Lack of Successful Implementation of Cancer Rehabilitation Guidelines: A Mixed-methods Study Highlighting Need for Better Preconditions in Primary Care

Abstract

Implementing cancer rehabilitation in primary care that addresses the physical, psychological, social, and existential consequences of cancer is considered important.

Aim:

To describe primary care practitioners’ self-reported preconditions—including facilitators and barriers—related to cancer rehabilitation and physical activity, as well as their interest in responding to questions about cancer rehabilitation.

Methods:

This convergent mixed-methods study collected self-reported quantitative questionnaire data using 0 to 10 scales (10 = maximum) from 229 primary care practitioners (104 rehabilitation practitioners and 125 healthcare center practitioners), and written qualitative data from a sub-sample of 120.

Results:

Among rehabilitation practitioners, 20% provided some form of cancer rehabilitation and 70% prescribed physical activity to consulting cancer survivors. Corresponding figures for healthcare center practitioners were 10% and 15%, respectively. Both rehabilitation and healthcare center practitioners reported a median score of 0 (no knowledge) regarding physical activity advice for cancer survivors, and 95% of participants had not read cancer rehabilitation guidelines. Rehabilitation practitioners gave median ratings of 8 and 9 for the importance of providing cancer rehabilitation and physical activity advice, respectively, compared with 6 and 7 among healthcare center practitioners. Median ratings among rehabilitation practitioners were 3 for workplace preparedness and 3 for sufficient time for cancer rehabilitation, compared with 2 and 0 (no time at all) among healthcare center practitioners. Facilitators of the implementation were that providing cancer rehabilitation was considered important, and that practitioners were experienced in rehabilitation and physical activity counseling in non-cancer populations. To have committed and motivated co-workers facilitated a positive work culture for cancer rehabilitation. Primary barriers were the limited knowledge and skills and perceived unsatisfactory organizational preconditions, shaping an uncertainty on if primary care has any responsibility for cancer rehabilitation. Of the 168 rehabilitation practitioners invited, 104 (62%) were interested in answering questions regarding cancer rehabilitation. Among the 1055 invited healthcare center practitioners, 125 (12%) were interested.

Conclusions:

Given the limited preconditions for cancer rehabilitation and physical activity implementation, the described barriers and facilitators, and the varying interest among practitioners, educational interventions and support strategies tailored to both individuals and organizations appear necessary.

Keywords

cancer integrative cancer care interdisciplinary collaboration implementation mixed-methods nursing physical activity primary care rehabilitation unmet needs

Introduction

Implementing cancer rehabilitation in primary care that addresses the physical, psychological, social, and existential consequences of cancer is considered important.¹ However, there is a gap between cancer rehabilitation guidelines² and their implementation in clinical practice.^3
-5 More than one-fourth of people with cancer reported that they had not been offered any cancer rehabilitation, even though they were on sick leave due to cancer-related consequences.³ Many cancer survivors do not express their rehabilitation needs.⁵ Therefore, it is important that healthcare practitioners screen for rehabilitation needs and possess the necessary knowledge, skills, positive approaches, and perceive organizational support to facilitate cancer rehabilitation, as this likely affects survivors’ opportunities. More studies are welcomed to understand the transferal of cancer rehabilitation guidelines into routine cancer care practice.^2
-9

Significant advances in early cancer detection and treatment have improved survival rates, increasing the need for cancer rehabilitation,^1,2,6
-9 and highlighting the growing responsibility of primary care in supporting survivors.⁹ Cancer rehabilitation is a holistic concept, covering interventions based on the individual’s needs and conditions, aimed to prevent functional impairments, and maintain or regain the best possible functional and activity capacity and quality of life, for participation in community life despite the consequences of cancer and its treatment.^1,2 In Sweden, cancer rehabilitation guidelines (developed year 2014, updated year 2023) guide healthcare practitioners,² in for example, assessing cancer rehabilitation needs and practicing interventions.^{1,2,6,7,9
-12} Previous studies show that 25% to 33% of people with cancer did not discuss rehabilitation needs with healthcare practitioners despite experiencing physical, psychological, social, or existential consequences and fear of relapse.⁵ Healthcare practitioners thus trustfully need to systematically assess cancer rehabilitation needs,^7,12
-14 and apply evidence-based interventions to facilitate the cancer rehabilitation process.^1,2,15
-18

