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Rural Oncology Access

Rural Communities Access to Oncology Services

Jalyn Stinardo

College of Nursing, Idaho State University

NURS 8809: Rural and Global Communities

Dr. Melody Weaver

11/23/2020
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Rural Oncology Access

Rural Communities Access to Oncology Services

Introduction

According to Rural Healthy People 2020, “access to quality health services” is the number

one priority (2020). Access to care not only includes the provision and availability of health

services, but also the barriers that rural communities may face in addition to lack of resources.

These include transportation, health literacy, “stigma associated with conditions in rural

communities”, and barriers such as “workforce shortages and health insurance status” (Rural

Health Information Hub, 2019). These barriers not only impede rural communities access to

primary health, but especially for access to specialized services such as oncology. The World

Health Organization (2017) is projecting the annual cases of cancer will rise from 14.1 million in

2012 to 21.6 million in 2030. The Center for Disease Control published a report in 2017 that

illustrated that although rates of cancer have decreased worldwide, the rates of lung, colorectal,

and cervical cancers in rural communities occurred at higher incidences than in urban

communities. Additionally, the death rates from these cancers were higher in rural communities

as well. Although there is a lower incidence of cancer overall, rural communities have a higher

death rate related to cancer (Centers for Disease Control, 2017). The growing need for oncology

services cannot be ignored, especially for rural communities. This paper will discuss the issue of

lack of oncology access for American rural populations and through a scholarly literature review

and corresponding theoretical framework, propose ways as a DNP to increase access, improve

care, and suggest changes.

Population Focus

For the purposes of this paper, rural is a community that has 2,500 people or fewer and

disparities in access to healthcare. Moreover, these communities may have a unique approach to
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healthcare as they may see health in terms of ability and seek healthcare when ability is lost. In

other words, these communities are less likely to seek preventative care and more likely to only

seek out care when they experience debilitating effects from their conditions. The population

focus is people that reside within a rural community and require oncology services for any or all

cancer diagnoses, or related healthcare conditions. This population, as mentioned above, faces

higher average death rates related to cancer as compared to urban areas. This problem is

multifaceted, stemming from barriers to care, differences in health behaviors, and health seeking

behaviors.

Literature Review

Barriers include financials (such as no insurance or insufficient coverage), lack of

transportation, and lack of preventative measures such as screenings. As opposed to urban

populations, rural communities have higher incidences of alcohol and tobacco consumption, as

well as obesity. These communities also have lower rates of physical activity, sun-protective

measures, and HPV vaccinations (National Cancer Institute, 2020). All these measures are

related to cancer incidences. Rural residents are more likely to be diagnosed with cancer in its

later stages and are “less likely to receive standard of care treatment, follow up, or supportive

services and have worse health outcomes during survivorship than nonrural patients” (LaRaia &

Worden, 2020). Rural residents are also more likely to be of older age, in poorer general health

and decreased engagement in preventative health (Henley & Jemal, 2018). A study conducted in

Louisiana compared women with diagnosed breast cancer between rural and urban communities,

specifically analyzing the difference between “sociodemographic, clinical pathologic, and

treatment variables” (LaRaia & Worden, 2020). Their results suggested that less than 10% of

their population size were rural residents. Of these patients, they were older, more likely to be
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Rural Oncology Access

uninsured, and more likely to be treated at a “low volume center” than urban patients. Rural

patients were also less likely to survive overall as compared to urban patients and decreased

cancer specific survival. However, the article also concluded that rural residence was not an

independent indicator of survival (Chu et al, 2020).

Although great strides have been made, cancer is still very difficult and complicated to treat,

requiring an interdisciplinary approach to adequately treat patient needs. Rural residents face

limitations in the amount of “diagnostic, treatment, and supportive services that are available”

(Levit et al, 2020). Research has shown that mortality rates are decreased when patients receive

specialty care in cancer centers than compared to community hospitals (Nass et al, 2019). Studies

have also shown that among gynecologic oncologists, 72% practiced in urban settings and 39%

“strongly agreed” that patients with cancer in rural settings “should travel to urban cancer centers

to receive care within a center of excellence model” (Ricci et al, 2017).

To improve healthcare outcomes for rural communities, several models have been proposed.

A qualitative study researched three different states and their approaches to increasing access to

care for oncology patients in each rural region. Community based-coalitions, such as Ohio’s

Breast Health Connection Program, screens women and connects those with abnormal results

with appropriate resources via a patient navigator. Missouri’s Heartland Cancer Research, a

community based research center, trains and sends oncologists and oncology nurses to rural

areas. New Mexico Cancer Care Alliance specifically addresses rural discrepancies by following

a hub and spoke model, opening many smaller clinics to provide care (Levit et al, 2020). This

research suggests that multiple strategies are needed to address rural and urban discrepancies

among rural cancer services.

