MILITARY MEDICINE, 179, 9:998, 2014
Perceptions of Barriers and Facilitators to Health Behavior Change Among Veteran Cancer Survivors Gregory P. Beehler, PhD, M A * ft; Amy E. Rodrigues, PhD§; Morgan A. Kay, PhDH; Marc T. Kiviniemi, P hD f; Lynn Steinbrenner, MDf]
ABSTRACT Objective: This study aimed to identify barriers and facilitators to health behavior change related to body size in a sample of veteran cancer survivors. Methods: A qualitative study was conducted with a sample of 35 male and female cancer survivors receiving care at a Veterans Administration comprehensive cancer center. Participants completed individual interviews regarding barriers and facilitators to lifestyle change and responded to a brief question naire regarding current health behaviors. Results: Participants reported suboptimal adherence to recommended health behavior goals and the majority were overweight or obese (80%). Qualitative analysis revealed numerous barriers and facilitators to health behavior change across six broad categories: environmental factors, health services delivery factors, health-related factors, factors related to attitudes toward change, factors related to enacting change, and motivational factors. Veteran cancer survivors were impacted by common barriers to change affecting the general population, cancer-specific factors related to personal diagnosis and treatment history, and health service delivery factors related to the Veterans Administration health care system. Conclusions: There are many barriers and facilitators that exist in diverse domains for veteran cancer survivors, each of which offers unique challenges and opportunities for improving engagement in behavior change following cancer diagnosis and treatment.
INTRODUCTION C ancer diagnosis has been described as a “teachable m om ent” in w hich survivors are particularly receptive to engaging in health-prom oting behaviors.1" 1 H ow ever, research has suggested that adherence to health behavior guidelines am ong cancer survivors is heterogeneous and m ay not differ significantly from the general public.4-8 H ealthy lifestyle changes, such as increasing physical activity and im proving diet, are likely challenging for cancer survi vors w ho often face m any physical, em otional, and social adjustm ents follow ing diagnosis and treatm ent.9,10 Even sev eral years follow ing diagnosis, few cancer survivors appear to adopt m ultiple healthy lifestyle changes.4 T here were over 500,000 veterans w ith a diagnosis o f cancer identified in V eterans A ffairs (VA) electronic m edical records in 2 007,11 yet the health prom otion needs o f these survivors have rarely been reported to date. The needs of *VA Center for Integrated Healthcare, VA Western New York Health care System, 3495 Bailey Avenue, Buffalo, NY 14215. tSchool of Public Health and Health Professions, University at Buffalo, The State University of New York, 3435 Main Street, Buffalo, NY 14214. tSchool of Nursing, University at Buffalo, The State University of New York, Buffalo, 3435 Main Street, Buffalo, NY 14214. §Behavioral VA Careline, VA Western New York Healthcare System, 3495 Bailey Avenue, Buffalo, NY 14215. ||Behavioral VA Careline, VA Greater Los Angeles Healthcare System. 11301 Wilshire Boulevard, Los Angeles, CA 90073. ^Medical VA Careline, VA Western New York Healthcare System, 3495 Bailey Avenue, Buffalo, NY 14215. The preliminary findings of this article was presented in poster format at the 32nd Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine, Washington, DC, April 2011. The information provided in this article does not represent the views of the Department of Veterans Affairs or the U.S. Government, doi: 10.7205/MILMED-D-14-00027
998
veteran cancer survivors deserve special consideration given that they have w ell-docum ented rates o f m ultim orbidity that exceed that o f the general p u b lic,1 -14 w hich m ay m ake engaging in healthy lifestyle change m ore challenging. S im i larly, com pared to the general population o f survivors, vet eran cancer survivors are m ore likely to be m ale and of advanced a g e ,11 both o f w hich are associated w ith m aking few er health behavior changes follow ing diagnosis.2 For exam ple, one o f the few studies o f healthy lifestyle change am ong veteran cancer survivors found that after diagnosis, only 35% o f veteran survivors increased their fruit and v eg e table consum ption w hereas 43% decreased their level of physical ac tiv ity .1:1 In a sam ple o f veteran prostate cancer survivors, over tw o-thirds were not only overw eight or obese at diagnosis, but they typically show ed small but significant w eight gain for at least 3 years after d iag n o sis16 and rarely accessed assistance from prim ary care-b ased w eight m an agem ent services. Thus, veteran cancer survivors m ay be particularly in need o f assistance in overcom ing barriers to healthy lifestyle changes. For cancer survivors in general, and veteran cancer survi vors in particular, survivorship care planning needs to include effective interventions to address physical activity, diet, and body size. Perceptions o f facilitators and barriers to behavior are w ell-know n predictors o f diet and exercise behaviors.17,18 W ithout anticipating that a variety o f barriers are likely to influence survivors’ ability to initiate and m aintain healthy lifestyle change, post-treatm ent care planning alone is unlikely to achieve its intended im p a ct.11 Y et little previous w ork has focused on barriers and facilitators o f health behav ior change elicited from veteran cancer survivors. Because perceptions o f benefits and barriers can be both behavior and population specific, addressing the needs o f veteran cancer
