Barriers and facilitators for healthy lifestyle and recommendations for counseling in endometrial cancer follow-up care: a qualitative study

Figures & data

Figure 1. Behavior change wheel, including COM-B components (green), TDF domains (red) and intervention functions (red) [22].

Table 1. Codebook, generated both inductively and deductively.

Behavior
Capability	Opportunity	Motivation
Physical skills Behavior regulation Knowledge Cognitive and interpersonal skills Memory, attention and decision processes Behavioral regulation Emotion regulation^a	Social influences Physical environmental context Health care environmental context^a Resources	Social and professional role and identity Vulnerability^a Intentions Goals Beliefs about consequences Beliefs about capabilities Emotions Reinforcements

Top two rows: COM-B model; bottom row: TDF domains.

^a Inductive codes.

Table 2. Patient characteristics.

Patient characteristics (N = 18)	n (%)
Age at time of recruitment
50–59	6 (33.3)
60–69	4 (22.2)
≥70	8 (44.4)
FIGO stage
I	11 (61.1)
II	7 (38.9)
Partner status^a
Partner	15 (83.3)
No partner	3 (16.7)
Level of education
Primary	1 (5.6)
Secondary	7 (38.9)
Higher	10 (55.6)
Primary treatment
<1 year ago	10 (55.6)
≥1 year ago	8 (44.4)
BMI^b (kg/m^2)
Normal (18.5–24.9)	2 (11.1)
Overweight (25.0–29.9)	5 (27.8)
Obese (≥30.0)	11 (61.1)
Radiotherapy
Yes	2 (11.1)^Table Footnotec
Co-morbidities^d
None	3 (16.7)
1	5 (27.8)
≥2	10 (55.6)
Smoking status
Never	9 (50.0)
Former	7 (38.9)
Current	2 (11.1)

The percentages do not always add to 100% due to rounding.

^a Partner: married or living together; no partner: divorced, widower, not married.

^b BMI ranges for adults over 20 years old, following standards of World Health Organization (WHO) [31].

^c One of the two patients received adjuvant radiotherapy for breast cancer prior to the endometrial cancer diagnosis.

^d Listed co-morbidities: arthritis, cholelithiasis, Conn’s syndrome, COPD or asthma, diabetes mellitus type 2, duodenal ulcer, heart disease, hypercholesterolemia, hypertension, mamma carcinoma, obstructive sleep apnea syndrome, radiation colitis, and hypothyroidism.

Table 3. Patient interview quotes per TDF domain.

Patient quotes	TDF domains
Capability
“I can lose 30 kilos without a dietician. No problem. Keeping the weight off, that is the problem. Dieting is not the problem. What comes after is the problem.”	Behavior regulation, memory, attention, and decision processes
“I thought that [lifestyle] does not influence it [endometrial cancer]. Obviously I know that colon cancer and certain other types have something to do with your lifestyle and eating habits. But not endometrial cancer.”	Knowledge, cognitive and personal skills
“The consequence is to again gain a lot of kilos after a few months. After that, I have not found the courage to start again.”	Emotion regulation
“Then I thought to myself: ‘I can still walk.’. You just have to leave your house and you are walking.”	Physical skills
Opportunity
“How many times have I heard: ‘First, you have to lose weight.’. From my primary care physician and a woman who took my blood pressure but apparently that is where the care ends. People have such an aversion against overweight people. Health care professionals as well, or at least the people I meet.”	Social influences
“I specifically forbid myself to do it, I will not bring something unhealthy home. I make a list of my groceries, for the whole week of everything I want to eat.”	Physical environmental context
Interviewer asked if any HCP had spoken to the interviewee about lifestyle since the cancer diagnosis. Her response: “No, not specifically, no. They told me that I could not lift anything for 6 weeks after surgery. No heavy lifting. But apart from that, nothing. You have nothing else, not something about lifestyle.”	Healthcare environmental context
“I understood [from a dietician] that if I lose only 10% of my weight, in my case about 12 kilos, that that would bring about important health benefits.”	Resources
Motivation
“In a way, they [her family] do motivate me. But we are a real family of Burgundians, which makes it hard to stick to healthy habits.”	Social and professional role and identity
“You do become more aware after you hear the word ‘cancer’.”	Vulnerability
“If they can tell me how I can maintain that weight, fine. But not if it means that I have to survive on a single salad leave. Impossible. I cannot do that. I can stick to such a diet for a few months at best but that is it.”	Intentions and beliefs about consequences
“When I started, I lost 15 kilos and gained 20. Then I lost 20 and gained 25. Again, I lost 25 kilos and gained 35 kilos. You see what I mean? That is how it goes. It is just a ‘yo-yo effect’ which cannot be stopped.”	Goals
“It is just a habit now, I do not even think about doing it anymore.”	Beliefs about capabilities
“Starting again is the hardest part. Because the disappointment, when it [building healthier new habits] fails again, should not be underestimated. Of course, that is why you lose the motivation.”	Emotions
“It is demotivating, every time I am dieting I never see it [her weight loss] in the right places, you know?”	Reinforcements

Michie S, Atkins L, West R. The behaviour change wheel: a guide to designing interventions. London: Silverback Publishing; 2014. www.behaviourchangewheel.com

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A healthy lifestyle – WHO recommendations; 2022 [cited 2022 June 11]. Available from: https://www.who.int/europe/news-room/fact-sheets/item/a-healthy-lifestyle---who-recommendations

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Data availability statement

The data that support the findings of this study are available on request from the corresponding author, AK. The data are not publicly available due to restrictions; data contain information that could compromise the privacy of research participants.