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A Survey of Therapeutic Radiographers’ Knowledge, Practices, and Barriers in Delivering Health Behaviour Advice to Cancer Patients

A Survey of Therapeutic Radiographers’ Knowledge, Practices, and Barriers in Delivering Health... Therapeutic radiographers (TRs) are well-placed to deliver advice to cancer patients; however, limited research exists on their practices in providing advice on healthy lifestyle behaviours. Through an online survey, this study aimed to explore TRs’ current practices, barriers, and facilitators around delivering healthy behaviour advice to cancer patients. An online survey was sent to 72 radiotherapy departments in the UK and 583 TRs responded to the survey. Findings showed that levels of enquiry and provision of advice on healthy behaviours were low, with less than 25% advising patients on physical activity, healthy eating, weight management, smoking cessation, and reducing alcohol intake as standard practice. Lack of knowledge, resources, and training were identified as barriers, in addition to perceived lack of patient interest and lack of time. TRs reported a strong desire to undergo training to enable them to deliver health behaviour advice to patients, with an identified preference for online training. Cancer patients look to healthcare professionals for advice on health behaviours, and TRs are well-placed to deliver this advice. The findings of this study provide insight into the areas that need addressing to enable TRs to support positive health behaviours among cancer patients. . . . . Keywords Health behaviours Healthy lifestyle Therapeutic radiography Radiation therapy Advice provision Introduction However, whilst research shows that some oncology healthcare professionals (HCPs) offer guidance to oncology Healthcare providers are expected to deliver advice on healthy patients on healthy lifestyle changes, provision remains sub- eating, weight control, physical activity (PA), limiting alcohol optimal [2–6]. In the UK, a qualitative study among ten on- consumption, and reducing smoking to all cancer patients to cology HCPs and sixteen prostate cancer patients found that reduce their risk of secondary cancers and comorbidities [1]. HCPs do not routinely provide advice on diet and PA to men This work was undertaken in the Department of Behavioural Science and Health, University College London, London, UK. The lead author was based there as a pre-doctoral research fellow. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s13187-020-01896-x) contains supplementary material, which is available to authorized users. * Nickola D. Pallin Department of Behavioural Science and Health, University College pallinn@lsbu.ac.uk London, London, UK Rebecca J. Beeken Department of Allied Health Sciences, School of Health and Social R.Beeken@leeds.ac.uk Care, London South Bank University, London, UK Kathy Pritchard Jones Leeds Institute of Health Sciences, University of Leeds, Leeds, UK k.pritchard-jones@ucl.ac.uk Nick Woznitza University College London Partners Academic Health Science Nicholas.woznitza@nhs.net Network, London, UK Abigail Fisher Abigail.fisher@ucl.ac.uk Radiology Department, Homerton University Hospital, London, UK 1 3 J Canc Educ (2022) 37:890–897 891 diagnosed with prostate cancer, with some patients unable to approved by University College London’sethics committee, recall receiving any advice on diet or PA from their healthcare reference 12945/001. team [3]. Reported barriers among oncology HCPs in deliver- ing advice on health behaviours include believing that giving Measures advice is not part of their role, lack of support and time, lack of guidelines, lack of knowledge of the evidence base, and con- The survey questions were based on a previous study carried cerns around seeming to blame the patient [2–6]. out by Williams et al. [2]. The survey (Supplementary At least 50% of those with a cancer diagnosis undergo Material) was adapted for use among TRs, with additional radiotherapy as part of their treatment [7]. Therapeutic questions added to identify the practices in delivering advice radiographers (TRs), also known as radiation therapists, are on alcohol consumption and sun safety. The questionnaire uniquely placed to deliver advice on healthy lifestyle behav- was piloted among a group of TRs working clinically (n = iours to cancer patients. Patient education is a key part of 2) and in the academic sector (n = 2). As a result of the feed- radiotherapy practice, with TRs providing care to the same back, one question designed to explore the delivery of advice patient every day, often over a number of weeks [8]. Despite on healthy eating, but which used the term ‘diet’,was this, there has been less research among TRs and the delivery amended to ‘healthy eating’. Respondents were asked to pro- of health behaviour advice. Only one study has been under- vide their professional grade, to allow for comparison with taken in the UK that investigated the current provision of public statistics on the profile of TRs in the UK. The UK advice on health behaviours including smoking, alcohol, radiotherapy radiography workforce census only reports the healthy eating, and exercise [5]. This study, through a survey workforce’s AfC band, also known as professional grade, and (n = 102), found that levels of advice provided to patients on do not report any other demographics [11]. Therefore, to allow these topics were low [5]. No research has been undertaken to for comparison with public statistics, respondents were asked assess TRs’ barriers to providing health behaviour advice for to provide their AfC band and no other demographics were cancer patients, and how to address these. Therefore, this collected. study aimed to explore TRs’ current practices, knowledge, barriers, and facilitators around delivering healthy behaviour Analyses advice to cancer patients. Therapeutic radiographers’ needs and preferences in terms of training on this topic were also The survey responses were analysed using descriptive statis- explored. tics with the statistical package SPSS version 25. Missing data were recoded as ‘unknown’ for analyses to include as many respondents as possible. To assess whether awareness of life- style guidelines was related to the provision of advice on each Methods health behaviour, a multinomial logistic regression model was carried out. The dependent variable was each level of advice Participants and Recruitment provision (advice provided to no patients/advice provided to 1–25%/26–50%/51–75%/> 75% of patients). Respondents’ TRs and assistant practitioner TRs in the UK working within professional grade was added as covariates to each of these the cancer care setting were invited to take part in an online models. Data obtained from the open-ended questions were survey. Practising TRs in the UK have completed a recognised transferred into qualitative data analysis software (NVivo, ver- degree to meet the standards of proficiency for a band 5 agen- sion 12) and coded line by line. The open responses from each da for change (AfC) radiographer and are registered with the question were grouped together and analysed to identify any Health and Care Professions Council (HCPC) [9]. An assistant patterns or themes. A deductive approach to analysis was un- practitioner is a non-registered practitioner but performs dertaken using the content analysis process [12]. Themes are protocol-limited clinical tasks under the direction and super- presented in the results with supporting quotes and the partic- vision of a state-registered TR practitioner, and works within a ipant’s AfC band. band 4 AfC definition [10]. In the UK, the professional grade of TRs is defined by AfC, from band 5 to band 8 which reflect an individual’s professional skills, responsibilities, and job- Results related knowledge [10]. From August 2018 to April 2019, a link to an online survey was emailed to 72 radiotherapy de- Response Rate partments in the UK and cascaded through the mailing lists within each department. Participants were made aware that by The exact response rate is unknown because the link to the completing the survey, they were providing informed consent survey was cascaded independently within each radiotherapy for the use of their data for this research. This study was department. However, according to the 2019 census of the UK 1 3 892 J Canc Educ (2022) 37:890–897 radiotherapy workforce [11], there are 3392 TRs in the UK. Levels of Enquiry The survey was started by 583 TRs who answered at least one question, and therefore, the responses are representative of The proportion of patients seeking advice on health behav- 17% of the radiotherapy workforce in the UK. Of these 583, iours reported by the respondents is shown in Table 1. 