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Perceptions of Barriers and Facilitators to Health Behavior [Military Medicine](Military Medicine Via Acquire Media NewsEdge) 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 questionnaire 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 Cancer diagnosis has been described as a "teachable moment" in which survivors are particularly receptive to engaging in health-promoting behaviors.1-3 However, research has suggested that adherence to health behavior guidelines among cancer survivors is heterogeneous and may not differ significantly from the general public.4-8 Healthy lifestyle changes, such as increasing physical activity and improving diet, are likely challenging for cancer survivors who often face many physical, emotional, and social adjustments following diagnosis and treatment.9,10 Even several years following diagnosis, few cancer survivors appear to adopt multiple healthy lifestyle changes.4 There were over 500,000 veterans with a diagnosis of cancer identified in Veterans Affairs (VA) electronic medical records in 2007,11 yet the health promotion needs of these survivors have rarely been reported to date. The needs of veteran cancer survivors deserve special consideration given that they have well-documented rates of multimorbidity that exceed that of the general public,12-14 which may make engaging in healthy lifestyle change more challenging. Similarly, compared to the general population of survivors, veteran cancer survivors are more likely to be male and of advanced age,11 both of which are associated with making fewer health behavior changes following diagnosis.2 For example, one of the few studies of healthy lifestyle change among veteran cancer survivors found that after diagnosis, only 35% of veteran survivors increased their fruit and vegetable consumption whereas 43% decreased their level of physical activity.15 In a sample of veteran prostate cancer survivors, over two-thirds were not only overweight or obese at diagnosis, but they typically showed small but significant weight gain for at least 3 years after diagnosis16 and rarely accessed assistance from primary care-based weight management services. Thus, veteran cancer survivors may be particularly in need of assistance in overcoming barriers to healthy lifestyle changes. For cancer survivors in general, and veteran cancer survivors in particular, survivorship care planning needs to include effective interventions to address physical activity, diet, and body size. Perceptions of facilitators and barriers to behavior are well-known predictors of diet and exercise behaviors.17,18 Without anticipating that a variety of barriers are likely to influence survivors' ability to initiate and maintain healthy lifestyle change, post-treatment care planning alone is unlikely to achieve its intended impact.11 Yet little previous work has focused on barriers and facilitators of health behavior change elicited from veteran cancer survivors. Because perceptions of benefits and barriers can be both behavior and population specific, addressing the needs of veteran cancer 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 commonly available in VA primary care clinics,20 suggesting that obstacles exist to connecting some veterans to relevant interventions. 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 preparing 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 impairment, or those experiencing active psychosis or recent history of self-injurious/suicidal behaviors. A sample of 35 participants 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 qualitative 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. Individual face-to-face interviews were conducted by the lead author (GPB) either in a private examination room or conference 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 wished to participate provided verbal consent and an additional signed consent for audio recording the interview. Three participants elected to complete the interview by phone. Following the interview, participants also completed a brief survey of demographic characteristics, cancer history, and current health behaviors (fruit and vegetable consumption, physical 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 giftcard as a thank you for participating. All interviews were digitally recorded and transcribed verbatim. On receipt of the word-processed transcripts from the professional transcription service, transcripts were compared to the original audio files to ensure accuracy. Finalized transcripts 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 quantitative data from the self-report survey. As described by Sandelowski,27,28 a qualitative descriptive study was conducted 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 content 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 descriptive 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 largest 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. The clear majority of participants rated their current general health status (78%) or quality of life (89%) as ranging from good to excellent. Endorsement of self-reported health behaviors varied considerably. On average, participants reported consuming five serving of fruits or vegetables