Rural cancer patients and health care providers face challenges beyond access and distance

Rural Americans have higher rates of lung, colorectal and cervical cancers and higher cancer death rates overall compared to their metropolitan counterparts. They also have lower access to cancer screening, treatment and specialty care, are less likely to have access to reliable transportation and health insurance and have higher prevalence of cancer risk factors, like smoking and obesity.

Although much is known about rural patients' cancer risk factors and barriers to care, little research to date has focused on rural health care providers' views regarding cancer screening and prevention.

To fill this gap, Alee Lockman, Ph.D., assistant professor of health policy and management at the Texas A&M University School of Public Health, along with two colleagues from Harvard University and two from St. Francis Medical Center in Illinois, asked rural health care providers at a regional health system about their perceptions of cancer control in rural communities.

"We wanted to understand how health care providers view the factors—at both the individual and system level—that limit rural patients' access to care and how these perspectives affect cancer screening and prevention efforts," Lockman said.

For the study, conducted over six months in 2021, the researchers led semi-structured interviews with 23 primary care providers, nurse navigators and community health workers affiliated with a regional health system that primarily serves rural communities. The providers were asked for their opinions on three issues: barriers that limit rural patients' access to cancer screenings and preventative behaviors, how health care providers and systems acquire accurate information about these barriers and how providers use this information to make recommendations about cancer screenings and preventative behaviors.

A thematic analysis of the data identified three primary domains influencing the relationship between providers and rural patients: provider beliefs and assumptions about rural patients; factors affecting information-gathering and care coordination; and providers' approach to care coordination, including decision-making, communication style and trust-building.

"Our main finding is that trust is crucial to the relationship between rural patients and health care providers, and it's a two-way street," Lockman said. "The level of patient-provider trust influences how much rural patients are willing to believe their providers, to follow providers' health care recommendations, and to provide information that helps providers make appropriate health care decisions."

Those surveyed stated that many rural patients preferred to manage health conditions on their own or trusted family and friends more than health care providers for health advice, often because of patients' religious beliefs, views on quality-of-life issues and reluctance to discuss their financial struggles and health behaviors.

The providers emphasized the importance of building trust and gathering information through in-person conversations, during which they could observe patients' demeanor, social support and body language, and adjust health care recommendations according to the patient's likely compliance.

The ability to have in-person consultations, however, is hampered by factors on the provider side, such as limited appointment times and problems with electronic health record systems. On the patient side, lack of transportation was identified as a major factor. Most rural communities lack public transportation, which makes in-person medical appointments difficult for elderly patients who do not drive, patients from single-car households and those lacking social support that might provide transportation. In addition, the providers stated that many of their rural patients are hesitant to get specialty health care in urban areas, given the long distance, expense and inconvenience and a desire to receive care closer to home.

"Most solutions intended to reduce barriers to cancer screenings for rural patients focus on structural and institutional barriers, such as reducing administrative challenges and adding telehealth options and mobile clinics," Lockman said. "We believe that our research on the role of patient-provider communication and trust-building can inform additional solutions addressing the unique challenges of rural communities."

The study is published in the journal SSM - Qualitative Research in Health.