367 (63%) completed all of the survey questions. The results Patients seeking advice was highest for sun safety, followed are reported in percentages of those who answered the corre- by alcohol intake and healthy eating. Patients seek advice sponding question. In total, 662 individual open-response about smoking, weight management, and PA less frequently. qualitative comments were analysed. Table 1 shows the proportion of respondents who reported enquiring about each health behaviour and providing advice. Less than 20% of TRs reported advising patients on healthy Agenda for Change Band eating, weight management, smoking cessation, and reducing alcohol intake to more than 50% of their patients. Twenty-four One percent (n = 6) were band 4 assistant practitioner TRs, percent reported advising patients on PA to more than 50% of 23% (n = 128) were band 5 TRs, 31% (n =174) wereband 6, their patients, with TRs enquiring and advising on sun safety 30% (n =168) wereband 7, and15%(n = 88) were band 8 more frequently than other health behaviours. TRs. Beliefs on Role Responsibilities Familiarity with Guidelines Eighty-nine percent (n = 399) thought providing healthy life- Seventy six percent (n = 344) were aware of some guidelines style advice was part of their role. Of those who said no (11%; for cancer patients on health behaviours. Awareness was n = 51), analysis of the open-ended questions showed that the highest for smoking cessation guidelines (69%; n =312) and main reasons were believing that advice provided within their lowest for weight management guidelines (31%; n = 140). role should only be related to the impact on radiotherapy de- livery or radiotherapy–related side effects. For example, one Table 1 Proportion of patients seeking health behaviour advice and respondent commented ‘Give advice on how it can impact TRs enquiring and advising on health behaviours treatment, i.e. smoking, but not on alternative to stop smoking etc. … just to stop 2 hours before and after RT’ (Band 6 TR). None 1–50% > 50% Other reasons were lack of knowledge, lack of time, and be- The percentage of TRs reporting the percentage of patients seeking advice lieving that the delivery of lifestyle advice is the responsibility (N =435) of other members of the multidisciplinary team (MDT). One Physical activity 25% 67% 8% respondent commented ‘I feel it is not specific to our role to Healthy eating 26% 62% 12% provide healthy lifestyle advice. There are more specially Weight management 46% 47% 7% trained members of the MDT’ (Band 6 TR). Smoking cessation 44% 53% 3% Alcohol intake 23% 62% 15% Beliefs on Having the Skills and Knowledge to Deliver Sun safety 25% 56% 19% Health Behaviour Advice The percentage of TRs who report enquiring about health behaviours (N = 420) Of all the health behaviours, sun safety was the topic that most Physical activity 28% 48% 24% TRs (80%; n = 323) felt they had the skills and knowledge to Healthy eating 34% 47% 19% deliver advice on, followed by PA (59%; n = 238), smoking Weight management 47% 39% 14% cessation (54%; n = 218), healthy eating (53%; n = 214), and Smoking cessation 27% 48% 25% alcohol intake (52%; n = 210). Providing advice on weight Alcohol intake 24% 53% 23% management was the topic respondents felt they had the least Sun safety 17% 44% 39% amount of skills and knowledge to deliver advice on (36%; n The percentage of TRs who report advising patients on health behaviours = 145). The main theme from the open-ended responses was (n =408) TRs particularly felt unqualified and lacked knowledge of Physical activity 22% 54% 24% guidelines on the topic of healthy eating. One TR commented Healthy eating 31% 52% 17% ‘I feel unqualified to give specific healthy eating advice with Weight management 35% 47% 18% differing opinions on diets such as dairy free, red meat free Smoking cessation 29% 55% 16% etc.’ (Band 7 TR). Another respondent wrote ‘Iam aware of Alcohol intake 28% 54% 18% what constitutes as healthy eating, but lack confidence in my Sun safety 11% 46% 43% knowledge of published guidelines’ (Band 7 TR). 1 3 J Canc Educ (2022) 37:890–897 893 Sixty percent (n = 271) were aware of guidelines for sun safety delivering advice on healthy eating (44%; n = 166) and weight (60%; n =271), 52%(n = 235) were aware of guidelines for management (41%; n = 155). For smoking and alcohol intake, alcohol intake, 48% (n = 217) were aware of PA guidelines, perceived lack of patient interest was the most frequently re- and 44% (n = 199) were aware of healthy eating guidelines. ported barrier in delivering advice on these topics, 45% and Seventy percent (n = 315) of respondents were unable to recall 41%, respectively. Lack of time as a barrier was commonly the source of the guidelines. Of those who could recall a reported for all health behaviours (Table 3). guideline, Macmillan Cancer Support was the most common- Qualitative comments gave further insight into TRs’ bar- ly mentioned resource (n = 55) followed by in house depart- riers in delivering advice, most commonly lack of training and mental guidelines (n =23). knowledge. ‘We are given very little training/guidance on As shown in Table 2, awareness of guidelines for each how to approach and advise on these issues but I believe we health behaviour was associated with increased likelihood of should’ (Band 7 TR). One TR wrote ‘Topics aren’tcovered at TRs enquiring about patients’ lifestyle behaviours and provid- University level so the background knowledge and confidence ing advice for all health behaviours. The baseline was the to discuss isn’tthere’ (Band 5 TR). Risk of patients’ changing provision of no advice on health behaviours. Awareness of body shape affecting the accuracy of radiotherapy treatment guidelines was associated with increased likelihood of provid- was also a reported barrier. ‘Maintaining healthy weight (los- ing advice on PA to more than 75% of patients [odds ratio ing weight or gaining weight) is not appropriate during treat- (OR) = 5.61; 95% confidence interval (CI) 2.57–12.3, P < ment as weight should be maintained post CT scan in order to 0.001], healthy eating [OR = 4.11 (95% CI 1.51–11.23), P < deliver accurate treatment, therefore I feel it is an issue to 0.01], weight [OR = 3.18 (95% CI 1.43–7.04), P < 0.01], tackle afterwards’ (Band 5 TR). Additionally, one theme that smoking [OR = 3.13 (95% CI 1.26–7.79), P < 0.05], alcohol emerged from the comments was the belief that advice on [OR = 2.61 (95% CI 1.19–5.75), P < 0.05], and sun [OR = healthy eating may exacerbate treatment–related side effects 2.85 (95% CI 1.39–5.85), P <0.001] (Table 2). ‘Healthy eating advice is not always appropriate