A Qualitative Study of Self-Efficacy-Related Experiences and Needs in Postoperative Self- Management Among Patients with Advanced Gastric Cancer

A Qualitative Study of Self-Efficacy-Related Experiences and Needs in Postoperative Self- Management Among Patients with Advanced Gastric Cancer | 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 A Qualitative Study of Self-Efficacy-Related Experiences and Needs in Postoperative Self- Management Among Patients with Advanced Gastric Cancer Xiaolu Yang, Jian Wang, Meiyu Jiang, Wenhui Huang, Chengcheng Liu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7274719/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Postoperative self-management is critical for recovery in patients with advanced gastric cancer (AGC). However, many struggle with complex physical, emotional, and informational challenges. Self-efficacy plays a key role in facilitating effective self-management, but little is known about how it is shaped by patients’ lived experiences, particularly in the Chinese context. Objective To explore the experiences, challenges, and needs that influence self-efficacy during postoperative self-management among Chinese patients with AGC. Methods This descriptive phenomenological study involved semi-structured, face-to-face interviews with nine postoperative AGC patients at a tertiary hospital in southern China. Data were analyzed inductively using Colaizzi’s seven-step method to identify key themes grounded in participants’ lived experiences. Results Three interrelated themes were identified: (1) Polarized awareness and deficiencies in self-management abilities, reflecting varied levels of health monitoring, confusion around symptom management, and inadequate nutritional knowledge; (2) Limited capacity for patient-provider communication and accessing reliable health information, marked by constrained clinical interactions and dependence on informal or inaccessible information sources; and (3) Varied emotional coping capacities, encompassing both family-supported resilience and deeply distressing emotional reactions. These findings reveal substantial gaps in postoperative education, psychosocial support, and health communication, all of which affect patients’ confidence and ability to manage recovery. Conclusions Patients with AGC face multifaceted challenges in postoperative self-management that directly impact their self-efficacy. Culturally appropriate and peer-supported interventions that address informational, emotional, and practical needs may be essential to supporting effective self-management in this population. These insights provide a patient-centered foundation for future intervention development. advanced gastric cancer self-efficacy qualitative research self-management expert patient programme Figures Figure 1 1. Introduction Gastric cancer (GC) remains a major global health concern, ranking as the fifth most common cancer and the third leading cause of cancer-related death, with an estimated 1.1 million new cases and nearly 800,000 deaths each year [ 1 , 2 ]. Despite the decline in age-standardized incidence and mortality rates, which can be attributed to improved sanitation, widespread Helicobacter pylori eradication, and healthier lifestyles, the absolute number of gastric cancer cases continues to rise as a result of global population aging and growth [ 3 , 4 ]. Notably, GC prevalence exhibits substantial geographic disparities, with East Asia disproportionately affected [ 1 , 5 ]. China accounts for approximately 44–45% of global GC cases, with around 478,000 new diagnoses annually and marked disparities between urban and rural areas [ 6 – 9 ]. In China, gastric cancer remains a major clinical challenge, as patients are often diagnosed at advanced stages, requiring aggressive surgery with high complication rates and prolonged recovery [ 10 , 11 ]. Extensive research highlights that postoperative periods involve increased anxiety, depression, and fear, complicating patients' adherence to essential self-management regimens [ 10 , 11 ]. Central to overcoming these challenges is the concept of self-efficacy, defined by Bandura as an individual’s belief in their ability to perform actions required to attain desired outcomes [ 12 ]. High self-efficacy significantly enhances patients' abilities to manage postoperative challenges, resulting in positive clinical outcomes, improved symptom control, and increased engagement in health-promoting behaviors [ 13 , 14 ]. Enhancing self-efficacy has emerged as a focus in supporting postoperative recovery among patients with advanced gastric cancer (AGC), prompting the development and implementation of diverse intervention strategies. Structured nursing interventions in China have increasingly incorporated theoretical frameworks such as the Information-Knowledge-Attitude-Practice (IKAP) model to systematically address patients' medical and psychosocial needs [ 10 ]. Such interventions have demonstrated improved self-efficacy, reduced postoperative symptoms (e.g., fatigue and anxiety), and increased self-care activities. In parallel, interdisciplinary interventions combining patient education with coordinated care have improved daily self-management, enhanced psychological resilience, and reduced postoperative complications [ 10 , 11 ]. Recent studies also indicate the effectiveness of psychosocial strategies, particularly behavioral activation (BA) therapy, in enhancing self-efficacy among cancer patients. BA encourages engagement in meaningful activities, disrupts patterns of avoidance and negative affect, and improves psychological outcomes. Tested in gastric and esophageal cancer populations, BA has shown considerable promise, with self-efficacy improvements mediating reductions in psychological distress [ 15 ]. While these interventions offer demonstrated benefits, they are typically designed from a clinical or theoretical perspective, with limited incorporation of patients’ subjective experiences. This may constrain their ability to fully address the complex, individualized challenges patients face during postoperative recovery. Accordingly, there is a growing recognition of the value of grounding intervention development in first-hand patient perspectives. An emerging and promising approach for enhancing self-efficacy is the expert-patient programme (EPP), in which individuals with successful recovery experiences share experiential knowledge and provide peer support to patients facing similar health challenges [ 16 ]. Grounded in self-efficacy theory, the EPP is a self-management intervention that emphasizes patient empowerment through health education, peer interaction, and the development of caregiving and coping skills (Fig. 1 ) [ 17 ]. Typically delivered in small group settings over several weeks, the programme is facilitated by trained “expert patients” who themselves have navigated similar health journeys [ 17 , 18 ]. Studies in cancer populations, including colorectal and breast cancer, have demonstrated the effectiveness of EPP in improving self-care behaviors, psychological well-being, and overall quality of life [ 19 , 20 ]. However, research on EPP for AGC remains limited, particularly within the Chinese healthcare context [ 21 ]. In China, cultural values such as family interdependence and deference to medical authority influence how patients engage in care [ 22 ]. To ensure the relevance and effectiveness of such interventions, it is critical to base their development on patients’ lived experiences and perspectives. Furthermore, previous qualitative studies have identified key factors influencing self-efficacy and quality of life, including caregiver dynamics, communication barriers, cultural beliefs, and health literacy [ 23 ]. These interpersonal and contextual variables differ widely across individuals and social settings, affecting how patients manage their recovery and perceive their ability to do so. Such findings underscore the need for culturally sensitive, patient-centered interventions grounded in qualitative insight [ 22 ]. To address these gaps, this study adopts a qualitative approach to explore the psychosocial (e.g., emotional well-being, social support) and practical (e.g., symptom burden, access to care) factors shaping self-efficacy among postoperative AGC patients. By capturing patients’ voices, the study aims to identify core components essential for designing a culturally adapted, context-specific EPP. Such a programme may enhance clinical outcomes, foster psychological resilience, and support sustained self-management in this vulnerable population. 2. Methods 2.1. Study Design This qualitative study adopted a descriptive phenomenological approach [24], grounded in Husserlian philosophy [25], to deeply explore the lived experiences and self-management challenges of surgical patients with AGC. The objective was to identify core barriers and adaptive strategies in self-management, with the ultimate aim of informing the design of a culturally appropriate EPP based on Bandura’s self-efficacy theory [12, 26]. Phenomenology was selected for its strength in uncovering subjective meanings embedded in patients’ postoperative experiences. To ensure analytical rigor and minimize bias, the research team engaged in bracketing through reflective journaling and team discussions [27]. In addition to the qualitative interviews, an expert panel comprising clinicians, oncology nurses, and academic researchers was sequentially consulted to review emerging findings and provide preliminary input on the design of a future EPP. A literature review was previously conducted to strengthen the evidence foundation of the study, drawing on existing research related to self-efficacy, expert-patient models, and gastric cancer. 2.2. Setting and Participants The study was conducted in the gastrointestinal surgical ward of a tertiary-level Grade A hospital located in Guangzhou, China. This institution serves as a regional referral center for gastrointestinal oncology and provides comprehensive diagnostic, surgical, and rehabilitative services for patients with AGC. All semi-structured interviews were held in quiet, private consultation rooms to ensure confidentiality and participant comfort. All participating patients were recruited with participant information sheets during their postoperative hospitalization or early recovery period. Interviews were scheduled at a time suitable for the participants, with attention to fatigue and emotional well-being. Surgical patients with AGC were recruited using purposive sampling (e.g., patients’ age and education al level) [28]. Participants were selected based on their ability to provide rich, first-person accounts of their postoperative self-management experiences. Participants were selected based on their ability to provide rich, first-person accounts of their postoperative self-management experiences. Sampling continued until data saturation was reached. The inclusion criteria for patients were: Aged 18 years or older; Confirmed diagnosis of advanced gastric cancer (TNM stage: cT 1~2 N 1~3 M 0 , cT 3~4 N 0 M 0 , cT 3~4a N 1~3 M 0 , or cT 3~4b N 0~3 M 0 ); Underwent surgical resection with or without adjuvant chemotherapy; Clear mental status and communication ability sufficient for interview participation; Provided written informed consent and agreed to audio recording. The exclusion criteria for patients were: Presence of other primary malignant tumors. Severe cachexia or critical illness precluding participation. Cognitive impairment or psychiatric conditions affecting comprehension or communication. Withdrawal of consent or loss to follow-up during the study. 