HealthCare in Rural Areas: What's Different? Part 2

The first section of this blog provided general information regarding healthcare in rural areas. This portion will discuss the conceptualization of health in rural areas and barriers to accessing healthcare.The last portion focuses on the psychosocial needs of rural cancer patients.

IS THERE A DIFFERENCE IN HOW RURAL AND URBAN PEOPLE VIEW HEALTH? Yes! (Keep in mind my caution in Part 1 regarding generalizations vs. stereotypes.) In a study exploring urban and rural differences in the conceptualization of health, Elliot-Schmidt and Strong¹ describe a farmer who severed his finger while working a combine. Rather than going immediately to the hospital, the farmer waited several hours to seek medical attention because he needed to complete his work day. To rural healthcare providers, this scenario is not surprising. In rural areas it is not uncommon for oncologists to hear that patients have been experiencing symptoms for some time, but are only seeking care once harvest has been completed. Folks in rural areas conceptualize health in a “role performance model,” in which health is determined by one’s ability to fulfill one’s roles, especially regarding work and family responsibilities. In addition, people in rural areas often view illness and injury as indicating a weakness in the individual, and therefore illness may be stigmatized. In contrast, folks in urban areas view health through the “acute clinical model,” in which health is defined as the absence of disease or dysfunction, and illness occurs when the body experiences irregularity or dysfunction. These attitudes impact how people perceive the role of healthcare, with urban folks expecting healthcare providers to reduce and relieve the patient’s symptoms, and rural folks wanting healthcare providers to restore and maintain the patient’s ability to fulfill their roles and functions.¹

WHAT ARE THE PSYCHOSOCIAL NEEDS OF CANCER PATIENTS LIVING IN RURAL AREAS?

In comparison to the status of mental health of urban cancer patients, rural cancer patients have a lower level of mental health², a lower quality of life³, and a higher level of unmet psychosocial needs³. In a review focusing on rural women diagnosed with breast cancer, Bettencourt et al.⁴ documented that rural breast cancer patients experience higher levels of anxiety, depression, distress, lower quality of life, and poorer mental health functioning. Barriers to meeting psychosocial needs are numerous: scarcity of mental health providers, geographic isolation limiting access to support groups, dearth of information regarding resources, reluctance to admit needs, social stigma, the possibility of having a dual relationship with the provider, and concerns of confidentiality.⁵

DO THESE DIFFERENCES RESULT IN DISPARITIES IN CARE BETWEEN URBAN AND RURAL CANCER PATIENTS?

Yes. Bettencourt⁴ documented several dissimilarities in the experiences of urban and rural breast cancer survivors. Differences in access to treatment were the result of having to travel long distances to receive treatment, and travel was stressful and disruptive to family life and employment. In addition, having to travel for treatment led to loss of social support and feelings of isolation and displacement. The review also demonstrated differences in treatment type, with rural patients being more likely to have had a mastectomy and chemotherapy rather than breast-conserving surgery and radiation, even when the tumor size was equal. There was also a longer latency time between surgery and initiation of chemotherapy.

Thirty percent of rural patients believed living in a rural area restricted their access to information, which led to instances of misinformation and/or a lack of information (such as being unaware of the effects of chemotherapy or options regarding reconstruction). There were many misconceptions regarding cancer among rural breast cancer patients: believing their cancer was caused by hard work or a bump, thinking they were too young to get cancer, that screening is “looking for trouble,” and that cancer will grow if exposed to air during surgery.

Rural patients also had poorer psychosocial adjustment to their breast cancer. They reported high levels of distress at diagnosis, and even though their quality of life improved during the first year, it remained lower than in the general population. Compared to urban breast cancer patients, rural patients had lower levels of emotional self-efficacy and higher levels of cancer-related fear. Rural breast cancer patients had higher levels of distress regarding body image and the stigma of having breast cancer, due in part to rural areas having more defined gender roles. Cancer was considered contagious and equated with death, and breast cancer was seen as a “taboo” topic. Rural breast cancer patients were more likely to use avoidant coping strategies, such as denial and avoidance, and a frequent comment was “Don’t dwell on it.”⁴

HOW MIGHT THIS INFORMATION INFORM MY CARE OF PATIENTS FROM RURAL AREAS?

Delivering quality healthcare means being able to tailor care to fit the needs of individual patients. The information presented on healthcare in rural areas is meant to demonstrate aspects of care in rural areas that may impact the needs of rural patients, as well as their ability to adhere to health-related recommendations. The information presented does not dictate your care of rural patients; rather, it provides a starting point for a conversation which will guide you in how to meet the patient’s needs.

References

• Elliot-Schmidt R, Strong J. The concept of well-being in a rural setting: understanding health and illness. Aust J Rural Health. 1997;5(2):59-63.
• Burris JL, Andrykowski M. Disparities in mental health between rural and nonrural cancer survivors: a preliminary study. Psychooncology. 2010;19:637-645.
• Butow PN, Phillips F, Schweder J, et al. Psychosocial well-being and supportive care needs of cancer patients living in urban and rural/regional areas: a systematic review. Support Care Cancer. 2012;20:1-22.
• Bettencourt BA, Schlegel RJ, Talley AE, et al. The breast cancer experience of rural women: a literature review. Psycho-Oncology. 2007;16:875-887.
• National Rural Health Association: What’s different about rural health care? http://www.ruralhealthweb.org/go/left/about-rural-health/what-s-different-about-rural-health.