Facilitators of and barriers to continued recording of patient-reported outcomes based on qualitative interviews of patients with gynecological cancer

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The factors that affect patient adherence with PRO recording remain unclear. This study aimed to provide qualitative insights by identifying facilitators of and barriers to PRO adherence in patients with gynecological cancer. Methods Data were collected from nine patients diagnosed with gynecological cancer and admitted for treatment at the Kyoto University Hospital via semistructured interviews. Interviews were audiotaped and transcribed verbatim. Coding and qualitative content analysis of the transcripts were completed by two independent researchers. Results Eight categories, including five facilitators and five barriers to PRO adherence, were identified. The five facilitators were “adopting a healthier lifestyle,” “perceiving the benefits of PRO recording,” “desiring communication with the physician,” “having a trustful relationship with the physician,” and “understanding functions and benefits of PRO recording.” The five barriers were “cumbersome nature,” “unnecessary exercise,” “fear of cancer recurrence,” “lack of suitable format,” and “poor relationship with the physician.” Conclusions Suitable interventions to improve adherence to PROs may enable patient-centered care by enhancing facilitators of and eliminating barriers to such adherence. PRO (Patient- Reported Outcome) Advance Directive Adherence User-Centered Design Patient-Centered Care Physician-Patient Relations 1. BACKGROUND The systematic monitoring of patients using patient-reported outcomes (PROs) improves patient–physician communication [ 1 ], physicians’ awareness of symptoms, symptom management [ 2 ], self-management of quality of life (QOL), patient satisfaction [ 2 ], QOL [ 3 ], and overall survival [ 4 ]. Despite increasing interest in the electronic collection of PROs using ePRO (electronic PRO) systems, such systems are not yet widely used in clinical practice. A major problem with the clinical use of PROs is lack of adherence [ 5 ]. Studies [ 6 , 7 ] have shown that improvements in the online intervention system, such as intended usage frequency, application updates, and persuasive design, increase patient adherence to web-based interventions and ePROs. However, few studies have reported on patients’ views on PRO adherence. Thus, qualitative research is required to understand the patient perspective on facilitators of and barriers to PRO adherence and to develop strategies [ 8 ]. This study aimed to provide qualitative insights by identifying facilitators of and barriers to patient adherence to PROs via semistructured interviews with patients. Based on the identified facilitators and barriers, we propose interventions to improve patient adherence. 2. METHODS 2.1. Sampling, recruitment, and eligibility criteria Nine patients diagnosed with gynecological cancer and admitted for treatment at the Kyoto University Hospital between October 18 and 27, 2021, were interviewed in this study (Table 1 ). The participants were recruited via convenience sampling. Although all participants had their first meetings with the interviewer (N.W), all participants knew the recruiter (N.H) well. Two patients declined to participate in this study due to poor physical condition. Written informed consent was obtained from all participants. Table 1 Participant characteristics. ID Age Cancer type Stage Primary or recurrence Treatment status P1 69 Corpus cancer IA Primary After surgery P2 41 Ovarian cancer IC2 Primary Chemotherapy P3 44 Corpus cancer IVB Recurrence Chemotherapy P4 62 Peritoneal cancer IIIA Primary Molecular targeting therapy P5 68 Ovarian cancer IVB Recurrence Molecular targeting therapy P6 46 Choriocarcinoma III Primary Chemotherapy P7 53 Peritoneal cancer IIIC2 Primary Chemotherapy P8 65 Peritoneal cancer IVB Recurrence Chemotherapy P9 76 Ovarian cancer IIIB Primary Chemotherapy 2.2. Data collection Semistructured interviews were conducted using an interview guide with open-ended questions related to PROs (Table 2 ) in Japanese. The interview guide was developed using information on PROs obtained from the literature [ 4 ] and included personal questions about the patient’s residence, family members living with the patient, job, hobbies, etc. Subsequent questions were focused on the cancer type, treatment status, side