Physical activity is a key cancer rehabilitation intervention.¹ Early, initially controversial evidence on the benefits of physical activity in cancer emerged in the 1990s.¹⁹ Accumulating evidence shows that physical activity reduces symptom burden, improves quality of life and work ability, and may contribute to improved survival in cancer survivors.^1,15
-18 The evidence has led to international guidelines.¹⁶ They strongly recommend that physical activity should be an integral part of standard cancer rehabilitation regardless of the cancer diagnosis or stage. At least 150 minutes of moderately intensive or 75 minutes of vigorous physical activity a week has been recommended.^2,16 However, cancer survivors’ adherence to engaging in physical activity is often poor according to a meta-analysis of 64 studies, highlighting the association between adherence and psychosocial factors, such as behavioral control and approaches,²⁰ which may be affectable by sufficient support from healthcare practitioners.^6,21

The cancer survivors’ needs^7,12
-14 and the benefits of rehabilitation for people with cancer are now well-established,^1,15
-18 yet the transitional pathway from research findings, policies and guidelines to widespread implementation and everyday use of evidence-based practices has proved arduous.^6
-9,21,22 The dissemination of guidelines alone is often insufficient, and the implementation of cancer rehabilitation interventions has been sparsely studied in real-world routine practice.²¹ The fast-growing field of implementation science has emerged from the recognition that evidence does not spread by itself and addresses the uptake of scientific evidence into routine practice. Implementation strategies focus on optimizing preconditions, minimizing barriers and maximizing facilitators that impact the implementation of evidence-based practices.²³ The widely used Theoretical Domains Framework was developed to identify stakeholders’—for example, healthcare practitioners’—behaviors and preconditions (such as practices, knowledge, skills, attitudes, and perceived organizational support) that influence the implementation of evidence-based guidelines.²⁴ Researchers and clinicians have heeded the need for the adoption of supportive strategies in the cancer rehabilitation implementation process.^6,9,21,25 Such strategies should be based on the healthcare practitioners’ behaviors and preconditions²⁴ as well as perceived barriers and facilitators for implementation.^21,23
-25 Reasons for non-implementation of cancer rehabilitation have mostly been studied from the perspective of cancer survivors,^3
-5,12,13 while healthcare practitioners’ perspectives remain sparsely explored.^6,21,25 Primary care practitioners’ perceptions of the preconditions for implementing cancer rehabilitation according to guidelines² are not known. To address a pivotal knowledge gap in research, the aim was to describe primary care practitioners’ self-reported preconditions—including facilitators and barriers—related to cancer rehabilitation and physical activity, as well as their interest in responding to questions about cancer rehabilitation.

Material and Methods

Study Design and Setting

This study was performed in accordance with the ethical standards laid down in the Declaration of Helsinki. The study did not require ethical approval since it did not include sensitive personal information. This is specified in the Swedish ethical law regulating ethical approval for research concerning humans (SFS 2003:460), as confirmed in an Ethical Review Board’s advisory statement (protocol number: Umeå 2018/423-31, date 2018-12-04) regarding collecting data in healthcare practitioners. The head director in charge of the departments employing primary care healthcare practitioners approved the study.

This was a convergent mixed methods study,²⁶ collecting self-reported quantitative and written qualitative data in a study questionnaire from primary care healthcare practitioners. The study setting was a regional healthcare municipality in eastern Sweden. It consists of 4 geographic areas that provide health services to approximately 442 000 inhabitants. It included 31 primary care centers and 4 rehabilitation centers (1 in each geographical area of the municipality). Health care in Sweden is taxpayer funded, but privately funded health care also exists. Out-of-pocket fees are low and regulated by law. Cancer survivors consult with their primary care practitioners during the detection and diagnostic phase, as well as in-between and after receiving treatments given at specialized care settings. According to cancer rehabilitation guidelines,² basic cancer rehabilitation needs should be addressed for all cancer survivors, including information about self-care and advice on physical activity. Primary care therefore plays an important role in cancer rehabilitation.⁹

