Living habits affecting subsequent gastrointestinal cancer surgery: An interpretative phenomenological interview study

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Living habits affecting subsequent gastrointestinal cancer surgery: An interpretative phenomenological interview study

https://doi.org/10.21203/rs.3.rs-570593/v1

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Purpose

There is limited in-depth understanding of patients’ views and experiences with physical training, nutritional care, psychological support, and smoking/alcohol cessation prior to gastrointestinal cancer surgery. Therefore, patients' thoughts and influences regarding prehabilitation components are of interest in the effort to provide optimal supportive cancer care and to improve health. The aim of this study was to explore patients’ thoughts, lived experiences and influences regarding their living habits prior to gastrointestinal cancer surgery.

Methods

The participants in this qualitative study were recruited from a university hospital in southeast Sweden. In total, six in-depth digital interviews were held from November 2020 to March 2021. An interpretative phenomenological analysis approach was used throughout the research process.

Results

The interpretative analysis identified three themes: the influence of the cancer diagnosis on awareness and motivation, life circumstances affecting living habits and activities bringing mental strength. The main findings deepen the current understanding of the situation that patients face when committing to presurgical preparation plans. The participants expressed the impact of their motivation level and circumstances in life. Physical and mental health was promoted by various types of activities and support.

Conclusion

Nursing

Cancer Biology

Surgery

Cancer

Health Promotion Model

Interpretative Phenomenological Analysis

Living Habits

Prehabilitation

Qualitative Research

Cancer patients scheduled for surgery require high functional capacity to benefit from the treatment. Frail patients have reduced physiological reserves and therefore moderate to severe postoperative complications, prolonged hospital time, an increased incidence of readmission and decreased survival [1]. For patients with poor functional capacity preoperatively, the mortality risk after surgery increases [2].

Prehabilitation supports patients in building their strength prior to surgery and facilitates postoperative recovery [3]. Prehabilitation programs include education and therapeutic exercise designed to meet the functional, psychological, and social needs of the patients. Previous research has explored the impact of physical training, nutritional care, psychological counselling and preoperative smoking cessation [4, 5].

Exercise, nutrition, anxiety reduction and/or smoking cessation have been shown to improve physical recovery after gastrointestinal cancer surgery [6–8] and significantly decrease the length of hospitalization [9]. In major gastrointestinal cancer surgery, studies have shown that postoperative functional capacity benefits from prehabilitation, but there are still questions about what level of impact multimodal programs have on postoperative complications and health-related quality of life (HRQoL) [3, 10, 11]. Multimodal prehabilitation may reduce morbidity after abdominal surgery, but research on older patients, complications and mortality is sparse [12, 13].

Studies on patient adherence to prehabilitation have shown the need to make the programs patient-centred by taking personal thoughts, needs and abilities into account [14–16], and practical barriers and facilitators should be considered [14, 17]. Patients with depressive symptoms have been shown to benefit from prehabilitation interventions [18]. However, there is insufficient evidence to confirm that preoperative psychological interventions are beneficial or to determine which interventions are most effective [19]. Individualized optimization strategies in prehabilitation programs should focus on different stressors already present in the preoperative phase and may be able to influence the patient’s recovery and reduce postoperative complications [16, 20]. By proactively identifying patients at risk for deterioration and by applying the correct set of strategies at the appropriate time, superior outcomes may be achieved [21]. The World Health Organization (WHO) defines health promotion as a fundamental health care strategy that consists of enabling people to increase control over their health and improve its quality [22, 23].

The Health Promotion Model (HPM) is a nursing model that integrates several constructs; central to the HPM is the social learning theory of Bandura [24, 25]. Bandura postulates the importance of cognitive processes in the changing of behaviour. Social cognitive theory includes the following self-beliefs: self-attribution, self-evaluation, and self-efficacy. Self-efficacy is a central construct of the HPM [25–27]. The model not only focuses on supporting patients in achieving higher levels of well-being/health but also encourages health care professionals to provide positive resources to help patients achieve specific behavioural changes.

There is limited knowledge of how patients experienced prehabilitation programs in surgical cancer care, and there is a lack of in-depth understanding of the patients’ views and experiences of physical training, nutritional care, psychological support, and smoking/alcohol cessation in the preoperative phase. Therefore, patients' views and influences regarding prehabilitation components are of interest in the effort to provide optimal supportive cancer care and to improve health.

