Abstract
Rural cancer survivors experience worse quality of life (QoL) and greater cancer-related distress (CRD) when compared to urban survivors. These cancer disparities are attributed to poor healthcare access and culturally inappropriate care for rural cancer survivors. Rural survivors travel an average of 60 minutes to reach a healthcare facility, and healthcare providers may perceive rural cultural norms, such as spirituality, to be a barrier to providing care. One way nurses can improve rural survivors’ QoL and reduce survivors’ CRD is by promoting resilience. Resilience improves QoL and reduces CRD in cancer survivors. Therefore, the goals of this dissertation are to 1) explore the cultural and geographic contexts of resilience in rural cancer survivors, and 2) inform the development of future interventions that are geographically-accessible and culturally appropriate. To achieve these goals, three manuscripts are presented.
In the first manuscript, I develop an evidence-based conceptual framework for rural resilience in cancer survivors. I use the Walker & Avant method to construct an evidence-based conceptual framework of rural resiliency for cancer survivors grounded in three domains of rural culture: spirituality, cultural norms, and social capital. These domains impact a cancer survivor’s status on the continuum of resilience-distress, leading to either negative or positive psychosocial outcomes.
In the second manuscript, I use a multi-method approach using descriptive qualitative interviews and a quantitative survey, the Telemedicine Satisfaction and Use Questionnaire. Three themes were extracted from the qualitative interviews: rural cancer survivors trust oncology nurses with their distress experience, an oncology nurse telehealth visit increases survivors’ access to information and education, and rural cancer survivors overcome technology barriers to speak with an oncology nurse. Quantitative findings indicated high satisfaction with the nurse-patient relationship over telemedicine and lower satisfaction with using telemedicine equipment to connect to a visit.
In the third manuscript, I use semi-structured interviews and thematic analysis guided by the conceptual framework of rural resilience to identify facilitators and barriers of resilience in rural cancer survivors, and to identify community locations for future interventions. Three themes emerged from the data: 1) spirituality facilitates resilience in rural cancer survivors, 2) rural cancer survivors accommodate the cultural norms of fatalism, mistrust of providers, and cultural differences to maintain resilience, and 3) rural cancer survivors strengthen resilience through social capital on virtual platforms in the context of COVID-19. We found that rural cancer survivors are seeking to strengthen resilience and reduce CRD through virtual platforms in the context of COVID-19, despite the challenge of poor broadband. We also found that spirituality facilitates resilience in rural cancer survivors, while rural cultural norms of fatalism, mistrust of local hospitals, and cultural differences are barriers to resilience.
I conclude that the evidence-based conceptual framework of rural resilience can guide nursing interventions promoting resilience in rural cancer survivors, and that future interventions should be implemented on virtual platforms. The findings of this dissertation can be used to inform nursing interventions that support resilience, improve QoL, and reduce CRD.