Sampling Strategy

A purposive sampling strategy was used; 2 cohorts of primary care healthcare practitioners were screened for potential participation: rehabilitation practitioners from 4 rehabilitation centers and healthcare center practitioners from 31 centers. Inclusion criteria were rehabilitation practitioners (ie, physiotherapists, occupational therapists, and rehabilitation assistants) or healthcare center practitioners (ie, registered nurses, physicians, and other professionals such as social workers, speech therapists, dietitians, psychologists, and rehabilitation coordinators) hired within primary care. Exclusion criteria: Primary care healthcare practitioners who collected the data (n = 4); the head director in charge of the primary care healthcare; the heads of the primary healthcare centers (n = 31); the heads of the rehabilitation centers (n = 4). As presented in Figure 1, 1223 primary care healthcare practitioners (168 rehabilitation practitioners and 1055 healthcare center practitioners) received study information via an e-mail inviting them to participate. They were asked to either give their digital informed consent to participate at a web link or choose the alternative “I do not want to participate.” Of the 168 rehabilitation practitioners, 104 (62%) participated.

Figure 1.

Overview of the survey’s sampling and data collecting procedures.

Data Collection Using a Self-Reported Study Questionnaire

A digital questionnaire collected descriptive socio-demographic and profession-related data. The theory-guided questionnaire collected self-reported quantitative data on 5 domains of preconditions^24,27: Practices (6 questions), Knowledge (2), Skills (3), Approaches (2), and Perceived organizational preconditions for cancer rehabilitation (2)—a total of 15 questions with fixed response options (see Table 2), mostly from 0, not at all, to 10, entirely. An open-ended question asked about common conditions warranting cancer rehabilitation. The questionnaire included 4 open-ended questions, allowing participants to describe in their own words perceived barriers and facilitators for cancer rehabilitation in general and for providing physical activity advice to cancer survivors.

After conducting focus group interviews,²⁵ the study questionnaire was developed using the Theoretical Domains Framework²⁴ guide²⁷ to assess primary care practitioners’ self-reported preconditions across the 5 domains of interest. During content validation, a convenience sample of 10 healthcare practitioners (not involved in this study) completed the questionnaire and provided written feedback on its relevance, clarity, and completion time. Based on this feedback, redundant questions were removed—shortening completion time—and minor linguistic clarifications were made.

Data Analysis

Convergence analysis of the quantitative and the qualitative results was performed in line with proposals regarding mixed methods data.²⁶ Each cohort’s dataset was analyzed independently, separately for the healthcare center practitioners and the rehabilitation practitioners. Descriptive quantitative analyses used frequencies (n, %) and distributions (median [25th-75th percentiles] for ordinal variables; mean ± SD for continuous variables) for socio-demographic and profession-related data, as well as for the 5 domains²⁴ of self-reported preconditions: practices, knowledge, skills, approaches, and perceived organizational preconditions.

To answer the aim regarding barriers and facilitators, responses to the 4 open-ended questions were analyzed using deductive qualitative content analysis.²⁸ The first author (ML) analyzed the responses on barriers and facilitators for the 5 domains²⁴ practice, knowledge, skills, approaches, and perceived organizational preconditions for cancer rehabilitation. ML read the written content several times to create a sense of the whole and to identify phrases and sentences which contained information relevant to the studied domains. A structured categorization matrix was developed, and the content was placed into separate columns representing different categories of barriers and facilitators. The categories were iteratively analyzed and reviewed to reflect the aim of the study as accurately as possible, and to be mutually exclusive as well as exhaustive.²⁸ The qualitative content analysis was subsequently validated²⁹ independently by the last author (AE), who reviewed the coding and categorization to ensure that the categories accurately for each of the 5 domains²⁴ reflected the content of the qualitative responses. Any discrepancies were discussed until consensus was reached, in line with established validation methodology for qualitative research.²⁹ Results from the quantitative and qualitative analyses were compared, contrasted, and integrated during the interpretation stage to gain a deeper understanding and address the study aim. The qualitative responses were generally brief (1 or a few sentences). Consistent with convergent mixed-methods,²⁶ the qualitative analysis both confirmed and complemented the quantitative results, providing deeper insight into participants’ perceptions of preconditions, barriers and facilitators for implementing cancer rehabilitation guidelines in routine practice.

To answer the last part of the aim, frequences of rehabilitation practitioners and of healthcare center practitioners who responded to the questionnaire were calculated. The IBM SPSS Statistics for windows version 25.0 (IBM Corp. Armonk, NY, USA) was used for all quantitative calculations.