for patients receiving treatment in certain areas e.g. for pelvis treatment where high fibre intake may exacerbate symptoms’ (Band 6 TR). Barriers to Providing Advice Table 3 shows the reported barriers in providing health behav- Facilitators to Providing Advice iour advice. Patients being too frail or ill were the most com- monly reported barrier to delivering advice on PA (45%; n = Of those who answered the question (n = 375), online training 170) followed by perceived lack of patient interest (42%; n = (73%; n = 273) was the most commonly requested support for 157), and not knowing the guidelines (41%; n = 156). Not facilitating the delivery of lifestyle advice. This was followed knowing the guidelines was the most common barrier to by the provision of referral pathways for lifestyle support Table 2 Associations between awareness of health behaviour guidelines and level of enquiry and advice provision on each health behaviour Physical activity Healthy eating Weight management Smoking cessation Alcohol intake Sun safety OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Level of enquire about lifestyle (N =420) Ref = none 1–25% 1.11 (0.66–1.86) 1.00 (0.59–1.68) 2.09 (1.25–3.49)* 2.08 (1.26–3.46)* 1.3 (0.78–2.16) 2.36 (1.27–4.39)** 26–50% 2.28 (1.24–4.17)** 2.079 (1.18–3.66) 4.50 (2.28–8.92)*** 1.97 (0.95–4.07) 2.14 (1.16–3.97)* 2.73 (1.44–5.16)** 51–75% 2.70 (1.34–5.46)** 4.03 (1.97–8.23)*** 2.68 (1.21–5.98)* 2.05 (0.93–4.52) 2.09 (1.04–4.21)* 1.98 (1.01–3.87)* > 75% 4.01 (1.99–8.07)*** 5.44 (2.35–12.56)*** 4.25 (1.81–9.97)*** 5.35 (2.42–1.84)*** 2.15(1.07–4.32)* 3.58 (1.87–6.87)*** Level of advice provision (N =408) Ref = none 1–25% 2.29 (1.29–4.07)* 1.94 (1.17–3.21)** 1.36 (0.75–2.44) 2.36 (1.44–3.88)*** 1.53 (0.94–2.49) 2.67 (1.26–5.34)** 26–50% 5.52 (2.82–10.89)*** 3.14 (1.68–5.87)*** 3.71 (1.99–6.94)*** 2.41 (1.19–4.92)* 2.87 (1.49–5.54)* 2.35 (1.12–4.94)* 51–75% 3.50 (1.78–7.23)*** 3.26 (1.62–6.55)*** 4.01 (1.98–8.48)*** 5.86 (1.93–17.88)** 7.40 (3.01–8.22)*** 2.38 (1.17–5.16)* > 75% 5.61 (2.57–12.3)*** 4.11 (1.51–11.23)** 3.18 (1.43–7.04)** 3.13 (1.26–7.79)* 2.61 (1.19–5.75)* 2.85 (1.39–5.85)** A multinomial logistic regression model with awareness of lifestyle guidelines (Y/N) and level of enquiry and advice provision (none/1–25% of patients/ 26–50% of patients/51–75% of patients/> 75% of patients) as the dependent variable Ref: Reference category no advice = provide advice to no patients OR odds ratio, CI confidence intervals *P <0.05; **P < 0.01; ***P <0.001 1 3 894 J Canc Educ (2022) 37:890–897 Table 3 Barriers among TRs in providing health behaviour advice (N =378) Physical activity (%) Healthy eating (%) Weight Smoking (%) Alcohol (%) Sun safety (%) management (%) Not knowing the guidelines 41 44 41 25 31 22 Not knowing what to say 17 18 28 21 21 7 Lack of time 39 36 34 33 33 30 Do not think part of role 11 12 16 7 8 4 Don’t know where to refer patients to 29 17 23 19 25 19 Lack of patient interest 42 36 30 45 41 28 Seeming to blame patient 10 14 21 26 22 5 Not convinced it affects cancer outcomes 2 2 2 1 2 1 Patient being too frail or ill 45 24 25 25 21 19 (69%; n = 259) and education resources for patients within the are expected to deliver nutrition and lifestyle advice [14, 15]. department (64%; n = 239). Sixty-one percent (n =229) re- It is only in recent years that TRs have been recognised as a ported that in house training (61%; n = 229) would be helpful, key healthcare member in delivering health behaviour advice as well as role expansion (50%; n = 189) and mandatory [16] and this may explain why self-reported delivery of continuous professional development (CPD) training (39%; healthy lifestyle advice is higher among oncology HCPs in n = 147). The qualitative comments from the open-ended re- previous studies. Data collected from oncology HCPs have sponses further highlighted the role of training both in the pre- most commonly identified lack of knowledge, confidence, registration and post-registration setting in facilitating TRs’ to and skills as barriers to the delivery of health behaviour advice deliver health behaviour advice. ‘Inclusion in degree as part of [2–4], in addition to lack of time, perception that patients lack advice giving during practical’ (Band 6 TR). Another TR interest, patient being too frail or ill, and believing they are not wrote ‘Would be nice to have staff take a mandatory module the right persons to provide advice [2–4]. This study con- to be able to personally provide the information with confi- firmed these barriers among TRs and illustrated from the qual- dence’ (Band 7 TR). Preferred topics delivered within a train- itative comments some TRs felt that lifestyle advice provided ing course were the current evidence for specific health be- within their role should only be in relation to the management haviours and cancer outcomes (91%; n = 339), followed by of radiotherapy treatment–related side effects. information of available support and patient education re- Our qualitative data suggest that the low level of advice sources (88%; n = 327), video examples of how to deliver provision on weight management may be in part due to TRs advice (51%; n = 188), and role play of having a conversation not wanting patients to change their body shape as this can with a patient (20%; n = 76). Open-ended responses further affect the accuracy of radiotherapy treatment. In addition, as showed a preference for online training, mainly because of the reported in other studies [13], some HCPs may be hesitant to difficulties associated with permitting all staff to attend face to discuss sensitive topics such as weight management to avoid face training. ‘Face to face would take a long time for all the risk of offending patients. Therefore, TRs may need sup- radiotherapy staff to be trained unless it was done at a lunch- port and guidance with initiating and managing potentially time or out of hours with overtime to be claimed back. Part difficult conversations around lifestyle behaviour changes. In time staff may miss out if the training is not on their day to addition to identifying an appropriate time to initiate these work’ (Band 6 TR). Another respondent wrote ‘Online train- conversations, there needs to be a balance between immediate ing is good too, only if it is made mandatory’ (Band 7 TR). treatment requirements and long-term survivorship needs. Although it is well-known that continued smoking after a cancer diagnosis is associated with increased risk of cancer Discussion recurrence and higher mortality rates [17], advice on smoking cessation was low, with only 25% enquiring and 16% advis- The findings show that whilst the majority (89%) of TRs ing on smoking cessation to more than 50% of their patients. believe providing health behaviour advice to cancer patients Perceived lack of patient interest was the highest reported is part of their role, this is not matched by provision of advice. barrier in delivering advice on smoking cessation. Likewise, These results are lower than reported in previous studies in a UK study, this was reported as a barrier among TRs in among oncology HCPs [2, 13]. One explanation may be that providing smoking cessation support [6]. Considering that the participants within these studies were primarily oncolo- cancer patients show a desire and motivation to quit but often do not ask for help [18], TRs should be skilled in initiating a gists and nurses. It is well-documented that doctors and nurses 1 3 J Canc Educ (2022) 37:890–897 895 conversation around smoking cessation and referring patients be positive, with self-reported improvements in knowledge for further smoking cessation support. This is particularly im- and practices on delivering nutrition and