effects, and symptoms. Because this study aimed to identify facilitators of and barriers to patient adherence with PROs, we asked detailed questions regarding PRO records, medical examinations, and daily routines for managing physical conditions. Furthermore, open-ended questions were included to elicit information about patient health and well-being. The interview was conducted over Zoom or FaceTime in a private room for approximately 60 min by a nonmedical researcher who was familiar with semistructured interviews (N.W). In addition to the interviewer and patient, a nonmedical researcher (N.N) was in attendance. Following the nine interviews, we determined that no additional data would be needed, with categories and their relationships having been well developed. The protocol for this study was approved by the Kyoto University Graduate School and Faculty of Medicine Ethics Committee (C1458). All interviews were audio- and video-recorded with permission from the patients. Table 2 The lists of the questions in the semi-structured interview. No. Questions 1. About your profile 1–1 Do you have family members living with you? 1–2 Which city do you live in? 1–3 Do you have any hobbies? 1–4 What type of cancer are you treating? 1–5 What kind of treatment are you receiving now? 1–6 What symptoms or side effects do you have now? 1–7 What concerns or burdens did you have as you proceeded with treatment? 2. About recording PROs 2 − 1 How aware are you of changes or unusual changes in your physical condition? 2–2 Is there anything you do to notice changes in your physical condition? 2–3 What are some of the best things about taking care of your physical condition? 2–4 Are there any problems in managing your physical condition? 2–5 Do you record your PRO? 2–6 What are some of the best things about recording your PRO? 2–7 Are there any problems in recording your PRO 2–8 What functions do you require for self-monitoring and PRO? 2–9 What encourages you to recording your PRO? 2–10 What records would you like to see useful? 2–11 (For those who don't keep a record of PRO) why don't you record your PRO? 2–12 (For those who do not record PROs) What triggers or motivations would make you think you would record your PRO? 3. About a daily life and QOL 3 − 1 What is the most difficult thing in parallel with treatment? 3 − 2 Are there any aspects of your daily life that you would like to improve? 3–3 Is there anything you have started doing since you started treatment for cancer? 3–4 What is the biggest discrepancy between the ideal and the current situation? 4. About medical examination with a healthcare provider 4 − 1 What is the usual process for medical interviews and examinations? 4 − 2 What do you usually talk about during medical interviews? 4 − 3 What is the good point of medical interviews? 4–4 Is there anything that you could not tell doctors in your routine medical interviews? 4–5 Is there anything that you feel uneasy or dissatisfied about in your routine medical interviews? 4–6 What do you feel comfortable to tell in a routine medical interview? 2.3. Data analysis All interviews were audio recorded and transcribed. The researchers performed qualitative content analysis according to a previously established method [ 9 ][ 9 ]. The interviews were coded independently by two researchers (N.H and K.Y), and discrepancies were resolved by consensus. The adopted codes were clustered into meaningful categories based on differences and similarities. The codes and categories were entered into an Excel spreadsheet (WA, Microsoft Corporation) for analysis. 3. RESULTS 4.1. Categories Nine individuals consented to be interviewed. The content analysis revealed eight main categories related to patient adherence with PROs (Table 3 ). The eight categories and eight subcategories could be classified into five facilitators and five barriers, with two categories overlapping between them. Table 3 The lists of four problems related to sustainable self-management and three interventions to solve these problems Categories Subcategories Adopting a healthier lifestyle Perceiving the benefits of PRO recording Improved communication with health care providers Self-management Cumbersome nature Unnecessary exercise Anxiety generated by recording Desiring communication with the physician Fear of cancer recurrence Lack of suitable format Relationship between physicians and patients Having a trustful relationship with the physician Poor