Results

The Primary Care Healthcare Practitioners

Of the 229 participating primary care healthcare practitioners, 3 quarters were women and the mean age was 43 (SD ± 12.0). Eighty percent of the rehabilitation practitioners were physiotherapists, and 74% of the healthcare center practitioners were physicians and registered nurses (Table 1). Qualitative data was provided by a sub-set of 120 (73 rehabilitation practitioners and 47 healthcare center practitioners) of the 229 participants.

Table 1.

Descriptive Characteristics of the Responding Primary Care Healthcare Practitioners.

Variable	Rehabilitation practitioners (n = 104)	Healthcare center practitioners (n = 125)
Sex, n (%)	n = 101	n = 111
Women	77 (76)	84 (76)
Men	24 (24)	27 (24)
Age	n = 101	n = 105
Mean ± SD	39 ± 11	47 ± 11
n (%)
≤30	35 (34)	5 (5)
31-40	19 (19)	26 (25)
41-50	29 (29)	28 (26)
>50	18 (18)	46 (44)
Profession, n (%)	n = 101	n = 111
Physician	NA	42 (38)
Nurse	NA	40 (36)
Assistant nurse	NA	6 (5)
Physiotherapist	81 (80)	1 (1)
Occupational therapist	18 (18)	3 (3)
Other^a	2 (2)	19 (17)
Years in present profession	n = 99	n = 90
Mean ± SD	12 ± 10	19 ± 11
n (%)
≤5	41 (42)	10 (11)
6-10	16 (16)	16 (18)
11-20	24 (24)	25 (28)
>20	18 (18)	39 (43)

Number (n) and percentages (%) are presented. The number of responding primary care healthcare practitioners is reported for each variable, reflecting attrition; there were no hired physicians, nurses or assistant nurses beyond the rehabilitation practitioners.

Abbreviations: SD, ±1 standard deviation. NA, not applicable.

Other professions consisted of social workers, speech therapists, dieticians, psychologists, and rehabilitation coordinators.

Practice of Cancer Rehabilitation

During the preceding 6 months, a median of 5 (range 0-60) cancer survivors had consulted the rehabilitation practitioners, and cancer rehabilitation needs had been screened in a median number of 0 of them. Cancer rehabilitation had been provided to a median of 20% of them, and 28% (n = 18) of the rehabilitation practitioners had provided cancer rehabilitation to at least 50% of the consulting cancer survivors (Table 2).

Table 2.

Primary Care Healthcare Practitioners’ Self-Reported Preconditions Concerning Cancer Rehabilitation.

Variables	Rehabilitation practitioners (n = 104)	Healthcare center practitioners (n = 125)
Practices, median, 25th-75th percentile
Of the patients who have consulted you in the last 6 mo, how many have or have had some form of cancer? Scale 0-unlimited number of patients	5, 2-10	25, 10-50
How many of those cancer survivors did you screen/assess for cancer rehabilitation needs? Scale 0-unlimited number of patients	0, 0-2	0/1, 0-5
Cancer rehabilitation can involve the identification of rehabilitation needs by assessing symptoms, ability to function, capacity for activity and quality of life. Do you make such assessments?^a Scale 0-10	3, 1-6	2, 0-5
Cancer rehabilitation can involve the delivery of cancer rehabilitation in a safe way based on the individual’s needs. Does the rehabilitation you deliver involve such practices?^a Scale 0-10	2, 0-5	2, 0-4
What percentage of the consulting cancer survivors (any kind of cancer) do you provide some kind of cancer rehabilitation to?^b Scale 0%-100%	20, 0-50	10, 0-25
What percentage of the consulting cancer survivors do you prescribe physical activity to or give physical activity advice to?^b Scale 0%-100%	70, 20-100	10, 0-50
Knowledge and skills
Do you perceive that you have sufficient education in cancer rehabilitation to perform cancer rehabilitation in primary care? n, (%)
Yes	16 (15)	17 (14)
No	83 (80)	93 (74)
Did not respond	5 (5)	15 (12)
Do you have knowledge regarding the physical activity recommendations for cancer survivors as suggested in the cancer rehabilitation guidelines^a median, 25th-75th percentile; Scale 0-10	0, 0-3	0, 0-1
Do you have the skills needed to identify cancer rehabilitation needs in cancer survivors?^a Scale 0-10	5, 3-7	3, 0-5/6
Do you have the skills needed to deliver cancer rehabilitation to cancer survivors no matter what kind of cancer rehabilitation?^a Scale 0-10	3, 3-6	2, 0-5
Do you have the skills needed to prescribe physical activity or give physical activity advice to cancer survivors?^a Scale 0-10	4, 2-6	2, 0-5
Approaches, median, 25th-75th percentile
How important is it for you to be able to provide cancer rehabilitation to cancer survivors who consult you for cancer rehabilitation needs?^a Scale 0-10	8, 7-10	6, 2-9
How important is it for you to be able to prescribe physical activity or give physical activity advice to cancer survivors who consult you for cancer rehabilitation needs?^a Scale 0-10	9, 7-10	7, 4-9
Perceived organizational preconditions, median, 25th-75th percentile
How prepared do you perceive your workplace is to provide cancer rehabilitation?^a Scale 0-10	3, 2-5	2, 1-3
Do you perceive that you have sufficient time to practice cancer rehabilitation according to the needs of cancer rehabilitation?^a Scale 0-10	3, 1-5	0/1, 0-2

