Psychological strain in nutritional management for gastric cancer patients: a multicenter qualitative study informing a supportive-care pathway

Psychological strain in nutritional management for gastric cancer patients: a multicenter qualitative study informing a supportive-care pathway | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychological strain in nutritional management for gastric cancer patients: a multicenter qualitative study informing a supportive-care pathway shiyu xiao, ping xu, chun zhang, yanxi li, xiangbo liao, yan xiong, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8716097/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Purpose To identify potentially modifiable determinants underlying psychological strain during nutritional management among gastric cancer patients, and to translate these determinants into actionable components for a supportive-care pathway. Methods This qualitative descriptive study recruited gastric cancer patients from eight hospitals in eastern Sichuan, China, between March and August 2025. Using purposive sampling, we enrolled adults (≥ 18 years) with pathologically confirmed gastric cancer who had nutritional risk (NRS-2002 ≥ 3) and reported barriers to nutritional support. Data were collected via semi-structured interviews and analyzed using thematic analysis. Ethical approval was obtained, and all participants provided informed consent. Results Fifteen interviews were analyzed. Overall, patients’ nutritional management was shaped by competing psychological forces that intensified psychological strain and undermined sustained adherence. Key themes included: (1) The conflict between physiological tolerance and nutritional requirements; (2) Decision paralysis amid knowledge gaps and multi-source conflict; (3) Resource accessibility and affordability constraints; (4) Compliance and conflict driven by family relationships; (5) The negative cycle of psychological strain and social comparison. Conclusions We translate patient experiences into potentially modifiable determinants and outline a supportive-care pathway comprising symptom-linked nutrition coaching, decision support and consistent messaging, resource navigation, family alignment, and psychosocial support with structured follow-up. Future work should pilot the pathway to assess feasibility and acceptability in routine care. Gastric cancer Nutritional management Psychological strain theory Qualitative interviews Eastern Sichuan Background Gastric cancer (GC) remains one of the most prevalent and deadly malignancies worldwide, representing a major contributor to the global cancer burden [ 1 ] . Based on the latest epidemiological data from 2022, it ranks fifth in incidence among all malignant tumors and fourth in cancer-related mortality [ 2 ] . Globally, the age-standardized incidence rate (ASIR) is estimated at 9.2 cases per 100,000 person-years, while the age-standardized mortality rate (ASMR) reaches 6.1 per 100,000 person-years [ 3 ] . In China, however, the burden of gastric cancer is considerably heavier. The latest data indicate that the incidence rate of this disease is 13.7 per 100,000 population, while the mortality rate stands at 9.4 per 100,000 population. These figures exceed the global average by approximately 49% and 54%, respectively. Notably, China alone accounts for nearly 37% of all new gastric cancer cases worldwide and around 39% of related deaths. These figures highlight the disproportionate impact of gastric cancer in China and underscore its profound public-health significance within the global framework of cancer prevention and control [ 4 , 5 ] . Patients with gastric cancer frequently present with gastrointestinal symptoms such as early satiety, nausea, and vomiting. These manifestations are often the result of tumor-induced pyloric obstruction or a markedly reduced gastric capacity [ 6 – 8 ] . Consequently, dietary intake declines, resulting in insufficient energy and protein intake and a markedly increased risk of malnutrition. Epidemiological data indicate that the prevalence of malnutrition in this population may reach 65%–85% [ 9 ] . Accumulating evidence has demonstrated that malnutrition is strongly linked to increased mortality, diminished quality of life, and shorter disease-free survival [ 10 – 13 ] . Early, individualized, and sustained nutritional intervention, therefore, plays a pivotal role in improving clinical outcomes, lowering complication rates, and extending survival time [ 14 – 15 ] . It remains one of the most essential strategies for optimizing patient prognosis. Yet, in real-world clinical practice, adherence to nutritional support is often suboptimal. In the actual process of nutritional support, patients often experience reduced intervention compliance due to factors such as anxiety, depression, fear of the disease, and related cognitive misconceptions [ 16 – 17 ] . Existing research has predominantly concentrated on the physiological nutritional indicators of gastric cancer patients, with relatively little attention paid to their psychological experiences and subjective perceptions during nutritional management [ 18 – 20 ] . Psychological strain is defined as the intense psychological pressure and internal distress that arise when an individual grapples with two or more conflicting and difficult-to-resolve psychological cognitions or emotional states [ 21 – 22 ] . For gastric cancer patients, the concept of "nutritional intake" extends far beyond simple eating behavior. It becomes a daily challenge intricately linked with survival needs, physical discomfort, belief maintenance, and emotional turmoil. During this ongoing struggle, patients often experience multiple, competing psychological forces, which in turn contribute to heightened psychological strain. This strain can hinder their ability to effectively adhere to and benefit from nutritional management plans. The nutritional status of gastric cancer patients plays a crucial role in their surgical tolerance, chemotherapy response, immune function, and overall prognosis [ 23 – 25 ] . Meanwhile, the feasibility and sustainability of nutritional interventions are largely influenced by economic factors [ 26 – 27 ] . In practice, the success of nutritional management hinges on several key factors, including funding allocation, medical insurance coverage, industrial supply chains, and the financial capacity of households [ 28 – 30 ] . This study focuses on the Eastern Sichuan region, which includes Dazhou, Guang'an, Nanchong, and Bazhong cities in Sichuan Province. The region is ranked in the lower-middle tier of Sichuan’s economic development, with its economy heavily reliant on resource-dependent industries, traditional manufacturing, and agriculture [ 31 ] . Per capita disposable income here is approximately 30%–40% lower than in the Chengdu Plain Economic Zone [ 32 ] . In addition, the region faces challenges such as underdeveloped medical infrastructure, limited government health funding, and a stark urban-rural divide [ 33 – 34 ] . These socioeconomic factors shape the practical environment and determine the feasibility of implementing effective nutritional management for gastric cancer patients in this area. In routine care, many patients know that nutrition matters, yet still struggle to sustain daily nutrition plans. We therefore conducted a multicenter qualitative study in eastern Sichuan to understand what drives psychological strain during nutritional management and which parts of this strain might be modifiable. Using psychological strain theory as a lens, we aimed to translate patients’ lived barriers into practical targets for a supportive-care pathway that can be piloted in future work. Methods Design This study adopted a qualitative descriptive research design. Semi-structured interviews were used to gather detailed insights into participants' experiences with nutritional management for gastric cancer. From a psychological strain perspective, the study explored the barriers encountered by gastric cancer patients in eastern Sichuan, China, during their nutritional management. The research covered four prefecture-level cities (Dazhou, Guang'an, Nanchong, and Bazhong) and included 15 counties and cities. Theoretical Framework This study employs the “psychological strain theory” proposed by Jie Zhang [ 22 ] and colleagues as its principal analytical framework. Psychological strain describes an internal state of strain or conflict that arises when individuals are exposed to the combined influence of multiple psychosocial stressors. Within this theory, psychological strain comprises four interrelated dimensions: value strain, aspiration strain, deprivation strain, and coping strain. Given the continual need to balance competing demands during nutritional management among patients with gastric cancer, this study applies psychological strain theory to their nutritional management experiences in order to elucidate the underlying psychological mechanisms that influence their nutritional behaviors. Setting and Participants The study used purposive sampling and was conducted from March to August 2025 in eight hospitals in eastern Sichuan Province. The research team implemented a multi-site collaboration, and each hospital designated an on-site nurse liaison to support standardized recruitment and interview procedures. The team first contacted hospital staff by phone or WeChat to explain the study aims and procedures. Hospital administrators granted permission before recruitment began. With support from hospital staff, the team approached eligible gastric cancer patients and introduced the study in detail. The interviewers built rapport with potential participants before scheduling interviews. The team also used referrals through personal networks to identify additional participants when needed. The team applied maximum variation sampling to reduce selection bias. The sample included participants with diverse ages, genders, educational backgrounds, and occupations. Multi-site coordination and governance Data collection took place at eight hospitals in eastern Sichuan. Three institutions acted as coordinating centers, as reflected in the author affiliations. The other hospitals served as recruitment sites and followed the same study protocol. Each site appointed a local liaison. The liaison facilitated recruitment, verified eligibility, and supported consistent implementation of approved ethical procedures, including information provision, written consent, and privacy protection. The inclusion criteria were: (1) patients aged 18 years or older; (2) those with pathologically confirmed gastric cancer; (3) an NRS-2002 score of 3 or higher or self-reported nutritional support challenges; and (4) individuals with normal communication and comprehension abilities. Patients who were not local residents