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Short Report

Health behaviours of Indigenous and non-Indigenous cancer survivors living in regional and remote geographic areas of Australia: a short report

Elder-Robinson, Elaina C.a,c,∗; Parikh, Darshit Rajeshkumarb; Diaz, Abbeyc; Ferguson, Megan M.a,c; Reeves, Marina M.a; Garvey, Gailc

Author Information
Journal of Psychosocial Oncology Research and Practice: December 2020 - Volume 2 - Issue 4 - p e039
doi: 10.1097/OR9.0000000000000039

Abstract

Introduction

More people than ever before are living beyond their cancer diagnosis.[1] While cancer mortality rates are generally declining,[2] available data indicate increasing rates in Indigenous populations.[3] In Australia, cancer mortality between 1998 and 2016 increased by 21% for Indigenous people but decreased by 13% for non-Indigenous people.[4] Similar disparities have been reported in New Zealand and Canada.[5,6] Discrepancies in cancer mortality between Indigenous and non-Indigenous Australians are associated with more advanced disease at diagnosis, less optimal cancer treatment, poorer access to health services, and higher comorbidity prevalence.[5,7,8]

Exposure to modifiable behavioral risk-factors, such as tobacco smoking, physical inactivity, and poor diet, increase the risk of developing and dying from cancer.[4] Variations in the rates of exposure to these risk-factors have been observed across Australian population groups,[9,10] indicative of structural inequalities.[3] For example, despite recent declines, Indigenous Australians are about 3 times more likely to smoke than non-Indigenous Australians (39.3% vs 13.9%).[9] Although research on health behaviors in cancer survivorship is growing, there is limited research in Indigenous and non-urban populations, in Australia and internationally. This exploratory study aims to describe adherence to health behaviour guidelines in a sample of Indigenous and non-Indigenous cancer patients living in the geographically dispersed Northern Territory (NT) of Australia.

Methods

Participants were recruited from a large cancer centre in Darwin, NT, between February 2015 and September 2016. Center staff identified potentially eligible patients from daily patient attendance lists. Patients diagnosed with a malignant cancer in the previous 5 years and aged 18 years or older were considered eligible and invited to participate. The research team provided interested patients with detailed study information and sought informed written consent.

In total, 89 patients (39% of potentially eligible patients) were invited to participate and 76 consented to an interview (85% of those approached). Some potentially eligible patients were not invited to participate due to patients missing appointments or staff unavailability. Patients not invited were similar to those invited in sex (52% vs 53% women, respectively) and cancer type (breast cancer the most common in both groups) but were on average 5 years younger than those invited. The current analysis was restricted to participants diagnosed in the last 12 months (n = 63).

Self-reported sociodemographic and health behaviour information were collected via face-to-face interviews. Health behaviors were assessed using published tools for physical activity (minutes of moderate-vigorous activity/week),[11] fruit and vegetable intake (serves/day),[12] cigarette smoking (never, past, current),[13] and alcohol intake (standard drinks/week).[13] Additional questions were asked about red and processed meat consumption (serves/week).[14] These data were compared to national[15–17] and international[1] standards, with participants classified as having met guidelines or not (Supplement 1, http://links.lww.com/OR9/A17). For each modifiable health behavior, except smoking, participants self-reported if their exposure had increased, decreased, or remained the same as before their cancer diagnosis. Past smokers were asked their age at time of quitting and were classified as either having quit before, or around the time of their cancer diagnosis. Information on cancer type, diagnosis date, treatment type, and comorbidities were collected via medical chart review.

Descriptive analyses were conducted in Stata 15.[18] Ethics approval was obtained from the Northern Territory Health Department and Menzies School of Health Research Human Research Ethics Committee (#13-2038).

Results

Participants (n = 63) were mostly non-Indigenous (68%), with a median age of 58 years and most were receiving cancer treatment (97%) (Table 1). Similar proportions of Indigenous and non-Indigenous participants were female (50% vs 51%), married/de facto (65% vs. 63%) and received a cancer diagnosis within the last 3 months (50% vs 49%). Indigenous participants were younger (median 51 vs 65 years) and more commonly from the most disadvantaged (65% vs 21%) and very remote areas (55% vs 14%) of the NT than non-Indigenous participants.