Definitions in the questionnaire: Physical activity: Activity that takes energy exceeding the energy normally expended in basic human metabolism and has as a target to get the individual into better physical shape; Cancer survivor: An individual who has been diagnosed with cancer and is still alive. The 5 domains of self-reported preconditions are derived from the Theoretical Domains Framework.²⁴

Rated on a numerical rating scale ranging from 0, not at all, to 10, entirely.

Rated from 0% to 100% of the consulting cancer survivors.

During the preceding 6 months, a median of 25 cancer survivors had consulted the healthcare center practitioners, and rehabilitation needs had been screened for a median of 0 times. They had provided cancer rehabilitation to a median of 10% of the consulting cancer survivors, and 16% (n = 8) reported providing cancer rehabilitation to at least 50% (Table 2). Among rehabilitation practitioners, 62% (n = 40) had provided physical activity advice to at least 50% of consulting cancer survivors, whereas the corresponding figure among healthcare center practitioners was 29% (n = 14; Table 2).

The most frequently identified conditions by both rehabilitation practitioners and healthcare center practitioners were poor general physical condition and muscle strength, post-cancer therapy pain, and psychological issues. Rehabilitation practitioners also identified cognitive impairments and lymphedema, whereas healthcare center practitioners identified poor nutritional status.

According to the qualitative data, both rehabilitation practitioners and primary healthcare center practitioners reported that few cancer survivors were referred from specialized care or sought cancer rehabilitation on their own initiative, which they perceived as a major reason for their limited provision of cancer rehabilitation, particularly physical activity advice. Rehabilitation practitioners stated that patients often appear unaware that primary care can provide support for cancer rehabilitation. They emphasized that, without better patient information, effective cancer rehabilitation is difficult to deliver. In addition, assessing rehabilitation needs is easier when written referrals containing relevant health information are provided, rather than when patients—who may lack insight into their condition—seek care on their own.

“Maybe more information is needed for patients to seek help themselves, or alternatively referrals, so that the needs become clear” (Rehabilitation practitioner)

Healthcare center practitioners perceived that they rarely saw cancer survivors soon after the completion of cancer treatment. Patients typically contacted primary care for other concerns that occupied the entire visit; however, practitioners often considered these issues to be related to the patient’s cancer.

Knowledge and Skills in Cancer Rehabilitation

Among the rehabilitation practitioners and the healthcare center practitioners, 80% and 74%, respectively, reported having insufficient education in cancer rehabilitation. Almost all respondents, 95% (n = 75) of the rehabilitation practitioners and 94% (n = 50) of the healthcare center practitioners, stated that they had not read the cancer rehabilitation guidelines.² Rehabilitation practitioners rated their skills in identifying rehabilitation needs at a median of 5, and their skills in providing cancer rehabilitation at a median of 3. The corresponding figures for healthcare center practitioners were 3 for identifying rehabilitation needs and 2 for providing cancer rehabilitation (Table 2).

The rehabilitation practitioners and healthcare center practitioners stated they completely lacked knowledge about the physical activity recommendations for cancer survivors presented in the cancer rehabilitation guidelines,² that is, they rated their knowledge to be median 0 (Table 2). The rehabilitation practitioners rated their skills to give advice regarding physical activity to be 4 on a scale of 0-10 (0 = lowest). The corresponding figure for the healthcare center practitioners was 2 (Table 2).