The aim was to explore the patient’s thoughts, lived experiences and influences concerning their living habits prior to gastrointestinal cancer surgery.

Ethics

This study was approved by the Research Ethics Committee in Sweden (No. 2020–04289).

Oral and written informed consent was obtained in compliance with the Declaration of Helsinki [28].

Design

The study employed a qualitative research approach with in-depth interviews.

Participants, sampling and data collection

The study recruited and included patients from a university hospital in southeast Sweden. The COREQ Checklist was used to ensure quality in this study [29]. The inclusion criteria called for adult patients receiving preoperative oncological treatment and scheduled for abdominal cancer surgery. The exclusion criteria were as follows: patients with cognitive dysfunction and patients who did not have mastery of the Swedish language. The sampling strategy was purposive and aimed at achieving maximum variation in sex, age, and cancer diagnosis/treatments. The patients were recruited by a clinical nurse in surgical care who informed them about the study orally and in writing. Patients received an information letter containing a description of the purpose of the study, an informed consent form and a postage-paid return envelope. Patients who consented to participate were contacted by telephone by the interviewer (KB). In total, 6 participants were interviewed between November 2020 and March 2021. Patient characteristics are presented in Table 1. Pseudonyms were assigned to the participants.

Table 1

Patient characteristics (with pseudonyms).
Pseudonyms of participants	Age	Sex (female/male)	Marital status	Diagnosis, malignancy	Oncological treatment
Ali	56	M	Single	Gastric cancer	Chemotherapy
Marianne	68	F	Married	Oesophageal cancer	Radio-/ chemotherapy
Ralf	78	M	Married	Rectal cancer	Radiotherapy
Sarah	51	F	Married	Oesophageal cancer	Radio-/ chemotherapy
Thomas	76	M	Married	Rectal cancer	Radio-/ chemotherapy
Viola	77	F	Married	Rectal cancer	Radio-/ chemotherapy

An interview guide including open-ended questions was developed by the research group (see Table 2). The guide underwent pilot testing in one patient to ensure clarity; no adjustments were made. The interview was included in the analysis. Before the interviews began, a relaxed atmosphere was created through small talk so that the patients would be safe and comfortable. Probing and looping questions were used continuously during the interviews in relation to the patients’ specific views and experiences.

Table 2

Interview guide.
a)	Tell me about your living habits, how you have lived your life until today. - Your perspectives and habits regarding exercise, nutrition, smoking/alcohol and mental health.
b)	What are your thoughts about your mental health and how it can affect your living habits?
c)	What are your thoughts on how your living habits can influence the surgical procedure that you are planned for and the effect on your recovery after surgery?

The interviews were conducted in digital video meetings (owing to COVID-19 safety measures) and were digitally recorded. The interviews were conducted by the first author (KB), a clinical nurse specialist in surgical care with long experience in cancer care. The interviews were held 4 to 17 days (median 10 days) prior to surgery. The interviews lasted between 23 and 64 minutes (median 55 minutes).

Analysis

The interviews were transcribed verbatim by the first author (KB); the data were analysed with interpretative phenomenological analysis (IPA) to investigate how individuals make sense of their lived experiences, particularly during changes in life [30–32]. The analysis was guided by the six-step IPA process as described by Smith et al. [32]. For immersion in the participants’ narratives, the recorded interviews and transcribed text were listened to, read, and re-read to absorb the essence of their lived experiences. A detailed set of notes was made with a descriptive core, linguistic and conceptual notes, and initial interpretative comments. The comprehensive notes that reflect the source material were transformed into emerging themes. All transcripts were separately analysed; the next step was designed to search for patterns across cases. A reconfiguring and relabelling process began, and the themes were identified. The data coding, coding tree and identification of themes were derived from the data and were performed by the first author (KB). To increase the validity of the findings, the analysis was subjected to peer debriefing and was continuously scrutinized by the research group. To illuminate the findings and to exemplify the interpretive text, the participants’ own words are quoted extensively, both integrated with the text and inserted as block quotes.

Three themes were identified in the interpretative analysis: the influence of the cancer diagnosis on awareness and motivation, life circumstances affecting living habits and activities bringing mental strength. These themes represent the essence of the participants’ lived lifeworld according to their living habits during cancer prior to surgery.