relationship with physicians Understanding functions and benefits of PRO recording 4.2. Adapting a healthier lifestyle Many patients with cancer were committed to adopting good habits for their health” following their cancer diagnosis. Many tried to eat healthier, exercise more, and pay more attention to changes in their physical condition. Many patients are provided with notebooks by the hospital to record their PROs during chemotherapy; however, most preferred to record changes in their PROs in their own notebooks before and during chemotherapy. “After my cancer diagnosis, I became more aware of changes in my physical condition and more attentive to my health than I had been before I was diagnosed. I keep taking care of changes in my physical condition and do stretches and massages.” (P2) “I became more attentive to changes in my physical health after my cancer diagnosis. I meditate and try to listen to my body. I try to record any changes in my physical condition that I feel.” (P8) 4.3. Perceiving the benefits of PRO recording Patients with high PRO adherence perceive benefits from recording them. There are two subcategories of benefits in this category. The first subcategory is improved communication with healthcare providers. Based on the PROs while out of the hospital, patients were able to explain their condition in detail to the healthcare provider. PROs can remind patients what they wanted to ask or what they intended to inform their healthcare providers. Patients indicated that using PROs while talking to healthcare providers ensured that patients were less likely to omit or forget a discussion point. “Since I have to see the doctor every three weeks, I wouldn’t be able to remember what happened during that time if I didn’t have the records. It gives me peace of mind knowing that the doctor who looked at my records knows I’m okay.” (P3) “When I went to the hospital because of an upset stomach, it was easy to tell the doctor when the laxative was changed by looking at the records.” (P4) “I always show my records to the doctor so that I don’t forget to tell him what happened.” (P6) The second subcategory is self-management. In the case of concerning symptoms during chemotherapy, patients may check the record of a previous course to determine whether their symptoms are normal. Further, the records include information about medications; patients can thus consider whether any new symptoms are influenced by newly started medications. “If I feel something is wrong with my health, I look at my previous record. I think records are important.” (P5) “I understand the cycle of physical changes caused by the side effects of chemotherapy.” (P8) 4.4. Cumbersome nature Regardless of whether they record PROs, most patients find it “cumbersome” to maintain their PROs. Even patients with high PRO adherence reported that they sometimes forget to record their PROs when they are feeling very well or very sick. “I am too lazy to continue.” (P1) “I think I will forget when I resume work.” (P2) “I forget when I’m feeling relatively well and very sick.” (P3) “It’s a hassle.” (P4) “I recorded some information at the beginning of treatment, but it became tedious and I stopped.” (P6) “I was given a notebook to record PROs, but I don’t keep it. It is clearly a hassle.” (P9) 4.5. Unnecessary exercise Patients who do not record their PROs feel that recording them is unnecessary. If do not find any benefit in recording PROs, they feel that the exercise is not worthwhile. “I never looked back and felt it was necessary.” (P6) “Side effects are always the same and I remember them myself, so I don’t need them.” (P9) 4.6. Anxiety generated by recording Most patients feel anxious about exacerbation or recurrence of their disease while recording their symptoms. This anxiety can be classified into two subcategories. The first subcategory involves the desire to communicate with physicians. When a patient feels anxious about their symptoms while recording PROs, they try to communicate the symptoms to their physician. This subcategory is a facilitator of PRO adherence. “Whenever there is a change in my condition, I worry that I think it might be because I am relapsing. I think I need to tell my doctor about the symptoms I am concerned about. That is why I will record my symptoms.” (P3). The second subcategory is fear of cancer recurrence. When a patient feels anxious about their symptoms, they stop recording PROs because want