between 2 and 3 days per week, and 66% reported no change in consumption following diagnosis. Similarly, participants reported exercising for 30 minutes or more about 2 to 3 days per week, with the majority making no change following diagnosis (57%). On the basis of self-reported height and weight, body mass index was calculated (weight [lbs]/height [in]2 + 703). The majority of the sample was overweight (51%) or obese (29%). Barriers and Facilitators of Health Behavior Change During the interviews, participants reported a wide variety of factors that acted as barriers or facilitators to making healthy behavior changes regarding physical activity, diet, and body size. Table II summarizes six categories and specific factors within each category of barriers and facilitators. The first category of barriers and facilitators was the most heterogeneous and reflected how the physical environment, one's social and occupational status, and financial limitations impacted engagement in health behavior change. For example, easy access to a gym or workout center, as well as a workout partner, helped with engagement in exercise. In contrast, the cost of healthy foods was commonly cited as a barrier among those participants with limited income, an issue that was compounded for one participant because of where he resided: Aside from diet, my living circumstances preclude me from - I reside at the YMCA. I basically have a microwave to cook with. If anything, I found trying to eat healthy is more expensive than getting lots of starches, fats, and sugars. . . . I mean you could steam [vegetables] or whatever, but aside from the ability, being able to cook, it's also making the point. . .for those veterans who aren't that wealthy, it is rather expensive to eat healthy. (Participant 103) The second category, health service delivery factors, was described primarily in relation to interactions with the VA health care system. Health care providers in the VA system played a crucial role in making the recommendation to engage in healthy lifestyle change, as well as referring veterans to programs to assist with change goals, such as the VA's Managing Overweight/Obesity for Veterans Everywhere (MOVE!) weight management program.30 Health care providers who made unrealistic demands on veterans or who were punitive when goals were not achieved presented barriers to change. One participant noted the following experience with a provider regarding weight loss: Like one provider I had when we changed she said, "I want you to lose ten pounds by the next time you're in here, really seriously, or I'm going to be upset with you." I lost ten pounds. I busted my butt and I just did it for her maybe in the wrong way but it wasn't probably a healthy way of losing weight. It was more of almost starvation to lose the weight so she wouldn't be mad at me. (Participant 102) The third category consisted of cancer-specific and other health-related factors, which highlighted the role of treatment side effects and comorbid medical and psychiatric conditions. Chronic pain, fatigue, interference from ostomies, and difficulty swallowing bulky or fibrous foods were common barriers. A participant who had received significant radiation therapy to treat his nasopharyngeal cancer noted the significant barriers he encountered when trying to eat healthy foods: . . .Some things I can't eat like I used to, like some of the fresh fruits like apples or something, because I don't have the saliva. . .And I have been still adjusting how to get, you know, breads are not good for me. I have to wash them down but some of the things like I said apple or something, I wind up chewing for, oh gosh, I chew forever. One of the doctors said that some of the nerves in my throat area that trigger when you swallow or something has been affected. My whole eating process is different than it used to be. (Participant 127) Healthy weight loss following cancer treatment that reduced excess weight sometimes facilitated subsequent improvements in physical activity or weight maintenance. However, for those individuals whose body changes included excessive loss of muscle mass or gaining body fat felt these changes made it difficult to achieve a healthy weight. The fourth group of factors related to participants' perceptions of how to enact and maintain healthy lifestyle changes. Participants noted that plans for initiating or sustaining change can easily be deprioritized because of competing demands from work or family. One participant noted how his participation in a weight loss program offered outside the VA was impacted by his responsibilities as a family caregiver: My father got sick. . .and so I was doing a lot of running between hospital and nursing home and back and forth and just. . . I just didn't have time. I didn't make time to do it. I might have been able to if I had arranged my days better but at that time I was working and it just. . .Everything went haywire. (Participant 107) Attempting to modify long-standing patterns of dietary behavior or attempting to make changes too large in scope was also seen as barriers to realistic change. In contrast, attempting smaller changes that stem from current healthy routines, such as walking the dog more frequently, was seen as a way of incorporating