Theme 1: The influence of the cancer diagnosis on awareness and motivation

The participants expressed their thoughts and feelings in the period shortly after cancer diagnosis. Existential feelings such as “chaos” and “anxiety” appeared and made them aware of their rapidly changing life situation. These feelings were experienced as a normal reaction. The participants attempted to be in the present, focusing on living. There was a process of accepting the cancer diagnosis and becoming able to live with cancer and its treatments for a relatively long period of life.

“This anxiety that you had in the beginning there….there was a way to realize where you are.” – Thomas

This awareness of a life-threatening cancer awakened feelings of uncertainty. There was uncertainty due to lack of knowledge about the cancer and how it would affect life, and patients thought about how they could maintain an ordinary life. This awareness also brought forth uncertainty regarding the future and negative information about the prognosis. The participants reflected on being forced to live with uncertainty for the rest of their lives.

”You live, so to speak, in a bubble of uncertainty … where is this taking me?”

– Thomas

”This is like….no one has really sat down with me and explained to me … what I could do to make it … become good for me.” – Sarah

Some participants expressed the sentiment, “Finally!” when diagnosed with cancer. The uncertainty and the feeling that something was wrong were verified. The body and mind signalled it with various symptoms. When the cancer was confirmed, the patients’ confidence grew, and they felt convinced that they would manage the disease. Living day by day and focusing on taking care of themselves contributed to a better outcome,

”It´s not like handing in the car for service… you need to contribute by yourself.… I think that’s really important” – Marianne

Participants were mentally preparing for major surgery and reflecting upon this issue with someone outside their nearest social network. They were aware of the major surgical procedure and that would place heavy individual demands on them. Issues regarding mental and physical support and aid and what to eat and drink were raised. The participants were aware of the effects of these factors on their lives and wanted to be prepared and motivated to oversee their recovery and living habits.

”if the surgery and everything goes well there won´t be a change in life, the difference is that you might have a stoma” – Ralf

Awareness of the situation exists, and motivation was a factor that could affect their lives during cancer, leading to a more inactive everyday life than the participants wanted and were accustomed to. Some participants saw themselves as active persons with many activities and hobbies, but they became inactive. They felt that it was meaningless to do these activities.

”It´s hard every day when getting out of bed … finding something that feels meaningful” – Viola

There could also be thoughts such as “to what use”, questioning why there should be exercise and good performance as before. Despite these thoughts, the living habits that the participants had developed over many years was the essence of the maintenance of health-related behaviour despite lack of motivation (Table 3).

Table 3

Additional quotes from patients.
Theme 1	Theme 2	Theme 3
”I´m depressed at times; that´s how it is. I lose appetite; I lose my sparkle, I´m doing that, maybe everyone does?” – Ali	”Then you need to consider that we are becoming older … it´s of course not like when I went through the last abdominal surgery sometimes in the eighties … then it was quite easy … that´s what I have here in the back of my mind…but it´s obviously going to take longer now.” – Viola	”To have this contact with your old friends and so on … so that you don´t lose like all outside connections because of illness…I think that´s really important.” – Marianne

Theme 2: Life circumstances affecting living habits

The participants described earlier experiences in life and how these might affect living habits. There were participants who had heart disease and became aware that life is fragile and requires self-care. Others struggled with depression and symptoms such as fatigue and severe difficulties with memory. These circumstances affected their ability to maintain their living habits. Some participants reported various types of skeletal injuries leading to impaired mobility and pain, which limited physical activity. Long-term effects led to acceptance and adjustment of the situation, and their living habits were not negatively impacted in the long term. They were as active as they wished to be.

”I have pain … it would never stop me … and I don’t take support from anyone else because I’m feeling pain … there is always something positive in the end.” – Viola

Some of the participants mentioned prior surgical experiences and referred to them when talking about recovery. They recalled positive experiences of their ability to recover and embraced self-efficacy for their planned surgical procedures. Despite their confidence in an excellent recovery, the older participants reflected upon the fact that they were older now (Table 3).

One participant had acute abdominal surgery a few months prior and had the new positive experience that being physically active after surgery, even when feeling weak, led to quick recovery. Previous experiences will be used as a force to manage this situation and thoughts of recovery. Being empowered will bring the strength to manage new circumstances such as oncological treatment. Participants who know what happens and why and who are confident in their own ability to manage will develop their living habits by adjusting their diet and physical activity to prepare for major surgery.