to avoid this anxiety. This subcategory is a barrier to PRO adherence. “It is better to stay positive. I don’t want it to be stressful. I think it’s stressful to record PROs when I’m not doing well.” (P9) 4.7. Lack of suitable format Patients who exhibit high adherence with recording PROs on forms handed to them at hospitals and other institutions are stressed by their uniform format. For example, the remarks column is small, the column to record the symptoms that doesn’t appear to the patient is disturbing, and it is difficult to rate the intensity of symptoms on a scale of 1 to 10. For this reason, in addition to the notebook handed to them at the hospital, some patients prefer to write freely in a diary or blog. “With a notebook, space is limited.” (P2) “The remarks column is too small.” (P4, 8) “I would like to have space to write down oral medications.” (P7) 4.8. Relationships between physicians and patients This category contains two contradicting subcategories. The first is having a trustful relationship with the physician. When the relationship between physicians and patients is trustful, patients adhere to the treatment and lifestyle recommended by their physicians and adopt a proactive approach toward their treatment. A virtuous cycle ensues when patients continue to record PROs although they consider it cumbersome. They perceive benefits, such as improved communication and self-management, which further encourages them to continue to maintain records. This subcategory is considered a facilitator. “I can have a casual conversation with my doctor, such as ‘Did you go on a trip?’. When I was struggling with my diet, my doctor arranged for me to receive nutritional guidance…I keep recording my symptoms because my doctor checks them.” (P5) “My doctor is a very good doctor. He suggested me to increase my enjoyment, and I consciously increased the number of things I enjoy and reported them. Not only did he talk to me about my illness, but he also improved my environment, including my long-term care insurance, and I was able to discuss everything with him…I keep recording my symptoms because my doctor told me to do so.” (P8) The second subcategory is poor relationship with the physician. Under these circumstances, even if the PRO record is recommended, the patient will not record it because they think it is cumbersome and unnecessary. This results in no change in communication with the physician, lack of a trustful relationship, and, in some cases, the patient takes no active role in the treatment and often seeks a second opinion. This subcategory is considered a barrier. “Frequent changes of doctors are stressful. Some doctors are businesslike in their attitude and I cannot communicate with them. I am thinking of going for a second opinion. I recorded some information at the beginning of treatment, but it became tedious and I stopped.” (P6) “I don’t even know who my doctor is. I was given a notebook to record PROs, but I don’t keep it. It is clearly a hassle.” (P9) 4.9. Understanding functions and benefits of PRO recording This category has two subcategories. The first subcategory is an additional benefit of recording PROs. Patients who do not routinely record their PROs indicate that they might do so if it had a function beyond simply recording them. For example, patients would like to be alerted when their recorded PRO requires medical attention or self-care. As discussed above, many patients feel anxious when recording their PROs. They are reassured when a medical decision about their symptoms is immediately available after recording their PROs. This subcategory is considered a facilitator. “If it had an alert feature that told me ‘This is unusual’, I might record a PRO.” (P6) “When symptoms are severe, it is difficult to know how to get better even if I only record the symptoms. I would like you to suggest self-care.” (P8) The second subcategory is awareness of the benefits. It is difficult for patients to imagine how recording their PROs improves their QOL or prolongs overall survival. In fact, many patients may be willing to record PROs if it improves their prognosis. This subcategory is also considered a facilitator. “I would record it if it would help me recover faster.” (P1) 4. DISCUSSION Eight categories were identified regarding patient adherence with PROs, and these categories were grouped into facilitators and barriers. To our knowledge, this is the first report to identify the facilitators of and barriers to PRO adherence from the perspective of patients. 