Table 1 - Sociodemographic and clinical characteristics of cancer survivors from the Northern Territory.
Sociodemographic and clinical characteristics (n = 63) N (%)
≤58 years of age 32 (51)
Male 32 (51)
Aboriginal and/or Torres Strait Islander 20 (32)
Cancer site
 Breast 18 (28)
 Lip, oral cavity and pharynx 9 (14)
 Digestive organs 8 (13)
 Skin 8 (13)
 Male genital organ 7 (11)
 Other 13 (21)
Time since diagnosis
 ≤ 3 mo 31 (49)
 3–12 mo 32 (51)
Education
 Year 10 39 (62)
 Year 12 13 (21)
 TAFE certificate/diploma, trade, University level 11 (17)
Marital Status
 Married or de facto 40 (63)
 Single, separated, divorced or widowed 23 (37)
SEIFA by decile
 1–5 22 (35)
 6–10 41 (65)
ARIA
 Outer regional 35 (56)
 Remote 11 (17)
 Very remote 17 (27)
Cancer stage
 1 15 (24)
 2 13 (20)
 3 16 (25)
 4 16 (25)
Cancer treatment
 Chemotherapy
  Current 19 (30)
  Completed 11 (17)
  Planned 4 (6)
  Not applicable 28 (44)
  Not sure 1 (2)
 Radiotherapy
  Current 48 (76)
  Completed 7 (11)
  Planned 1 (2)
  Not applicable 6 (10)
  Not sure 1 (2)
 Hormone therapy
  Current 3 (5)
  Completed 1 (2)
  Planned 7 (11)
  Not applicable 43 (68)
  Not sure 9 (14)
 Surgery
  Completed 35 (56)
  Planned 2 (3)
  Not applicable 26 (41)
Other cancer sites included eye, brain, CNS; ill-defined; female genital organ; respiratory; lymphoid.
SEIFA—Socioeconomic indexes for areas: a measure ranking Australian areas relative to their socio-economic advantage and disadvantage by decile, with lowest scoring areas (1) the least advantaged, and higher scoring areas (up to 10) the most advantaged.
ARIA—Accessibility/Remoteness Index of Australia: an Australian measure of accessibility, including categories “Major City," “Inner Regional," “Outer Regional," “Remote," and “Very Remote." These range from unrestricted to significantly restricted access to goods, services, and opportunities for social interactions, based on road distance to the nearest service centre. The NT has “Inner Regional," “Remote," and “Very Remote" areas only.

Adherence to red meat, alcohol and fruit intake guidelines was relatively high, but lower for vegetable and processed meat intake, and physical activity guidelines (Table 2). One-third of participants (32%) were current smokers. Indigenous participants were more likely than non-Indigenous participants to adhere to fruit intake (80% vs 70%) and physical activity guidelines (45% vs 16%), less likely to adhere to red (65% vs 81%) and processed meat (20% vs 40%) intake guidelines and more likely to be current smokers (50% vs 23%).

Table 2 - Self-reported health behaviour adherence to guidelines and change since diagnosis
Health behavior adherence and change in behavior since diagnosis (n = 63) N (%)
Fruit intake
 Met guidelines (≥2 serves day) 46 (73)
 Increase 10 (16)
 Decrease 16 (25)
 No change 37 (59)
Vegetable intake
 Met guidelines (≥5 serves/day) 6 (10)
 Increase 7 (11)
 Decrease 17 (27)
 No change 39 (62)
Red meat intake
 Met guidelines (≤5 serves/wk) 48 (76)
 Increase 2 (3)
 Decrease 18 (29)
 No change 43 (69)
Processed meat intake
 Met guidelines (0 serves/wk) 21 (33)
 Increase 2 (3)
 Decrease 19 (30)
 No change 42 (67)
Physical activity
 Met guidelines (≥150 min/wk) 16 (25)
 Increase 3 (5)
 Decrease 44 (70)
 No change 16 (25)
Alcohol intake
 Met guidelines (≤2 standard drinks/day) 47 (75)
 Increase 0 (0)
 Decrease 30 (49)
 No change 31 (51)
Tobacco smoking status
 Current smoker 20 (32)
 Past smoker—quit on or after cancer diagnosis 4 (6)
 Past smoker—quit before cancer diagnosis 18 (29)
 Never smoked 21 (33)
A serve is equal to half a cup of cooked vegetables, 1 cup of salad vegetables, or 1 medium-sized piece of fruit.[15]
A serve is equal to 65 to 100 g, consistent with upper limit recommendations.[1,15]
≥150 minutes per week of moderate-intensity and/or vigorous-intensity physical activity, where vigorous-intensity activity accounts for double the time (in minutes) of moderate-intensity activity.[12]