According to the qualitative responses, both rehabilitation and healthcare center practitioners perceived that the low number of patients consulting them for cancer rehabilitation limits their skill development. Consequently, they expressed concerns about their lack of experience and knowledge regarding the side effects and restrictions associated with cancer therapy. The rehabilitation practitioners perceived themselves as having a high degree of general knowledge about rehabilitation as well as experience in it. A desire to learn more, along with opportunities for further education, was perceived as facilitating the delivery of cancer rehabilitation. The healthcare center practitioners stated that being informed, gaining knowledge and education as well as practicing their skills facilitated. Healthcare center practitioners specifically regarded insufficient knowledge and skills as barriers to implementing cancer rehabilitation. They also believed that, without simultaneous changes in how they perceived the organizational conditions, education alone would be ineffective, as they rarely encounter these patients.

“Knowledge is perishable, seldom seeing [cancer survivors] makes it ineffective” (Healthcare center practitioner)

The rehabilitation practitioners considered themselves especially proficient in involving physical activity within rehabilitation efforts in non-cancer patient populations. This knowledge was important when giving physical activity advice to cancer survivors. Having a desire to know more and the possibility to get further education was considered by them as facilitating factors for the implementation of physical activity in cancer survivors.

“I already have a good amount of knowledge regarding physical activity and training that is applicable” (Rehabilitation practitioner)

The rehabilitation practitioners described that they do not use a specific counseling approach when giving physical activity advice to cancer survivors, which was seen as a barrier for compliance.

The healthcare center practitioners stated that being informed, gaining knowledge and education as well as practicing their skills were facilitators. The lack of knowledge within the primary care center and not possessing the right skills was regarded by the healthcare center practitioners as barriers to the implementation of physical activity. They perceived that education would be ineffective unless organizational preconditions were also improved, as they rarely encounter cancer survivors seeking advice in primary care.

Approaches Regarding Cancer Rehabilitation

Rehabilitation practitioners rated the importance of cancer rehabilitation in general as 8 and the importance of providing physical activity advice to cancer survivors as 9 (median values). The corresponding median values among healthcare center practitioners were 6 and 7, respectively (Table 2).

According to the qualitative responses, the rehabilitation practitioners’ approaches toward cancer rehabilitation were described as a part of the work culture. Their interest and curiosity facilitated and motivated the work. They place the patients’ needs first and strive to support them to help themselves. Working with fragile patients was perceived to encourage them to work with implementation of cancer rehabilitation. Meeting cancer survivors gave them energy. It was important to feel joy and inspiration. A good atmosphere at the workplace, a positive approach, a willingness to change, courage, self-efficacy and an interest in transdisciplinary work in integrated care were perceived as facilitating factors.

The rehabilitation practitioners described the work culture to affect their approaches toward giving physical activity advice to cancer survivors. If the practitioner was interested, dedicated and curious, that facilitated and motivated physical activity implementation. They perceived that a low interest in oncology among the practitioners is a barrier for relevant physical activity advice. Advice regarding physical activity was general rather than specifically tailored to cancer rehabilitation needs. They attributed this to the perception that cancer rehabilitation is overly complex and that cancer is treated in other clinical settings.

Healthcare center practitioners described referrals to primary care rehabilitation centers as easy, whereas they perceived difficulties in interprofessional collaboration across levels of care. They surmised that this may be because cancer rehabilitation issues are regarded as too complex, cancer therapies are provided by other clinics, and there are competing priorities and numerous ongoing projects. Therefore, they found it difficult to work with the implementation of cancer rehabilitation as well. Furthermore, their colleagues’ negative approaches dampened their motivation regarding new duties. The healthcare center practitioners stated that primary care centers cannot assume the duties and services of other clinics.

“Our scope of services is already too large; we can’t take on other clinics services” (Healthcare center practitioner)

Healthcare center practitioners stated that physical activity advice could always be provided in general terms, as it is integral to rehabilitation across populations.

“We meet many people with ongoing and completed cancer therapies. Advice on physical activity is something we can always give” (Healthcare center practitioner)

The healthcare center practitioners, however, considered that the rehabilitation center was best suited for this task and that the clinic that conducts cancer therapy should also be responsible for their rehabilitation.