4.1. Facilitators In this study, the following five facilitators were identified: Adopting a healthier lifestyle, Perceiving the benefits of PRO recording, Desiring communication with the physician, Having a trustful relationship with the physician, and Understanding functions and benefits of PRO recording One study reported that many patients with cancer adopted a healthier lifestyle after diagnosis [ 10 ]. Patients with gynecologic malignancies exhibit stronger consciousness regarding a healthy lifestyle after cancer treatment compared with before treatment, determined using the Healthy Lifestyle Consciousness Index scale [ 11 ]. This semistructured interview–based study revealed that patients with gynecologic malignancies were more attentive to changes in their own physical condition and documented changes early after the start of cancer treatment. By showing their records when talking to healthcare providers about their physical condition, patients with cancer acquire the ability to communicate their condition without forgetting anything. Even if they feel anxious while recording PROs, they are reassured when their physicians make decisions about their treatment based on the records. Improved communication has been previously reported as a benefit of PRO records [ 1 ]. Patients who maintained good communication with their physicians also had a trustful relationship with them, positive attitude toward treatment, and continued practice of recording PROs, which led to even better communication with their physicians and generated a virtuous cycle. It has been previously reported that good patient–physician communication builds trustful relationships [ 1 ], improves medication adherence [ 12 ], and may result in good treatment outcomes. Self-administration, another benefit of PRO records identified in this study, is an important factor. Previous reports identified that recording and monitoring PROs improved self-efficacy [ 13 ]. Moreover, patients with higher self-efficacy could build more trustful relationships with their physicians [ 14 ] and ensure higher adherence to medications [ 15 ]. Here, similar virtuous cycles were observed in which patients who perform self-management using PRO records showed increased self-efficacy, resulting in higher adherence to PROs during their medical care. Patients are unlikely to benefit from simply recording their PROs. When alerts are issued or self-care is suggested based on the PROs, patients will perceive a concrete benefit, thus yielding good adherence. These features were included and developed into ePRO to form eRAPID [ 16 ], which reported high adherence [ 17 ]. Although recording PROs was reported to prolong overall survival [ 18 ] and improve QOL [ 3 ], these favorable effects are not widely known among physicians or patients with cancer. Explaining the benefits of PRO records to patients could ensure high adherence. 4.2. Barriers In this study, the following five barriers were identified: Cumbersome nature, Unnecessary exercise, Fear of cancer recurrence, Lack of suitable format, and Poor relationship with the physician Almost all patients in this study considered that recording PROs was cumbersome. Patients who benefited from recording PROs were able to continue to record them although they considered this exercise cumbersome. In contrast, patients who did not perceive any benefit in PRO recording considered it “cumbersome” and “unnecessary” and finally stopped. The same was reported for medication adherence in patients with hypertension and diabetes; in these patients, lack of patient comprehension regarding the need for treatment was considered a barrier to PRO adherence [19; 20]. Fear of cancer recurrence was also a barrier to PRO adherence. Similarly, it has been reported that patients with breast cancer who have high fear of cancer recurrence are less likely to engage in healthy behavior [ 21 ]. As discussed above, recording PROs is perceived as part of a healthy lifestyle for patients with cancer. High fear of cancer recurrence also decreases PRO adherence. In the present study, we observed that patients with poor relationships with physicians were reluctant and showed little interest in their condition and treatment. Similarly, adherence to medication was reported to be low in cases of poor patient–physician relationships [ 12 ]. Moreover, poor patient–physician relationships are associated with greater fear of cancer recurrence [ 22 ]. A vicious cycle is created in which a poor patient–physician relationship further decreases PRO adherence due to increased fear of cancer recurrence. The lack of a suitable form was also a barrier to PRO recording, but this issue did not cause patients to quit recording PROs. Similarly, the use of a mobile application to improve medication adherence enhanced usability and was effective, but its effect on medication adherence remains unclear [ 23 ]. 