2.3. Data Collection Semi-structured face-to-face interviews were conducted in a quiet hospital consultation room between February 1 and 29, 2024, lasting 30 to 50 minutes per patient. An interview guide was developed based on literature review and expert input. The guide was piloted with two AGC patients to refine clarity and content before formal implementation. Topics included illness perception, postoperative self-management experiences, nutrition and symptom management, information-seeking behavior, emotional adjustment, and social support. The details of the interview guide are provided in Appendix 1. All interviews were conducted by two trained researcher (XY and MJ) and audio-recorded with consent and supplemented by field notes capturing non-verbal cues and observations. No repeated interviews were carried out. 2.4. Data Analysis Audio recordings were transcribed verbatim in Chinese and analyzed using Colaizzi’s seven-step phenomenological method, involving: (1) familiarization with transcripts, (2) identification of significant statements, (3) formulation of meanings, (4) clustering into themes, (5) development of exhaustive descriptions, (6) extraction of fundamental structures, and (7) member checking for validation [29]. Transcripts were not returned to participants for comment and/or correction. Two independent researchers (XY and JW) conducted the coding process and resolved discrepancies through discussion and peer debriefing. An inductive coding approach was applied to allow themes to emerge directly from the data. NVivo software (version 12, ©Lumivero, Denver, CO) was used to facilitate coding, comparison, and theme development [30]. This process entailed iterative reviews across cases to enhance analytic rigor and maintain a transparent audit trail. Participants’ original quotations were carefully translated into English for reporting, with attention to preserving meaning. Researcher reflexivity was maintained through team discussions and analytic memos, acknowledging the researchers’ backgrounds in oncology nursing and qualitative health research. The participants were not required to provide feedback on the findings. 2.5. Quality control To ensure credibility, dependability, and confirmability, the study implemented multiple strategies: member checking with participants, dual coding, audit trails of analytical decisions, and reflexive journaling. Transferability was addressed by providing thick descriptions of participant backgrounds and contextual details. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Appendix 2) guidelines to ensure methodological rigor, credibility, and transparency throughout all phases of design, data collection, and analysis [31]. 2.6. Researcher Reflexivity The interviewer (XY, female, MSN) had a background in oncology nursing and prior qualitative research experience in cancer self-management. XY’s clinical familiarity and local cultural knowledge facilitated rapport and nuanced understanding during interviews. To maintain reflexivity, XY used open-ended, non-leading prompts and engaged in bracketing through reflective journaling and team discussions. While XY’s background enhanced sensitivity to relevant issues, data were analyzed inductively, allowing themes to emerge from participants’ perspectives. Bandura’s self-efficacy theory served as a sensitizing framework without constraining data interpretation. 2.7. Ethical Considerations Ethical approval was obtained from the hospital’s ethics committee (Approval No. KY2024-076-02). Participants provided written informed consent after being informed of the study’s purpose, procedures, confidentiality safeguards, and their right to withdraw at any time without consequences. All identifying information was anonymized to ensure privacy and confidentiality. 3. Results 3.1. Sample characteristics A total of nine postoperative patients with AGC participated in the study. As shown in Table 1, participants ranged in age from 46 to 72 years. The sample included six females and three males. All participants were married. In terms of education, most had completed junior high school or below ( n = 5), while others had technical secondary education ( n = 3) or a bachelor's degree ( n = 1). Table 1. Basic Information of Interview Patients (n = 9) Patient ID Age (years) Sex Marital Status Education level N1 48 Male Married Technical Secondary N2 66 Female Married Junior High or Below N3 63 Female Married Junior High or Below N4 69 Female Married Junior High or Below N5 59 Female Married Junior High or Below N6 72 Female Married Junior High or Below N7 46 Male Married Bachelor’s Degree N8 70 Female Married Technical Secondary N9 52 Male Married Technical Secondary 3.2. Patient interview findings: experiences, challenges, and needs Three major themes were identified through the in-depth semi-structured interviews, which capture the experiences, challenges, and needs of surgical patients with AGC in their journey of postoperative self-management. The coding tree was structured around three main themes, each encompassing subthemes that reflect patients’ challenges in symptom management, nutritional understanding, information access, and emotional coping. The coding structure captures the diverse and complex experiences that shape self-efficacy after surgery, offering a nuanced understanding of the barriers that the patients encountered and the coping strategies that they employed. Theme 1: Polarized Awareness and Deficiencies in Self-Management Abilities Self-management among postoperative gastric cancer patients was found to vary greatly. This included differences in their proactive acquisition of disease-related knowledge, monitoring of symptoms, timely medical visits, and lifestyle adjustments. Subtheme 1.1 Divergent levels of self-management awareness Some patients demonstrated strong self-management awareness, proactively monitoring their health and engaging in preventive behaviors. For example, N4 reported undergoing regular check-ups (“I have regular medical check-ups.”), N5 described long-term medication and follow-ups for H. pylori infection (“Because I was previously diagnosed with a Helicobacter pylori infection, I have been taking medication to control it and come for regular follow-ups.”), and N9 shared that annual health checks led to early treatment (“I have regular annual check-ups, so as soon as a problem arose, I came here immediately for treatment.”). However, others displayed a passive approach, lacking early prevention or intervention awareness, which resulted in delayed diagnoses. N1 admitted ignoring reports and postponed follow-ups for two years despite knowing about an H. pylori infection, which progressed to cancer (“I didn’t have any discomfort or symptoms. I knew I had a Helicobacter pylori infection and even went for a check-up, but I never picked up the report because I didn’t think it was a big deal. I delayed from 2021 to 2023, and when I finally went for another check-up, they told me it was already cancer.”). N2 delayed seeking care for six months despite experiencing reflux symptoms (“I had acid reflux and some discomfort, but I kept putting it off and didn’t come for a check-up until six months later.”). This highlights weak risk perceptions and a tendency to overlook or misjudge early symptoms, affecting timely treatment. Subtheme 1.2 Confusion and worries about postoperative self-care Many patients expressed concerns about their ability to manage recovery at home. N1 described difficulty even getting out of bed due to pain (“Now I can hardly get out of bed. Every movement causes pain. I feel like a useless person.”), N5 worried about handling wound bleeding from a distant location (“What should I do if the wound starts bleeding after I’ve returned home? I’m out of town, and it’s inconvenient to come back. My child also has to work.”), and N6 was unsure how to interpret and respond to symptoms (“The main issue is that after returning home, I’m experiencing some symptoms but I’m not sure if they’re normal or not, and I don’t know how to handle them.”). This reflects significant uncertainty in managing postoperative pain, mobility, and complications, indicating a lack of targeted self-care guidance. Subtheme 1.3 Insufficient understanding of nutritional management Despite the high risk of postoperative malnutrition, patients generally lacked knowledge on nutritional management. N4 was confused about the duration and progression of diet stages (“I was told that the diet should progress gradually, from full liquid to regular food, but how many days should each stage last? Or is it possible to have full liquid for breakfast, then move to semi-liquid or soft food for lunch?”), N6 asked if tonic soups were appropriate (“I think I should make more soups to drink. Is it okay to have nourishing soups? I looked up some recipes, and they say sea cucumber is nutritious and good to eat.”), and N7 worried if eating mainly porridge and noodles was nutritionally adequate, noting a weight loss (“It seems like aside from congee, rice noodles, and noodles, I don’t really know what else I can eat. Is that enough nutrition? I’ve already lost 3.5 kg so far”). Other patients, such as N8 (“I’m not sure about the recommended intake of vitamins, protein, carbohydrates, and meat, and I don’t know where I can learn about it either.”) and N9 (“I’m not quite sure about this issue. I eat three regular meals a day, and I add nutritional supplements in the afternoon and at night. Would that be considered sufficient?”), were unclear on how to balance proteins, carbohydrates, and vitamins, and questioned whether common approaches like adding nutritional powders sufficed. This underscores the urgent need for structured dietary education to prevent misinformation and inadequate intake. Theme 2: Limited Capacity for Patient-Provider Communication and Accessing Reliable Health Information Subtheme 2.1 Constraints in communication with healthcare providers Many patients found communication with doctors and nurses limited by time constraints and information asymmetry. N1 noted brief ward rounds with minimal exchanges (“The doctor only stopped by briefly during morning rounds and was very busy—barely said a few words before leaving.”), and N7 was hesitant to ask more questions because staff were busy (“I rely on myself to ask a few more questions when I can. Sometimes I asked the doctors or nurses, or I looked things up on Baidu. But the doctors and nurses were all very busy, so I don’t feel comfortable asking too much.”). Patients like N9 struggled to find channels for clarifying personal concerns beyond general content on hospital social media platforms (“I do follow your official WeChat account, and there are some health articles on it. But when I want to ask something more specific about a certain detail, I don’t know who to turn to.”). N5 shared skepticism about the reliability of information from online searches, facing conflicting guidance (“I use Baidu to look things up, but I’m not