Barriers to utilisation of cancer rehabilitation from the expert's view: A cross‐sectional survey

4.1 Results and implications

We investigated various barriers influencing the application and utilisation of cancer rehabilitation based on a large sample of professional experts involved in the process of counselling, decision-making and referral to cancer rehabilitation in Germany. The health care professionals rated the various factors based on their experience with the patients in their professional field. Problems with the admission of multimorbid patients in rehab centres, difficulties of patients with a migrant background in understanding the application process, complicated application procedures as well as patients' coping strategies and negative beliefs about the effects of rehabilitation were rated as the most relevant individual barriers. These findings were underscored by the results of a factor analysis detecting an insufficient coordination and the patients' coping style as the two factors with the highest mean values. Conversely, the factor low appreciation of rehabilitation by medical professionals had the lowest mean value. When the different professional groups were compared to each other, statistically significant differences concerning the ratings of the barriers could be found, but the effect sizes were mostly small (Cohen, 1988).

As a conclusion, we found a number of barriers that from the point of view of experts involved in the cancer rehabilitation process in Germany may obstructing rehabilitation utilisation. The fact that our findings mainly implicate the patients' coping style and an insufficient coordination is in line with the findings of publications investigating these barriers to utilisation of rehabilitation from the patients' point of view. In these studies, an avoidant coping style has also been found to function as a barrier (Handberg et al., 2015; Miedema & Easley, 2012). Notably, in one recent quantitative publication, items relating to patients viewing rehabilitation as unnecessary or unhelpful also received the highest values (Deck et al., 2018). This accordance of patient-centred and expert-centred studies lends credibility to the notion that the patients' coping style could be the most influential barrier to utilisation of cancer rehabilitation.

From these findings, some suggestions for diminishing the effect of said barriers can be derived. For instance, in order to address the patients' coping style, one could try providing the patients with more information about rehabilitation and promoting its potential benefits. As an example, the patients' worries of being burdened by other patients, their doubts about the helpfulness of rehabilitation and their desire for living a normal life instead of consciously dealing with the disease could be addressed by investing in patient education about cancer rehabilitation and its effects (Eakin & Strycker, 2001; Silver et al., 2018; Stubblefield, 2017).

Additionally, our results can be interpreted in the way that efforts aiming at facilitation and a better coordination of the referral of patients could be helpful to enable more patients to participate in rehabilitation. For example, it emerged that patients can “get lost” to rehabilitation when the application process is not initiated in time due to early discharge from clinics or because of the fact that completion of the adjuvant treatment is difficult to predict. Comparable barriers resulting from insufficient care coordination have also been reported by other authors (la Cour & Cutchin, 2013; Nwosu et al., 2012; Walsh et al., 2010). As a remedy for these problems, too strict deadlines during the application process could be alleviated, accessibility of the rehab funders could be improved in order to resolve emerging problems in time, and complicated application forms could be simplified. Also, collaboration between different institutions like clinics and family physicians could be facilitated via the implementation of multidisciplinary team meetings (MDTs), ensuring that the responsibility that somebody initiates the application procedure does not get lost between the various actors (Walsh et al., 2010).

Furthermore, the items describing patients with a migrant background as having difficulties understanding the application process and more often rejecting rehabilitation received high mean values. This finding coincides with publications by other authors reporting ethnic minorities to be underrepresented in cancer rehabilitation (Kristiansen et al., 2015; la Cour & Cutchin, 2013). Therefore, measures to make cancer rehabilitation more inclusive should be established.

In addition to examining which barriers were rated to be the most obstructing by the whole sample, we also examined whether statistically significant differences between the ratings of the professional groups existed. This was the case for six of our seven scales. The biggest effect sizes were discovered in case of the two factors rated to be the least important by the participants: low appreciation of rehabilitation by professionals and patients' social responsibilities. Conversely, in case of the two factors rated to be the most hindering, the insufficient coordination and the patients' coping style, no effect, respectively a small effect of the professional group was found, because the mean values were comparatively high in all groups. This can be interpreted in the way that between the professional groups a consensus emerged which barriers should be considered the most obstructing. In accordance with that, we could not find evidence of a general disregard for the negative impact of the given barriers in one group of professionals, which would have shown as a pattern of one group generally having lower mean values. The differences which we found rather seem to reflect the specialisations, or possibly the particular blind spots, of the various professions. For example, the social workers with their expertise related to the regulations of the application process considered the insufficient application procedure as less obstructing than all other groups.

4.2 Strengths and limitations

An important strength of our study is the mixed methods approach. The questionnaire is based on the qualitative part of the study (Dresch et al., 2021), leading to a diverse and comprehensive set of items. In the quantitative part, we were able to recruit a large and varied sample of various health care professionals involved in the referral process all over Germany, enabling us to carry out rigorous statistical analyses with the necessary reliability. Despite our efforts we could not achieve a more balanced distribution of professionals in health care, especially with respect to the specialists in oncology. Regardless of some limitations in that regard, we still consider our sample to be large and varied enough for a cautious generalisation the results.

The inclusion of the “do not know” option in the questionnaire was bound to lead to a relatively large number of missing values for some of the items, because not all professional groups surveyed are equally involved in all of the procedures leading to oncological rehabilitation in Germany. However, we consider the chosen approach to be more beneficial compared to drastically reducing the number of investigated barriers or forcing a choice and risking higher dropout.

Furthermore, in the factor analysis there were substantial double loadings in some cases, leading to lower values for Cronbach's alpha in some of the scales. We would argue that these shortcomings are acceptable, since the factors were not constructed in order to enable a precise measurement of a psychological construct in an individual, but rather as a way to reduce our data to meaningful types of barriers, as well as to allow for a ranking and intergroup comparison of these factors. Moreover, a certain overlapping is to be expected, since for instance the application procedure and the coordination in the clinics are related to a certain degree.

Finally, the design of our questionnaire sometimes asked of the participants to indicate their views on behaviour and experiences of patients and other professionals in healthcare. Therefore, some of our results reflect primarily the participants' beliefs and attitudes about the thoughts or motivations of other people (e.g., in case of the coping style a fear on the part of the patients of being forced to face their disease) and may not be over-interpreted. As a remedy, instead of taking the ratings of the experts as completely “factual” and educating the patients accordingly, shared decision making (Légaré & Witteman, 2013) could be a means to ensure that both the patients' preferences and their coping strategies are accounted for. Furthermore, as already pointed out, our findings are mostly in line with the results from patients' studies.

4.3 Conclusion

Our paper supports the findings of previous publications from the patients' perspective, with the professionals in health care queried by us also evaluating the patients' coping style as the most important barrier to utilisation of cancer rehabilitation. Beyond that, by focusing on professional experts involved in the referral process, we found evidence for the effect of barriers relating to processes and organisational issues, as for example an insufficient coordination. Therefore, the improvement of multidisciplinary coordination seems required. Moreover, we concluded from our findings that investing in patient-centred information, patient education and shared decision-making might facilitate and optimise the referral of cancer patients to rehabilitation. In addition, measures making cancer rehabilitation more inclusive with regard to patients with a migrant background should be adopted.

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