrows S. Perceived needs of women diagnosed with breast cancer: rural versus urban location. Aust N Z J Public Health 2000; 24:166-73. [PMID: 10790936 DOI: 10.1111/j.1467-842x.2000.tb00137.x] [Citation(s) in RCA: 162] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To assess the prevalence and predictors of perceived unmet needs among women diagnosed with breast cancer, with a particular focus on the impact of location (rural/urban). METHOD A random sample of women in NSW diagnosed with breast cancer was surveyed during 1995-96. The Breast Cancer Patients' Needs Questionnaire (BR-CPNQ) explores patients' perceived needs across five domains: psychological, health information, physical/daily living, patient care/support and interpersonal communication. Items assessing breast cancer specific needs and access to services and resources were included. Of 235 eligible rural women, 134 (57%) consented to participate and 129 (55%) returned completed surveys. Of 196 eligible urban women, 102 (52%) consented to participate and 100 (51%) returned completed surveys. RESULTS For 12 of the 52 items, at least one-third of the sample reported ever having a moderate/high need for help. Of the 15 highest moderate or high unmet needs, 10 related to health information and three to psychological needs. There were few differences in the prevalence of needs reported by rural and urban women. Only in the physical/daily living domain were rural women more likely than urban women to report some need for help (OR = 2.59, 95% CI 1.21-5.52). CONCLUSIONS Unmet needs, particularly in the information and psycho-social domains, are reported by both rural and urban women with breast cancer, with sub-groups experiencing different types of needs. IMPLICATIONS There is a need to develop and trial targeted and innovative strategies to meet the health information and psychological needs of women with breast cancer, and the physical/daily living needs of rural women diagnosed with breast cancer.
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Abstract
The Patient Transit Assistance Scheme (PTAS) is an important government program designed to ensure equity of access for residents in rural and remote Queensland to essential healthcare services. Where specialist services cannot be provided at recognised hospitals, PTAS ensures equity by accepting the responsibility for assisting with the transport and accommodation of patients and at times their escort, to locations where such services are available. This article presents research findings on the concerns of clerks involved in administering PTAS for patients with leukaemia and associated haematological disorders. The findings indicate that there are many problems with this scheme that need attention and can be remedied.
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Affiliation(s)
- P McGrath
- Centre for Public Health Research, Queensland University of Technology, Australia.
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