sure if the results are accurate. There are so many different answers, and I don’t know which one to trust.”). Subtheme 2.2 Scarce pathways for acquiring health information Due to limited formal education and digital literacy, many patients relied on informal sources such as social media or family. N1 mentioned reading health stories on online medias (“I usually browse Today’s Headlines; sometimes there are health-related news articles on there. I read them just to relax and stay a bit informed.”), while N3 (“I basically don’t have any reliable sources, so I just ask my child. They’ll look it up and then tell me what they find.”) and N2 (“I don’t really have any channels for information. Usually, I only find things out when you doctors or nurses tell me. I don’t really trust the information I see elsewhere.”) depended mainly on explanations from family or healthcare staff. N2 specifically noted being a rural woman with low literacy, unable to use online tools (“I’m just a rural woman with little education. I can’t read some of the words, and I don’t know how to use the internet.”). These challenges reflect systemic gaps in accessible, structured health education. Theme 3: Varied Emotional Coping Capacities Subtheme 3.1 Positive coping supported by family Some patients benefited from strong family support, which alleviated psychological stress. N6 shared that her family accompanied and cared for her throughout treatment (“My eldest daughter-in-law was with me throughout the whole process and also took care of me at home. We're both doing very well.”), N7 described managing well with his wife’s help while shielding their children from worry (“It’s my wife who has been accompanying me the whole time. We run our own company, so work hasn’t been affected much. As for the kids, we just told them it was a polyp removal to keep them from worrying.”), and N8 highlighted relatives adjusting their lives to care for her (“I usually take care of myself—buying groceries, cooking, and looking after the children. But now, they’ve arranged for someone to take time off just to accompany me, so everything is going well.”). Subtheme 3.2 Prevalence of negative emotions Conversely, some patients experienced profound anxiety, depression, or even despair. N1 fatalistically accepted the illness, referencing early death (“There’s nothing I can do. I didn’t take my health seriously before. Now that I have this illness, maybe it’s just fate—live or die, I’ll accept it.”), while N3 was shocked by the sudden diagnosis after a lifetime of health (“It was all so sudden. I rarely even caught colds before and had never been hospitalized. When the test results came back, I was completely shocked.”). N9 described feeling extremely low for months, questioning “ Why me? I had never experienced anything like this in my life—I felt completely hopeless. Thoughts of preparing for the worst, even making end-of-life arrangements, started to cross my mind. ” and even contemplating end-of-life arrangements. Subtheme 3.3 Individual differences in psychological adjustment Other patients managed to maintain a positive outlook. N2 found comfort in her children’s support and lack of work obligations (“Fortunately, my children have been by my side, encouraging me. And since I’m not working like the younger generation, I don’t need to take time off.”), N5 pragmatically stated, “ If you’re sick, you treat it. It’s nothing to be too worried about. ”, and N8 accepted the diagnosis, reassured by modern treatments (“This is just the reality—you just have to accept it. Although my family is very worried, medical technology is advanced now, and it’s not as painful as it used to be.”). These differences illustrate the wide variability in patients’ emotional resilience and underscore the necessity of personalized psychological support. 4. Discussion 4.1. Self-management challenges and cultural considerations in AGC care This qualitative study revealed critical self-management challenges faced by Chinese surgical patients with AGC. Three interrelated themes emerged: polarized self-management awareness and inadequate management skills, limited communication with healthcare providers and difficulty accessing reliable health information, and wide variability in emotional coping capacities. These findings underscore that postoperative AGC patients often struggle to navigate complex regimens of symptom monitoring, nutritional management, and psychological adjustment, reflecting individual and systemic gaps in support [ 22 ]. The polarized levels of self-management awareness highlight an important barrier. While some patients demonstrated proactive health monitoring and engagement, others delayed seeking care despite the presence of known risk factors or symptoms, echoing findings from prior research that underscored weak risk perception and reliance on informal knowledge sources [ 32 ]. Nutritional management deficiencies were particularly pronounced, with many patients expressing confusion about diet stages and balanced nutrient intake aligned with prior Chinese studies documenting high rates of postoperative malnutrition in gastric cancer patients [ 33 , 34 ]. Additionally, many participants described brief and superficial communication with clinicians, leading to persistent uncertainty and unmet informational needs, especially among older adults and those with low health literacy [ 35 ]. The cultural context in China further shapes these dynamics. Traditional norms emphasize family involvement and deference to medical authority, which may discourage patients from actively questioning clinicians or seeking peer-led support [ 36 ]. On the other hand, family support emerged as a crucial buffer against emotional distress, consistent with studies that highlight the role of familial networks in psychological adaptation [ 37 ]. Thus, designing interventions that incorporate family engagement and acknowledge cultural hierarchies is essential for maximizing acceptability and effectiveness. 4.2. Strengthening self-efficacy through a tailored Expert-Patient Programme Findings from this study underscore the need for culturally responsive, peer-supported interventions that address the psychological, informational, and practical barriers to self-management faced by AGC surgical patients. Participants described uncertainty in symptom monitoring and nutrition, emotional distress, and a lack of accessible, reliable guidance, which directly impact their confidence and capacity to manage recovery. The qualitative themes align closely with Bandura’s four sources of self-efficacy: mastery experience, vicarious learning, verbal persuasion, and emotional regulation, suggesting that peer-led, experience-based interventions may effectively reinforce these mechanisms [ 26 ]. These insights point to the value of a structured EPP that leverages lived experience, peer role modeling, and practical skill-building to enhance self-efficacy. Based on the existing evidence, EPPs and similar self-management interventions have been shown to improve self-efficacy, psychological resilience, symptom control, and quality of life in various cancer populations, including those with colorectal, breast, and esophageal cancers [ 38 , 39 ]. However, there is a lack of research specifically examining the application of EPPs in advanced gastric cancer, particularly within the Chinese healthcare context [ 40 ]. Future work should explore the feasibility and impact of implementing such a programme within routine postoperative care for AGC patients. An EPP informed by these findings should prioritize clear, relatable content; emotional support through shared experience; and guidance on symptom and nutritional management. Tailoring delivery formats to patient preferences, such as small group discussions or digital communication platforms, may further support engagement and accessibility [ 41 , 42 ]. Anchoring the intervention in patients’ lived experiences helps ensure that support strategies are theoretically grounded and culturally relevant and practically applicable. 4.3. Implications for clinical practice This study highlights critical implications for enhancing postoperative care in patients with advanced gastric cancer in China. The findings identify key gaps in patient knowledge, symptom monitoring, nutritional management, and emotional support, underscoring the need for patient-centered intervention approaches. Peer-based educational interventions represent a particularly promising strategy for improving patient engagement and self-efficacy [ 43 ]. Integrating experienced peer facilitators into postoperative education may complement current nursing and multidisciplinary care practices by increasing personalized support, particularly benefiting patients with limited health literacy or restricted access to healthcare resources. Incorporating culturally relevant elements, such as family involvement, simplified medical information [ 44 ], and familiar digital platforms (e.g., WeChat), could further enhance the acceptability and feasibility of interventions [ 45 ]. Moreover, fostering peer connections and experiential knowledge sharing may improve patient trust, normalize discussions around postoperative difficulties, and empower patients to actively participate in their own recovery [ 46 ]. These qualitative insights provide a foundation for developing and evaluating culturally sensitive, peer-supported programmes as part of routine gastric cancer care. 4.4. Limitations This study has several limitations. First, as a qualitative exploration conducted in a single tertiary hospital in southern China, the findings may not be transferable to all regions or healthcare settings. Second, although efforts were made to include patients with diverse educational and age backgrounds, the relatively small and geographically limited sample may not capture the full range of postoperative self-management experiences among AGC patients across China. Third, while this study aimed to inform the early development of a peer-based intervention, it did not incorporate perspectives from caregivers or healthcare professionals, whose views may further enrich the design and feasibility of future programmes. Including these additional stakeholders in subsequent research will be important to ensure cultural relevance and practical applicability. 5. Conclusion This study shows the complex and multidimensional challenges that Chinese patients face in managing recovery after surgery for advanced gastric cancer, including limited self-management awareness, inadequate access to reliable information, and varied emotional coping capacities. These findings underscore the central role of self-efficacy in postoperative care and highlight the unmet need for culturally appropriate, patient-centered support strategies. Insights from this qualitative exploration offer a foundation for the future development of interventions that integrate lived experience, emotional support, and practical skill-building to strengthen patients’ confidence and engagement in self-care. Further research is needed to translate these findings into feasible, context-sensitive programmes within routine clinical practice. Declarations Acknowledgements We are grateful to all individuals who took part in this study. We extend our sincere appreciation to the patients and expert patients who generously shared their experiences and insights. We also thank the clinical staff and expert panel members for their valuable contributions and thoughtful guidance throughout the development of the programme. Additionally, we acknowledge the support of our research team colleagues for their dedication to conducting the interviews and preparing the transcripts. Author contributions LH and XY conceived and designed the study. XY and DX conducted the literature review and developed the interview guide. XY and MJ carried out the patient interviews. WH, CL, and RY performed the initial data transcription. XY and JW led the qualitative data analysis with input from LH. XY and JW drafted the manuscript. All authors read, provided critical revisions, and approved the final manuscript. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability The data supporting the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy or ethical restrictions. Ethics approval and consent to participate The study protocol was approved by the Ethics Committee of Guangdong Provincial People's Hospital (Approval No. KY2024-076-02). All participants provided written informed consent form. The study was conducted in line with all relevant regulations and the Declaration of Helsinki. Competing interests The authors declare no competing interests. References Ilic, M. and I. Ilic, Epidemiology of stomach cancer. World J Gastroenterol, 2022. 28 (12): p. 1187-1203. Yang, L., et al., Gastric cancer: Epidemiology, risk factors and prevention strategies. Chin J Cancer Res, 2020. 32 (6): p. 695-704. Lin, J.L., et al., Global incidence and mortality trends of gastric cancer and predicted mortality of gastric cancer by 2035. 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Fischer, C.T., Bracketing in qualitative research: Conceptual and practical matters. Psychotherapy Research, 2009. 19 (4-5): p. 583-590. Suri, H., Purposeful sampling in qualitative research synthesis. Qualitative research journal, 2011. 11 (2): p. 63-75. Morrow, R., A. Rodriguez, and N. King, Colaizzi’s descriptive phenomenological method. The psychologist, 2015. 28 (8): p. 643-644. Elliott-Mainwaring, H., Exploring using NVivo software to facilitate inductive coding for thematic narrative synthesis. British Journal of Midwifery, 2021. 29 (11): p. 628-632. Tong, A., P. Sainsbury, and J. Craig, Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care, 2007. 19 (6): p. 349-357. Wang, Q., et al., Public awareness of gastric cancer risk factors and screening behaviours in Shijiazhuang, China: A community-based survey. Plos One, 2024. 19 (10). Wang, H.M., et al., Nutritional Status and Related Factors in Patients with Gastric Cancer after Gastrectomy: A Cross-Sectional Study. Nutrients, 2022. 14 (13). Ren, L.P., et al., Effectiveness of the CANCER-AIMS intervention on nutritional status and symptom management in patients with gastric cancer following gastrectomy: A randomized controlled trial. International Journal of Nursing Studies, 2024. 159 . Liu, Q., et al., Awareness of risk factors and warning symptoms and attitude towards gastric cancer screening among the general public in China: a cross-sectional study. Bmj Open, 2019. 9 (7). Meng, M.Q., et al., When western concept meets eastern culture: Exploring the impact of Confucianism on shared decision-making in China. Asia-Pacific Journal of Oncology Nursing, 2024. 11 (11). Epstein, N.B., et al., Therapy with families in China: Cultural factors influencing the therapeutic alliance and therapy goals. Contemporary Family Therapy, 2014. 36 : p. 201-212. Rimmer, B., et al., Characteristics and Components of Self-Management Interventions for Improving Quality of Life in Cancer Survivors: A Systematic Review. Cancers, 2024. 16 (1). Huang, F.F., et al., Psychometric properties and performance of existing self-efficacy instruments in cancer populations: a systematic review. Health and Quality of Life Outcomes, 2018. 16 . Cao, N.D., et al., Chinese Medicine Prolongs Overall Survival of Chinese Patients with Advanced Gastric Cancer: Treatment Pattern and Survival Analysis of a 20-Year Real-World Study. Chinese Journal of Integrative Medicine, 2024. 30 (6): p. 489-498. White, S.J., et al., Tailoring communication practices to support effective delivery of telehealth in general practice. BMC Prim Care, 2024. 25 (1): p. 232. Madanian, S., et al., Patients' perspectives on digital health tools. PEC Innov, 2023. 2 : p. 100171. Gao, Q.A., et al., Effectiveness of a comprehensive post-operative health education program in improving quality of life after gastric cancer surgery. Annals of Palliative Medicine, 2020. 9 (3): p. 921-926. Jazieh, A.R., S. Volker, and S. Taher, Involving the family in patient care: a culturally tailored communication model. Global Journal on Quality and Safety in Healthcare, 2018. 1 (2): p. 33-37. He, Y.S., et al., Exploring nurse and patient perspectives on WeChat-based prenatal education in Chinese public hospitals: a qualitative inquiry. Bmc Nursing, 2025. 24 (1). Ussher, J., et al., What do cancer support groups provide which other supportive relationships do not? The experience of peer support groups for people with cancer. Social science & medicine, 2006. 62 (10): p. 2565-2576. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7274719","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":500961931,"identity":"f7803839-813c-406e-871c-70dde1454c0f","order_by":0,"name":"Xiaolu Yang","email":"","orcid":"","institution":"Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiaolu","middleName":"","lastName":"Yang","suffix":""},{"id":500961932,"identity":"89ff91b3-4f89-4127-8b1c-c3058024596f","order_by":1,"name":"Jian Wang","email":"","orcid":"","institution":"King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Jian","middleName":"","lastName":"Wang","suffix":""},{"id":500961933,"identity":"850c6fc8-8849-4e7a-841a-9a1883e89fd9","order_by":2,"name":"Meiyu Jiang","email":"","orcid":"","institution":"Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Meiyu","middleName":"","lastName":"Jiang","suffix":""},{"id":500961934,"identity":"bd3385b3-57b5-4961-9390-2b4ad8df57a4","order_by":3,"name":"Wenhui Huang","email":"","orcid":"","institution":"Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wenhui","middleName":"","lastName":"Huang","suffix":""},{"id":500961935,"identity":"67337439-9c99-4431-84e3-aed774023528","order_by":4,"name":"Chengcheng Liu","email":"","orcid":"","institution":"Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Chengcheng","middleName":"","lastName":"Liu","suffix":""},{"id":500961936,"identity":"a91123d1-5a24-45a6-9f41-f2f2cd1e1bba","order_by":5,"name":"Ruya Yuan","email":"","orcid":"","institution":"Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Ruya","middleName":"","lastName":"Yuan","suffix":""},{"id":500961937,"identity":"f9e52b7d-131a-4482-9c62-c77f18689ec1","order_by":6,"name":"Dailan Xiong","email":"","orcid":"","institution":"Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Dailan","middleName":"","lastName":"Xiong","suffix":""},{"id":500961938,"identity":"5bdd27ec-a721-4d9b-8b13-c39a06bd859b","order_by":7,"name":"Lijing Hu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYBACAwbmhgMSBgwM/EDOgQcwYR68WhghWiQbgFoSiNUCYRwAEkRpMZdIbDxgUXDHbvO1ww+BttQlzp+RwPjgbRuDvDkOLZYzEkEOe5a87XaaAVDL4cQNNxKYDee2MRjubMDhsBtgLYeTzW4ngLQcSNwgkcAmzdvGkAB2Kj4txrPTP8Acxv6bGC12BtI5IFuYExtuJLAx49Vy5iFYS4LE7ZyCAwkGh403nHnYLDnnnIThBlxajicf/izx57A9/+z0zR8+VNTJzm9PPvjhTZmNPC5bQIBZgoEhsQFiAoNjAySmJHCrBwLGDwwM9jCOPT6Vo2AUjIJRMDIBAFRLZ4iNjAvqAAAAAElFTkSuQmCC","orcid":"","institution":"Sun Yat-sen University","correspondingAuthor":true,"prefix":"","firstName":"Lijing","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2025-08-02 00:38:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7274719/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7274719/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89591035,"identity":"c0f2b130-8633-4257-a67f-1af2d9aa1241","added_by":"auto","created_at":"2025-08-21 16:07:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":116050,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual Model for the Development of an Expert-Patient Programme in Surgical Patients with Advanced Gastric Cancer\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7274719/v1/bb006a418f1bf7530c7a665c.png"},{"id":89593060,"identity":"c5e437ea-e558-4014-b6a2-d0ac0dcce603","added_by":"auto","created_at":"2025-08-21 16:15:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":874304,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7274719/v1/5902d894-e5c2-4bd1-b491-2adbeb20b89a.pdf"},{"id":89591036,"identity":"9abca180-f4ba-4078-8dc5-b9c1e8093e6a","added_by":"auto","created_at":"2025-08-21 16:07:39","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":21677,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-7274719/v1/2a7b8a458ce2d6c64e0c0121.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Qualitative Study of Self-Efficacy-Related Experiences and Needs in Postoperative Self- Management Among Patients with Advanced Gastric Cancer","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eGastric cancer (GC) remains a major global health concern, ranking as the fifth most common cancer and the third leading cause of cancer-related death, with an estimated 1.1\u0026nbsp;million new cases and nearly 800,000 deaths each year [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite the decline in age-standardized incidence and mortality rates, which can be attributed to improved sanitation, widespread Helicobacter pylori eradication, and healthier lifestyles, the absolute number of gastric cancer cases continues to rise as a result of global population aging and growth [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Notably, GC prevalence exhibits substantial geographic disparities, with East Asia disproportionately affected [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. China accounts for approximately 44\u0026ndash;45% of global GC cases, with around 478,000 new diagnoses annually and marked disparities between urban and rural areas [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn China, gastric cancer remains a major clinical challenge, as patients are often diagnosed at advanced stages, requiring aggressive surgery with high complication rates and prolonged recovery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Extensive research highlights that postoperative periods involve increased anxiety, depression, and fear, complicating patients' adherence to essential self-management regimens [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Central to overcoming these challenges is the concept of self-efficacy, defined by Bandura as an individual\u0026rsquo;s belief in their ability to perform actions required to attain desired outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. High self-efficacy significantly enhances patients' abilities to manage postoperative challenges, resulting in positive clinical outcomes, improved symptom control, and increased engagement in health-promoting behaviors [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEnhancing self-efficacy has emerged as a focus in supporting postoperative recovery among patients with advanced gastric cancer (AGC), prompting the