Perceived Organizational Preconditions Regarding Cancer Rehabilitation

Rehabilitation practitioners rated the preparedness of their workplace for cancer rehabilitation practices at a median of 3 and gave a median rating of 3 for having sufficient time to practice cancer rehabilitation at their workplace. The corresponding median values among healthcare center practitioners were 2 for preparedness and 0 (no time at all) for sufficient time (Table 2).

According to the qualitative descriptions, both rehabilitation practitioners and healthcare center practitioners were uncertain whether cancer rehabilitation falls within the scope of primary care or specialized oncology care. They described a need for additional funding, better use of existing staff, and recruitment of psychologists and other allied health professionals to allow more time for cancer rehabilitation. A management mandate for team-based work, supportive leadership that prioritizes guidelines, and close collaboration with other clinics were considered facilitators. Rehabilitation practitioners further noted that implementation would have been easier if cancer rehabilitation had been part of an established project and if greater financial compensation were available.

“The primary healthcare centers should have a physiotherapist, occupational therapist and psychotherapist all in the same location; it would be good if teamwork could be a standard way of working with these patients” (Rehabilitation practitioner)

Rehabilitation practitioners stated that late referrals to the rehabilitation center complicated rehabilitation planning. Limited referral options for prescribed physical activity and restricted access to medical consultants further hindered effective work with cancer survivors’ physical activity. Cancer rehabilitation was also perceived to be facilitated by patients living close to the care facility. As home-based consultations are no longer permitted in primary care, practitioners reported missing the broader context of the rehabilitation process.

Healthcare center practitioners perceived that cancer rehabilitation in primary care lacks dedicated funding and a clear organizational structure due to low managerial priority. They described increasing workloads despite limited resources, as well as implementation barriers related to unclear collaboration between clinics and municipalities, insufficient internal cooperation among physicians and nurses, and limited access to key professions such as psychologists. Participants emphasized the need for increased government funding to support the expanded scope of primary care services and noted that physician visits should be prioritized for higher-urgency issues rather than cancer rehabilitation.

“Difficult because more and more services are being designated to primary care. While at the same time resources are so very limited.” (Healthcare center practitioner)

Healthcare center practitioners perceived that additional resources, including funding, staff, and appropriate training facilities for individual and group exercise, would facilitate the implementation of physical activity advice.

Primary Care Healthcare Practitioners’ Inclination to Answer Questions Regarding Cancer Rehabilitation

Of the 168 rehabilitation practitioners invited to the questionnaire on cancer rehabilitation, 104 (62%) expressed interest in participating. Among the 1055 invited healthcare center practitioners, 125 (12%) did so.

Discussion

This study found that primary care practitioners’ self-reported preconditions—including practices, knowledge, skills, approaches, and perceived organizational support—for cancer rehabilitation and physical activity advice were inconsistent in the studied context. Facilitators of the implementation were that providing cancer rehabilitation was considered important, and that practitioners were experienced in rehabilitation and physical activity counseling in non-cancer populations. To have committed and motivated co-workers facilitated a positive work culture for cancer rehabilitation. Primary barriers were the limited knowledge and skills and perceived unsatisfactory organizational preconditions, shaping an uncertainty on if primary care has any responsibility for cancer rehabilitation. Many rehabilitation practitioners appeared willing to answer questions on cancer rehabilitation, whereas few healthcare center practitioners were interested or had time to do so.

These findings can be viewed from multiple perspectives. From the patient perspective, the infrequent practice of cancer rehabilitation—such as screening for needs and providing interventions—suggests that many survivors may have unmet needs with potential health and socio-economic consequences,^1,5 consistent with previous reports.⁷ From the practitioner perspective, participants considered cancer rehabilitation and physical activity important but reported limited knowledge and skills, and uncertainty about primary care’s responsibility. Physical activity advice has been linked to practitioners’ knowledge and confidence,³⁰ yet few were aware of cancer rehabilitation guidelines,² and only 5% had read them, leaving them without guidance on recommendations for survivors. This aligns with prior findings in oncology care, where most providers acknowledge the importance of physical activity counseling but lack knowledge on how to implement it.^30
-33 According to implementation science, awareness and understanding of guidelines may not suffice if practitioners are unaware or do not agree with them.²³ Our findings indicate a need for structured implementation strategies^21
-23 to strengthen primary care practitioners’ preconditions for supporting cancer survivors. From a theoretical perspective, routine implementation of cancer rehabilitation guidelines² could benefit from frameworks such as the Theoretical Domains Framework.²⁴ Rehabilitation practitioners indicated that conducting such an implementation project would have facilitated the integration of cancer rehabilitation guidelines into routine practice.