4.3. Interventions Based on the facilitators and barriers extracted in this study, we identified four interventions that could contribute to increased adherence to PRO recording. The first is patient education. Patients who do not currently record PROs regarded them as “cumbersome” and “unnecessary”; however, they indicated that they would record PROs if it indicated a favorable prognosis. Although recording PROs was reported to prolong overall survival [ 18 ] and improve QOL [ 3 ], these favorable effects are not widely known among physicians or patients with cancer. Educating patients with cancer regarding the effects of recording PROs could result in better adherence to PRO recording. Second, PROs should be recorded to serve as a communication tool with healthcare providers and self-management. Patients with gynecologic cancer would like to communicate better with their physicians. As previously reported, recording PROs can improve patient–physician communication [ 1 ]. Patients can continue to record their PROs because they benefit from improved communication with their healthcare providers by referring to their PROs, explaining the progression of their symptoms, and showing the relationship between their medications and symptoms. Summary and graphical functions can display the time course of symptoms and abnormal data in PROs for easy understanding, thus resulting in improved communication with healthcare providers [ 24 ], and higher PRO adherence. Patients also continue recording PROs owing to the benefit of self-management. Patients should review their symptom records from previous doses, particularly because symptoms during chemotherapy are cyclical. Other features that can further support PRO adherence include the facility to monitor or review their symptom reports over time, which is useful for self-management [ 24 ] and may ensure better adherence. Third, a personalized format is desirable. Six of nine patients documented information on medications, vaccination dates, etc., in their notes. Free space provided for notes may increase patient satisfaction. The free-text feature was generally valued highly in previous reports [ 25 ]. In addition, ePRO created an easy-to-record format by placing symptoms related to medical conditions or treatments at the top of the list. Previous reports have also suggested that personalized intervention content afforded higher PRO adherence [ 7 ]. A user-friendly format also induced higher adherence. Fourth, providing information according to the contents of the record is important. Some patients were anxious and stressed about their symptoms, causing them to stop recording PROs altogether. Previous reports have indicated that providing appropriate information regarding medical conditions and symptoms can help reduce anxiety [ 26 ]. Therefore, the ability to obtain recommendations for self-care and medical consultation based on the PROs recorded by patients recorded resolved their concerns and resulted in high adherence. 4.4. Limitations This study had several limitations. First, the study was conducted at a single institution with nine participants. The results cannot be generalized to all patients with cancer. However, all interviews were coded independently by two researchers, and discrepancies were resolved by consensus. Following the nine interviews, we determined that no new data was needed, with categories and their relationships being well developed. Second, the participants were patients undergoing cancer treatment and were in less than perfect physical condition, which may have caused volunteer bias. Although it is difficult to generalize these results to all cancer patients, including those who have completed treatment, patients under treatment are the most important targets for PRO recording. A third limitation was the reliability and generalizability of qualitative data. However, the two researchers independently