MILITARY MEDICINE, Vol. 179, September 2014
Perceptions o f Health Behavior Change Among Veteran Cancer Survivors
survivors requires knowledge of the barriers and facilitators associated with their engagement (or lack thereof) in healthy diet and exercise practices. As part of a larger study regarding health and wellness promotion following cancer, we conducted a qualitative study with the aim of identifying barriers and facilitators of health behavior change among veteran cancer survivors. We chose to focus specifically on factors impacting changes in physical activity, diet, and body size because of the well-established rates of overweight and obesity among veterans.13’19 At the same time, interventions for weight management are com monly available in VA primary care clinics,20 suggesting that obstacles exist to connecting some veterans to relevant inter ventions. Our overarching goal was to better understand how veteran-identified barriers and facilitators can be used to inform the survivorship care planning process while also pre paring health care providers in both oncology and primary care to meet the health promotion needs of cancer survivors.
METHODS Participants Male and female veterans over age 18 and conversant in English who had a diagnosis of cancer of any type and received treatment or outpatient follow-up care at the VA Western New York Healthcare System Comprehensive Cancer Center were eligible to participate in this study. Excluded from the study were those individuals who were receiving definitive or first round cancer treatment, those who were critically ill, unable to carry out basic self-care, enrolled in palliative care programs, those diagnosed with significant cognitive impair ment, or those experiencing active psychosis or recent history of self-injurious/suicidal behaviors. A sample of 35 partici pants was recruited using informational study flyers posted in the oncology and infusion clinics, referral by the oncology staff, and by sending invitation letters to eligible individuals identified by the chief of oncology (LS). This sample size has been suggested previously as sufficient to conduct the qualita tive analysis described below.21’22 interview Schedule and Procedures The semistructured interview items were developed based on prior experience of the research team and from relevant social and behavioral theories23-26 to focus on barriers and facilitators of health behavior change. Participants were first asked “After you were diagnosed with cancer, did you make any changes to your lifestyle to promote your health?” Throughout the interview process, probes and prompts were used to elicit more information or clarify responses from main interview items regarding barriers and facilitators. Indi vidual face-to-face interviews were conducted by the lead author (GPB) either in a private examination room or confer ence room of the oncology clinic. Participants were first presented with information on the present study as well as information about participating in VA research. Those who
MILITARY MEDICINE, Vol. 179, September 2014
wished to participate provided verbal consent and an addi tional signed consent for audio recording the interview. Three participants elected to complete the interview by phone. Fol lowing the interview, participants also completed a brief survey of demographic characteristics, cancer history, and cur rent health behaviors (fruit and vegetable consumption, physi cal activity, and body size). The survey also included items regarding whether participants had changed each of these health behaviors following cancer diagnosis. Participants were provided a $25 gift card as a thank you for participating. All interviews were digitally recorded and transcribed ver batim. On receipt of the word-processed transcripts from the professional transcription service, transcripts were compared to the original audio files to ensure accuracy. Finalized tran scripts were imported into qualitative data analysis computer software, ATLAS.ti, to facilitate coding, searching and retrieving text, and linking relevant data segments. Analytic Approach Descriptive statistics were used to summarize the quanti tative data from the self-report survey. As described by Sandelowski,27'28 a qualitative descriptive study was con ducted to identify and summarize specific, veteran-identified factors that could be classified as barriers or facilitators of health behavior change. Using an inductive approach to con tent analysis,29 open codes were developed and applied to each segment of text that identified a factor that impacted likelihood of initiating or maintaining healthy behavior change related to improving diet, increasing physical activity, or achieving and maintaining a healthy body size. Lineby-line coding resulted in hundreds of open codes, which were examined within and across interviews. Open codes were first identified as either barriers to or facilitators of change. Within these broad characterizations of the data, conceptually similar open codes were clustered together to develop more descrip tive categories of barriers and facilitators. Six final categories were identified. Open codes and associated narrative data from each category were reviewed again to summarize the most common barriers and facilitators to change.