”… best possible result….I´m sure…. I have really experienced that after this acute operation.” – Marianne

Participants had experiences with changing their living habits earlier in life. The causes were sometimes medical conditions and sometimes other causes such as overweight. In particular, patients focused on their eating and smoking habits. Some participants had diabetes, and when informed that changing their eating habits would be beneficial for their health, they rapidly changed their eating habits and made plans to continue with these new habits. Smoking cessation was another change that some patients made after having a myocardial infarction: ”this is a date you never forget”.

”The only thing I could influence then was my living habits.” – Ralf

There were also experiences of counselling for eating habits due to overweight caused by immobility. The dietary recommendations that patients received when diagnosed with cancer became confusing and were difficult to handle because they were directly contrary to recommendations given previously.

”… but yes, I´m scared … think if I only continue to eat like this afterwards?… then I have thoughts of… I will roll forward and become really fat (laughs)” – Sarah

The participants expressed similar thoughts about food and healthy eating and drinking habits. The use of alcohol was described as a habit that was unprioritized and unrewarding during cancer. Older participants expressed that they could have eaten more vegetables earlier in life: “We have tried to add more vegetables over time … but we should have done that much sooner”. Their circumstances in life were different then, and lifestyle issues were not in focus at that time. Patients had thoughts of what could have caused their cancer.

Theme 3: Activities bringing mental strength

The participants expressed that activities such as physical/social activities and support from health care professionals raised their physical and mental energy levels. Participants identified themselves as active persons, but there were differences in their definitions of physical activity. Various activity levels existed, such as exercising every day at the gym, walking several hours in the forest, taking the dog for a walk, or being engaged in a sport association. These are all ordinary physical activities, and the participants saw themselves as active and thought of it as a positive quality.

The participants related physical strength to positive feelings. They expressed that it was easier to remain in a good mood when they had physical strength or at least regained their strength before the next dose of chemotherapy. “It’s so nice… this feeling of regaining strength”. Patients noted that physical activity strengthened the body and mind, and even more favourably, they found that it enhanced their adjustment to the situation; for example, one participant expressed that sentiment as follows:

”I feel I haven´t the same strength in the body … but strangely, when I thought, ‘Now I will go to the gym’, it disappears … unbelievable … the pain just disappears because I think of something else … everything is inside here (pointing to his head).” – Ali

Physical weakness, on the other hand, elicited adverse feelings: patients did not recognize themselves and feared that their condition would worsen: ”You don´t feel like yourself”. Physical energy levels affect the ability to maintain prior behaviour. Physical symptoms caused by cancer itself or by side effects of oncological treatment were common. Support from health care professionals was crucial. The participants who received insufficient support experienced difficulties handling their living habits, particularly eating and physical activity, in a satisfying manner. Loneliness sometimes occurred, negatively affecting the patients’ mental strength. Receiving support too late or only after the fact made the participants frustrated.

“After that, there haven’t been any problems … I know exactly what I shall do … but I had not a clue before … so that was like super hard.” – Sarah

”I have a consulting nurse, and I think it has been functional if I need anything, but in a way I miss a steady hand that follows me and knows how I feel on a weekly basis … the same person.” – Thomas

The participants highlighted their social interactions with family, friends and other persons in their environment as an important part of life. Social activities including support from the nearest members of their social network were experienced by participants as strengthening their health. They identified their life partner as their strongest mental support, and if needed, the partner rendered practical assistance in everyday life. Practical support due to reduced physical energy awakened reactions of reluctance to be more dependent. Feelings of losing their habitual role in their social context appeared (Table 3). The experience of maintaining their habitual role and identity in their social lifeworld brought significant mental strength during cancer.

The main findings show that the participants managed to maintain and improve their living habits prior to cancer surgery. The importance of maintaining their identity and their habitual roles during the cancer continuum to strengthen their mental health was a common element. It can be postulated that different types of support facilitated the maintenance or development of presurgical living habits. This illustrates that health promotion has an important role in cancer care. There is a growing body of research on preoperative multimodal optimization programs for patients before gastrointestinal cancer surgery [6–8, 33]. Although the programs include interventions, they do not motivate patients to behavioural changes [4]. In the HPM, the outcome is a health-promoting behaviour to enhance functional ability and health [27]. The most consistent predictors of health behaviour are self-efficacy, how barriers are perceived and social support. A high level of self-efficacy leads to a reduced perception of barriers.