agreed that data saturation was achieved after the ninth interview, and there was consensus regarding the categories and subcategories that emerged. To the best of our knowledge, this study is the first to identify the factors responsible for patients’ inability to continuously record PROs. 5. CONCLUSIONS Adopting a healthier lifestyle, perceiving the benefits of PRO recording, desiring communication with the physician, having a trustful relationship with the physician, and understanding functions and benefits of PRO recording are facilitators of adherence with PROs. Cumbersome nature, unnecessary exercise, fear of cancer recurrence, lack of suitable format, and poor relationship with the physician are barriers. Interventions contributing to PRO adherence include patient education, PROs as a communication and self-management tool, personalized forms, and provision of information based on the content of the record. These results can help design future ePROs to ensure higher adherence. Abbreviations PRO patient-reported outcome QOL quality of life ePRO electronic patient-reported outcome Declarations Ethics approval and consent to participate : This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by Kyoto University Graduate School and Faculty of Medicine, Ethics Committee (December/27 th /2019 / C1458). Informed consent was obtained from all participants included in the study. Consent for publication: All participants have given their consent for the publication of this study. Availability of data and materials: Due to data protective restrictions, additional data are not available. Competing interests : The authors have no relevant financial or non-financial interests to disclose. Funding: This work was supported by the Suzuken Memorial Foundation and MIRAI2021 GAP grant. DUMSCO Incorporated provided financial support for conducting interviews. Author s’ contributions: Nozomi Higashiyama: Conceptualization, Formal analysis, Investigation, Data Curation, Writing - Original Draft, Ken Yamaguchi: Conceptualization, Formal analysis, Investigation, Data Curation, Writing - Original Draft, Supervision, Funding acquisition, Naofumi Wakabayashi: Conceptualization, Methodology, Writing – Review & Editing, Ayami Koike: Writing – Review & Editing, Yoshihide Inayama: Writing – Review & Editing, Yosuke Yamamoto: Methodology, Writing – Review & Editing, Koji Yamanoi: Resources, Writing – Review & Editing, Mana Taki: Writing – Review & Editing, Ryusuke Murakami: Writing – Review & Editing, Junzo Hamanishi: Resources, Writing – Review & Editing, Noriyoshi Nishiike: Writing – Review & Editing, Project administration, Funding acquisition, and Masaki Mandai: Writing – Review & Editing, Project administration Acknowledgements : Not applicable References Howell D, Molloy S, Wilkinson K, Green E, Orchard K, Wang K, Liberty J. 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Alkan A, Yaşar A, Güç ZG, Gürbüz M, Başoğlu T, Sezgin Göksu S, Buğdaycı Başal F, Türk HM, Özdemir Ö, Yeşil Çınkır H, Güven DC, Kuş T, Türker S, Koral L, Karakaş Y, Ak N, Paydaş S, Karcı E, Demiray AG, Demir A, Alan Ö, Keskin Ö, Nayır E, Tanrıverdi Ö, Yavuzşen T, Yumuk PF, Ateş Ö, Coşkun H, Turhal S. Worse patient-physician relationship is associated with more fear of cancer recurrence (Deimos Study): A study of the Palliative Care Working Committee of the Turkish Oncology Group (TOG). Eur J Cancer Care (Engl). 2020;29(6):e13296. https://doi.org/10.1111/ecc.13296 . & Çay Şenler. Al-Arkee S, Mason J, Lane DA, Fabritz L, Chua W, Haque MS, Jalal Z. Mobile Apps to Improve Medication Adherence in Cardiovascular Disease: Systematic Review and Meta-analysis. J Med Internet Res. 2021;23(5):e24190. https://doi.org/10.2196/24190 . Warrington L, Absolom K, Conner M, Kellar I, Clayton B, Ayres M, Velikova G. Electronic Systems for Patients to Report and Manage Side Effects of Cancer Treatment: Systematic Review. J Med Internet Res. 2019;21(1):e10875. https://doi.org/10.2196/10875 . Crafoord MT, Fjell M, Sundberg K, Nilsson M, Langius-Eklöf A. Engagement in an Interactive App for Symptom Self-Management during Treatment in Patients With Breast or Prostate Cancer: Mixed Methods Study. J Med Internet Res. 2020;22(8):e17058. https://doi.org/10.2196/17058 . Fallowfield LJ. Treatment decision-making in breast cancer: the patient-doctor relationship. Breast Cancer Res Treat. 