of the area were excluded from the study. Interview guides This study developed a draft interview guide, grounded in a systematic literature review, and incorporating the four interrelated conflict domains of psychological strain. Before conducting the formal interviews, two eligible gastric cancer patients were recruited for pilot interviews to evaluate the interview guide’s accuracy and cultural adaptability. Pilot interviews were used to refine the guide and were not included in the final analysis. The insights gained from these interviews, along with expert feedback, were used to refine the interview guide, ultimately shaping the final formal interview guide. The interview guide includes the following six questions: (1) What do you perceive as your biggest challenge regarding diet and nutrition at present? (2) In your opinion, what dietary concepts or habits are considered “good” or “right”? Have these views changed since you were diagnosed with illness? (3) What is the ideal outcome you hope to achieve through nutrition management? (4) Have you ever felt powerless or frustrated when managing your nutrition? (5) Do you believe some patients have access to better or more resources for nutrition management? How do you feel about this disparity? (6) When you face difficulties or confusion regarding nutrition management, what steps do you typically take to address them? Data collection Interviews were conducted in Chinese. The interviews in this study were conducted by two master's degree candidates in nursing. Prior to data collection, both interviewers underwent a week-long systematic training program, which covered the theoretical framework of psychological strain and qualitative interview techniques. This training ensured their proficiency in active listening and in-depth interviewing. Regarding participant recruitment, face-to-face interviews were conducted with patients who were local and available for in-person meetings. For participants residing elsewhere, online interviews were arranged via the Tencent Meeting platform, with assistance from nurse liaisons at local hospitals. Before each interview, participants signed informed consent forms and completed demographic information questionnaires. To guarantee confidentiality and participant comfort, all interviews took place in private, quiet environments. Throughout the interview process, various qualitative research techniques were employed, including probing questions, content clarification, and reflective listening. These techniques helped guide participants to elaborate on the barriers they encountered in nutritional management and their subjective experiences as gastric cancer patients within the Eastern Sichuan healthcare system. Interviews did not have a fixed time limit; instead, their duration was adjusted based on each participant's specific circumstances and communication needs. In addition to the coordinating ethics approval, the team obtained administrative permission from each participating hospital, as required. The team applied the same consent and confidentiality procedures at all sites. All interview content was recorded anonymously, either using the Tencent Meeting platform's built-in recording function or via smartphones. Data collection continued until information saturation was reached, defined as the point at which no new meaningful themes emerged, and responses began to overlap with previously collected data. At this stage, both recruitment and interviews were concluded. Data analysis This study employed thematic analysis to investigate the challenges and subjective experiences of gastric cancer patients in nutritional management. All interview recordings were transcribed verbatim into Chinese and independently verified by two researchers to ensure transcriptional accuracy and completeness. Selected quotations were translated into English by bilingual researchers and cross-checked to preserve meaning. A total of fifteen validated transcripts were imported into NVivo 14 (Lumivero) for systematic qualitative analysis. The research team conducted repeated and immersive readings of the transcripts to achieve a comprehensive understanding of the dataset and to develop an initial thematic framework. Analytically, the team used a hybrid deductive and inductive approach. The team conducted a theory-informed thematic analysis guided by psychological strain theory. The initial codebook defined four domains: value strain, aspiration strain, deprivation strain, and coping strain. The team added inductive codes when participants’ accounts did not align with the a priori categories. The team refined the codebook through constant comparison and regular consensus meetings. Based on this framework, researchers extracted analytically meaningful concepts and expressions guided by the interview guide. These textual elements were treated as meaning units for abstraction, condensation, and coding. Semantically related codes were then grouped into higher-order categories and labeled descriptively. Any discrepancies between the two coders were resolved through discussion and re-examination of the original recordings. To enhance methodological rigor, a third researcher served as an independent auditor, reviewing the coding procedures and outcomes to ensure credibility, dependability, and confirmability. All codes were iteratively refined and integrated under the guidance of the interview framework until no new categories or themes emerged, indicating information saturation. The research team held weekly consensus meetings to review and adjust the analytic process. The finalized thematic structure was established once all members reached agreement on the interpretation of findings. Ethical Considerations This study protocol was reviewed and approved by the Ethics Committee of Dazhou Central Hospital (No.2024156). Written informed consent was obtained from all participants prior to their inclusion in the study. Participants were informed that their involvement was entirely voluntary and that they could withdraw from the study at any time without providing a reason or experiencing any negative consequences. No monetary or material compensation was provided. All personal information and interview materials were anonymized and stored in an encrypted, password-protected cloud system accessible only to the research team. These measures were implemented to ensure data confidentiality and participant privacy throughout the research process. Results Characteristics of Participants The relevant demographic information of the respondents (including highest level of education, gender, age, occupation, etc.) is summarized in Table 1. Major themes Data analysis identified five themes with 16 subthemes (Table 2): (1) the conflict between physiological tolerance and nutritional requirements; (2) decision paralysis amid knowledge gaps and multi-source conflict; (3) resource accessibility and affordability constraints; (4) compliance and conflict driven by family relationships; and (5) the negative cycle of psychological strain and social comparison. Guided by psychological strain theory, these themes reflect how practical barriers are experienced as internal strains shaping nutritional decisions and adherence over time. We mapped subthemes to the core constructs of the theory to clarify the hypothesised mechanisms underpinning unstable nutrition adherence patterns. The mapping is summarised in Table 3. Theme 1: The conflict between physiological tolerance and nutritional requirements Potentially modifiable determinant : symptom-driven feasibility constraints and low confidence in symptom-linked nutrition strategies. Subtheme 1: Eating tolerance disorder and somatic symptoms Fluctuating symptoms, such as nausea, early satiety, and vomiting, severely constrained eating. This turned nutrition management into a process of repeated trial-and-error, rather than a stable routine. Before, I'd eat whenever I felt hungry. Now, when mealtime comes around, I actually dread it. I'm afraid of what might happen after eating (H). Symptom-driven avoidance and reduced portions often undermined sustained adherence to nutrition recommendations. Subtheme 2: Supplement confusion and tolerance issues Participants expressed uncertainty about nutritional supplements, including concerns about ingredients, safety, and whether supplements should be treated like medication. Some discontinued or reduced supplements after experiencing gastrointestinal discomfort. The doctor said I could take some nutritional powder, but I've been wondering, does this count as medicine? Could taking too much be bad for my liver and kidneys? No one has explained it clearly to me (D). Uncertainty and intolerance led to intermittent use and frequent self-adjustment. Subtheme 3: Behavioral adjustment and coping strategies Instead of stopping eating, participants adopted trial-and-error strategies to cope with discomfort, such as eating smaller, more frequent meals, choosing softer foods, and selecting items they found personally “tolerable.” Now I can only manage half a boiled egg at a time, any more makes me feel sick. I just try to eat whatever I can stomach, sometimes having some congee or steamed egg custard. When I really can't eat anything, I just go hungry until I'm ravenous, then force myself to eat a little(A). These adaptations enabled short-term intake but often lacked consistency without professional guidance. Subtheme 4: Rehabilitation motivation and functional goals Participants framed nutritional goals in pragmatic terms, emphasizing survival, maintaining strength for treatment, and preserving basic daily functioning to reduce dependence on family. I just want to live a few more years, stay in better health, at least be able to take care of myself, and not be a burden to my children (B). Functional goals motivated effort, but symptom fluctuations still limited what could be maintained. Subtheme 5: Pathological transformation of value orientation Illness reshaped how participants viewed food, shifting from taste and convenience to a task-oriented focus on “nutrition for recovery,” sometimes reducing enjoyment and reinforcing illness identity. Sometimes I feel like a robot, forced to eat the prescribed foods at set times, it's utterly joyless. Plus, every meal serves as a stark reminder that I'm sick (D). Moralizing “eating well” increased emotional burden and, for some, heightened frustration when intake was poor. Theme 2: Decision paralysis amid knowledge gaps and multi-source conflict Potentially modifiable determinant : decisional conflict due to inconsistent information and limited actionable guidance. Subtheme 1: Lack of nutritional knowledge and insufficient health literacy Although participants recognized nutrition as important, many lacked concrete knowledge about balanced diets and how to translate