development and implementation of diverse intervention strategies. Structured nursing interventions in China have increasingly incorporated theoretical frameworks such as the Information-Knowledge-Attitude-Practice (IKAP) model to systematically address patients' medical and psychosocial needs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Such interventions have demonstrated improved self-efficacy, reduced postoperative symptoms (e.g., fatigue and anxiety), and increased self-care activities. In parallel, interdisciplinary interventions combining patient education with coordinated care have improved daily self-management, enhanced psychological resilience, and reduced postoperative complications [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Recent studies also indicate the effectiveness of psychosocial strategies, particularly behavioral activation (BA) therapy, in enhancing self-efficacy among cancer patients. BA encourages engagement in meaningful activities, disrupts patterns of avoidance and negative affect, and improves psychological outcomes. Tested in gastric and esophageal cancer populations, BA has shown considerable promise, with self-efficacy improvements mediating reductions in psychological distress [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile these interventions offer demonstrated benefits, they are typically designed from a clinical or theoretical perspective, with limited incorporation of patients\u0026rsquo; subjective experiences. This may constrain their ability to fully address the complex, individualized challenges patients face during postoperative recovery. Accordingly, there is a growing recognition of the value of grounding intervention development in first-hand patient perspectives.\u003c/p\u003e\u003cp\u003eAn emerging and promising approach for enhancing self-efficacy is the expert-patient programme (EPP), in which individuals with successful recovery experiences share experiential knowledge and provide peer support to patients facing similar health challenges [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Grounded in self-efficacy theory, the EPP is a self-management intervention that emphasizes patient empowerment through health education, peer interaction, and the development of caregiving and coping skills (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Typically delivered in small group settings over several weeks, the programme is facilitated by trained \u0026ldquo;expert patients\u0026rdquo; who themselves have navigated similar health journeys [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Studies in cancer populations, including colorectal and breast cancer, have demonstrated the effectiveness of EPP in improving self-care behaviors, psychological well-being, and overall quality of life [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, research on EPP for AGC remains limited, particularly within the Chinese healthcare context [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In China, cultural values such as family interdependence and deference to medical authority influence how patients engage in care [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. To ensure the relevance and effectiveness of such interventions, it is critical to base their development on patients\u0026rsquo; lived experiences and perspectives. Furthermore, previous qualitative studies have identified key factors influencing self-efficacy and quality of life, including caregiver dynamics, communication barriers, cultural beliefs, and health literacy [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These interpersonal and contextual variables differ widely across individuals and social settings, affecting how patients manage their recovery and perceive their ability to do so. Such findings underscore the need for culturally sensitive, patient-centered interventions grounded in qualitative insight [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTo address these gaps, this study adopts a qualitative approach to explore the psychosocial (e.g., emotional well-being, social support) and practical (e.g., symptom burden, access to care) factors shaping self-efficacy among postoperative AGC patients. By capturing patients\u0026rsquo; voices, the study aims to identify core components essential for designing a culturally adapted, context-specific EPP. Such a programme may enhance clinical outcomes, foster psychological resilience, and support sustained self-management in this vulnerable population.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e2.1. Study Design\u003c/p\u003e\n\u003cp\u003eThis qualitative study adopted a descriptive phenomenological approach [24], grounded in Husserlian philosophy [25], to deeply explore the lived experiences and self-management challenges of surgical patients with AGC. The objective was to identify core barriers and adaptive strategies in self-management, with the ultimate aim of informing the design of a culturally appropriate EPP based on Bandura\u0026rsquo;s self-efficacy theory [12, 26].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePhenomenology was selected for its strength in uncovering subjective meanings embedded in patients\u0026rsquo; postoperative experiences. To ensure analytical rigor and minimize bias, the research team engaged in bracketing through reflective journaling and team discussions [27]. In addition to the qualitative interviews, an expert panel comprising clinicians, oncology nurses, and academic researchers was sequentially consulted to review emerging findings and provide preliminary input on the design of a future EPP. A literature review was previously conducted to strengthen the evidence foundation of the study, drawing on existing research related to self-efficacy, expert-patient models, and gastric cancer. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.2. Setting and Participants\u003c/p\u003e\n\u003cp\u003eThe study was conducted in the gastrointestinal surgical ward of a tertiary-level Grade A hospital located in Guangzhou, China. This institution serves as a regional referral center for gastrointestinal oncology and provides comprehensive diagnostic, surgical, and rehabilitative services for patients with AGC. All semi-structured interviews were held in quiet, private consultation rooms to ensure confidentiality and participant comfort. All participating patients were recruited with participant information sheets during their postoperative hospitalization or early recovery period. Interviews were scheduled at a time suitable for the participants, with attention to fatigue and emotional well-being.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSurgical patients with AGC were recruited using purposive sampling (e.g., patients\u0026rsquo; age and education al level) [28]. Participants were selected based on their ability to provide rich, first-person accounts of their postoperative self-management experiences. Participants were selected based on their ability to provide rich, first-person accounts of their postoperative self-management experiences. Sampling continued until data saturation was reached.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria for patients were:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eAged 18 years or older;\u003c/li\u003e\n \u003cli\u003eConfirmed diagnosis of advanced gastric cancer (TNM stage: cT\u003csub\u003e1~2\u003c/sub\u003eN\u003csub\u003e1~3\u003c/sub\u003eM\u003csub\u003e0\u003c/sub\u003e, cT\u003csub\u003e3~4\u003c/sub\u003eN\u003csub\u003e0\u003c/sub\u003eM\u003csub\u003e0\u003c/sub\u003e, cT\u003csub\u003e3~4a\u003c/sub\u003eN\u003csub\u003e1~3\u003c/sub\u003eM\u003csub\u003e0\u003c/sub\u003e, or cT\u003csub\u003e3~4b\u003c/sub\u003eN\u003csub\u003e0~3\u003c/sub\u003eM\u003csub\u003e0\u003c/sub\u003e);\u003c/li\u003e\n \u003cli\u003eUnderwent surgical resection with or without adjuvant chemotherapy;\u003c/li\u003e\n \u003cli\u003eClear mental status and communication ability sufficient for interview participation;\u003c/li\u003e\n \u003cli\u003eProvided written informed consent and agreed to audio recording.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe exclusion criteria for patients were:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003ePresence of other primary malignant tumors.\u003c/li\u003e\n \u003cli\u003eSevere cachexia or critical illness precluding participation.\u003c/li\u003e\n \u003cli\u003eCognitive impairment or psychiatric conditions affecting comprehension or communication.\u003c/li\u003e\n \u003cli\u003eWithdrawal of consent or loss to follow-up during the study.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e2.3. Data Collection\u003c/p\u003e\n\u003cp\u003eSemi-structured face-to-face interviews were conducted in a quiet hospital consultation room between February 1 and 29, 2024, lasting 30 to 50 minutes per patient. An interview guide was developed based on literature review and expert input. The guide was piloted with two AGC patients to refine clarity and content before formal implementation. Topics included illness perception, postoperative self-management experiences, nutrition and symptom management, information-seeking behavior, emotional adjustment, and social support. The details of the interview guide are provided in Appendix 1. All interviews were conducted by two trained researcher (XY and MJ) and audio-recorded with consent and supplemented by field notes capturing non-verbal cues and observations. No repeated interviews were carried out.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.4. Data Analysis\u003c/p\u003e\n\u003cp\u003eAudio recordings were transcribed verbatim in Chinese and analyzed using Colaizzi\u0026rsquo;s seven-step phenomenological method, involving: (1) familiarization with transcripts, (2) identification of significant statements, (3) formulation of meanings, (4) clustering into themes, (5) development of exhaustive descriptions, (6) extraction of fundamental structures, and (7) member checking for validation [29]. Transcripts were not returned to participants for comment and/or correction. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo independent researchers (XY and JW) conducted the coding process and resolved discrepancies through discussion and peer debriefing. An inductive coding approach was applied to allow themes to emerge directly from the data. NVivo software (version 12, \u0026copy;Lumivero, Denver, CO) was used to facilitate coding, comparison, and theme development [30]. This process entailed iterative reviews across cases to enhance analytic rigor and maintain a transparent audit trail.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants\u0026rsquo; original quotations were carefully translated into English for reporting, with attention to preserving meaning. Researcher reflexivity was maintained through team discussions and analytic memos, acknowledging the researchers\u0026rsquo; backgrounds in oncology nursing and qualitative health research. The participants were not required to provide feedback on the findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.5. Quality control\u003c/p\u003e\n\u003cp\u003eTo ensure credibility, dependability, and confirmability, the study implemented multiple strategies: member checking with participants, dual coding, audit trails of analytical decisions, and reflexive journaling. Transferability was addressed by providing thick descriptions of participant backgrounds and contextual details. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Appendix 2) guidelines to ensure methodological rigor, credibility, and transparency throughout all phases of design, data collection, and analysis [31].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.6. Researcher Reflexivity\u003c/p\u003e\n\u003cp\u003eThe interviewer (XY, female, MSN) had a background in oncology nursing and prior qualitative research experience in cancer self-management. XY\u0026rsquo;s clinical familiarity and local cultural knowledge facilitated rapport and nuanced understanding during interviews. To maintain reflexivity, XY used open-ended, non-leading prompts and engaged in bracketing through reflective journaling and team discussions. While XY\u0026rsquo;s background enhanced sensitivity to relevant issues, data were analyzed inductively, allowing themes to emerge from participants\u0026rsquo; perspectives. Bandura\u0026rsquo;s self-efficacy theory served as a sensitizing framework without constraining data interpretation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.7. Ethical Considerations\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the hospital\u0026rsquo;s ethics committee (Approval No. KY2024-076-02). Participants provided written informed consent after being informed of the study\u0026rsquo;s purpose, procedures, confidentiality safeguards, and their right to withdraw at any time without consequences. All identifying information was anonymized to ensure privacy and confidentiality.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e3.1. Sample characteristics\u003c/p\u003e\n\u003cp\u003eA total of nine postoperative patients with AGC participated in the study. As shown in Table 1, participants ranged in age from 46 to 72 years. The sample included six females and three males. All participants were married. In terms of education, most had completed junior high school or below (\u003cem\u003en\u003c/em\u003e = 5), while others had technical secondary education (\u003cem\u003en\u003c/em\u003e = 3) or a bachelor\u0026apos;s degree (\u003cem\u003en\u003c/em\u003e = 1).\u003c/p\u003e\n\u003cp\u003eTable 1. Basic Information of Interview Patients (n = 9)\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003ePatient ID\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 181px;\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eN1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 181px;\"\u003e\n \u003cp\u003eTechnical Secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eN2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003eJunior High or Below\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eN3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003eJunior High or Below\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eN4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003eJunior High or Below\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eN5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003eJunior High or Below\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eN6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003eJunior High or Below\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eN7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 181px;\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eN8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003eTechnical Secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eN9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 181px;\"\u003e\n \u003cp\u003eTechnical Secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e3.2. Patient interview findings: experiences, challenges, and needs\u003c/p\u003e\n\u003cp\u003eThree major themes were identified through the in-depth semi-structured interviews, which capture the experiences, challenges, and needs of surgical patients with AGC in their journey of postoperative self-management. The coding tree was structured around three main themes, each encompassing subthemes that reflect patients\u0026rsquo; challenges in symptom management, nutritional understanding, information access, and emotional coping. The coding structure captures the diverse and complex experiences that shape self-efficacy after surgery, offering a nuanced understanding of the barriers that the patients encountered and the coping strategies that they employed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: Polarized Awareness and Deficiencies in Self-Management Abilities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelf-management among postoperative gastric cancer patients was found to vary greatly. This included differences in their proactive acquisition of disease-related knowledge, monitoring of symptoms, timely medical visits, and lifestyle adjustments.\u003c/p\u003e\n\u003cp\u003eSubtheme 1.1\u0026nbsp;Divergent levels of self-management awareness\u003c/p\u003e\n\u003cp\u003eSome patients demonstrated strong self-management awareness, proactively monitoring their health and engaging in preventive behaviors. For example, \u003cem\u003eN4\u003c/em\u003e reported undergoing regular check-ups (\u0026ldquo;I have regular medical check-ups.\u0026rdquo;), \u003cem\u003eN5\u003c/em\u003e described long-term medication and follow-ups for H. pylori infection (\u0026ldquo;Because I was previously diagnosed with a Helicobacter pylori infection, I have been taking medication to control it and come for regular follow-ups.\u0026rdquo;), and \u003cem\u003eN9\u003c/em\u003e shared that annual health checks led to early treatment (\u0026ldquo;I have regular annual check-ups, so as soon as a problem arose, I came here immediately for treatment.\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003eHowever, others displayed a passive approach, lacking early prevention or intervention awareness, which resulted in delayed diagnoses. \u003cem\u003eN1\u003c/em\u003e admitted ignoring reports and postponed follow-ups for two years despite knowing about an H. pylori infection, which progressed to cancer (\u0026ldquo;I didn\u0026rsquo;t have any discomfort or symptoms. I knew I had a Helicobacter pylori infection and even went for a check-up, but I never picked up the report because I didn\u0026rsquo;t think it was a big deal. I delayed from 2021 to 2023, and when I finally went for another check-up, they told me it was already cancer.\u0026rdquo;). \u003cem\u003eN2\u003c/em\u003e delayed seeking care for six months despite experiencing reflux symptoms (\u0026ldquo;I had acid reflux and some discomfort, but I kept putting it off and didn\u0026rsquo;t come for a check-up until six months later.\u0026rdquo;). This highlights weak risk perceptions and a tendency to overlook or misjudge early symptoms, affecting timely treatment.\u003c/p\u003e\n\u003cp\u003eSubtheme 1.2\u0026nbsp;Confusion and worries about postoperative self-care\u003c/p\u003e\n\u003cp\u003eMany patients expressed concerns about their ability to manage recovery at home. \u003cem\u003eN1\u003c/em\u003e described difficulty even getting out of bed due to pain (\u0026ldquo;Now I can hardly get out of bed. Every movement causes pain. I feel like a useless person.\u0026rdquo;), \u003cem\u003eN5\u003c/em\u003e worried about handling wound bleeding from a distant location (\u0026ldquo;What should I do if the wound starts bleeding after I\u0026rsquo;ve returned home? I\u0026rsquo;m out of town, and it\u0026rsquo;s inconvenient to come back. My child also has to work.\u0026rdquo;), and \u003cem\u003eN6\u003c/em\u003e was unsure how to interpret and respond to symptoms (\u0026ldquo;The main issue is that after returning home, I\u0026rsquo;m experiencing some symptoms but I\u0026rsquo;m not sure if they\u0026rsquo;re normal or not, and I don\u0026rsquo;t know how to handle them.\u0026rdquo;). This reflects significant uncertainty in managing postoperative pain, mobility, and complications, indicating a lack of targeted self-care guidance.\u003c/p\u003e\n\u003cp\u003eSubtheme 1.3\u0026nbsp;Insufficient understanding of nutritional management\u003c/p\u003e\n\u003cp\u003eDespite the high risk of postoperative malnutrition, patients generally lacked knowledge on nutritional management. \u003cem\u003eN4\u003c/em\u003e was confused about the duration and progression of diet stages (\u0026ldquo;I was told that the diet should progress gradually, from full liquid to regular food, but how many days should each stage last? Or is it possible to have full liquid for breakfast, then move to semi-liquid or soft food for lunch?\u0026rdquo;), \u003cem\u003eN6\u003c/em\u003e asked if tonic soups were appropriate (\u0026ldquo;I think I should make more soups to drink. Is it okay to have nourishing soups? I looked up some recipes, and they say sea cucumber is nutritious and good to eat.\u0026rdquo;), and \u003cem\u003eN7\u003c/em\u003e worried if eating mainly porridge and noodles was nutritionally adequate, noting a weight loss (\u0026ldquo;It seems like aside from congee, rice noodles, and noodles, I don\u0026rsquo;t really know what else I can eat. Is that enough nutrition? I\u0026rsquo;ve already lost 3.5 kg so far\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003eOther patients, such as \u003cem\u003eN8\u003c/em\u003e (\u0026ldquo;I\u0026rsquo;m not sure about the recommended intake of vitamins, protein, carbohydrates, and meat, and I don\u0026rsquo;t know where I can learn about it either.\u0026rdquo;) and \u003cem\u003eN9\u003c/em\u003e (\u0026ldquo;I\u0026rsquo;m not quite sure about this issue. I eat three regular meals a day, and I add nutritional supplements in the afternoon and at night. Would that be considered sufficient?\u0026rdquo;), were unclear on how to balance proteins, carbohydrates, and vitamins, and questioned whether common approaches like adding nutritional powders sufficed. This underscores the urgent need for structured dietary education to prevent misinformation and inadequate intake.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: Limited Capacity for Patient-Provider Communication and Accessing Reliable Health Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubtheme 2.1\u0026nbsp;Constraints in communication with healthcare providers\u003c/p\u003e\n\u003cp\u003eMany patients found communication with doctors and nurses limited by time constraints and information asymmetry. \u003cem\u003eN1\u003c/em\u003e noted brief ward rounds with minimal exchanges (\u0026ldquo;The doctor only stopped by briefly during morning rounds and was very busy\u0026mdash;barely said a few words before leaving.\u0026rdquo;), and \u003cem\u003eN7\u003c/em\u003e was hesitant to ask more questions because staff were busy (\u0026ldquo;I rely on myself to ask a few more questions when I can. Sometimes I asked the doctors or nurses, or I looked things up on Baidu. But the doctors and nurses were all very busy, so I don\u0026rsquo;t feel comfortable asking too much.\u0026rdquo;). Patients like \u003cem\u003eN9\u003c/em\u003e struggled to find channels for clarifying personal concerns beyond general content on hospital social media platforms (\u0026ldquo;I do follow your official WeChat account, and there are some health articles on it. But when I want to ask something more specific about a certain detail, I don\u0026rsquo;t know who to turn to.