Promoting equitable health services for Colorectal Cancer patients in rural New Zealand.

Written by Samantha Collis

  Executive Summary

Equitable health services should be available for all New Zealanders, regardless of ethnicity, socioeconomic status, and geographical location. New Zealand is distinct in that 14% of the population live rurally, and cover 80% of the landmass, consequentially making efficient and accessible health care problematic (New Zealand Institute of Rural Health, 2008). Robson, Purdie, and Cormack (2010) reported poorer survival rates from cancer in rural areas when compared to urban centres as rural living is often associated with delays in diagnosis, challenges of traveling long distances, and limited access to oncology services. One of the key themes of the 2016 New Zealand Health Strategy is providing care closer to where people live, integrating health services, and promoting wellness by designing services that can reach New Zealanders living in remote locations using approaches such as telehealth which can connect people with the care and support they need (Ministry of Health, 2016).

A current area of concern for New Zealand is that of Colorectal Cancer (CRC) which has one of the highest incidences of CRC in the world, where it is the second highest cause of cancer related death (Shah, Sarfati, Blakely, Atkinson, & Dennett, 2012). CRC survivors have a 40% risk of developing a second primary or recurrent bowel cancer, signifying that follow-up care is critical for these individuals, to reduce the burden of further disease (Jefford et al., 2011). The evidence explored within the subsequent submission supports the need to promote healthy lifestyle behaviours in CRC patients, as they have been shown to increase Quality of Life (QoL) and overall survival. Providing appropriate interventions for CRC patients’ long-term health needs also leads to efficiencies in health care, and potential cost savings.

  Recommendation

Rural Health Alliance Aotearoa New Zealand (RHAANZ) to advocate for the initiation of a nurse-led, telephone based, support service for CRC patients following discharge from tertiary-level care. The goal is to provide up-to-date, evidence based health education on appropriate lifestyle modifications, and act as a positive motivator for behaviour change that can ultimately improve QoL and overall survival in CRC survivors regardless of rurality. Components of the service are as follows:

  • Nurses to individualise survivorship care plans in partnership with client
  • Collaboration with all members of healthcare team
  • Flexible nurse-client contact
  • Improvement in client health literacy, participation and compliance
  Clinical Issue

CRC has become the third most common cancer to be reported worldwide, attributing to 694,000 deaths in 2012 (World Health Organisation, 2015). In New Zealand, CRC is the second highest cause of cancer related death, and is home to one of the highest incidences of CRC in the world (Shah et al., 2012). Each year, approximately 2800 people are diagnosed with CRC in New Zealand, where the five-year survival rate is 55% (Ministry of Health, 2012). The relevance of this fact means that there are numerous long-term survivors, the incidence of which is expected to increase significantly in the next decade due to an aging population, advances in early detection, and improved treatment (Hawkes, Gollschewski, Lynch, & Chambers, 2009). The objective of the following research was to evaluate the impact of healthy lifestyle behaviours on improving CRC survivors’ QoL post-diagnosis. As well as discussing the applicability of these interventions to New Zealand CRC survivors, their motivation for change, and barriers to providing supportive care. 

  Literature Review

Currently, conventional treatment for early stage CRC is surgery and adjuvant chemotherapy. Lifestyle modifications post-surgery are integrated into an emerging field called ‘integrative oncology’, defined as a “rational, evidence-based combination of conventional therapy with complimentary interventions into an individualised therapeutic regime that addresses the whole person living with and beyond cancer” (Jafri & Mills, 2013, p.207). Identifying lifestyle modifications, aims to improve outcomes for patients.  Research by Khaw et al. (2008) established that lifestyle modification such as an increase in fruit and vegetable intake, reduction in red meat consumption, regular exercise, and maintaining a healthy weight, could prevent 18% and 32% of cancers in men and women respectively. Further to this, a study by Grimmett, Bridgewater, Steptoe, and Wardle (2011) examined the effect of these behaviours on improving the QoL in CRC survivors, finding significant positive trends between healthy behaviours, QoL and Physical Activity (PA). This can be backed up by evidence that found a 50-60% reduced risk of overall mortality in females who partook in recreational PA, as well as finding CRC mortality risk doubled in patients who were overweight or obese (Boyle, Fritschi, Platell, & Heyworth, 2013). Grimmett et al. (2011) found that survivors who were physically active reported a higher QoL, however the extent of the PA necessary to achieve this was unclear. Jafri and Mills (2013) support this proposal by finding improved overall survival in stage I-III CRC patients who partake in PA both pre- and post-diagnosis.

Despite, the majority of evidence pointing towards a positive association between maintaining PA and improved outcomes for CRC patients, the adherence to such activities is reported to be low, in fact CRC survivors have the lowest rates of PA when compared to other cancer groups (Courneya, Katzmarzyk, & Bacon, 2008).  When providing health education to patients, nurses need to consider what barriers may prevent concordance with advice. Nurses are in an opportune position to provide patient-centred, supportive care to CRC survivors, providing health education that is evidence-based and tailored to the specific needs of the patient. CRC survivors have a 40% risk of developing a second primary or recurrent bowel cancer, signifying that follow-up care is critical for these individuals, to reduce the burden of further disease (Jefford et al., 2011). Anderson, Caswell, Wells, Steele, and MacAskill (2009) discovered a serious knowledge gap amidst both healthcare professionals and patients about the necessary advice for lifestyle modifications following treatment for CRC to improve QoL and mortality. Patients have reported being given conflicting advice, which illustrates the importance of improving knowledge and approaches of nursing staff towards secondary prevention in this vulnerable population. Nurses play an active role across the cancer care continuum, and as patients move from an acute care setting to long-term management at home, nurses need to consider their short, and long-term, self-management needs.