general advice into feasible plans during treatment or symptom flare-ups. The doctor, nurse, and even my son all tell me to eat more nutritious food, but I don't know what else is nutritious besides meat (A). Limited decision rules increased uncertainty and reliance on personal experience, leading to unstable routines. Subtheme 2: Multi-source information and conflicting perspectives Participants obtained dietary advice from clinicians, family, peers, and online content, but contradictory messages often created confusion and hesitation about what to follow. My wife says eating red dates and goji berries is good for me, but the doctor never mentioned those. My son keeps saying I should take protein powder, and I'm not sure whether to believe him (A). Subtheme 2: Operational guidance and culinary skill requirements Participants reported a gap between knowing “nutrition matters” and knowing how to implement meal preparation in daily life; technical language and lack of step-by-step guidance compounded difficulties. Every time I see those nutritional recipes, there are so many ingredients I've never even heard of, and I have no idea how to prepare them. When I ask the doctors and nurses, they use terms that are too technical for me to understand. I come back still clueless about what I should actually eat (J). Practical barriers in cooking and translation of advice limited feasibility at home. Theme 5: The negative cycle of psychological strain and social comparison Potentially modifiable determinant : unmanaged distress and maladaptive social comparison, compounded by communication barriers with professionals. Subtheme 1: Emotional responses and psychological strain Eating difficulties and weight loss were closely tied to anxiety and helplessness, with meals becoming a repeated source of distress during treatment. It feels like a war I can't win. Every meal is a battle, like fighting an enemy, but I have no idea when it will end or if I can ever win this fight (C). Persistent distress reduced motivation and tolerance for sustained nutritional effort. Subtheme 2: Social comparison and othering experiences Comparisons with other patients or healthy individuals intensified feelings of exclusion and perceived disadvantage, especially regarding dietary freedom and available support. Take that older woman in the same ward, for instance. Her kids buy her all kinds of health supplements, and she eats them like clockwork. My family can't afford that, and sometimes I just feel so useless (H). Comparison experiences reinforced discouragement and weakened persistence. Subtheme 3: Professional support gap and barriers in doctor-patient communication Brief consultations, limited access to nutrition professionals, and reluctance to ask questions left participants without ongoing, comprehensible guidance, prompting reliance on informal sources. There are no professional nutritionists in our area at all, and it's inconvenient to consult at large hospitals. It feels unfair compared to patients in big cities (I). Discontinuous professional support increased uncertainty and hindered long-term adherence. To enhance analytic transparency, we created a correspondence table linking each analytic subtheme to the four strain constructs in psychological strain theory (value strain, aspiration strain, deprivation strain, and coping strain) (Table 3). This mapping summarizes how strain-related mechanisms were represented across the 16 subthemes. Discussion This study identifies five themes that, when interpreted through psychological strain theory, indicate a set of potentially modifiable determinants shaping psychological strain and nutritional adherence over time. Building on these determinants, we outline an actionable supportive-care pathway that can be integrated into routine care and evaluated in future pilot work. Mechanistic interpretation using psychological strain theory Table 3 illustrates how strain-related mechanisms were reflected across analytic subthemes, suggesting that patients experience multiple, competing pressures during nutritional management. Two patterns were particularly salient. First, many accounts reflected an aspiration–reality gap. Patients often held strong beliefs and goals, such as the idea that eating more would restore strength. Patients also described goals related to living longer to spend more time with family. These beliefs and goals conflicted with lived constraints. Common constraints included dysphagia and other eating difficulties. Financial burden was also frequently reported. Limited caregiving capacity further restricted patients’ ability to follow their intended plans. In the absence of accessible, practical dietary adjustment strategies and sustained professional support, patients often described difficulty translating intentions into action, repeatedly shifting between “wanting to eat better” and “what is realistically achievable.” This intention–feasibility tension may help explain why adherence to nutritional management fluctuates over time. Second, Theme 5 suggests a potential self-reinforcing cycle in which social comparison intensifies perceived deprivation and aspiration strain. Patients frequently compared themselves with others who appeared to recover more smoothly or receive stronger support, which could trigger sadness, shame, and self-blame. These emotional responses may consume coping resources and reduce motivation to sustain nutritional efforts. As strain accumulates, some patients described disengagement from nutritional management, which may contribute to setbacks and, in turn, prompt further social comparison and renewed feelings of failure. This pattern is consistent with fluctuations between intention and action commonly described in chronic disease self-management. Mechanism model: intention–feasibility oscillation and a reinforcing loop Across themes, patients described nutritional management as a repeated tension between what they wanted to do and what they could realistically sustain. Many held a strong intention to eat better for recovery, yet day to day tolerance changed with symptoms and treatment demands. In response, they often made short term compromises, such as smaller portions, simplified meals, or intermittent supplement use. These adjustments reduced immediate burden, but they also made it harder to maintain consistency over time. This emphasis on nutrition impact symptoms as a practical constraint is consistent with evidence that symptom burden can materially affect nutrition outcomes in gastrointestinal cancers [ 38 ] . Uncertainty about supplements and medical foods further intensified this instability. Decisions about supplementation often became a focal point where expected benefits, safety concerns, and tolerability had to be weighed repeatedly. Patients therefore moved between trying different products, stopping use, or changing the way they used them, which echoes reports of variable perceptions and behaviours regarding dietary supplements during chemotherapy [ 39 ] . In parallel, exposure to conflicting dietary advice and misinformation increased fear and indecision, making it difficult to settle on stable rules for action [ 43 ] . Peer support could reduce isolation, but it sometimes added information noise or strengthened social comparison, depending on the group dynamics and content quality [ 44 ] . When eating well was framed as a measure of self discipline or worth, setbacks were more likely to be interpreted as personal failure. Shame and self blame then reduced help seeking and open communication, a pattern that is consistent with stigma related processes linked to lower engagement and worse outcomes in cancer contexts [ 41 ] . Together, these pressures depleted coping resources and made disengagement more likely, which in turn set the stage for further setbacks. This account also aligns with behaviour change scholarship. Durable change tends to require practical skills, feedback, and supportive conditions rather than information alone [ 42 ] . Clear specification of active components and techniques can further strengthen feasibility and reproducibility when translating findings into an intervention pathway [ 40 ] . Clinical implications: deliverable intervention components for supportive care Across themes, participants’ accounts suggest that nutritional management is undermined less by lack of motivation alone than by a repeated mismatch between intentions, symptom-contingent feasibility, and contextual constraints. Accordingly, supportive care may benefit from a small set of practice-oriented components that directly respond to the identified strain mechanisms. The components below are framed as clinically feasible targets rather than a fixed intervention “bundle,” and can be adapted to local service capacity. Component 1: Symptom-linked nutrition coaching with micro-skill training Participants’ accounts suggest that plans often break down when symptoms fluctuate and day-to-day tolerance changes. A feasible response is to provide brief, symptom-contingent guidance that helps patients decide what to prioritise on flare-up days versus symptom-stable days, supported by simple micro-skill coaching. Clinicians can focus on concrete strategies such as portioning, texture modification, and realistic substitutions that fit local food availability. This approach supports translation from intention to action by making guidance practicable in the moment, consistent with evidence that behaviour change is strengthened when support is concrete and actionable [ 42 ] . For feasibility and reproducibility, the pathway should describe what is delivered, to whom, and when, so that the active components are clear and can be evaluated [ 40 ] . Component 2: Decision support and consistent messaging to reduce decisional conflict To address knowledge gaps and multi-source conflict, the pathway could incorporate a short supplement decision support resource that clarifies common indications, how to monitor tolerance, when to pause or seek advice, and how to respond to conflicting recommendations. The aim is not to add information, but to reduce fear and indecision triggered by misinformation and inconsistent messaging [ 43 ] . Where peer communities are involved, curated content and light moderation may help preserve social support while reducing information noise and comparison-related distress [ 44 ] . Component 3: Resource navigation and affordability support to reduce deprivation strain Affordability and access barriers were central to deprivation strain and can undermine continuity even when motivation is high. A practical component is to include light-touch resource navigation, with a clear point of contact, streamlined referrals, and low-burden follow-up that supports continuity across transitions. This support can also include signposting to locally available