RESULTS Participant Characteristics The results of the background survey are summarized in Table I. Participants were primarily men (94%), of white racial background (80%), and unmarried (54%). The average age of participants was 64 years, and the majority (70%) of the sample reported an annual household income of less than $40,000. Veterans with prostate cancer were the single larg est subgroup (31%) of participants, with a variety of cancers represented such as lung, head and neck, colon or rectal, lymphoma, breast, and others. The single most common treatment modality was chemotherapy (60%). Participants reported their time since diagnosis as less than 1 year to 17 years, with a median of 4 years.
999
Perceptions of Health Behavior Change Among Veteran Cancer Survivors TA B LE I.
Demographic, Background, and Health-Related Information for Study Participants Characteristic
«(%)
Male Age" Non-White Race Married/Partnered Annual Household Income $60,000 Cancer Type Prostate Lung Head/Neck Lymphoma Colon/Rectal Breast Other Treatment History Chemotherapy Radiation Surgery Hormone Therapy Active Surveillance Years Since Diagnosis (Median, Range) Self-Rating of Current General Health Status Poor Fair Good Very Good Excellent Self-Report of Current Quality of Life Poor Fair Good Very Good Excellent Current Days per Week That 5 Servings of Fruits or Vegetables Were Consumed0 Change in Fruit or Vegetable Consumption After Diagnosis No Change Ate More Ate Less Current Days per Week That Included 30 Minutes or More of Exercise" Change in Frequency of Exercise After Diagnosis No Change Exercised More Exercised Less Current Body Mass Index Normal Overweight Obese
33 (94) 64 (10) 7 (20) 16 (46) 11(32) 13 (38) 8(24) 2(6) 11(31) 5(14) 4(11) 3(9) 3(9) 2(6) 7(20) 21(60) 19 (54) 18(51) 3(9) 2(6) 4 (
Perceptions of Barriers and Facilitators to Health Behavior Change Among Veteran Cancer Survivors Gregory P. Beehler, PhD, M A * ft; Amy E. Rodrigues, PhD§; Morgan A. Kay, PhDH; Marc T. Kiviniemi, P hD f; Lynn Steinbrenner, MDf]
ABSTRACT Objective: This study aimed to identify barriers and facilitators to health behavior change related to body size in a sample of veteran cancer survivors. Methods: A qualitative study was conducted with a sample of 35 male and female cancer survivors receiving care at a Veterans Administration comprehensive cancer center. Participants completed individual interviews regarding barriers and facilitators to lifestyle change and responded to a brief question naire regarding current health behaviors. Results: Participants reported suboptimal adherence to recommended health behavior goals and the majority were overweight or obese (80%). Qualitative analysis revealed numerous barriers and facilitators to health behavior change across six broad categories: environmental factors, health services delivery factors, health-related factors, factors related to attitudes toward change, factors related to enacting change, and motivational factors. Veteran cancer survivors were impacted by common barriers to change affecting the general population, cancer-specific factors related to personal diagnosis and treatment history, and health service delivery factors related to the Veterans Administration health care system. Conclusions: There are many barriers and facilitators that exist in diverse domains for veteran cancer survivors, each of which offers unique challenges and opportunities for improving engagement in behavior change following cancer diagnosis and treatment.