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Rural Oncology Access

Research regarding the use of tele oncology is new and emerging. One study performed

retrospective chart audits in hospitals in rural Montana. Their results suggested that through tele

oncology, “high quality and safe cancer care, including a variety of complex medical therapies,

can be provided to rural patients” (Linhart, 2017). Additionally, another study confirmed that tele

oncology reduces travel times for rural patients, is found agreeable among providers and

patients, and can reduce healthcare costs without compromising safety (Chan et al, 2015).

Theoretical Framework

The purpose of utilizing a theoretical framework/ model is to “achieve congruence between

process and product” and “defining the boundaries and goal of nursing actions, and by giving us

the framework through which to examine the effectiveness of our interventions” (Zaccagnini &

Moran, 2018, p. 13).

Theory of Planned Behavior is commonly sued for understanding, calculating, and

explaining behavior throughout several fields. It has been studied throughout nine different

domains (Steinmetz et al, 2016). One study via meta-analysis studied TBP use to influence

behavior and attitude changes. Central to the theory is that behaviors are influenced by

intentions, and intentions are influenced by the attitudes surrounding the “behavior, subjective

norm, and perceived behavioral control” (Steinmetz, 2016). Captured within the concepts of

attitudes and subjective norms, are the background influences that rural patients face when

deciding to engage with the healthcare system. As previously mentioned, these include

transportation, finances, and if the patient even decides that they need to. A literature review

found that rural communities defined their health in terms of being able to work, "reciprocate

social relationships,” “maintain their independence" and attribute their health to their "work hard

eat hard" mentality (Gessert et al., 2015, p. 3). There are many factors that influence the health of
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Rural Oncology Access

rural communities, and this theory could provide a framework to explain why or why not they

engage in healthcare.

DNP Preparation to Increase Access

As a DNP, there are several options for increasing access to care for oncology patients in

rural communities. As previously mentioned, one option is to practice through telehealth or tele-

oncology. Tele-oncology has the power to provide care for rural patients that may not be able to

travel. While simultaneously decreasing healthcare costs and providing specialized care to

patients that may not otherwise receive it. The DNP is prepared to use evidence based practice

within interprofessional teams in congruence with health information technology/informatics

(Moran, Burson, & Conrad, 2020, p. 34).

Additionally, DNPs have autonomy in many states. By practicing in rural communities,

DNPs can practice as an independent provider, increasing access to care. Research has suggested

that when Psychiatric Mental Health Nurse Practitioners practice in rural communities, they

increased access of mental health simply by “practicing at the fullest extent of their scope

without mandated supervision, utilizing telepsychiatry practice while expanding PMHNP rural

mental health education” (Finley, 2020).

Models for healthcare delivery in rural communities also include the Hub and Spoke

Model. The hub is a larger institution such as an established cancer care facility and the spokes

may include critical access hospitals, clinics, or infusion centers that “provide medical oncology

consultation and follow-up, chemotherapy, therapeutic infusion services, and survivorship care”

(LaRaia & Worden, 2020). This not only increases access to care, but also improves care within

the healthcare system, as there is still communication between the hub and the spokes.
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Rural Oncology Access

Regardless of the model, a pertinent challenge is the changes that are necessary within

the healthcare system to implicate these models. Rural communities, with their lack of access to

healthcare and decreased positive health outcomes, highlight that healthcare and the system it

provides still requires improvements. Increased education for rural communities about health and

health processes can provide them with the language to advocate for themselves and engage with

healthcare when appropriate. As a whole, healthcare is beginning to shift towards preventative

care. However, more emphasis needs to be placed on entering healthcare as a patient, not when a

disease process is beyond cure. One research article that examined colorectal screening rates in

rural communities found that decreased rate of screenings were related to patients lack of

knowledge as to why they needed screenings without symptoms (Wang et al, 2019). This means

educating these communities about the benefits of routine health checkups, and having this

concept become commonplace.

The DNP is also prepared to work interprofessionally. With decreased access to care the

ability to come together across disciplines is important for patient outcomes. As defined by the

AACN essentials (2006), the DNP is practiced not only in leadership, but also teaching and

learning strategies. In addition, the discipline of nursing is concerned with "the wholeness or

health of human being recognizing that they are in continuous interaction with their

environments" and "organizational and systems leadership component that emphasizes practice,

ongoing improvement of health outcomes and ensuring patient safety" (AACN, 2006, p. 9).

Regarding rural oncology, interprofessional healthcare could look like consultation between

physicians via telehealth, care provided by the community physician but oversaw by a specialist,

or increased community involvement across the disciplines already established.

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Conclusion

The lack of healthcare access for rural communities is not a new conversation. Through

interprofessional approaches and combinations of healthcare models such as Hub and Spoke,

access can be increased. Rural communities are at increased risk for cancer due to risky

behaviors such as smoking and alcohol consumption. In addition, due to the lack of access to

healthcare resources, they face greater mortality and poorer outcomes if they are to contract

cancer. The DNP is in a position to work interprofessionally to increase quality of care for rural

oncology patients as well as work autonomously to increase access to care. Further discussion

and research is needed for this population, but with increasing technology and emerging

healthcare professionals such as DNPs, the outcomes for rural oncology patients can be

improved.
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Rural Oncology Access

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