health advice follow- portant because patients who attend smoke-free services are ing completion of an online training resource [24]. However, four times more likely to quit [19]. With perceived lack of limited web-based training exists for oncology HCPs on the patient interest a reported barrier, TRs need to be supported delivery of health behaviour advice to cancer patients, with no to use their role to initiate discussions regarding this behaviour training available specifically for TRs. This study highlights as per recommendations [1]. the need for post-graduate training on health behaviour ad- Our qualitative data suggested TRs also felt they were par- vice. However, the value of including training within the un- ticularly unqualified and lacked the skills in delivering healthy dergraduate education for TRs was highlighted, which has eating advice. Evidence is increasingly showing the relation- been identified as a requirement within the allied health pro- ship between dietary habits and cancer development and the fessions pre-registration education recommendations in the role of a healthy diet in improving cancer survival [20]. UK [25]. Additionally, this study provides insight into TRs’ Advice regarding nutrition benefits for both the general public preferences on course content, with a particular desire for and cancer survivors is often inconsistent and at times contra- dissemination of the current evidence for specific health be- dictory [21], and patients therefore need directing to informa- haviours and cancer survivorship, followed by information of tion that is reliable and underpinned by high-quality evidence. available support and patient education resources. This is particularly important given that 74% of TRs in our study estimated that their patients ask for information on Strengths and Limitations healthy eating. Less than 50% of respondents reported awareness of life- This is the largest study to explore the practices, barriers, and style guidelines for PA, healthy eating, and weight manage- facilitators among TRs in delivering health behaviour advice ment for cancer survivors. Of those who could recall a guide- to cancer patients. The results provide insight into the prac- line for lifestyle advice, Macmillan Cancer Support was the tices among TRs across all AfC professional grades. The re- most commonly mentioned resource (n = 55). In a recent spondents from each AfC grade are also representative of the qualitative study, lack of knowledge of guidelines among on- UK radiotherapy radiography workforce [11]. In the UK, 2%, cology HCPS was also highlighted, with no HCP being able to 26%, 35%, 26%, and 10% are AfC bands 4, 5, 6, 7, and 8, name specific lifestyle guidelines for cancer survivors [4]. In respectively, similar to the distribution of respondents in this the current study, TRs who were aware of guidelines for each study. The large number of qualitative comments also provid- health behaviour were also more likely to enquire and provide ed a range of views, adding further insight into TRs’ beliefs on advice on each health behaviour. Similarly, in another study, the delivery of health behaviour advice within their role. awareness of guidelines was associated with increased likeli- However, there are a number of limitations. Although all ra- hood of providing lifestyle advice [2]. This illustrates the need diotherapy departments were invited to participate, it is un- for wider dissemination of evidence-based guidelines on known if the responses are representative of all radiotherapy health behaviours and cancer survivorship in the radiotherapy departments in the UK. Additionally, the respondents may department. This need is further recognised whereby 64% of also have been more motivated to respond due to already TRs reported that the provision of education resources for having an interest in healthy lifestyle behaviours, which may patients within the department would support the provision mean TRs are less likely to provide health behaviour advice of health behaviour advice within their role. than those who completed the survey. The reported barriers within this study around lack of knowledge and skills highlight the need for training and edu- cation. This is not surprising considering that education on Conclusion providing health behaviour advice has not been an important component of the training of HCPs [22]. With the recent call The findings of this study show that the provision of health for a radical upgrade in prevention in healthcare, it is expected behaviour advice among TRs is suboptimal, despite recogni- that allied health professionals have the appropriate education tion that this is part of their role. There is a clear need for and training to deliver advice to motivate people to make training and improved education among TRs in order to en- health behaviour changes [23]. Encouragingly, TRs reported hance their delivery of health behaviour advice. It is also vital a strong desire to undergo training to enable them in delivering to support TRs in delivering advice and subsequently increas- health behaviour advice and a preference for online training ing the number of cancer patients receiving advice on improv- was identified. From the qualitative comments, TRs ing health behaviours. recognised the benefit of online learning in allowing for man- datory continuous professional development. The provision of Acknowledgements The researchers are grateful to the health profes- web-based health education for oncology HCPs has shown to sionals who participated in the study. 1 3 896 J Canc Educ (2022) 37:890–897 Author Contributions NDP had the original idea for the study and ob- 4. Koutoukidis DA, Lopes S, Fisher A, Williams K, Croker H, Beeken tained the funding with AF, RJB, and KPJ. NDP developed the design of RJ (2018) Lifestyle advice to cancer survivors: a qualitative study the study, acquired the data, analysed and interpreted the data, drafted and on the perspectives of health professionals. BMJ Open 8(3): revised the article, and approved the final manuscript submitted. AF con- e020313 tributed to the development of the study design and the recruitment ap- 5. Pattinson L, Jessop A (2016) The delivery of health improvement proach, reviewed, edited, and approved the final manuscript. RJB provid- information during radiotherapy treatment: a survey of UK therapy ed behavioural science expertise, contributed to the development of the radiographers. J Radiother Pract 15(2):114–130 study design and the recruitment approach, edited, and approved the final 6. Charlesworth L, Hutton D, Hussain H (2019) Therapeutic manuscript. KPJ provided oncology expertise and intellectual input into radiographers’ perceptions of the barriers and enablers to effective the recruitment approach and design and approved the final manuscript. smoking cessation support. Radiography. 25(2):121–128 NW contributed to the development of the study design, reviewed the 7. Borras JM, Lievens Y, Grau C (2015b) The need for radiotherapy manuscript for important intellectual content, and approved the final the in Europe in 2020: not only data but also a cancer plan. 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Accessed 20 Translating research into practice: evaluation of an e-learning re- June 2020 source for health care professionals to provide nutrition advice and support for cancer survivors. Nurse Educ Today 35(1):271–276 Publisher’sNote Springer Nature remains neutral with regard to juris- 25. Council of Deans of Health (2017) Guidance: Public Health dictional claims in published maps and institutional affiliations. Content within the Pre-Registration Curricula for Allied Health 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cancer Education Springer Journals

