A Rural-Urban Comparison of Self-Management in People Affected by Cancer Following Treatment: A Mixed Methods Study
Creators: name: Nelson, David
Publisher: name: University of Lincoln
Year: 2024

description: BackgroundPeople affected by cancer have to self-manage the consequences of cancer long after primary treatment has ended. In cancer survivorship, self-management has been defined as awareness and active participation by the individual in their recovery, recuperation and rehabilitation to minimise the consequences of treatment, and promote survival, health and wellbeing (DH, Macmillan Cancer Support and NHS Improvement, 2010). Despite a significant drive towards promoting and supporting self-management with people affected by cancer there is a lack of research examining whether residence (rural-urban) has an influence on self-management following cancer treatment. The primary aim of this thesis was to investigate and compare self-management, in people affected by cancer following treatment from rural and urban areas. MethodsThe study utilised a cross-sectional mixed methods design that incorporated both quantitative and qualitative methods of data collection. Firstly, this involved a self-completion postal questionnaire (N=227) that collected quantitative data on demographics, rural-urban residence, health status, health-promoting behaviours, patient activation, cancer-related self-efficacy and qualitative free-text information on self-management behaviours. This was followed by a series of in-depth qualitative interviews (N=34) that aimed to identify, and compare the barriers and facilitators to self-management in people affected by cancer from rural and urban settings in the East Midlands of England. Both datasets were integrated to further explain the quantitative differences that were identified between rural and urban participants. ResultsParticipants from rural areas reported higher scores across a range of quantitative variables, indicative of greater levels of engagement with health promoting behaviours and self-management compared to those from urban areas. Specifically, rural participants scored higher with regard to health responsibility (p&lt;0.01; nutrition (p&lt;0.001); spiritual growth (p&lt;0.01); and interpersonal relationships (p&lt;0.001). Rural respondents (63.31Â±13.66) had higher patient activation than those in urban areas (59.59Â±12.75) although this was not statistically significant at p&lt;0.01. Those residing in rural areas (7.86Â±1.70) had significantly (p&lt;0.01) greater cancer-related self-efficacy compared to those in urban areas (7.09Â±1.96). Rural respondents had significantly higher self-efficacy than urban respondents with regard to confidence to manage physical discomfort (p&lt;0.01), emotional distress (p&lt;0.001), and to contact their doctor about problems caused by cancer (p&lt;0.01). The findings from the multivariate analysis highlighted that rural-urban residence was not a significant predictor of health-promoting behaviours, patient activation or cancer-related self-efficacy when adjusting for living arrangement, marital status, qualifications and self-reported health status. Selfreported health status proved to be a significant predictor on all three outcomes when controlling for confounders. Three themes were identified in the qualitative data which related to barriers that prevented participants from engaging with self-management: (1) Location (2) Relationship Based and (3) Personal. In relation to facilitators that enhanced participantsâ€™ active participation in their recovery, three subthemes were identified: (1) Effective Communication and Information; (2) Informal and Peer Support and (3) Motivation. The barriers and facilitators that were identified were prevalent in both the rural and urban setting. However, some aspects belonging to these barriers and facilitators were more explicit in the rural or urban environment. For example, there was a lack of bespoke support in rural areas and participants acknowledged how traveling long distances to urban centres for support groups was problematic. Motivation to engage with self-management was not unique and both sets of participants were motivated by a desire to be healthy and take part in group activities and sports. Although rural participants did have easier access to greenspaces and community activities, which could enhance motivation further. ConclusionThe quantitative findings highlighted that people in rural areas were more engaged with health-promoting behaviours and better at self-managing their health compared to those in urban areas. The majority of the barriers and facilitators that were identified were not necessarily unique to the urban or rural environment. Certainly, the qualitative data show that residency is not as unequivocal as the quantitative results would suggest. However, engagement with the local community was greater in rural areas which could account for the differences. Whilst the active treatment phase can present considerable challenges for people affected by cancer in rural areas the findings suggest that the rural environment has the potential to increase engagement with self-management in the transition to survivorship. LAY SUMMARYThere are an increasing number of people living with and beyond cancer who are having to self-manage the consequences of cancer long after treatment had ended. Self-management refers to how aware and active people are in their recovery as well as behaviours that they engage with to promote health and wellbeing. To date, there is no research that has examined the role of rural-urban residency in relation to self-management following cancer treatment.The research involved a questionnaire and a series of one-to-one interviews. 227 people completed a questionnaire that asked them about their engagement with a range of health-promoting behaviours as well as their knowledge, skills and confidence to self-manage. The findings were compared between rural and urban participants. 34 people took part in an interview that aimed to understand what helped or prevented them from self-managing their health and healthcare following cancer treatment. The findings highlighted that people in rural areas were more engaged with health-promoting behaviours and better at self-managing their health compared to those in urban areas. The interviews found that informal support positively influenced recovery and self-management, although support and involvement with the local community was greater in rural areas which could account for the differences.