options and routes for financial counselling when needed [ 46 ] . Component 4: Family alignment and implementation support with safeguards against caregiver burden Because nutritional management is commonly implemented within households, supportive care may benefit from brief family-inclusive goal setting and explicit role clarification to support shared decision-making and reduce conflict [ 51 ] . At the same time, safeguards are needed to avoid shifting excessive responsibility to caregivers. Incorporating caregiver burden screening and access to appropriate psychological support within a structured pathway may reduce attrition and strengthen coordination and accountability across transitions [ 48 ] . Component 5: Psychosocial and communication support to interrupt the strain–comparison cycle To interrupt the cycle of strain and social comparison, the pathway can include brief distress screening and targeted psychoeducation, with escalation or referral when thresholds are met. In routine visits, structured check-ins and prompt-based question guides may support timely clinician–patient communication and facilitate problem-solving. For future piloting, these components can be operationalised with clear delivery roles and follow-up triggers to support feasibility and reproducibility without increasing burden on routine services. Implementation options to support continuity Low-burden follow-up modalities may help maintain continuity when in-person nutrition services are limited. Evidence from a randomized multicenter trial supports the effectiveness of phone-based nurse monitoring for chemotherapy-related toxicity management, suggesting a practical model for symptom-triggered monitoring and timely escalation in supportive care settings. In parallel, digital interventions have been associated with improved adherence in oncology settings, including during oral systemic therapy. These findings support the feasibility of implementing structured digital reminders, routine check-ins, and standardized follow-up workflows to reinforce and maintain self-management routines [ 50 ] . The broader eHealth self-management literature also offers practical design patterns for scalable support, including structured modules, symptom and behavior monitoring, and feedback mechanisms. With appropriate clinical oversight, these elements could be cautiously adapted to oncology nutrition to enhance self-management while maintaining safety and clinical appropriateness [ 52 ] . Strengths, limitations, and future directions A key strength is the theory-informed mechanism framing, which clarifies why multiple barriers converge into unstable adherence patterns and identifies actionable intervention targets. Limitations include the region-specific qualitative context and the lack of outcome evaluation. Future studies should test whether the proposed components, including a symptom-linked nutrition toolkit, a decision aid for supplement use, and a family-inclusive pathway with structured follow-up, can reduce psychological strain and strengthen nutritional continuity when integrated into routine supportive care. Conclusion This study translates patient experiences into potentially modifiable determinants of psychological strain during nutritional management in gastric cancer and outlines a supportive-care pathway to address them. Future studies should pilot the pathway to examine feasibility, acceptability, and implementation in real-world oncology settings. Abbreviations GC: Gastric cancer ASIR: Age-Standardized Incidence Rate ASMR: Age-Standardized Mortality Rate Declarations Funding: This study was supported by the 2024 Nursing Scientific Research Project of the Sichuan Nursing Association (Grant No. H24061). The funding body had no role in the study design, data collection, data analysis, interpretation of results, or manuscript writing. Competing interests: The authors have no relevant financial or non-financial interests to disclose. Ethics approval: The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Dazhou Central Hospital (study reference number: 2024156). The study was performed in accordance with the Declaration of Helsinki. Consent to participate: Informed consent was obtained from all individual participants included in the study. Consent to publish: Not applicable. Data availability: Data analyzed during the current study are not publicly available due to confidentiality, but are available from the corresponding author on reasonable request. Author Contributions: Shiyu Xiao: Conceptualization, Data collection, Formal analysis, Writing – original draft. Guirong Wu: Conceptualization, Methodology, Supervision, Writing – review and editing. Ping Xu: Data collection, Methodology. Chun Zhang: Data analysis, Interpretation of data. Yanxi Li: Data validation, Translation and language support. Xiangbo Liao: Data curation, Project coordination. Yan Xiong: Project administration, Resources. All authors have read and approved the final manuscript. References Thrift AP, Nguyen Wenker T, El-Serag HB. Global burden of gastric cancer: epidemiological trends, risk factors, screening and prevention. Nat Rev Clin Oncol. 2023;20(5):338–349. doi: 10.1038/s41571-023-00747-0 . Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. 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Cancer Patients’ Behavior and Perception on the Use of Medical Foods and Dietary Supplements During Chemotherapy[J]. Patient Preference and Adherence, 2025, Volume 19: 1385–1395. Rookes TA, Nimmons D, Frost R, Armstrong M, Tsang WN, Davies L, Ross J, Hopkins J, Mistry M, Taylor SJC, Walters K. Identifying the active components through the behaviour change techniques taxonomy in complex interventions for people living with multiple long-term health conditions: a systematic review. Br J Health Psychol. 2025;30(3):e70019. doi: 10.1111/bjhp.70019 . Akin-odanye Elizabeth-O,Husman Anisah-J. Impact of stigma and stigma-focused interventions on screening and treatment outcomes in cancer patients[J]. Ecancermedicalscience, 2021, 15: 1308. Jessica A. Matthews,Simon Matthews,Mark D. Faries, et al. Supporting Sustainable Health Behavior Change: The Whole is Greater Than the Sum of Its Parts[J]. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 2024, 8: 263–275. Allison J Lazard,Sydney Nicolla,Rhyan N Vereen, et al. Exposure and Reactions to Cancer Treatment Misinformation and Advice: Survey Study[J]. Jmir Cancer, 2023, 9: e43749. Freya Mills,John Drury,Charlotte E. Hall, et al. A mixed studies systematic review on the health and wellbeing effects, and underlying mechanisms, of online support groups for chronic conditions[J]. Communications Psychology, 2025, 3. Ramnath Subbaraman,Tulip Jhaveri,Ruvandhi R. Nathavitharana. Closing gaps in the tuberculosis care cascade: an action-oriented research agenda[J]. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 2020, 19: 100144. Anna Santos Salas,Nahyeni Bassah,Anna Pujadas Botey, et al. Interventions to improve access to cancer care in underserved populations in high income countries: a systematic review[J]. Oncology Reviews, 2024, 18. Andrea Antonuzzo,Carla Ida Ripamonti,Fausto Roila, et al. Effectiveness of a phone-based nurse monitoring assessment and intervention for chemotherapy-related toxicity: A randomized multicenter trial[J]. Frontiers in Oncology, 2022, 12. Stanislaw Klek,Alessandro Laviano,Hervé Chrostek, et al. Nutrition in Oncology: Overcoming Challenges to Optimize the Patient Journey from Prehabilitation to Rehabilitation[J]. Oncology and Therapy, 2025, 13: 577–593. Panpan Cui,Ming Yang,Hengyu Hu, et al. The impact of caregiver burden on quality of life in family caregivers of patients with advanced cancer: a moderated mediation analysis of the role of psychological distress and family resilience[J]. Bmc Public Health, 2024, 24: 817. Wan-Chuen Liao,Fiona Angus,Jane Conley, et al. The Efficacy of Digital Interventions on Adherence to Oral Systemic Anticancer Therapy Among Patients With Cancer: Systematic Review and Meta-Analysis[J]. Jmir Cancer, 2025, 11: e64208-e64208. Karina Dahl Steffensen,Leonard Berry. Shared Decision Making Can—and Should—Actively Involve Family Caregivers[J]. Jco Oncology Practice, 2025. Eline te Braake,Roswita Vaseur,Christiane Grünloh, et al. The State of the Art of eHealth Self-Management Interventions for People With Chronic Obstructive Pulmonary Disease: Scoping Review[J]. Journal of Medical Internet Research, 2025, 27: e57649. Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table2.docx Table3.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 03 Mar, 2026 Editor assigned by journal 03 Mar, 2026 Submission checks completed at journal 03 Feb, 2026 First submitted to journal 27 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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18:00:39","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14344,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8716097/v1/75aa528634dd7f743d3c8d3f.docx"},{"id":104097019,"identity":"f2f4a1d6-9f41-425c-b589-fcf5565cb93e","added_by":"auto","created_at":"2026-03-06 18:00:40","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14470,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8716097/v1/1a91ff0db6c67c050a2b6487.docx"},{"id":104402604,"identity":"bf1a3a50-30e8-4001-931a-8abe010af402","added_by":"auto","created_at":"2026-03-11 12:15:52","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15951,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8716097/v1/62034915ee9f66be0e622bb1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological strain in nutritional management for gastric cancer patients: a multicenter qualitative study informing a supportive-care pathway","fulltext":[{"header":"Background","content":"\u003cp\u003eGastric cancer (GC) remains one of the most prevalent and deadly malignancies worldwide, representing a major contributor to the global cancer burden\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Based on the latest epidemiological data from 2022, it ranks fifth in incidence among all malignant tumors and fourth in cancer-related mortality\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Globally, the age-standardized incidence rate (ASIR) is estimated at 9.2 cases per 100,000 person-years, while the age-standardized mortality rate (ASMR) reaches 6.1 per 100,000 person-years\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In China, however, the burden of gastric cancer is considerably heavier. The latest data indicate that the incidence rate of this disease is 13.7 per 100,000 population, while the mortality rate stands at 9.4 per 100,000 population. These figures exceed the global average by approximately 49% and 54%, respectively. Notably, China alone accounts for nearly 37% of all new gastric cancer cases worldwide and around 39% of related