A Survey of Therapeutic Radiographers’ Knowledge, Practices, and Barriers in Delivering Health Behaviour Advice to Cancer Patients

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Springer Journals
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Copyright © The Author(s) 2020
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0885-8195
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1543-0154
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10.1007/s13187-020-01896-x
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Abstract

Therapeutic radiographers (TRs) are well-placed to deliver advice to cancer patients; however, limited research exists on their practices in providing advice on healthy lifestyle behaviours. Through an online survey, this study aimed to explore TRs’ current practices, barriers, and facilitators around delivering healthy behaviour advice to cancer patients. An online survey was sent to 72 radiotherapy departments in the UK and 583 TRs responded to the survey. Findings showed that levels of enquiry and provision of advice on healthy behaviours were low, with less than 25% advising patients on physical activity, healthy eating, weight management, smoking cessation, and reducing alcohol intake as standard practice. Lack of knowledge, resources, and training were identified as barriers, in addition to perceived lack of patient interest and lack of time. TRs reported a strong desire to undergo training to enable them to deliver health behaviour advice to patients, with an identified preference for online training. Cancer patients look to healthcare professionals for advice on health behaviours, and TRs are well-placed to deliver this advice. The findings of this study provide insight into the areas that need addressing to enable TRs to support positive health behaviours among cancer patients. . . . . Keywords Health behaviours Healthy lifestyle Therapeutic radiography Radiation therapy Advice provision Introduction However, whilst research shows that some oncology healthcare professionals (HCPs) offer guidance to oncology Healthcare providers are expected to deliver advice on healthy patients on healthy lifestyle changes, provision remains sub- eating, weight control, physical activity (PA), limiting alcohol optimal [2–6]. In the UK, a qualitative study among ten on- consumption, and reducing smoking to all cancer patients to cology HCPs and sixteen prostate cancer patients found that reduce their risk of secondary cancers and comorbidities [1]. HCPs do not routinely provide advice on diet and PA to men This work was undertaken in the Department of Behavioural Science and Health, University College London, London, UK. The lead author was based there as a pre-doctoral research fellow. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s13187-020-01896-x) contains supplementary material, which is available to authorized users. * Nickola D. Pallin Department of Behavioural Science and Health, University College pallinn@lsbu.ac.uk London, London, UK Rebecca J. Beeken Department of Allied Health Sciences, School of Health and Social R.Beeken@leeds.ac.uk Care, London South Bank University, London, UK Kathy Pritchard Jones Leeds Institute of Health Sciences, University of Leeds, Leeds, UK k.pritchard-jones@ucl.ac.uk Nick Woznitza University College London Partners Academic Health Science Nicholas.woznitza@nhs.net Network, London, UK Abigail Fisher Abigail.fisher@ucl.ac.uk Radiology Department, Homerton University Hospital, London, UK 1 3 J Canc Educ (2022) 37:890–897 891 diagnosed with prostate cancer, with some patients unable to approved by University College London’sethics committee, recall receiving any advice on diet or PA from their healthcare reference 12945/001. team [3]. Reported barriers among oncology HCPs in deliver- ing advice on health behaviours include believing that giving Measures advice is not part of their role, lack of support and time, lack of guidelines, lack of knowledge of the evidence base, and con- The survey questions were based on a previous study carried cerns around seeming to blame the patient [2–6]. out by Williams et al. [2]. The survey (Supplementary At least 50% of those with a cancer diagnosis undergo Material) was adapted for use among TRs, with additional radiotherapy as part of their treatment [7]. Therapeutic questions added to identify the practices in delivering advice radiographers (TRs), also known as radiation therapists, are on alcohol consumption and sun safety. The questionnaire uniquely placed to deliver advice on healthy lifestyle behav- was piloted among a group of TRs working clinically (n = iours to cancer patients. Patient education is a key part of 2) and in the academic sector (n = 2). As a result of the feed- radiotherapy practice, with TRs providing care to the same back, one question designed to explore the delivery of advice patient every day, often over a number of weeks [8]. Despite on healthy eating, but which used the term ‘diet’,was this, there has been less research among TRs and the delivery amended to ‘healthy eating’. Respondents were asked to pro- of health behaviour advice. Only one study has been under- vide their professional grade, to allow for comparison with taken in the UK that investigated the current provision of public statistics on the profile of TRs in the UK. The UK advice on health behaviours including smoking, alcohol, radiotherapy radiography workforce census only reports the healthy eating, and exercise [5]. This study, through a survey workforce’s AfC band, also known as professional grade, and (n = 102), found that levels of advice provided to patients on do not report any other demographics [11]. Therefore, to allow these topics were low [5]. No research has been undertaken to for comparison with public statistics, respondents were asked assess TRs’ barriers to providing health behaviour advice for to provide their AfC band and no other demographics were cancer patients, and how to address these. Therefore, this collected. study aimed to explore TRs’ current practices, knowledge, barriers, and facilitators around delivering healthy behaviour Analyses advice to cancer patients. Therapeutic radiographers’ needs and preferences in terms of training on this topic were also The survey responses were analysed using descriptive statis- explored. tics with the statistical package SPSS version 25. Missing data were recoded as ‘unknown’ for analyses to include as many respondents as possible. To assess whether awareness of life- style guidelines was related to the provision of advice on each Methods health behaviour, a multinomial logistic regression model was carried out. The dependent variable was each level of advice Participants and Recruitment provision (advice provided to no patients/advice provided to 1–25%/26–50%/51–75%/> 75% of patients). Respondents’ TRs and assistant practitioner TRs in the UK working within professional grade was added as covariates to each of these the cancer care setting were invited to take part in an online models. Data obtained from the open-ended questions were survey. Practising TRs in the UK have completed a recognised transferred into qualitative data analysis software (NVivo, ver- degree to meet the standards of proficiency for a band 5 agen- sion 12) and coded line by line. The open responses from each da for change (AfC) radiographer and are registered with the question were grouped together and analysed to identify any Health and Care Professions Council (HCPC) [9]. An assistant patterns or themes. A deductive approach to analysis was un- practitioner is a non-registered practitioner but performs dertaken using the content