INTRODUCTION C ancer diagnosis has been described as a “teachable m om ent” in w hich survivors are particularly receptive to engaging in health-prom oting behaviors.1" 1 H ow ever, research has suggested that adherence to health behavior guidelines am ong cancer survivors is heterogeneous and m ay not differ significantly from the general public.4-8 H ealthy lifestyle changes, such as increasing physical activity and im proving diet, are likely challenging for cancer survi vors w ho often face m any physical, em otional, and social adjustm ents follow ing diagnosis and treatm ent.9,10 Even sev eral years follow ing diagnosis, few cancer survivors appear to adopt m ultiple healthy lifestyle changes.4 T here were over 500,000 veterans w ith a diagnosis o f cancer identified in V eterans A ffairs (VA) electronic m edical records in 2 007,11 yet the health prom otion needs o f these survivors have rarely been reported to date. The needs of *VA Center for Integrated Healthcare, VA Western New York Health care System, 3495 Bailey Avenue, Buffalo, NY 14215. tSchool of Public Health and Health Professions, University at Buffalo, The State University of New York, 3435 Main Street, Buffalo, NY 14214. tSchool of Nursing, University at Buffalo, The State University of New York, Buffalo, 3435 Main Street, Buffalo, NY 14214. §Behavioral VA Careline, VA Western New York Healthcare System, 3495 Bailey Avenue, Buffalo, NY 14215. ||Behavioral VA Careline, VA Greater Los Angeles Healthcare System. 11301 Wilshire Boulevard, Los Angeles, CA 90073. ^Medical VA Careline, VA Western New York Healthcare System, 3495 Bailey Avenue, Buffalo, NY 14215. The preliminary findings of this article was presented in poster format at the 32nd Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine, Washington, DC, April 2011. The information provided in this article does not represent the views of the Department of Veterans Affairs or the U.S. Government, doi: 10.7205/MILMED-D-14-00027
998
veteran cancer survivors deserve special consideration given that they have w ell-docum ented rates o f m ultim orbidity that exceed that o f the general p u b lic,1 -14 w hich m ay m ake engaging in healthy lifestyle change m ore challenging. S im i larly, com pared to the general population o f survivors, vet eran cancer survivors are m ore likely to be m ale and of advanced a g e ,11 both o f w hich are associated w ith m aking few er health behavior changes follow ing diagnosis.2 For exam ple, one o f the few studies o f healthy lifestyle change am ong veteran cancer survivors found that after diagnosis, only 35% o f veteran survivors increased their fruit and v eg e table consum ption w hereas 43% decreased their level of physical ac tiv ity .1:1 In a sam ple o f veteran prostate cancer survivors, over tw o-thirds were not only overw eight or obese at diagnosis, but they typically show ed small but significant w eight gain for at least 3 years after d iag n o sis16 and rarely accessed assistance from prim ary care-b ased w eight m an agem ent services. Thus, veteran cancer survivors m ay be particularly in need o f assistance in overcom ing barriers to healthy lifestyle changes. For cancer survivors in general, and veteran cancer survi vors in particular, survivorship care planning needs to include effective interventions to address physical activity, diet, and body size. Perceptions o f facilitators and barriers to behavior are w ell-know n predictors o f diet and exercise behaviors.17,18 W ithout anticipating that a variety o f barriers are likely to influence survivors’ ability to initiate and m aintain healthy lifestyle change, post-treatm ent care planning alone is unlikely to achieve its intended im p a ct.11 Y et little previous w ork has focused on barriers and facilitators o f health behav ior change elicited from veteran cancer survivors. Because perceptions o f benefits and barriers can be both behavior and population specific, addressing the needs o f veteran cancer
MILITARY MEDICINE, Vol. 179, September 2014
Perceptions o f Health Behavior Change Among Veteran Cancer Survivors
survivors requires knowledge of the barriers and facilitators associated with their engagement (or lack thereof) in healthy diet and exercise practices. As part of a larger study regarding health and wellness promotion following cancer, we conducted a qualitative study with the aim of identifying barriers and facilitators of health behavior change among veteran cancer survivors. We chose to focus specifically on factors impacting changes in physical activity, diet, and body size because of the well-established rates of overweight and obesity among veterans.13’19 At the same time, interventions for weight management are com monly available in VA primary care clinics,20 suggesting that obstacles exist to connecting some veterans to relevant inter ventions. Our overarching goal was to better understand how veteran-identified barriers and facilitators can be used to inform the survivorship care planning process while also pre paring health care providers in both oncology and primary care to meet the health promotion needs of cancer survivors.