deaths. These figures highlight the disproportionate impact of gastric cancer in China and underscore its profound public-health significance within the global framework of cancer prevention and control\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePatients with gastric cancer frequently present with gastrointestinal symptoms such as early satiety, nausea, and vomiting. These manifestations are often the result of tumor-induced pyloric obstruction or a markedly reduced gastric capacity\u003csup\u003e[\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Consequently, dietary intake declines, resulting in insufficient energy and protein intake and a markedly increased risk of malnutrition. Epidemiological data indicate that the prevalence of malnutrition in this population may reach 65%\u0026ndash;85%\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Accumulating evidence has demonstrated that malnutrition is strongly linked to increased mortality, diminished quality of life, and shorter disease-free survival\u003csup\u003e[\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Early, individualized, and sustained nutritional intervention, therefore, plays a pivotal role in improving clinical outcomes, lowering complication rates, and extending survival time\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. It remains one of the most essential strategies for optimizing patient prognosis. Yet, in real-world clinical practice, adherence to nutritional support is often suboptimal. In the actual process of nutritional support, patients often experience reduced intervention compliance due to factors such as anxiety, depression, fear of the disease, and related cognitive misconceptions\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eExisting research has predominantly concentrated on the physiological nutritional indicators of gastric cancer patients, with relatively little attention paid to their psychological experiences and subjective perceptions during nutritional management\u003csup\u003e[\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Psychological strain is defined as the intense psychological pressure and internal distress that arise when an individual grapples with two or more conflicting and difficult-to-resolve psychological cognitions or emotional states\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. For gastric cancer patients, the concept of \"nutritional intake\" extends far beyond simple eating behavior. It becomes a daily challenge intricately linked with survival needs, physical discomfort, belief maintenance, and emotional turmoil. During this ongoing struggle, patients often experience multiple, competing psychological forces, which in turn contribute to heightened psychological strain. This strain can hinder their ability to effectively adhere to and benefit from nutritional management plans.\u003c/p\u003e \u003cp\u003eThe nutritional status of gastric cancer patients plays a crucial role in their surgical tolerance, chemotherapy response, immune function, and overall prognosis\u003csup\u003e[\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Meanwhile, the feasibility and sustainability of nutritional interventions are largely influenced by economic factors\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. In practice, the success of nutritional management hinges on several key factors, including funding allocation, medical insurance coverage, industrial supply chains, and the financial capacity of households\u003csup\u003e[\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. This study focuses on the Eastern Sichuan region, which includes Dazhou, Guang'an, Nanchong, and Bazhong cities in Sichuan Province. The region is ranked in the lower-middle tier of Sichuan\u0026rsquo;s economic development, with its economy heavily reliant on resource-dependent industries, traditional manufacturing, and agriculture\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. Per capita disposable income here is approximately 30%\u0026ndash;40% lower than in the Chengdu Plain Economic Zone\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. In addition, the region faces challenges such as underdeveloped medical infrastructure, limited government health funding, and a stark urban-rural divide\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e. These socioeconomic factors shape the practical environment and determine the feasibility of implementing effective nutritional management for gastric cancer patients in this area.\u003c/p\u003e \u003cp\u003eIn routine care, many patients know that nutrition matters, yet still struggle to sustain daily nutrition plans. We therefore conducted a multicenter qualitative study in eastern Sichuan to understand what drives psychological strain during nutritional management and which parts of this strain might be modifiable. Using psychological strain theory as a lens, we aimed to translate patients\u0026rsquo; lived barriers into practical targets for a supportive-care pathway that can be piloted in future work.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThis study adopted a qualitative descriptive research design. Semi-structured interviews were used to gather detailed insights into participants' experiences with nutritional management for gastric cancer. From a psychological strain perspective, the study explored the barriers encountered by gastric cancer patients in eastern Sichuan, China, during their nutritional management. The research covered four prefecture-level cities (Dazhou, Guang'an, Nanchong, and Bazhong) and included 15 counties and cities.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTheoretical Framework\u003c/h3\u003e\n\u003cp\u003eThis study employs the \u0026ldquo;psychological strain theory\u0026rdquo; proposed by Jie Zhang\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e and colleagues as its principal analytical framework. Psychological strain describes an internal state of strain or conflict that arises when individuals are exposed to the combined influence of multiple psychosocial stressors. Within this theory, psychological strain comprises four interrelated dimensions: value strain, aspiration strain, deprivation strain, and coping strain. Given the continual need to balance competing demands during nutritional management among patients with gastric cancer, this study applies psychological strain theory to their nutritional management experiences in order to elucidate the underlying psychological mechanisms that influence their nutritional behaviors.\u003c/p\u003e\n\u003ch3\u003eSetting and Participants\u003c/h3\u003e\n\u003cp\u003eThe study used purposive sampling and was conducted from March to August 2025 in eight hospitals in eastern Sichuan Province. The research team implemented a multi-site collaboration, and each hospital designated an on-site nurse liaison to support standardized recruitment and interview procedures. The team first contacted hospital staff by phone or WeChat to explain the study aims and procedures. Hospital administrators granted permission before recruitment began. With support from hospital staff, the team approached eligible gastric cancer patients and introduced the study in detail. The interviewers built rapport with potential participants before scheduling interviews. The team also used referrals through personal networks to identify additional participants when needed. The team applied maximum variation sampling to reduce selection bias. The sample included participants with diverse ages, genders, educational backgrounds, and occupations.\u003c/p\u003e\n\u003ch3\u003eMulti-site coordination and governance\u003c/h3\u003e\n\u003cp\u003eData collection took place at eight hospitals in eastern Sichuan. Three institutions acted as coordinating centers, as reflected in the author affiliations. The other hospitals served as recruitment sites and followed the same study protocol. Each site appointed a local liaison. The liaison facilitated recruitment, verified eligibility, and supported consistent implementation of approved ethical procedures, including information provision, written consent, and privacy protection.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were: (1) patients aged 18 years or older; (2) those with pathologically confirmed gastric cancer; (3) an NRS-2002 score of 3 or higher or self-reported nutritional support challenges; and (4) individuals with normal communication and comprehension abilities. Patients who were not local residents of the area were excluded from the study.\u003c/p\u003e\n\u003ch3\u003eInterview guides\u003c/h3\u003e\n\u003cp\u003eThis study developed a draft interview guide, grounded in a systematic literature review, and incorporating the four interrelated conflict domains of psychological strain. Before conducting the formal interviews, two eligible gastric cancer patients were recruited for pilot interviews to evaluate the interview guide\u0026rsquo;s accuracy and cultural adaptability. Pilot interviews were used to refine the guide and were not included in the final analysis. The insights gained from these interviews, along with expert feedback, were used to refine the interview guide, ultimately shaping the final formal interview guide.\u003c/p\u003e \u003cp\u003eThe interview guide includes the following six questions: (1) What do you perceive as your biggest challenge regarding diet and nutrition at present? (2) In your opinion, what dietary concepts or habits are considered \u0026ldquo;good\u0026rdquo; or \u0026ldquo;right\u0026rdquo;? Have these views changed since you were diagnosed with illness? (3) What is the ideal outcome you hope to achieve through nutrition management? (4) Have you ever felt powerless or frustrated when managing your nutrition? (5) Do you believe some patients have access to better or more resources for nutrition management? How do you feel about this disparity? (6) When you face difficulties or confusion regarding nutrition management, what steps do you typically take to address them?\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eInterviews were conducted in Chinese. The interviews in this study were conducted by two master's degree candidates in nursing. Prior to data collection, both interviewers underwent a week-long systematic training program, which covered the theoretical framework of psychological strain and qualitative interview techniques. This training ensured their proficiency in active listening and in-depth interviewing.