Following discharge from an acute care setting, patients may be dealing with anxiety, fatigue, and a reduction in physical functioning. These changes, in addition to the shock of a cancer diagnosis, are likely to influence a patient’s motivation for developing self-management strategies, and behaviour change. Anderson, Steele, and Coyle (2012) recognise the importance of a cancer diagnosis as a ‘teachable moment’ where patients and families would welcome guidance on lifestyle modification to help alleviate symptoms, and reduce further risk of CRC reoccurrence. This unmet need for supportive care was also identified in an Australian based study, whereby needs still persisted more than six months after discharge (Harrison et al., 2011). Patients need to be considered in the context of their environment, perceived benefits, as well as barriers to action that are important to address in predicting whether a patient will incorporate new healthy behaviours into their lifestyle. Barriers to adopting healthy lifestyle behaviours cannot be ignored, and may be highly individual to the patient.

  Rural Context

In New Zealand, an important barrier to consider in relation to access of treatment is the distance to the tertiary care facility, as so much of New Zealand’s population is rurally located. CRC patients who live far away from their tertiary provider report lower physical and social functioning, which consequentially affects their overall QoL (Thomas et al., 2014). The distance between hospital-level care and primary health providers can also present barriers for patients, as rural localities can often be resource poor, leading to uncoordinated care. The experiences of those living with cancer in rural localities are distinct and unique from their urban counterparts as there are additional challenges and stressors to be considered in order for equitable care to be provided. Therefore it is essential that when developing survivorship care plans for patients, all members of the healthcare team need to collaborate effectively to ensure care is patient-centred and individualised (Zapka et al., 2015).

A number of survivorship interventions have been trialled outside of New Zealand as potential supportive tools for lifestyle modification in CRC patients. An initiative trialled in Australia called ‘CanChange’ involved health coaches who remained in telephone contact with CRC patients for six weeks following discharge from hospital. Results revealed that 100% of participants felt that CanChange increased their motivation to make healthy behaviour changes (Hawkes et al., 2009). This is further supported by a nurse-led, telephone-based support intervention piloted by Grimmett, Simon, Lawson, and Wardle (2015), which was determined to have a positive effect on health behaviours in CRC patients. Patients reported an increase in their PA levels, a reduction in their consumption of red meat, and an increase in fruit and vegetable intake. Significant improvements were also found when assessing QoL and functional well-being; supporting the evidence that adhering to healthy lifestyle behaviours has a positive effect on the QoL of CRC survivors. It also shows that telephone support is highly acceptable for cancer patients, which leads to the following recommendation to address the QoL of CRC survivors here in Aotearoa.

  Recommendation
  • Initiate the development of a telehealth intervention to deliver supportive and informative survivorship care plans to CRC patients living in rural New Zealand, following discharge from hospital.

Evidence byHawkes et al., (2009) and Grimmett et al., (2015) strongly supports the potential for organised follow-up care for CRC patients in New Zealand. This recommendation suggests that RHĀNZ advocates for a similar pilot study to the ‘CanChange’ program to be trialled here in New Zealand. A nurse-led intervention should be established, that is tailored and individualised for each patient in collaboration with all members of the multi-disciplinary team. This promotes communication between primary health care nurses, oncology specialists, and the patient, thus ensuring support is provided into the long-term management plan for CRC survivors. A telephone-based intervention would overcome the aforementioned barriers to healthcare, such as geographical location and the associated travel costs; it would be acceptable to the patient and flexible to fit into their daily routine, ultimately reducing stress and striving to achieve an improved QoL. For example, a lifestyle modification program designed to reduce the risk of diabetes was found to be effectual, and inexpensive, with an average cost of US$2780 per patient over a three-year period (as cited in Jafri & Mills, 2013). This substantiates that this type of intervention is cost effective, has minimal adverse effects and is sustainable into the future, improving patients’ general health as well as improving CRC patients’ QoL post-diagnosis. Nurses should provide evidence-based, up-to-date information to patients in regards to healthy lifestyle behaviours, and design the intervention using proven, effective, nursing models of care to ensure care plans maximise the patients’ self-efficacy, participation, and compliance.

  Conclusion

Tackling the high incidence of CRC in New Zealand needs to be a priority, with a focus on the importance of delivering equitable and sustainable healthcare to those who are geographically disadvantaged. The National Rectal Cancer Summit in 2013 emphasised the need for supportive care regardless of geography or socioeconomic status, and demonstrated a high level of provider commitment to improving outcomes for all New Zealanders (Jackson et al., 2014). The vision of the RHĀNZ Rural Health Strategy (2014) underpins the proposed solution to CRC survivorship care discussed in this submission. The strategy advocates for the development of services that improve equity of access to health services; the benefit of the proposed intervention is that it is telephone-based, thus not restricted by geographical boundaries. Nurses can discuss and implement a plan of care individual to the patient, in consideration of their particular environment, needs, and expectations. In accordance with the philosophy behind the development of the Rural Health Strategy, a telephone-based supportive care programme is an appropriate model of care that is safe, effective and acceptable to rural communities.

  References

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