When discussing the described barriers and facilitators, implementation of cancer rehabilitation guidelines² in primary care is influenced by multiple factors. Characteristics of the guidelines themselves, such as clarity and relevance, and characteristics of the target population may affect implementation.^4,6,34
-37 Practitioner factors—including motivation awareness, prior experience, knowledge, skills, and attitudes—also play a role, as do environmental and perceived organizational factors such as time constraints, support, and team culture.^24,36,38 Our study highlights barriers across these domains, including doubts about treating cancer survivors, perceived complexity, resource limitations, and role ambiguity. Successful implementation may require structured strategies,^{6,8,21,23,24,36,39
-42} engagement and motivation of practitioners,⁴⁰ and managerial support to establish a team-based rehabilitation friendly work culture.^39
-42 Greater collaboration between healthcare sectors and a broader perspective on rehabilitation needs are also warranted to prevent unmet needs and poorer outcomes for cancer survivors.^7,39,41,42

In the studied Swedish primary care setting, nearly two-thirds of rehabilitation practitioners and only 1 in 10 healthcare center practitioners participated in the questionnaire on cancer rehabilitation. This difference likely reflects greater professional interest among rehabilitation practitioners, who work specifically with rehabilitation. The low participation of healthcare center practitioners aligns with qualitative findings regarding the unclear role of primary care in cancer rehabilitation²⁵ and may also be explained by high workload and time constraints, particularly among physicians and nurses.^{25,35,37,43
-45} Assessing practitioners’ interest was considered important, as engagement is a prerequisite for behavior change.³⁸

Methodological Considerations

The study’s strengths include data collection guided by the Theoretical Domains Framework^24,27 and a convergent mixed-methods design.²⁶ Quantitative and qualitative data were analyzed separately using appropriate methods and then integrated to validate findings and achieve a more complete understanding. The questionnaire was pilot-tested for validity.^24,27 Although self-reported questions are cost-effective for large samples, they carry risks of recall bias, misunderstanding, or misestimation; clear definitions were provided to mitigate this. Practitioners responded anonymously to encourage disclosure of perceived shortcomings in rehabilitation practices. Qualitative responses were sometimes brief but sufficient to enrich understanding. Deductive content analysis²⁸ was conducted independently of the studied centers and validated by the last author,²⁹ enhancing trustworthiness.

Study Limitations

While the response rate among rehabilitation practitioners was considered as good,^43
-45 the low participation^43
-45 of healthcare center practitioners is a limitation that may introduce selection bias. The sample should be considered purposeful rather than consecutive due to high attrition. Lack of information on non-responders may lead to over- or underestimation of practitioners’ practices, knowledge, skills, approaches, and perceived organizational preconditions. Generalizability beyond primary care is limited.

Conclusions

Footnotes

Acknowledgements

We wish to thank the participating primary care healthcare practitioners at the healthcare centers and the rehabilitation centers for their cooperation. We thank PhD Maria Landén Ludvigsson in memorial for contributions to study design and data collection, professor Per Nilsson for advice during planning, and the pilot test practitioners for their participation.

ORCID iD

Anna Efverman

Ethical Considerations

In accordance with national laws, the study followed the advisory statement of an Ethical Review Board (protocol number: Umeå 2018/423-31, date 2018-12-04) before data collection began. The study was conducted in accordance with the Declaration of Helsinki.

Consent to Participate

All participants were informed that participation was voluntary, that data would be reported at the group level or categorized into themes to ensure confidentiality, and that they could withdraw at any time. All participants gave written informed consent.

Author Contributions

M.L. and A.E contributed to the study conception and design. Material preparation and data collection were performed by A.E. The data analyses were performed by A.E and M.L. The manuscript was written by A.E and M.L, who both read and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the County Council of Östergötland (grant number NA), the Medical Research Council of Southeast Sweden (grant number FORSS-612191; FORSS-612041), and the University of Gävle (grant number NA).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data underlaying this paper may be available upon request to the corresponding author.

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