\u003c/p\u003e \u003cp\u003e Regarding participant recruitment, face-to-face interviews were conducted with patients who were local and available for in-person meetings. For participants residing elsewhere, online interviews were arranged via the Tencent Meeting platform, with assistance from nurse liaisons at local hospitals. Before each interview, participants signed informed consent forms and completed demographic information questionnaires. To guarantee confidentiality and participant comfort, all interviews took place in private, quiet environments. Throughout the interview process, various qualitative research techniques were employed, including probing questions, content clarification, and reflective listening. These techniques helped guide participants to elaborate on the barriers they encountered in nutritional management and their subjective experiences as gastric cancer patients within the Eastern Sichuan healthcare system. Interviews did not have a fixed time limit; instead, their duration was adjusted based on each participant's specific circumstances and communication needs.\u003c/p\u003e \u003cp\u003eIn addition to the coordinating ethics approval, the team obtained administrative permission from each participating hospital, as required. The team applied the same consent and confidentiality procedures at all sites.\u003c/p\u003e \u003cp\u003eAll interview content was recorded anonymously, either using the Tencent Meeting platform's built-in recording function or via smartphones. Data collection continued until information saturation was reached, defined as the point at which no new meaningful themes emerged, and responses began to overlap with previously collected data. At this stage, both recruitment and interviews were concluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThis study employed thematic analysis to investigate the challenges and subjective experiences of gastric cancer patients in nutritional management. All interview recordings were transcribed verbatim into Chinese and independently verified by two researchers to ensure transcriptional accuracy and completeness. Selected quotations were translated into English by bilingual researchers and cross-checked to preserve meaning. A total of fifteen validated transcripts were imported into NVivo 14 (Lumivero) for systematic qualitative analysis. The research team conducted repeated and immersive readings of the transcripts to achieve a comprehensive understanding of the dataset and to develop an initial thematic framework.\u003c/p\u003e \u003cp\u003eAnalytically, the team used a hybrid deductive and inductive approach. The team conducted a theory-informed thematic analysis guided by psychological strain theory. The initial codebook defined four domains: value strain, aspiration strain, deprivation strain, and coping strain. The team added inductive codes when participants\u0026rsquo; accounts did not align with the a priori categories. The team refined the codebook through constant comparison and regular consensus meetings.\u003c/p\u003e \u003cp\u003eBased on this framework, researchers extracted analytically meaningful concepts and expressions guided by the interview guide. These textual elements were treated as meaning units for abstraction, condensation, and coding. Semantically related codes were then grouped into higher-order categories and labeled descriptively. Any discrepancies between the two coders were resolved through discussion and re-examination of the original recordings. To enhance methodological rigor, a third researcher served as an independent auditor, reviewing the coding procedures and outcomes to ensure credibility, dependability, and confirmability.\u003c/p\u003e \u003cp\u003eAll codes were iteratively refined and integrated under the guidance of the interview framework until no new categories or themes emerged, indicating information saturation. The research team held weekly consensus meetings to review and adjust the analytic process. The finalized thematic structure was established once all members reached agreement on the interpretation of findings.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e This study protocol was reviewed and approved by the Ethics Committee of Dazhou Central Hospital (No.2024156). Written informed consent was obtained from all participants prior to their inclusion in the study. Participants were informed that their involvement was entirely voluntary and that they could withdraw from the study at any time without providing a reason or experiencing any negative consequences. No monetary or material compensation was provided.\u003c/p\u003e \u003cp\u003eAll personal information and interview materials were anonymized and stored in an encrypted, password-protected cloud system accessible only to the research team. These measures were implemented to ensure data confidentiality and participant privacy throughout the research process.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of Participants\u003c/h2\u003e \u003cp\u003eThe relevant demographic information of the respondents (including highest level of education, gender, age, occupation, etc.) is summarized in Table\u0026nbsp;1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMajor themes\u003c/h2\u003e \u003cp\u003eData analysis identified five themes with 16 subthemes (Table\u0026nbsp;2): (1) the conflict between physiological tolerance and nutritional requirements; (2) decision paralysis amid knowledge gaps and multi-source conflict; (3) resource accessibility and affordability constraints; (4) compliance and conflict driven by family relationships; and (5) the negative cycle of psychological strain and social comparison.\u003c/p\u003e \u003cp\u003eGuided by psychological strain theory, these themes reflect how practical barriers are experienced as internal strains shaping nutritional decisions and adherence over time. We mapped subthemes to the core constructs of the theory to clarify the hypothesised mechanisms underpinning unstable nutrition adherence patterns. The mapping is summarised in Table\u0026nbsp;3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: The conflict between physiological tolerance and nutritional requirements\u003c/h2\u003e \u003cp\u003e \u003cb\u003ePotentially modifiable determinant\u003c/b\u003e: \u003cem\u003esymptom-driven feasibility constraints and low confidence in symptom-linked nutrition strategies.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 1: Eating tolerance disorder and somatic symptoms\u003c/h2\u003e \u003cp\u003eFluctuating symptoms, such as nausea, early satiety, and vomiting, severely constrained eating. This turned nutrition management into a process of repeated trial-and-error, rather than a stable routine.\u003c/p\u003e \u003cp\u003e \u003cem\u003eBefore, I'd eat whenever I felt hungry. Now, when mealtime comes around, I actually dread it. I'm afraid of what might happen after eating (H).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSymptom-driven avoidance and reduced portions often undermined sustained adherence to nutrition recommendations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 2: Supplement confusion and tolerance issues\u003c/h2\u003e \u003cp\u003eParticipants expressed uncertainty about nutritional supplements, including concerns about ingredients, safety, and whether supplements should be treated like medication. Some discontinued or reduced supplements after experiencing gastrointestinal discomfort.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe doctor said I could take some nutritional powder, but I've been wondering, does this count as medicine? Could taking too much be bad for my liver and kidneys? No one has explained it clearly to me (D).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eUncertainty and intolerance led to intermittent use and frequent self-adjustment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 3: Behavioral adjustment and coping strategies\u003c/h2\u003e \u003cp\u003eInstead of stopping eating, participants adopted trial-and-error strategies to cope with discomfort, such as eating smaller, more frequent meals, choosing softer foods, and selecting items they found personally \u0026ldquo;tolerable.\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cem\u003eNow I can only manage half a boiled egg at a time, any more makes me feel sick. I just try to eat whatever I can stomach, sometimes having some congee or steamed egg custard. When I really can't eat anything, I just go hungry until I'm ravenous, then force myself to eat a little(A).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThese adaptations enabled short-term intake but often lacked consistency without professional guidance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 4: Rehabilitation motivation and functional goals\u003c/h2\u003e \u003cp\u003eParticipants framed nutritional goals in pragmatic terms, emphasizing survival, maintaining strength for treatment, and preserving basic daily functioning to reduce dependence on family.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI just want to live a few more years, stay in better health, at least be able to take care of myself, and not be a burden to my children (B).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFunctional goals motivated effort, but symptom fluctuations still limited what could be maintained.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 5: Pathological transformation of value orientation\u003c/h2\u003e \u003cp\u003eIllness reshaped how participants viewed food, shifting from taste and convenience to a task-oriented focus on \u0026ldquo;nutrition for recovery,\u0026rdquo; sometimes reducing enjoyment and reinforcing illness identity.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSometimes I feel like a robot, forced to eat the prescribed foods at set times, it's utterly joyless. Plus, every meal serves as a stark reminder that I'm sick (D).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMoralizing \u0026ldquo;eating well\u0026rdquo; increased emotional burden and, for some, heightened frustration when intake was poor.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Decision paralysis amid knowledge gaps and multi-source conflict\u003c/h2\u003e \u003cp\u003e \u003cb\u003ePotentially modifiable determinant\u003c/b\u003e: \u003cem\u003edecisional conflict due to inconsistent information and limited actionable guidance.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 1: Lack of nutritional knowledge and insufficient health literacy\u003c/h2\u003e \u003cp\u003eAlthough participants recognized nutrition as important, many lacked concrete knowledge about balanced diets and how to translate general advice into feasible plans during treatment or symptom flare-ups.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe doctor, nurse, and even my son all tell me to eat more nutritious food, but I don't know what else is nutritious besides meat (A).