change in a feasible manner. The fifth group of factors focused on attitudes of the meaning or value of health behavior change itself. Some participants noted skepticism about whether or not health behavior change was effective for improving their health or if change was better suited for younger people. One participant felt that the sacrifices associated with change were considerable: "I'm now trying to get back into working out, but it's just frustrating as all get out. Or [I] sit there on a treadmill and go, 'This is just boring as hell.'" (Participant 104). In contrast, participants who had positive perceptions of change tended to believe that avoiding a sedentary lifestyle was important and that health behavior change could even lead to changes in self-confidence. Finally, the sixth set of factors focused on motivation. In addition to the sense that experiencing cancer can decrease motivation for change broadly, examples of other motivational barriers included depression and reluctance to give up pleasure associated with eating favorite foods. Fewer motivation-related facilitators than barriers were identified, but they included embracing the inherent challenge of change, as reported by one participant: I was very adamant. I said, "If I don't get out of that mode, I will be lazy." And I've seen some people who just use that for granted, and I said, "I have to get up and do more each day." If you don't, then you're going to take a step backwards, or, if you will, be lazy, and I wasn't going to do that. Like I said, I'm headstrong and stubborn, so it was a challenge, and I like challenges. I like winning battles, so I wasn't going to let that defeat me. (Participant 122) Participants also noted that fear of recurrence and concern about developing other cancers were also important motivational enhancers. DISCUSSION The results of this study contribute to the small but growing body of research regarding veteran cancer survivors by exploring perceptions of barriers and facilitators to meeting physical activity, dietary, and body size guidelines. Previously, we reported on the larger psychosocial impact of cancer among this group of veterans, with the finding that physical and emotional side effects from cancer might negatively impact one's ability to initiate and sustain beneficial lifestyle changes after treatment.10 Therefore, in the current study, we more closely examined the specific survivor-identified factors perceived to be related to health behavior change. We identified numerous barriers to change-as well as facilitators-across multiple domains. Overall, the breadth of individual factors identified in this study are noteworthy, particularly when considering that this sample of survivors received care at a VA medical facility that routinely offers weight management services as part of multidisciplinary primary care teams. Our study findings are particularly novel in the health service delivery factors identified, including the role of VA health care providers and intervention programs. Often, barriers and facilitators are described in relation to the individual rather than the broader health care environment, which is unfortunate given that several provider and system factors can influence cancer care coordination and receipt of preventive health services. 31,32 For example, survivors in our study noted that providers should facilitate change by informing them of the need to prioritize weight management specifically as a cancer survivor, suggest referral to the MOVE! program, and provide supportive (rather than punitive) interactions regarding their weight management goals. Although all participants in this study could self-refer to VA prevention programs, these findings suggest the need to consider if and how survivors are connected to these programs and whether or not these population- based services are appropriate for cancer survivors. Understanding these larger health service delivery factors may be especially important for those veteran survivors who rely exclusively on VA services for the full scope of their health care. Previous quantitative studies that have examined factors impacting the likelihood of engaging in healthy lifestyle changes, particularly exercise, after cancer diagnosis have resulted in myriad findings. Some have suggested that general factors, such as lack of time, poor motivation, and bad weather are key barriers to change.33,34 Others have pointed to the importance of cancer-specific factors (e.g., fatigue or diarrhea)35 or a mix of general and cancer-specific factors.36 Although not focused on veterans, prior qualitative studies have yielded comparable findings to ours. For example, Satia et al37 studied an ethnically diverse sample of prostate cancer survivors and identified cancer-specific barriers, non-cancer barriers, motivation-enhancing factors, and facilitators related to receiving family and social support. Although focused on older breast cancer survivors, another study regarding perceptions of factors limiting engagement in physical activity identified barriers that were highly similar to the current study, including a lack of time, diminished health status related to older age and comorbid conditions, as well as fear of overexertion.38 In sum, it appears important