Do Rural Patients Experience Cancer Symptoms Differently to Urban Counterparts?

A Mixed Methods PhD Project Using a Large Community-based Cohort which Assesses Prevalence and Response to Potential Cancer Symptoms (The USEFUL Cohort)

Scottish people living further from key healthcare facilities have less chance of prompt cancer diagnosis and poorer cancer survival than those living closer-by[1]. This finding has been replicated worldwide. Several potential explanations have been offered for this phenomenon but the underlying mechanisms remain obscure.[2] There is, however, some evidence that rural people have lower expectations of health services, and different health behaviours from urban-dwellers[3,4]. Recent work using a cohort of people diagnosed with colorectal cancer in Northeast Scotland between 1998-1997 found that people living further from healthcare facilities were more likely to present initially to GPs with alarm, rather than more vague, symptoms suggestive of cancer[5]. Together, this evidence suggests that people who live remotely and in rural communities may experience and react to symptoms of potential cancer differently to those living in cities and suburban areas. USEFUL is a large community-based cohort which assesses prevalence and response to potential cancer symptoms and enables us the unique opportunity to gain further insight into differences in the prevalence, experience of, and reaction to potential cancer symptoms of rural compared to urban populations.

The student will work under the supervision of a health psychologist, medical statistician and academic GP, who together will provide expertise on cancer diagnosis within primary care, symptom experience and health behaviour, data-linkage and advanced statistical analysis. The student’s work will be based on the USEFUL cohort, a community-based cohort of approximately 20,000 people drawn from across the UK. Subjects in the USEFUL cohort have provided detailed information about their current experience of, and reaction to, 35 potential symptoms of cancer. The USEFUL cohort enables a unique insight into the prevalence of potential cancer symptoms within the UK population as well as how these symptoms are differentially experienced by and reacted to by people with different demographic characteristics.

This PhD project has three stages:

First, under the direction of supervisors Fielding and Murchie the student will conduct a detailed statistical exploration of rural/urban differences in symptom prevalence, experience and reaction amongst the USEFUL cohort [6] from 20,000 UK adults. This will establish the prevalence and patterns of symptoms associated with cancer in the UK general population compared to how people from rural and urban settings appraise and respond to these symptoms.

Second, under the direction of supervisor Allan the student will conduct a systematic review of the psychological mechanisms underpinning symptom experience, comparing urban and rural areas. This work will follow established systematic review methods[7] and will inform the development of a theoretical model of the potentially modifying effects of place of residence on symptom experience and response.

Third, under the direction of supervisors Allan and Murchie the student will explore the emergent model using in-depth face-to-face qualitative interviews with people affected by cancer, and health professionals, from rural environments to understand how geography may have influenced their experiences, including their perceptions and responses to their initial cancer symptoms.

Once synthesised the findings of the project will contribute to a developing programme of work which is seeking to build rural and urban cancer equality in Scotland. In particular the work will highlight ways in which public cancer awareness campaigns and primary care and other community-based healthcare services need to be best configured in order to best meet the needs of the most remote Scottish residents. This will include knowledge about the best way to raise awareness of potential cancer symptoms and the correct response to them in remote communities. The project will also inform how any barriers imposed by remote and rural healthcare services’ current organization can best be improved to meet the needs of those remote and rural patients that might have cancer.

This project will suit a student with a basic grounding in clinical science. An understanding of cancer, medical statistics and data-handling and a willingness to learn and develop new expertise and skills will be essential. Good scientific writing skills and practical experience of statistical analysis and literature review will also be essential. Experience of advanced statistical methods and database management will be highly desirable, as will experience of conducting qualitative interviews and managing the data electronically.