analysis process [12]. Themes are protocol-limited clinical tasks under the direction and super- presented in the results with supporting quotes and the partic- vision of a state-registered TR practitioner, and works within a ipant’s AfC band. band 4 AfC definition [10]. In the UK, the professional grade of TRs is defined by AfC, from band 5 to band 8 which reflect an individual’s professional skills, responsibilities, and job- Results related knowledge [10]. From August 2018 to April 2019, a link to an online survey was emailed to 72 radiotherapy de- Response Rate partments in the UK and cascaded through the mailing lists within each department. Participants were made aware that by The exact response rate is unknown because the link to the completing the survey, they were providing informed consent survey was cascaded independently within each radiotherapy for the use of their data for this research. This study was department. However, according to the 2019 census of the UK 1 3 892 J Canc Educ (2022) 37:890–897 radiotherapy workforce [11], there are 3392 TRs in the UK. Levels of Enquiry The survey was started by 583 TRs who answered at least one question, and therefore, the responses are representative of The proportion of patients seeking advice on health behav- 17% of the radiotherapy workforce in the UK. Of these 583, iours reported by the respondents is shown in Table 1. 367 (63%) completed all of the survey questions. The results Patients seeking advice was highest for sun safety, followed are reported in percentages of those who answered the corre- by alcohol intake and healthy eating. Patients seek advice sponding question. In total, 662 individual open-response about smoking, weight management, and PA less frequently. qualitative comments were analysed. Table 1 shows the proportion of respondents who reported enquiring about each health behaviour and providing advice. Less than 20% of TRs reported advising patients on healthy Agenda for Change Band eating, weight management, smoking cessation, and reducing alcohol intake to more than 50% of their patients. Twenty-four One percent (n = 6) were band 4 assistant practitioner TRs, percent reported advising patients on PA to more than 50% of 23% (n = 128) were band 5 TRs, 31% (n =174) wereband 6, their patients, with TRs enquiring and advising on sun safety 30% (n =168) wereband 7, and15%(n = 88) were band 8 more frequently than other health behaviours. TRs. Beliefs on Role Responsibilities Familiarity with Guidelines Eighty-nine percent (n = 399) thought providing healthy life- Seventy six percent (n = 344) were aware of some guidelines style advice was part of their role. Of those who said no (11%; for cancer patients on health behaviours. Awareness was n = 51), analysis of the open-ended questions showed that the highest for smoking cessation guidelines (69%; n =312) and main reasons were believing that advice provided within their lowest for weight management guidelines (31%; n = 140). role should only be related to the impact on radiotherapy de- livery or radiotherapy–related side effects. For example, one Table 1 Proportion of patients seeking health behaviour advice and respondent commented ‘Give advice on how it can impact TRs enquiring and advising on health behaviours treatment, i.e. smoking, but not on alternative to stop smoking etc. … just to stop 2 hours before and after RT’ (Band 6 TR). None 1–50% > 50% Other reasons were lack of knowledge, lack of time, and be- The percentage of TRs reporting the percentage of patients seeking advice lieving that the delivery of lifestyle advice is the responsibility (N =435) of other members of the multidisciplinary team (MDT). One Physical activity 25% 67% 8% respondent commented ‘I feel it is not specific to our role to Healthy eating 26% 62% 12% provide healthy lifestyle advice. There are more specially Weight management 46% 47% 7% trained members of the MDT’ (Band 6 TR). Smoking cessation 44% 53% 3% Alcohol intake 23% 62% 15% Beliefs on Having the Skills and Knowledge to Deliver Sun safety 25% 56% 19% Health Behaviour Advice The percentage of TRs who report enquiring about health behaviours (N = 420) Of all the health behaviours, sun safety was the topic that most Physical activity 28% 48% 24% TRs (80%; n = 323) felt they had the skills and knowledge to Healthy eating 34% 47% 19% deliver advice on, followed by PA (59%; n = 238), smoking Weight management 47% 39% 14% cessation (54%; n = 218), healthy eating (53%; n = 214), and Smoking cessation 27% 48% 25% alcohol intake (52%; n = 210). Providing advice on weight Alcohol intake 24% 53% 23% management was the topic respondents felt they had the least Sun safety 17% 44% 39% amount of skills and knowledge to deliver advice on (36%; n The percentage of TRs who report advising patients on health behaviours = 145). The main theme from the open-ended responses was (n =408) TRs particularly felt unqualified and lacked knowledge of Physical activity 22% 54% 24% guidelines on the topic of healthy eating. One TR commented Healthy eating 31% 52% 17% ‘I feel unqualified to give specific healthy eating advice with Weight management 35% 47% 18% differing opinions on diets such as dairy free, red meat free Smoking cessation 29% 55% 16% etc.’ (Band 7 TR). Another respondent wrote ‘Iam aware of Alcohol intake 28% 54% 18% what constitutes as healthy eating, but lack confidence in my Sun safety 11% 46% 43% knowledge of published guidelines’ (Band 7 TR). 1 3 J Canc Educ (2022) 37:890–897 893 Sixty percent (n = 271) were aware of guidelines for sun safety delivering advice on healthy eating (44%; n = 166) and weight (60%; n =271), 52%(n = 235) were aware of guidelines for management (41%; n = 155). For smoking and alcohol intake, alcohol intake, 48% (n = 217) were aware of PA guidelines, perceived lack of patient interest was the most frequently re- and 44% (n = 199) were aware of healthy eating guidelines. ported barrier in delivering advice on these topics, 45% and Seventy percent (n = 315) of respondents were unable to recall 41%, respectively. Lack of time as a barrier was commonly the source of the guidelines. Of those who could recall a reported for all health behaviours (Table 3). guideline, Macmillan Cancer Support was the most common- Qualitative comments gave further insight into TRs’ bar- ly mentioned resource (n = 55) followed by in house depart- riers in delivering advice, most commonly lack of training and mental guidelines (n =23). knowledge. ‘We are given very little training/guidance on As shown in Table 2, awareness of guidelines for each how to approach and advise on these issues but I believe we health behaviour was associated with increased likelihood of should’ (Band 7 TR). One TR wrote ‘Topics aren’tcovered at TRs enquiring about patients’ lifestyle behaviours and provid- University level so the background knowledge and confidence ing advice for all health behaviours. The baseline was the to discuss isn’tthere’ (Band 5 TR). Risk of patients’ changing provision of no advice on health behaviours. Awareness of body shape affecting the accuracy of radiotherapy treatment guidelines was associated with increased likelihood of provid- was also a reported barrier. ‘Maintaining healthy weight (los- ing advice on PA to more than 75% of patients [odds ratio ing weight or gaining weight) is not appropriate during treat- (OR) = 5.61; 95% confidence interval (CI) 2.57–12.3, P < ment as weight should be maintained post CT scan in order to 0.001], healthy eating [OR = 4.11 (95% CI 1.51–11.23), P < deliver accurate treatment, therefore I feel it is an issue to 0.01], weight [OR = 3.18 (95% CI 1.43–7.04), P < 0.01], tackle afterwards’ (Band 5 TR). Additionally, one theme that smoking [OR = 3.13 (95% CI 1.26–7.79), P < 0.05], alcohol emerged from the comments was the belief that advice on [OR = 2.61 (95% CI 1.19–5.75), P < 0.05], and sun [OR = healthy eating may exacerbate treatment–related side effects 2.85 (95% CI 1.39–5.85), P <0.001] (Table 2). ‘Healthy eating advice is not always appropriate for patients receiving treatment in certain areas e.g. for pelvis treatment where high fibre intake may exacerbate symptoms’ (Band 6 TR). Barriers to Providing Advice Table 3 shows the reported barriers in providing health behav- Facilitators to Providing Advice iour advice. Patients being too frail or ill were the most com- monly reported barrier to delivering advice on PA (45%; n = Of those who answered the question (n = 375), online training 170) followed by perceived lack of patient interest (42%; n = (73%; n = 273) was the most commonly requested support for 157), and not knowing the guidelines (41%; n = 156). Not facilitating the delivery of lifestyle advice. This was followed knowing the guidelines was the most common barrier to by the provision of referral pathways for lifestyle support Table 2 Associations between awareness of health behaviour guidelines and level of enquiry and advice provision on each health behaviour Physical activity Healthy eating Weight management Smoking cessation Alcohol intake Sun safety OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Level of enquire about lifestyle (N =420) Ref = none 1–25% 1.11 (0.66–1.86) 1.00 (0.59–1.68) 2.09 (1.25–3.49)* 2.08 (1.26–3.46)* 1.3 (0.78–2.16) 2.36 (1.27–4.39)** 26–50% 2.28 (1.24–4.17)** 2.079 (1.18–3.66) 4.50 (2.28–8.92)*** 1.97 (0.95–4.07) 2.14 (1.16–3.97)* 2.73 (1.44–5.16)** 51–75% 2.70 (1.34–5.46)** 4.03 (1.97–8.23)*** 2.68 (1.21–5.98)* 2.05 (0.93–4.52) 2.09 (1.04–4.21)* 1.98 (1.01–3.87)* > 75% 4.01 (1.99–8.07)*** 5.44 (2.35–12.56)*** 4.25 (1.81–9.97)*** 5.35 (2.42–1.84)*** 2.15(1.07–4.32)* 3.58 (1.87–6.87)*** Level of advice provision (N =408) Ref = none 1–25% 2.29 (1.29–4.07)* 1.94 (1.17–3.21)** 1.36 (0.75–2.44) 2.36 (1.44–3.88)*** 1.53 (0.94–2.49) 2.67 (1.26–5.34)** 26–50% 5.52 (2.82–10.89)*** 3.14 (1.68–5.87)*** 3.71 (1.99–6.94)*** 2.41 (1.19–4.92)* 2.87 (1.49–5.54)* 2.35 (1.12–4.94)* 51–75% 3.50 (1.78–7.23)*** 3.26 (1.62–6.55)*** 4.01 (1.98–8.48)*** 5.86 (1.93–17.88)** 7.40 (3.01–8.22)*** 2.38 (1.17–5.16)* > 75% 5.61 (2.57–12.3)*** 4.11 (1.51–11.23)** 3.18 (1.43–7.04)** 3.13 (1.26–7.79)* 2.61 (1.19–5.75)* 2.85 (1.39–5.85)** A multinomial logistic regression model with awareness of lifestyle guidelines (Y/N) and level of enquiry and advice provision (none/1–25% of patients/ 26–50% of patients/51–75% of patients/> 75% of patients) as the dependent variable Ref: Reference category no advice = provide advice to no patients OR odds ratio, CI confidence intervals *P <0.05; **P < 0.01; ***P <0.001 1 3 894 J Canc Educ (2022) 37:890–897 Table 3 Barriers among TRs in providing health behaviour advice (N =378) Physical activity (%) Healthy eating (%) Weight Smoking (%) Alcohol (%) Sun safety (%) management (%) Not knowing the guidelines 41 44 41 25 31 22 Not knowing what to say 17 18 28 21 21 7 Lack of time 39 36 34 33 33 30 Do not think part of role 11 12 16 7 8 4 Don’t know where to refer patients to 29 17 23 19 25 19 Lack of patient interest 42 36 30 45 41 28 Seeming to blame patient 10 14 21 26 22 5 Not convinced it affects cancer outcomes 2 2 2 1 2 1 Patient being too frail or ill 45 24 25 25 21 19 (69%; n = 259) and education resources for patients within the are expected to deliver nutrition and lifestyle advice [14, 15]. department (64%; n = 239). Sixty-one percent (n =229) re- It is only in recent years that TRs have been recognised as a ported that in house training (61%; n = 229) would be helpful, key healthcare member in delivering health behaviour advice as well as role expansion (50%; n = 189) and mandatory [16] and this may explain why self-reported delivery of continuous professional development (CPD) training (39%; healthy lifestyle advice is higher among oncology HCPs in n = 147). The qualitative comments from the open-ended re- previous studies. Data collected from oncology HCPs have sponses further highlighted the role of training both in the pre- most commonly identified lack of knowledge, confidence, registration and post-registration setting in facilitating TRs’ to and skills as barriers to the delivery of health behaviour advice deliver health behaviour advice. ‘Inclusion in degree as part of [2–4], in addition to lack of time, perception that patients lack advice giving during practical’ (Band 6 TR). Another TR interest, patient being too frail or ill, and believing they are not wrote ‘Would be nice to have staff take a mandatory module the right persons to provide advice [2–4]. This study con- to be able to personally provide the information with confi- firmed these barriers among TRs and illustrated from the qual- dence’ (Band 7 TR). Preferred topics delivered within a train- itative comments some TRs felt that lifestyle advice provided ing course were the current evidence for specific health be- within their role should only be in relation to the management haviours and cancer outcomes (91%; n = 339), followed by of radiotherapy treatment–related side effects. information of available support and patient education re- Our qualitative data suggest that the low level of advice sources (88%; n = 327), video examples of how to deliver provision on weight management may be in part due to TRs advice (51%; n = 188), and role play of having a conversation not wanting patients to change their body shape as this can with a patient (20%; n = 76). Open-ended responses further affect the accuracy of radiotherapy treatment. In addition, as showed a preference for online training, mainly because of the reported in other studies [13], some HCPs may be hesitant to difficulties associated with permitting all staff to attend face to discuss sensitive topics such as weight management to avoid face training. ‘Face to face would take a long time for all the risk of offending patients. Therefore, TRs may need sup- radiotherapy staff to be trained unless it was done at a lunch- port and guidance with initiating and managing potentially time or out of hours with overtime to be claimed back. Part difficult conversations around lifestyle behaviour changes. In time staff may miss out if the training is not on their day to addition to identifying an appropriate time to initiate these work’ (Band 6 TR). Another respondent wrote ‘Online train- conversations, there needs to be a balance between immediate ing is good too, only if it is made mandatory’ (Band 7 TR). treatment requirements and long-term survivorship needs. Although it is well-known that continued smoking after a cancer diagnosis is associated with increased risk of cancer Discussion recurrence and higher mortality rates [17], advice on smoking cessation was low, with only 25% enquiring and 16% advis- The findings show that whilst the majority (89%) of TRs ing on smoking cessation to more than 50% of their patients. believe providing health behaviour advice to cancer patients Perceived lack of patient interest was the highest reported is part of their role, this is not matched by provision of advice. barrier in delivering advice on smoking cessation. Likewise, These results are lower than reported in previous studies in a UK study, this was reported as a barrier among TRs in among oncology HCPs [2, 13]. One explanation may be that providing smoking cessation support [6]. Considering that the participants within these studies were primarily oncolo- cancer patients show a desire and motivation to quit but often do not ask for help [18], TRs should be skilled in initiating a gists