to consider that veteran cancer survivors are likely impacted by general barriers to change, cancer-specific barriers to change, and factors specific to the VA health care setting. STUDY IMPLICATIONS Health behavior change may become an increasing area of attention following the Commission on Cancer's mandate that accredited comprehensive cancer centers implement survivorship care plans by 2015.39 At the local level, routine development of survivorship care plans, which address healthy lifestyle changes as one of many post-treatment care concerns, will need to consider how to best utilize available resources for intervention and referral. Those providing followup care to survivors would benefit from assessing unique constellation of barriers and facilitators for each individual. Yet, measuring this wide range of factors likely to affect health lifestyle change remains a challenge because of the limited availability of appropriate measurement tools. For example, to evaluate some of the barrier and facilitator domains identified in the current study and others, multiple individual instruments would be necessary, such as an assessment of the functional consequence of cancer,40 a survey of social and personal resources,41 and a measure of closely related psychosocial constructs, such as exercise self-efficacy.42 Alternatively, the abovementioned qualitative findings could serve as a foundation on which to build a new patient-centered measurement tool or interview guide. Identifying the relative balance of general barriers and cancer-specific barriers could assist providers in oncology or primary care in determining if a survivor can be adequately served by primary care and community-based health promotion services, or if that individual's needs are more likely to be served in a more specialized cancer recovery program. Intervention programs designed around the specific needs of cancer survivors have been shown to improve adherence to diet and physical activity guidelines,43,44 yet many survivors do not benefit from easy access to survivor-specific interventions. In the VA system, general resources to aid in cancer recovery are available, such as referral to physical therapy, yet survivor-specific interventions regarding physical activity, diet, and weight loss are not typically offered. Alternatively, the VA's MOVE! weight management program is available in multidisciplinary primary care clinics for the general population of veterans. This program is an existing resource that may potentially be modified to improve access for veterans who are cancer survivors seeking to lose weight. MOVE! is primarily a self-management program, which includes individual or group-based support for making changes in physical activity and diet designed to create an energy deficit that leads to weight loss.20 Physical activity and diet goals are patient-specific and developed in consultation with a MOVE! provider. To aid in goal setting, veterans completed a detailed questionnaire regarding past experiences with weight loss, current level of motivation to lose weight, and current habits related to diet and exercise. The MOVE! questionnaire also includes several perceived barriers to physical activity and dietary change, such as lack of time and the competing demands of managing other comorbid diseases. However, to our knowledge, cancer history and associated concerns, such as difficulty chewing/ swallowing or persistent fatigue secondary to medical treatment, are not included. It may be important for MOVE! providers to specifically query their patients regarding cancerspecific barriers they perceive as impacting weight change goals. Further research will need to consider if additional tailoring of the MOVE! program could eliminate the need to develop new survivor-specific weight management programs in VA. LIMITATIONS Our study has several strengths and limitations that should also be considered when interpreting the findings. To our knowledge, this is the first study to explore perceptions of health behavior change exclusively among veterans receiving care at VA medical facilities, a group who may be particularly in need of health behavior change interventions because of their high rates of multimorbidity. Although not designed as a comparative study, our results suggest that veterans were in many ways similar to the general public in their identification of a wide range of barriers. In addition, several facilitators of change were identified that suggest practical ways to manage barriers. Also, in relation to our study sample, the use of a diverse group of cancer survivors overcomes some of the limitations of previous research that has usually focused on homogeneous survivor groups of similar cancer type or time since diagnosis. Although disease-specific cancer survivorship interventions are beneficial, they may not be practical to implement as some health care settings may be limited in their ability to offer multiple programs designed for specific survivor groups (e.g., an exercise program designed for prostate cancer survivors). Thus, identifying the concerns among a mixed group of survivors may assist in understanding if and how existing population-based programs could be modified to meet the needs of survivors. This study was