\u0026rdquo;). \u003cem\u003eN5\u003c/em\u003e shared skepticism about the reliability of information from online searches, facing conflicting guidance (\u0026ldquo;I use Baidu to look things up, but I\u0026rsquo;m not sure if the results are accurate. There are so many different answers, and I don\u0026rsquo;t know which one to trust.\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003eSubtheme 2.2\u0026nbsp;Scarce pathways for acquiring health information\u003c/p\u003e\n\u003cp\u003eDue to limited formal education and digital literacy, many patients relied on informal sources such as social media or family. \u003cem\u003eN1\u003c/em\u003e mentioned reading health stories on online medias (\u0026ldquo;I usually browse Today\u0026rsquo;s Headlines; sometimes there are health-related news articles on there. I read them just to relax and stay a bit informed.\u0026rdquo;), while \u003cem\u003eN3\u003c/em\u003e (\u0026ldquo;I basically don\u0026rsquo;t have any reliable sources, so I just ask my child. They\u0026rsquo;ll look it up and then tell me what they find.\u0026rdquo;) and \u003cem\u003eN2\u003c/em\u003e (\u0026ldquo;I don\u0026rsquo;t really have any channels for information. Usually, I only find things out when you doctors or nurses tell me. I don\u0026rsquo;t really trust the information I see elsewhere.\u0026rdquo;) depended mainly on explanations from family or healthcare staff. \u003cem\u003eN2\u003c/em\u003e specifically noted being a rural woman with low literacy, unable to use online tools (\u0026ldquo;I\u0026rsquo;m just a rural woman with little education. I can\u0026rsquo;t read some of the words, and I don\u0026rsquo;t know how to use the internet.\u0026rdquo;). These challenges reflect systemic gaps in accessible, structured health education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3: Varied Emotional Coping Capacities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubtheme 3.1\u0026nbsp;Positive coping supported by family\u003c/p\u003e\n\u003cp\u003eSome patients benefited from strong family support, which alleviated psychological stress. \u003cem\u003eN6\u003c/em\u003e shared that her family accompanied and cared for her throughout treatment (\u0026ldquo;My eldest daughter-in-law was with me throughout the whole process and also took care of me at home. We\u0026apos;re both doing very well.\u0026rdquo;), \u003cem\u003eN7\u003c/em\u003e described managing well with his wife\u0026rsquo;s help while shielding their children from worry (\u0026ldquo;It\u0026rsquo;s my wife who has been accompanying me the whole time. We run our own company, so work hasn\u0026rsquo;t been affected much. As for the kids, we just told them it was a polyp removal to keep them from worrying.\u0026rdquo;), and \u003cem\u003eN8\u003c/em\u003e highlighted relatives adjusting their lives to care for her (\u0026ldquo;I usually take care of myself\u0026mdash;buying groceries, cooking, and looking after the children. But now, they\u0026rsquo;ve arranged for someone to take time off just to accompany me, so everything is going well.\u0026rdquo;).\u003c/p\u003e\n\u003cp\u003eSubtheme 3.2\u0026nbsp;Prevalence of negative emotions\u003c/p\u003e\n\u003cp\u003eConversely, some patients experienced profound anxiety, depression, or even despair. \u003cem\u003eN1\u003c/em\u003e fatalistically accepted the illness, referencing early death (\u0026ldquo;There\u0026rsquo;s nothing I can do. I didn\u0026rsquo;t take my health seriously before. Now that I have this illness, maybe it\u0026rsquo;s just fate\u0026mdash;live or die, I\u0026rsquo;ll accept it.\u0026rdquo;), while \u003cem\u003eN3\u003c/em\u003e was shocked by the sudden diagnosis after a lifetime of health (\u0026ldquo;It was all so sudden. I rarely even caught colds before and had never been hospitalized. When the test results came back, I was completely shocked.\u0026rdquo;). \u003cem\u003eN9\u003c/em\u003e described feeling extremely low for months, questioning \u0026ldquo;\u003cem\u003eWhy me? I had never experienced anything like this in my life\u0026mdash;I felt completely hopeless. Thoughts of preparing for the worst, even making end-of-life arrangements, started to cross my mind.\u003c/em\u003e\u0026rdquo; and even contemplating end-of-life arrangements.\u003c/p\u003e\n\u003cp\u003eSubtheme 3.3\u0026nbsp;Individual differences in psychological adjustment\u003c/p\u003e\n\u003cp\u003eOther patients managed to maintain a positive outlook. \u003cem\u003eN2\u003c/em\u003e found comfort in her children\u0026rsquo;s support and lack of work obligations\u0026nbsp;(\u0026ldquo;Fortunately, my children have been by my side, encouraging me. And since I\u0026rsquo;m not working like the younger generation, I don\u0026rsquo;t need to take time off.\u0026rdquo;), \u003cem\u003eN5\u003c/em\u003e pragmatically stated, \u0026ldquo;\u003cem\u003eIf you\u0026rsquo;re sick, you treat it. It\u0026rsquo;s nothing to be too worried about.\u003c/em\u003e\u0026rdquo;, and \u003cem\u003eN8\u003c/em\u003e accepted the diagnosis, reassured by modern treatments (\u0026ldquo;This is just the reality\u0026mdash;you just have to accept it. Although my family is very worried, medical technology is advanced now, and it\u0026rsquo;s not as painful as it used to be.\u0026rdquo;). These differences illustrate the wide variability in patients\u0026rsquo; emotional resilience and underscore the necessity of personalized psychological support.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003e4.1. Self-management challenges and cultural considerations in AGC care\u003c/h2\u003e\u003cp\u003eThis qualitative study revealed critical self-management challenges faced by Chinese surgical patients with AGC. Three interrelated themes emerged: polarized self-management awareness and inadequate management skills, limited communication with healthcare providers and difficulty accessing reliable health information, and wide variability in emotional coping capacities. These findings underscore that postoperative AGC patients often struggle to navigate complex regimens of symptom monitoring, nutritional management, and psychological adjustment, reflecting individual and systemic gaps in support [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe polarized levels of self-management awareness highlight an important barrier. While some patients demonstrated proactive health monitoring and engagement, others delayed seeking care despite the presence of known risk factors or symptoms, echoing findings from prior research that underscored weak risk perception and reliance on informal knowledge sources [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Nutritional management deficiencies were particularly pronounced, with many patients expressing confusion about diet stages and balanced nutrient intake aligned with prior Chinese studies documenting high rates of postoperative malnutrition in gastric cancer patients [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Additionally, many participants described brief and superficial communication with clinicians, leading to persistent uncertainty and unmet informational needs, especially among older adults and those with low health literacy [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe cultural context in China further shapes these dynamics. Traditional norms emphasize family involvement and deference to medical authority, which may discourage patients from actively questioning clinicians or seeking peer-led support [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. On the other hand, family support emerged as a crucial buffer against emotional distress, consistent with studies that highlight the role of familial networks in psychological adaptation [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Thus, designing interventions that incorporate family engagement and acknowledge cultural hierarchies is essential for maximizing acceptability and effectiveness.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003e4.2. Strengthening self-efficacy through a tailored Expert-Patient Programme\u003c/h2\u003e\u003cp\u003eFindings from this study underscore the need for culturally responsive, peer-supported interventions that address the psychological, informational, and practical barriers to self-management faced by AGC surgical patients. Participants described uncertainty in symptom monitoring and nutrition, emotional distress, and a lack of accessible, reliable guidance, which directly impact their confidence and capacity to manage recovery. The qualitative themes align closely with Bandura\u0026rsquo;s four sources of self-efficacy: mastery experience, vicarious learning, verbal persuasion, and emotional regulation, suggesting that peer-led, experience-based interventions may effectively reinforce these mechanisms [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese insights point to the value of a structured EPP that leverages lived experience, peer role modeling, and practical skill-building to enhance self-efficacy. Based on the existing evidence, EPPs and similar self-management interventions have been shown to improve self-efficacy, psychological resilience, symptom control, and quality of life in various cancer populations, including those with colorectal, breast, and esophageal cancers [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. However, there is a lack of research specifically examining the application of EPPs in advanced gastric cancer, particularly within the Chinese healthcare context [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Future work should explore the feasibility and impact of implementing such a programme within routine postoperative care for AGC patients.\u003c/p\u003e\u003cp\u003eAn EPP informed by these findings should prioritize clear, relatable content; emotional support through shared experience; and guidance on symptom and nutritional management. Tailoring delivery formats to patient preferences, such as small group discussions or digital communication platforms, may further support engagement and accessibility [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Anchoring the intervention in patients\u0026rsquo; lived experiences helps ensure that support strategies are theoretically grounded and culturally relevant and practically applicable.