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eLimited decision rules increased uncertainty and reliance on personal experience, leading to unstable routines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 2: Multi-source information and conflicting perspectives\u003c/h2\u003e \u003cp\u003eParticipants obtained dietary advice from clinicians, family, peers, and online content, but contradictory messages often created confusion and hesitation about what to follow.\u003c/p\u003e \u003cp\u003e \u003cem\u003eMy wife says eating red dates and goji berries is good for me, but the doctor never mentioned those. My son keeps saying I should take protein powder, and I'm not sure whether to believe him (A).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSubtheme 2: Operational guidance and culinary skill requirements\u003c/h3\u003e\n\u003cp\u003eParticipants reported a gap between knowing \u0026ldquo;nutrition matters\u0026rdquo; and knowing how to implement meal preparation in daily life; technical language and lack of step-by-step guidance compounded difficulties.\u003c/p\u003e \u003cp\u003e \u003cem\u003eEvery time I see those nutritional recipes, there are so many ingredients I've never even heard of, and I have no idea how to prepare them. When I ask the doctors and nurses, they use terms that are too technical for me to understand. I come back still clueless about what I should actually eat (J).\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePractical barriers in cooking and translation of advice limited feasibility at home.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eTheme 5: The negative cycle of psychological strain and social comparison\u003c/h2\u003e \u003cp\u003e \u003cb\u003ePotentially modifiable determinant\u003c/b\u003e: \u003cem\u003eunmanaged distress and maladaptive social comparison, compounded by communication barriers with professionals.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 1: Emotional responses and psychological strain\u003c/h2\u003e \u003cp\u003eEating difficulties and weight loss were closely tied to anxiety and helplessness, with meals becoming a repeated source of distress during treatment.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt feels like a war I can't win. Every meal is a battle, like fighting an enemy, but I have no idea when it will end or if I can ever win this fight (C).\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePersistent distress reduced motivation and tolerance for sustained nutritional effort.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme 2: Social comparison and othering experiences\u003c/h2\u003e \u003cp\u003eComparisons with other patients or healthy individuals intensified feelings of exclusion and perceived disadvantage, especially regarding dietary freedom and available support.\u003c/p\u003e \u003cp\u003e \u003cem\u003eTake that older woman in the same ward, for instance. Her kids buy her all kinds of health supplements, and she eats them like clockwork. My family can't afford that, and sometimes I just feel so useless (H).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eComparison experiences reinforced discouragement and weakened persistence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme 3: Professional support gap and barriers in doctor-patient communication\u003c/h2\u003e \u003cp\u003eBrief consultations, limited access to nutrition professionals, and reluctance to ask questions left participants without ongoing, comprehensible guidance, prompting reliance on informal sources.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThere are no professional nutritionists in our area at all, and it's inconvenient to consult at large hospitals. It feels unfair compared to patients in big cities (I).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDiscontinuous professional support increased uncertainty and hindered long-term adherence.\u003c/p\u003e \u003cp\u003eTo enhance analytic transparency, we created a correspondence table linking each analytic subtheme to the four strain constructs in psychological strain theory (value strain, aspiration strain, deprivation strain, and coping strain) (Table\u0026nbsp;3). This mapping summarizes how strain-related mechanisms were represented across the 16 subthemes.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study identifies five themes that, when interpreted through psychological strain theory, indicate a set of potentially modifiable determinants shaping psychological strain and nutritional adherence over time. Building on these determinants, we outline an actionable supportive-care pathway that can be integrated into routine care and evaluated in future pilot work.\u003c/p\u003e\n\u003ch3\u003eMechanistic interpretation using psychological strain theory\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;3 illustrates how strain-related mechanisms were reflected across analytic subthemes, suggesting that patients experience multiple, competing pressures during nutritional management. Two patterns were particularly salient. First, many accounts reflected an aspiration\u0026ndash;reality gap. Patients often held strong beliefs and goals, such as the idea that eating more would restore strength. Patients also described goals related to living longer to spend more time with family. These beliefs and goals conflicted with lived constraints. Common constraints included dysphagia and other eating difficulties. Financial burden was also frequently reported. Limited caregiving capacity further restricted patients\u0026rsquo; ability to follow their intended plans. In the absence of accessible, practical dietary adjustment strategies and sustained professional support, patients often described difficulty translating intentions into action, repeatedly shifting between \u0026ldquo;wanting to eat better\u0026rdquo; and \u0026ldquo;what is realistically achievable.\u0026rdquo; This intention\u0026ndash;feasibility tension may help explain why adherence to nutritional management fluctuates over time.\u003c/p\u003e \u003cp\u003eSecond, Theme 5 suggests a potential self-reinforcing cycle in which social comparison intensifies perceived deprivation and aspiration strain. Patients frequently compared themselves with others who appeared to recover more smoothly or receive stronger support, which could trigger sadness, shame, and self-blame. These emotional responses may consume coping resources and reduce motivation to sustain nutritional efforts. As strain accumulates, some patients described disengagement from nutritional management, which may contribute to setbacks and, in turn, prompt further social comparison and renewed feelings of failure. This pattern is consistent with fluctuations between intention and action commonly described in chronic disease self-management.\u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eMechanism model: intention\u0026ndash;feasibility oscillation and a reinforcing loop\u003c/h2\u003e \u003cp\u003eAcross themes, patients described nutritional management as a repeated tension between what they wanted to do and what they could realistically sustain. Many held a strong intention to eat better for recovery, yet day to day tolerance changed with symptoms and treatment demands. In response, they often made short term compromises, such as smaller portions, simplified meals, or intermittent supplement use. These adjustments reduced immediate burden, but they also made it harder to maintain consistency over time. This emphasis on nutrition impact symptoms as a practical constraint is consistent with evidence that symptom burden can materially affect nutrition outcomes in gastrointestinal cancers\u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eUncertainty about supplements and medical foods further intensified this instability. Decisions about supplementation often became a focal point where expected benefits, safety concerns, and tolerability had to be weighed repeatedly. Patients therefore moved between trying different products, stopping use, or changing the way they used them, which echoes reports of variable perceptions and behaviours regarding dietary supplements during chemotherapy\u003csup\u003e[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/sup\u003e. In parallel, exposure to conflicting dietary advice and misinformation increased fear and indecision, making it difficult to settle on stable rules for action\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/sup\u003e. Peer support could reduce isolation, but it sometimes added information noise or strengthened social comparison, depending on the group dynamics and content quality\u003csup\u003e[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/sup\u003e. When eating well was framed as a measure of self discipline or worth, setbacks were more likely to be interpreted as personal failure. Shame and self blame then reduced help seeking and open communication, a pattern that is consistent with stigma related processes linked to lower engagement and worse outcomes in cancer contexts\u003csup\u003e[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/sup\u003e. Together, these pressures depleted coping resources and made disengagement more likely, which in turn set the stage for further setbacks.\u003c/p\u003e \u003cp\u003eThis account also aligns with behaviour change scholarship. Durable change tends to require practical skills, feedback, and supportive conditions rather than information alone\u003csup\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e. Clear specification of active components and techniques can further strengthen feasibility and reproducibility when translating findings into an intervention pathway\u003csup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003eClinical implications: deliverable intervention components for supportive care\u003c/h2\u003e \u003cp\u003eAcross themes, participants\u0026rsquo; accounts suggest that nutritional management is undermined less by lack of motivation alone than by a repeated mismatch between intentions, symptom-contingent feasibility, and contextual constraints. Accordingly, supportive care may benefit from a small set of practice-oriented components that directly respond to the identified strain mechanisms. The components below are framed as clinically feasible targets rather than a fixed intervention \u0026ldquo;bundle,\u0026rdquo; and can be adapted to local service capacity.