limited, however, in that it did not assess a wider range of health behaviors that are no less relevant to survivorship care planning, including smoking cessation, reducing alcohol use, distress management, and seeking routine oncology follow-up care and preventive screenings for other cancers. Our emphasis was on conducting a substantive analysis that identified specific statements from survivors about factors that impact perceived or actual health behavior change. Our qualitative methodology limited our ability to answer additional research questions, such as the degree to which barriers and facilitators we identified predict engagement and maintenance of health behavior change that would require a larger sample size to conduct advanced statistical analyses. In addition, our sample was from a single VA cancer center with limited survivor-specific resources. It is difficult to know if the factors identified by our sample are unique to our particular setting. CONCLUSIONS Veteran cancer survivors face a wide variety of factors that both facilitate and impede adoption of healthy lifestyle change. Future research will need to consider the potential value of developing survivor-specific measurement tools that could be used in population-based studies to determine the relative distribution and predictive power of a full range of barriers and facilitators among survivors. Survivorship care planning and intervention programming will need to consider health behavior change within the larger domain of recovery from cancer to achieve optimal patient outcomes. ACKNOWLEDGMENTS This study was supported with resources and the use of facilities at the VA Western New York Healthcare System. This study (BE-02-00694) was funded by the VA Center for Integrated Healthcare Pilot Grants Programs. REFERENCES 1. 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Martin L, Haskard-Zolnierek K, Robin M: Health Behavior Change and Treatment Adherence: Evidence-Based Guidelines for Improving Healthcare. New York, Oxford University Press, 2010. 19. Koepsell TD, Forsberg CW, Littman AJ: Obesity, overweight, and weight control practices in U.S. veterans. Prev Med 2009; 48(3): 267-71. 20. Department of Veterans Affairs: MOVE! Weight management program for Veterans (VHA Handbook 1120.01). 2011. Available at http://www1 .va.gov/vhapublications/ViewPublication.asp?pub_ID=2403; accessed December 1, 2013. 21. Sandelowski M: Sample size in qualitative research. Res Nurs Health 1995; 18: 179-83. 22. Guest G, Bunce A, Johnson L: How many interviews are enough? An experiment with data saturation and variability. Field Methods 2006; 18: 59-82. 23. Becker MH: The health belief model and personal health behavior. Health Educ Monogr 1974; 2: 328-35. 24. Janz NK, Champion VL, Strecher VJ: The health belief model. 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Support Care Cancer 2010; 18: 729-34. 36. Courneya KS, Friedenreich CM, Quinney HA, et al: A longitudinal study of exercise barriers in colorectal cancer survivors participating in a randomized controlled trial. Ann Behav Med 2005; 29(2): 147-53. 37. Satia JA, Walsh JF, Pruthi RS: Health behavior changes in white and African American prostate cancer survivors. Cancer Nurs 2009; 32(2): 107-17. 38. Whitehead S, Lavelle K: Older breast cancer survivors' views and preferences for physical activity. Qual Health Res, 2009; 19(7): 894-906. 39. Commission on Cancer. Cancer Program Standards 2012: Ensuring Patient-Centered Care. Chicago, IL, American College of Surgeons, 2012. 40. Webster K, Cella D, Yost K: The functional assessment of chronic illness therapy (FACIT) measurement system: properties, applications, and interpretation. Health Qual Life Outcomes 2003; 1: 79. 41. Glasgow RE, Strycher LA, Toobert DJ, Wakin E: A social-ecologic approach to assessing support for disease self-management: the chronic illness resources survey. J Behav Med 2000; 23(6): 559-83. 42. McAuley E, Mihalko SL: Measuring exercise-related self-efficacy. In: AdvancesinSportandExercisePsychologyMeasurement,pp371-90.Edited by Duda JL. Morgantown,WV,Fitness Information Technology, 1998. 43. Morey MC, Snyder DC, Sloane R, et al: Effects of home-based diet and exercise on functional outcomes among older, overweight long-term cancer survivors: RENEW: a randomized controlled trial. JAMA 2009; 301(18): 1883-91. 44. Demark-Wahnefried W, Morey MC, Sloane R, et al: Reach out to enhance wellness home-based diet-exercise intervention promotes reproducible and sustainable long-term improvements in health behaviors, body weight, and physical functioning in older, overweight/obese cancer survivors. J Clin Oncol 2012; 30(19): 2354-61. Gregory P. Beehler, PhD, MA*[dagger][double dagger]; Amy E. Rodrigues, PhD§; Morgan A. Kay, PhD?; Marc T. Kiviniemi, PhD[dagger]; Lynn Steinbrenner, MD¶ *VA Center for Integrated Healthcare, VA Western New York Healthcare System, 3495 Bailey Avenue, Buffalo, NY 14215. [dagger]School of Public Health and Health Professions, University at Buffalo, The State University of New York, 3435 Main Street, Buffalo, NY 14214. [double dagger]School 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. kBehavioral 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 (c) 2014 Association of Military Surgeons of the United States |