METHODS Participants Male and female veterans over age 18 and conversant in English who had a diagnosis of cancer of any type and received treatment or outpatient follow-up care at the VA Western New York Healthcare System Comprehensive Cancer Center were eligible to participate in this study. Excluded from the study were those individuals who were receiving definitive or first round cancer treatment, those who were critically ill, unable to carry out basic self-care, enrolled in palliative care programs, those diagnosed with significant cognitive impair ment, or those experiencing active psychosis or recent history of self-injurious/suicidal behaviors. A sample of 35 partici pants was recruited using informational study flyers posted in the oncology and infusion clinics, referral by the oncology staff, and by sending invitation letters to eligible individuals identified by the chief of oncology (LS). This sample size has been suggested previously as sufficient to conduct the qualita tive analysis described below.21’22 interview Schedule and Procedures The semistructured interview items were developed based on prior experience of the research team and from relevant social and behavioral theories23-26 to focus on barriers and facilitators of health behavior change. Participants were first asked “After you were diagnosed with cancer, did you make any changes to your lifestyle to promote your health?” Throughout the interview process, probes and prompts were used to elicit more information or clarify responses from main interview items regarding barriers and facilitators. Indi vidual face-to-face interviews were conducted by the lead author (GPB) either in a private examination room or confer ence room of the oncology clinic. Participants were first presented with information on the present study as well as information about participating in VA research. Those who
MILITARY MEDICINE, Vol. 179, September 2014
wished to participate provided verbal consent and an addi tional signed consent for audio recording the interview. Three participants elected to complete the interview by phone. Fol lowing the interview, participants also completed a brief survey of demographic characteristics, cancer history, and cur rent health behaviors (fruit and vegetable consumption, physi cal activity, and body size). The survey also included items regarding whether participants had changed each of these health behaviors following cancer diagnosis. Participants were provided a $25 gift card as a thank you for participating. All interviews were digitally recorded and transcribed ver batim. On receipt of the word-processed transcripts from the professional transcription service, transcripts were compared to the original audio files to ensure accuracy. Finalized tran scripts were imported into qualitative data analysis computer software, ATLAS.ti, to facilitate coding, searching and retrieving text, and linking relevant data segments. Analytic Approach Descriptive statistics were used to summarize the quanti tative data from the self-report survey. As described by Sandelowski,27'28 a qualitative descriptive study was con ducted to identify and summarize specific, veteran-identified factors that could be classified as barriers or facilitators of health behavior change. Using an inductive approach to con tent analysis,29 open codes were developed and applied to each segment of text that identified a factor that impacted likelihood of initiating or maintaining healthy behavior change related to improving diet, increasing physical activity, or achieving and maintaining a healthy body size. Lineby-line coding resulted in hundreds of open codes, which were examined within and across interviews. Open codes were first identified as either barriers to or facilitators of change. Within these broad characterizations of the data, conceptually similar open codes were clustered together to develop more descrip tive categories of barriers and facilitators. Six final categories were identified. Open codes and associated narrative data from each category were reviewed again to summarize the most common barriers and facilitators to change.
RESULTS Participant Characteristics The results of the background survey are summarized in Table I. Participants were primarily men (94%), of white racial background (80%), and unmarried (54%). The average age of participants was 64 years, and the majority (70%) of the sample reported an annual household income of less than $40,000. Veterans with prostate cancer were the single larg est subgroup (31%) of participants, with a variety of cancers represented such as lung, head and neck, colon or rectal, lymphoma, breast, and others. The single most common treatment modality was chemotherapy (60%). Participants reported their time since diagnosis as less than 1 year to 17 years, with a median of 4 years.
999
Perceptions of Health Behavior Change Among Veteran Cancer Survivors TA B LE I.
Demographic, Background, and Health-Related Information for Study Participants Characteristic
«(%)
Male Age" Non-White Race Married/Partnered Annual Household Income $60,000 Cancer Type Prostate Lung Head/Neck Lymphoma Colon/Rectal Breast Other Treatment History Chemotherapy Radiation Surgery Hormone Therapy Active Surveillance Years Since Diagnosis (Median, Range) Self-Rating of Current General Health Status Poor Fair Good Very Good Excellent Self-Report of Current Quality of Life Poor Fair Good Very Good Excellent Current Days per Week That 5 Servings of Fruits or Vegetables Were Consumed0 Change in Fruit or Vegetable Consumption After Diagnosis No Change Ate More Ate Less Current Days per Week That Included 30 Minutes or More of Exercise" Change in Frequency of Exercise After Diagnosis No Change Exercised More Exercised Less Current Body Mass Index Normal Overweight Obese
33 (94) 64 (10) 7 (20) 16 (46) 11(32) 13 (38) 8(24) 2(6) 11(31) 5(14) 4(11) 3(9) 3(9) 2(6) 7(20) 21(60) 19 (54) 18(51) 3(9) 2(6) 4 (