Overall, approximately half of participants reported no change in their health behaviours following diagnosis (Table 2). Around one-quarter of the sample reported decreased fruit and vegetable intake. Alcohol consumption stayed the same or reduced post-diagnosis, whereas physical activity decreased or did not change for most participants. Of those who were smoking in the year prior to their cancer diagnosis (n = 24), 17% quit around time of diagnosis. Decreases in physical activity were reported less frequently by participants who were Indigenous, employed, single, and from the most disadvantaged and remote areas. Decreases in vegetable intake were reported more frequently from participants in advantaged compared to disadvantaged areas of the NT (37% vs 9%).

Discussion

The findings from this exploratory study suggest that NT cancer patients’ adherence to health behaviour guidelines may be similar to that observed in other Australian cancer survivor populations and the general Australian population.[10,19–21] The most notable exception in the present study was a 20 percentage point higher adherence to fruit intake guidelines than previous reports (43%–58% adherence).[10,19–21] Although current adherence to vegetable intake guidelines was similar to previous Australian data,[21] the self-reported decrease in vegetable intake following diagnosis by 27% of participants is concerning. These decreases may be due to treatment-related side-effects such as nausea and taste changes, or impaired ability to shop and prepare meals.

Tobacco smoking prevalence was substantially higher (>23 percentage points) in both the entire and the Indigenous sample than previous Australian cancer survivor data,[10] but similar for Indigenous cancer survivors when compared to NT's general Indigenous population (54%),[22] and Native American cancer survivors (52%).[23] This higher prevalence of smoking is likely a reflection of the social and health inequities faced by these populations.[3]

Physical activity levels were particularly low among non-Indigenous participants, and a high proportion of both Indigenous and non-Indigenous participants reported reductions in physical activity post-diagnosis. This reduction is concerning given the benefits of physical activity on cancer survivorship outcomes[24] and may reflect participant recruitment close to diagnosis and during active treatment. Strategies to maintain physical activity, especially during treatment, may be necessary.

The experiences of cancer patients in the NT may be influenced by higher levels of geographical isolation, resulting increased costs of living and reduced access to care. These findings therefore may not reflect the experiences of cancer patients in other Australian localities. The self-reported nature of the data collection is prone to recall and potential social-desirability bias,[25] whereas missed potentially eligible participants may also have introduced bias into results. Although these data are 5 years’ old, it is unlikely that behaviors have improved given relatively stable health behaviour trends in the general Australian population.[9]

Due to the exploratory nature of this study and small sample size, statistical inferences regarding variations in health behavior change between subgroup populations are unable to be drawn. Here we have described observed differences that may have clinical relevance for which to generate hypotheses for testing in larger studies. Qualitative explorations could provide a complementary and more nuanced understanding of barriers and facilitators of positive health behaviors during cancer treatment and survivorship.

This study provides the first description of modifiable risk-factors in a sample of Indigenous and non-Indigenous, remote and rurally located Australian cancer patients, adding to the paucity of international evidence on modifiable behavior risk factors in Indigenous cancer survivors.

These findings indicate that in non-urban communities, interventions to promote and assist performance of healthy behaviours both pre- and post-cancer diagnosis are important. Interventions at the “teachable moment”[26] of cancer diagnosis and timely referrals to appropriate support services may be effective in maintaining health throughout the early stages, and later years, of survivorship. Further high-quality research to drive evidence-based strategies is needed to assist in addressing persistent inequities in cancer outcomes for Indigenous Australians and Australians living in regional and remote areas.

Conflicts of interest statement

The authors declare no conflicts of interest.

Acknowledgements

The authors acknowledge and thank Ms Zyana Gall for administrative support with this study, the Cancer Centre Practice Manager, Mr Giam Kar, and the patients who participated in the study.

References

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Keywords:

Aboriginal and Torres Strait Islander; Cancer; geographically disperse; Modifiable risk factors

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