The findings illustrate the participants’ awareness of life and death and how they struggled to find meaning in their everyday life. Motivational factors that motivated them earlier in life sometimes weakened, and they appeared to need a change in their source of motivation to maintain previous habits. Participants’ awareness of the situation can make a difference in optimizing conditions for surgery and can be a motivational factor. In the HPM, the consequences of actions are an effective factor in motivating behavioural changes. Positive consequences lead to feelings of benefit [27]. Participants who see benefits from their maintenance of living habits are likely to gain an increased sense of self-efficacy, reducing their perceived barriers. They are more likely to commit to the plan of optimizing their body and mind for cancer surgery. If negative consequences appear when cancer symptoms and side effects of treatment are present, there are difficulties in determining what health-related living habits can improve in their situation. The symptom burden and side effects of treatment are strong predictors of failure to perform physical exercise [34]. The participants expressed how circumstances in life had affected them and whether their lived experiences facilitated or burdened their living habits when a particularly demanding event in life appeared. In the HPM, a history of health-related behaviour strengthens habits and is an important factor in consolidating behaviour [27]. The participants illustrate this through the maintenance of, for example, regular physical activity and a nutritious, well-cooked diet despite the circumstances. The use of alcohol was unrewarding and unprioritized in this sample. Patients scheduled for cancer surgery may perceive the preoperative phase as a good opportunity to change alcohol and smoking habits. A non-judgemental style of support is recommended [35, 36]. Activities in the participants’ lives elevated their mental energy levels, and the findings illustrated that insufficient activity in certain areas could result in decreased mental strength. Social activities and support were prominent in ensuring that the participants retained their mental strength. The HPM posits that interpersonal influences including family, friends and healthcare staff are predictors of the maintenance of health-related behaviour [27]. These findings of strengthened mental health are similar to what was observed through qualitative research with participants in an exercise prehabilitation programme [37]. HRQoL and mental health have shown significant improvement preoperatively with exercise [38].

This study had a small sample size and a short enrolment period, and recruitment was limited by other studies being conducted in parallel. However, the IPA methodology can draw benefits from even a small sample [31, 32]. The pandemic situation might have negatively affected the data collection (by forcing the use of digital rather than in-person meetings), but digital interviews are similar to face-to-face interviews [39]. The interviews were richly detailed, and the study aim and validity were achieved, consistent with the principles of Yardley [32, 40]. The research team is experienced in cancer care, which facilitates awareness and dedication in the interview situation and promotes context sensitivity, commitment and rigour in the analysis. The findings encourage further study and possible clinical application of a system in which health care professionals provide person-centred supportive cancer care to achieve specific health-promoting activities.

Motivation level and circumstances in life both influence living habits. Patients’ physical and mental health is promoted by various types of activities and support. Health care professionals need to investigate patients’ lived experiences when developing person-centred support to achieve health-promoting behaviour prior to cancer surgery. Living habits might be a sensitive topic, but on the other hand, the findings of this study advanced the current understanding to facilitate the development of a supportive health-promotion approach aimed at improving health.

Funding

Not applicable.

Conflicts of interest/competing interests

The authors declare that they have no conflicts of interest.

Ethics approval

This study was approved by the Research Ethics Committee in Sweden (No. 2020-04289).

Consent to participate

Oral and written informed consent was obtained in compliance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Availability of data and materials

All data (in Swedish) can be found with request of the corresponding author.

Code availability

Not applicable.

Authors' contributions

Karin Blomquist performed data collection and data analysis and drafted the manuscript; Carina Wennerholm was involved in the data interpretation/analysis and reviewed the manuscript; Carina Berterö was involved in the data interpretation/analysis and reviewed the manuscript; Per Sandström and Bergthor Björnsson were involved in the conception and study design and critically reviewed the manuscript. Jenny Drott designed the study, analysed/interpreted the data, and reviewed the manuscript. All authors read and approved the manuscript.

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Living habits affecting subsequent gastrointestinal cancer surgery: An interpretative phenomenological interview study

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Abstract

Purpose

Methods

Results

Conclusion

Introduction

Methods

Ethics

Design

Participants, sampling and data collection

Analysis

Findings

Theme 1: The influence of the cancer diagnosis on awareness and motivation

Theme 2: Life circumstances affecting living habits

Theme 3: Activities bringing mental strength

Discussion

Conclusion

Declarations

References

Supplementary Files

Status:

Version 1