and nurses. It is well-documented that doctors and nurses 1 3 J Canc Educ (2022) 37:890–897 895 conversation around smoking cessation and referring patients be positive, with self-reported improvements in knowledge for further smoking cessation support. This is particularly im- and practices on delivering nutrition and health advice follow- portant because patients who attend smoke-free services are ing completion of an online training resource [24]. However, four times more likely to quit [19]. With perceived lack of limited web-based training exists for oncology HCPs on the patient interest a reported barrier, TRs need to be supported delivery of health behaviour advice to cancer patients, with no to use their role to initiate discussions regarding this behaviour training available specifically for TRs. This study highlights as per recommendations [1]. the need for post-graduate training on health behaviour ad- Our qualitative data suggested TRs also felt they were par- vice. However, the value of including training within the un- ticularly unqualified and lacked the skills in delivering healthy dergraduate education for TRs was highlighted, which has eating advice. Evidence is increasingly showing the relation- been identified as a requirement within the allied health pro- ship between dietary habits and cancer development and the fessions pre-registration education recommendations in the role of a healthy diet in improving cancer survival [20]. UK [25]. Additionally, this study provides insight into TRs’ Advice regarding nutrition benefits for both the general public preferences on course content, with a particular desire for and cancer survivors is often inconsistent and at times contra- dissemination of the current evidence for specific health be- dictory [21], and patients therefore need directing to informa- haviours and cancer survivorship, followed by information of tion that is reliable and underpinned by high-quality evidence. available support and patient education resources. This is particularly important given that 74% of TRs in our study estimated that their patients ask for information on Strengths and Limitations healthy eating. Less than 50% of respondents reported awareness of life- This is the largest study to explore the practices, barriers, and style guidelines for PA, healthy eating, and weight manage- facilitators among TRs in delivering health behaviour advice ment for cancer survivors. Of those who could recall a guide- to cancer patients. The results provide insight into the prac- line for lifestyle advice, Macmillan Cancer Support was the tices among TRs across all AfC professional grades. The re- most commonly mentioned resource (n = 55). In a recent spondents from each AfC grade are also representative of the qualitative study, lack of knowledge of guidelines among on- UK radiotherapy radiography workforce [11]. In the UK, 2%, cology HCPS was also highlighted, with no HCP being able to 26%, 35%, 26%, and 10% are AfC bands 4, 5, 6, 7, and 8, name specific lifestyle guidelines for cancer survivors [4]. In respectively, similar to the distribution of respondents in this the current study, TRs who were aware of guidelines for each study. The large number of qualitative comments also provid- health behaviour were also more likely to enquire and provide ed a range of views, adding further insight into TRs’ beliefs on advice on each health behaviour. Similarly, in another study, the delivery of health behaviour advice within their role. awareness of guidelines was associated with increased likeli- However, there are a number of limitations. Although all ra- hood of providing lifestyle advice [2]. This illustrates the need diotherapy departments were invited to participate, it is un- for wider dissemination of evidence-based guidelines on known if the responses are representative of all radiotherapy health behaviours and cancer survivorship in the radiotherapy departments in the UK. Additionally, the respondents may department. This need is further recognised whereby 64% of also have been more motivated to respond due to already TRs reported that the provision of education resources for having an interest in healthy lifestyle behaviours, which may patients within the department would support the provision mean TRs are less likely to provide health behaviour advice of health behaviour advice within their role. than those who completed the survey. The reported barriers within this study around lack of knowledge and skills highlight the need for training and edu- cation. This is not surprising considering that education on Conclusion providing health behaviour advice has not been an important component of the training of HCPs [22]. With the recent call The findings of this study show that the provision of health for a radical upgrade in prevention in healthcare, it is expected behaviour advice among TRs is suboptimal, despite recogni- that allied health professionals have the appropriate education tion that this is part of their role. There is a clear need for and training to deliver advice to motivate people to make training and improved education among TRs in order to en- health behaviour changes [23]. Encouragingly, TRs reported hance their delivery of health behaviour advice. It is also vital a strong desire to undergo training to enable them in delivering to support TRs in delivering advice and subsequently increas- health behaviour advice and a preference for online training ing the number of cancer patients receiving advice on improv- was identified. From the qualitative comments, TRs ing health behaviours. recognised the benefit of online learning in allowing for man- datory continuous professional development. The provision of Acknowledgements The researchers are grateful to the health profes- web-based health education for oncology HCPs has shown to sionals who participated in the study. 1 3 896 J Canc Educ (2022) 37:890–897 Author Contributions NDP had the original idea for the study and ob- 4. Koutoukidis DA, Lopes S, Fisher A, Williams K, Croker H, Beeken tained the funding with AF, RJB, and KPJ. NDP developed the design of RJ (2018) Lifestyle advice to cancer survivors: a qualitative study the study, acquired the data, analysed and interpreted the data, drafted and on the perspectives of health professionals. BMJ Open 8(3): revised the article, and approved the final manuscript submitted. AF con- e020313 tributed to the development of the study design and the recruitment ap- 5. Pattinson L, Jessop A (2016) The delivery of health improvement proach, reviewed, edited, and approved the final manuscript. RJB provid- information during radiotherapy treatment: a survey of UK therapy ed behavioural science expertise, contributed to the development of the radiographers. J Radiother Pract 15(2):114–130 study design and the recruitment approach, edited, and approved the final 6. Charlesworth L, Hutton D, Hussain H (2019) Therapeutic manuscript. KPJ provided oncology expertise and intellectual input into radiographers’ perceptions of the barriers and enablers to effective the recruitment approach and design and approved the final manuscript. smoking cessation support. Radiography. 25(2):121–128 NW contributed to the development of the study design, reviewed the 7. Borras JM, Lievens Y, Grau C (2015b) The need for radiotherapy manuscript for important intellectual content, and approved the final the in Europe in 2020: not only data but also a cancer plan. 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Journal

Journal of Cancer EducationSpringer Journals

Published: Aug 1, 2022

Keywords: Health behaviours; Healthy lifestyle; Therapeutic radiography; Radiation therapy; Advice provision

References