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003e4.3. Implications for clinical practice\u003c/h2\u003e\u003cp\u003e This study highlights critical implications for enhancing postoperative care in patients with advanced gastric cancer in China. The findings identify key gaps in patient knowledge, symptom monitoring, nutritional management, and emotional support, underscoring the need for patient-centered intervention approaches. Peer-based educational interventions represent a particularly promising strategy for improving patient engagement and self-efficacy [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIntegrating experienced peer facilitators into postoperative education may complement current nursing and multidisciplinary care practices by increasing personalized support, particularly benefiting patients with limited health literacy or restricted access to healthcare resources. Incorporating culturally relevant elements, such as family involvement, simplified medical information [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], and familiar digital platforms (e.g., WeChat), could further enhance the acceptability and feasibility of interventions [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMoreover, fostering peer connections and experiential knowledge sharing may improve patient trust, normalize discussions around postoperative difficulties, and empower patients to actively participate in their own recovery [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. These qualitative insights provide a foundation for developing and evaluating culturally sensitive, peer-supported programmes as part of routine gastric cancer care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\u003ch2\u003e4.4. Limitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations. First, as a qualitative exploration conducted in a single tertiary hospital in southern China, the findings may not be transferable to all regions or healthcare settings. Second, although efforts were made to include patients with diverse educational and age backgrounds, the relatively small and geographically limited sample may not capture the full range of postoperative self-management experiences among AGC patients across China. Third, while this study aimed to inform the early development of a peer-based intervention, it did not incorporate perspectives from caregivers or healthcare professionals, whose views may further enrich the design and feasibility of future programmes. Including these additional stakeholders in subsequent research will be important to ensure cultural relevance and practical applicability.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study shows the complex and multidimensional challenges that Chinese patients face in managing recovery after surgery for advanced gastric cancer, including limited self-management awareness, inadequate access to reliable information, and varied emotional coping capacities. These findings underscore the central role of self-efficacy in postoperative care and highlight the unmet need for culturally appropriate, patient-centered support strategies. Insights from this qualitative exploration offer a foundation for the future development of interventions that integrate lived experience, emotional support, and practical skill-building to strengthen patients\u0026rsquo; confidence and engagement in self-care. Further research is needed to translate these findings into feasible, context-sensitive programmes within routine clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to all individuals who took part in this study. We extend our sincere appreciation to the patients and expert patients who generously shared their experiences and insights. We also thank the clinical staff and expert panel members for their valuable contributions and thoughtful guidance throughout the development of the programme. Additionally, we acknowledge the support of our research team colleagues for their dedication to conducting the interviews and preparing the transcripts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLH and XY conceived and designed the study. XY and DX conducted the literature review and developed the interview guide. XY and MJ carried out the patient interviews. WH, CL, and RY performed the initial data transcription. XY and JW led the qualitative data analysis with input from LH. XY and JW drafted the manuscript. All authors read, provided critical revisions, and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy or ethical restrictions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of Guangdong Provincial People\u0026apos;s Hospital (Approval No. KY2024-076-02). All participants provided written informed consent form. The study was conducted in line with all relevant regulations and the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eIlic, M. and I. Ilic, Epidemiology of stomach cancer. 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The psychologist, 2015. \u003cstrong\u003e28\u003c/strong\u003e(8): p. 643-644.\u003c/li\u003e\n\u003cli\u003eElliott-Mainwaring, H., Exploring using NVivo software to facilitate inductive coding for thematic narrative synthesis. British Journal of Midwifery, 2021. \u003cstrong\u003e29\u003c/strong\u003e(11): p. 628-632.\u003c/li\u003e\n\u003cli\u003eTong, A., P. Sainsbury, and J. Craig, Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care, 2007. \u003cstrong\u003e19\u003c/strong\u003e(6): p. 349-357.\u003c/li\u003e\n\u003cli\u003eWang, Q., et al., Public awareness of gastric cancer risk factors and screening behaviours in Shijiazhuang, China: A community-based survey. 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Bmj Open, 2019. \u003cstrong\u003e9\u003c/strong\u003e(7).\u003c/li\u003e\n\u003cli\u003eMeng, M.Q., et al., When western concept meets eastern culture: Exploring the impact of Confucianism on shared decision-making in China. Asia-Pacific Journal of Oncology Nursing, 2024. \u003cstrong\u003e11\u003c/strong\u003e(11).\u003c/li\u003e\n\u003cli\u003eEpstein, N.B., et al., Therapy with families in China: Cultural factors influencing the therapeutic alliance and therapy goals. Contemporary Family Therapy, 2014. \u003cstrong\u003e36\u003c/strong\u003e: p. 201-212.\u003c/li\u003e\n\u003cli\u003eRimmer, B., et al., Characteristics and Components of Self-Management Interventions for Improving Quality of Life in Cancer Survivors: A Systematic Review. Cancers, 2024. \u003cstrong\u003e16\u003c/strong\u003e(1).\u003c/li\u003e\n\u003cli\u003eHuang, F.F., et al., Psychometric properties and performance of existing self-efficacy instruments in cancer populations: a systematic review. Health and Quality of Life Outcomes, 2018. \u003cstrong\u003e16\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eCao, N.D., et al., Chinese Medicine Prolongs Overall Survival of Chinese Patients with Advanced Gastric Cancer: Treatment Pattern and Survival Analysis of a 20-Year Real-World Study. Chinese Journal of Integrative Medicine, 2024. \u003cstrong\u003e30\u003c/strong\u003e(6): p. 489-498.\u003c/li\u003e\n\u003cli\u003eWhite, S.J., et al., Tailoring communication practices to support effective delivery of telehealth in general practice. BMC Prim Care, 2024. \u003cstrong\u003e25\u003c/strong\u003e(1): p. 232.\u003c/li\u003e\n\u003cli\u003eMadanian, S., et al., Patients\u0026apos; perspectives on digital health tools. PEC Innov, 2023. \u003cstrong\u003e2\u003c/strong\u003e: p. 100171.\u003c/li\u003e\n\u003cli\u003eGao, Q.A., et al., Effectiveness of a comprehensive post-operative health education program in improving quality of life after gastric cancer surgery. Annals of Palliative Medicine, 2020. \u003cstrong\u003e9\u003c/strong\u003e(3): p. 921-926.\u003c/li\u003e\n\u003cli\u003eJazieh, A.R., S. Volker, and S. Taher, Involving the family in patient care: a culturally tailored communication model. Global Journal on Quality and Safety in Healthcare, 2018. \u003cstrong\u003e1\u003c/strong\u003e(2): p. 33-37.\u003c/li\u003e\n\u003cli\u003eHe, Y.S., et al., Exploring nurse and patient perspectives on WeChat-based prenatal education in Chinese public hospitals: a qualitative inquiry. Bmc Nursing, 2025. \u003cstrong\u003e24\u003c/strong\u003e(1).\u003c/li\u003e\n\u003cli\u003eUssher, J., et al., What do cancer support groups provide which other supportive relationships do not? The experience of peer support groups for people with cancer. Social science \u0026amp; medicine, 2006. \u003cstrong\u003e62\u003c/strong\u003e(10): p. 2565-2576.\u003c/li\u003e\n\u003c/ol\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":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"advanced gastric cancer, self-efficacy, qualitative research, self-management, expert patient programme","lastPublishedDoi":"10.21203/rs.3.rs-7274719/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7274719/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePostoperative self-management is critical for recovery in patients with advanced gastric cancer (AGC). However, many struggle with complex physical, emotional, and informational challenges. Self-efficacy plays a key role in facilitating effective self-management, but little is known about how it is shaped by patients\u0026rsquo; lived experiences, particularly in the Chinese context.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo explore the experiences, challenges, and needs that influence self-efficacy during postoperative self-management among Chinese patients with AGC.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis descriptive phenomenological study involved semi-structured, face-to-face interviews with nine postoperative AGC patients at a tertiary hospital in southern China. Data were analyzed inductively using Colaizzi\u0026rsquo;s seven-step method to identify key themes grounded in participants\u0026rsquo; lived experiences.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThree interrelated themes were identified: (1) Polarized awareness and deficiencies in self-management abilities, reflecting varied levels of health monitoring, confusion around symptom management, and inadequate nutritional knowledge; (2) Limited capacity for patient-provider communication and accessing reliable health information, marked by constrained clinical interactions and dependence on informal or inaccessible information sources; and (3) Varied emotional coping capacities, encompassing both family-supported resilience and deeply distressing emotional reactions. These findings reveal substantial gaps in postoperative education, psychosocial support, and health communication, all of which affect patients\u0026rsquo; confidence and ability to manage recovery.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003ePatients with AGC face multifaceted challenges in postoperative self-management that directly impact their self-efficacy. Culturally appropriate and peer-supported interventions that address informational, emotional, and practical needs may be essential to supporting effective self-management in this population. These insights provide a patient-centered foundation for future intervention development.\u003c/p\u003e","manuscriptTitle":"A Qualitative Study of Self-Efficacy-Related Experiences and Needs in Postoperative Self- Management Among Patients with Advanced Gastric Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 16:07:35","doi":"10.21203/rs.3.rs-7274719/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-23T13:23:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276965838144824255570013180456654328992","date":"2025-12-21T13:19:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-13T10:04:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-04T06:00:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-04T05:57:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2025-08-02T00:24:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bbe2604b-fd5f-46d0-8b77-bc7542462027","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-21T16:07:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-21 16:07:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7274719","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7274719","identity":"rs-7274719","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}