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section2\"\u003e \u003ch2\u003eComponent 1: Symptom-linked nutrition coaching with micro-skill training\u003c/h2\u003e \u003cp\u003eParticipants\u0026rsquo; accounts suggest that plans often break down when symptoms fluctuate and day-to-day tolerance changes. A feasible response is to provide brief, symptom-contingent guidance that helps patients decide what to prioritise on flare-up days versus symptom-stable days, supported by simple micro-skill coaching. Clinicians can focus on concrete strategies such as portioning, texture modification, and realistic substitutions that fit local food availability. This approach supports translation from intention to action by making guidance practicable in the moment, consistent with evidence that behaviour change is strengthened when support is concrete and actionable\u003csup\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e. For feasibility and reproducibility, the pathway should describe what is delivered, to whom, and when, so that the active components are clear and can be evaluated\u003csup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec40\" class=\"Section3\"\u003e \u003ch2\u003eComponent 2: Decision support and consistent messaging to reduce decisional conflict\u003c/h2\u003e \u003cp\u003eTo address knowledge gaps and multi-source conflict, the pathway could incorporate a short supplement decision support resource that clarifies common indications, how to monitor tolerance, when to pause or seek advice, and how to respond to conflicting recommendations. The aim is not to add information, but to reduce fear and indecision triggered by misinformation and inconsistent messaging\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/sup\u003e. Where peer communities are involved, curated content and light moderation may help preserve social support while reducing information noise and comparison-related distress\u003csup\u003e[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cem\u003eComponent 3: Resource navigation and affordability support to reduce deprivation strain\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAffordability and access barriers were central to deprivation strain and can undermine continuity even when motivation is high. A practical component is to include light-touch resource navigation, with a clear point of contact, streamlined referrals, and low-burden follow-up that supports continuity across transitions. This support can also include signposting to locally available options and routes for financial counselling when needed\u003csup\u003e[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cem\u003eComponent 4: Family alignment and implementation support with safeguards against caregiver burden\u003c/em\u003e \u003c/p\u003e \u003cp\u003eBecause nutritional management is commonly implemented within households, supportive care may benefit from brief family-inclusive goal setting and explicit role clarification to support shared decision-making and reduce conflict\u003csup\u003e[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]\u003c/sup\u003e. At the same time, safeguards are needed to avoid shifting excessive responsibility to caregivers. Incorporating caregiver burden screening and access to appropriate psychological support within a structured pathway may reduce attrition and strengthen coordination and accountability across transitions\u003csup\u003e[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cem\u003eComponent 5: Psychosocial and communication support to interrupt the strain\u0026ndash;comparison cycle\u003c/em\u003e \u003c/p\u003e \u003cp\u003eTo interrupt the cycle of strain and social comparison, the pathway can include brief distress screening and targeted psychoeducation, with escalation or referral when thresholds are met. In routine visits, structured check-ins and prompt-based question guides may support timely clinician\u0026ndash;patient communication and facilitate problem-solving.\u003c/p\u003e \u003cp\u003eFor future piloting, these components can be operationalised with clear delivery roles and follow-up triggers to support feasibility and reproducibility without increasing burden on routine services.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplementation options to support continuity\u003c/b\u003e \u003c/p\u003e \u003cp\u003eLow-burden follow-up modalities may help maintain continuity when in-person nutrition services are limited. Evidence from a randomized multicenter trial supports the effectiveness of phone-based nurse monitoring for chemotherapy-related toxicity management, suggesting a practical model for symptom-triggered monitoring and timely escalation in supportive care settings. In parallel, digital interventions have been associated with improved adherence in oncology settings, including during oral systemic therapy. These findings support the feasibility of implementing structured digital reminders, routine check-ins, and standardized follow-up workflows to reinforce and maintain self-management routines\u003csup\u003e[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]\u003c/sup\u003e. The broader eHealth self-management literature also offers practical design patterns for scalable support, including structured modules, symptom and behavior monitoring, and feedback mechanisms. With appropriate clinical oversight, these elements could be cautiously adapted to oncology nutrition to enhance self-management while maintaining safety and clinical appropriateness\u003csup\u003e[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths, limitations, and future directions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA key strength is the theory-informed mechanism framing, which clarifies why multiple barriers converge into unstable adherence patterns and identifies actionable intervention targets. Limitations include the region-specific qualitative context and the lack of outcome evaluation. Future studies should test whether the proposed components, including a symptom-linked nutrition toolkit, a decision aid for supplement use, and a family-inclusive pathway with structured follow-up, can reduce psychological strain and strengthen nutritional continuity when integrated into routine supportive care.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study translates patient experiences into potentially modifiable determinants of psychological strain during nutritional management in gastric cancer and outlines a supportive-care pathway to address them. Future studies should pilot the pathway to examine feasibility, acceptability, and implementation in real-world oncology settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGC: Gastric cancer\u003c/p\u003e\n\u003cp\u003eASIR: Age-Standardized Incidence Rate\u003c/p\u003e\n\u003cp\u003eASMR: Age-Standardized Mortality Rate\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was supported by the 2024 Nursing Scientific Research Project of the Sichuan Nursing Association (Grant No. H24061). The funding body had no role in the study design, data collection, data analysis, interpretation of results, or manuscript writing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Dazhou Central Hospital \u0026nbsp;(study reference number: 2024156). The study was performed in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eData analyzed during the current study are not publicly available due to confidentiality, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eShiyu Xiao: Conceptualization, Data collection, Formal analysis, Writing – original draft.\u003c/p\u003e\n\u003cp\u003eGuirong Wu: Conceptualization, Methodology, Supervision, Writing – review and editing.\u003c/p\u003e\n\u003cp\u003ePing Xu: Data collection, Methodology.\u003c/p\u003e\n\u003cp\u003eChun Zhang: Data analysis, Interpretation of data.\u003c/p\u003e\n\u003cp\u003eYanxi Li: Data validation, Translation and language support.\u003c/p\u003e\n\u003cp\u003eXiangbo Liao: Data curation, Project coordination.\u003c/p\u003e\n\u003cp\u003eYan Xiong: Project administration, Resources.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThrift AP, Nguyen Wenker T, El-Serag HB. 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Journal of Medical Internet Research, 2025, 27: e57649.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Gastric cancer, Nutritional management, Psychological strain theory, Qualitative interviews, Eastern Sichuan","lastPublishedDoi":"10.21203/rs.3.rs-8716097/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8716097/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo identify potentially modifiable determinants underlying psychological strain during nutritional management among gastric cancer patients, and to translate these determinants into actionable components for a supportive-care pathway.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative descriptive study recruited gastric cancer patients from eight hospitals in eastern Sichuan, China, between March and August 2025. Using purposive sampling, we enrolled adults (\u0026ge;\u0026thinsp;18 years) with pathologically confirmed gastric cancer who had nutritional risk (NRS-2002\u0026thinsp;\u0026ge;\u0026thinsp;3) and reported barriers to nutritional support. Data were collected via semi-structured interviews and analyzed using thematic analysis. Ethical approval was obtained, and all participants provided informed consent.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFifteen interviews were analyzed. Overall, patients\u0026rsquo; nutritional management was shaped by competing psychological forces that intensified psychological strain and undermined sustained adherence. Key themes included: (1) The conflict between physiological tolerance and nutritional requirements; (2) Decision paralysis amid knowledge gaps and multi-source conflict; (3) Resource accessibility and affordability constraints; (4) Compliance and conflict driven by family relationships; (5) The negative cycle of psychological strain and social comparison.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe translate patient experiences into potentially modifiable determinants and outline a supportive-care pathway comprising symptom-linked nutrition coaching, decision support and consistent messaging, resource navigation, family alignment, and psychosocial support with structured follow-up. Future work should pilot the pathway to assess feasibility and acceptability in routine care.\u003c/p\u003e","manuscriptTitle":"Psychological strain in nutritional management for gastric cancer patients: a multicenter qualitative study informing a supportive-care pathway","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-06 18:00:32","doi":"10.21203/rs.3.rs-8716097/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-03-03T15:14:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-03T15:12:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-03T12:37:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2026-01-28T04:03:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4b83f05b-8ac9-4fc7-88fa-dd0a4452c1b8","owner":[],"postedDate":"March 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-06T18:00:32+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-06 18:00:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8716097","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8716097","identity":"rs-8716097","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}