2008;112(Suppl 1):5–13. https://doi.org/10.1007/s10549-008-0077-3 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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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-4446052","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308077790,"identity":"cb74fb66-a3d5-49e3-ab60-588aba2f85d2","order_by":0,"name":"Nozomi Higashiyama","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"prefix":"","firstName":"Nozomi","middleName":"","lastName":"Higashiyama","suffix":""},{"id":308077791,"identity":"62ec9611-9e4d-4d0e-ad56-a711e507088f","order_by":1,"name":"Ken Yamaguchi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIie3QMWrDMBSA4WcCzqIDPAjYV5AxpIVAehWZDF7stmOHUASBeDGdFVJ6huYGFgJ30QE8dEiWTh08ZQxV2tIaapGOheqfHoIPPQnA5fqbeZIDBAjEzFX3nNvNkcRfhPyWJOIHsRUWJZXi5jldibzeglbBxZD7CPMpDNb911CtqXzUL/kaL1MKjYoJqQypZ+DdV/0EMyp3S5U/YDZGaFVS4tUewa/AE6x/MXEkB5UG34SZWw52Ao0hG67Y6J00n8Rb2gnV9bUUtYpW5esZZTqNia4G58ndjNjeEhaLza6cqxCfsvG2rSfBsOBe0+6nQWT5sW4+MFh8jGYlEomTwhCA284CeJq4XC7Xv+gN2JhjTJrrum8AAAAASUVORK5CYII=","orcid":"","institution":"Kyoto University","correspondingAuthor":true,"prefix":"","firstName":"Ken","middleName":"","lastName":"Yamaguchi","suffix":""},{"id":308077792,"identity":"60a873b6-3995-4b2d-95f3-f5130ba2da3c","order_by":2,"name":"Naofumi Wakabayashi","email":"","orcid":"","institution":"DUMSCO Incorporated","correspondingAuthor":false,"prefix":"","firstName":"Naofumi","middleName":"","lastName":"Wakabayashi","suffix":""},{"id":308077793,"identity":"69539e32-ae8e-4ef1-94db-9e8ab15441c0","order_by":3,"name":"Ayami Koike","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"prefix":"","firstName":"Ayami","middleName":"","lastName":"Koike","suffix":""},{"id":308077794,"identity":"909bc232-c846-4807-991b-c0b669d19a67","order_by":4,"name":"Yoshihide Inayama","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"prefix":"","firstName":"Yoshihide","middleName":"","lastName":"Inayama","suffix":""},{"id":308077795,"identity":"8cdc05cc-cd9c-4ef8-a795-9315f6ae26cf","order_by":5,"name":"Yosuke Yamamoto","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"prefix":"","firstName":"Yosuke","middleName":"","lastName":"Yamamoto","suffix":""},{"id":308077796,"identity":"c5b2e5b6-5545-4a07-a4b6-841f628045ce","order_by":6,"name":"Koji Yamanoi","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"prefix":"","firstName":"Koji","middleName":"","lastName":"Yamanoi","suffix":""},{"id":308077797,"identity":"ee4adf70-4612-4777-8bb1-ee75a8fc169d","order_by":7,"name":"Mana Taki","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"prefix":"","firstName":"Mana","middleName":"","lastName":"Taki","suffix":""},{"id":308077798,"identity":"1a274fc9-a75e-401e-be7e-343d65744ced","order_by":8,"name":"Ryusuke Murakami","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"prefix":"","firstName":"Ryusuke","middleName":"","lastName":"Murakami","suffix":""},{"id":308077799,"identity":"549e9303-3aac-4447-ae1a-fa211bca8dfc","order_by":9,"name":"Junzo Hamanishi","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"prefix":"","firstName":"Junzo","middleName":"","lastName":"Hamanishi","suffix":""},{"id":308077800,"identity":"4052fda5-2bbe-4a7d-99ac-b4b69c4b5d2f","order_by":10,"name":"Noriyoshi Nishiike","email":"","orcid":"","institution":"DUMSCO Incorporated","correspondingAuthor":false,"prefix":"","firstName":"Noriyoshi","middleName":"","lastName":"Nishiike","suffix":""},{"id":308077801,"identity":"6205cf45-eb79-4223-a950-5897ed6a7f83","order_by":11,"name":"Masaki Mandai","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"prefix":"","firstName":"Masaki","middleName":"","lastName":"Mandai","suffix":""}],"badges":[],"createdAt":"2024-05-20 01:53:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4446052/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4446052/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61303066,"identity":"39d9b253-de7e-4a91-8d22-8e9639064900","added_by":"auto","created_at":"2024-07-29 09:23:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":632005,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4446052/v1/19ef616e-3134-4001-b0a7-f0e4be4a98a7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Facilitators of and barriers to continued recording of patient-reported outcomes based on qualitative interviews of patients with gynecological cancer","fulltext":[{"header":"1. BACKGROUND","content":"\u003cp\u003eThe systematic monitoring of patients using patient-reported outcomes (PROs) improves patient\u0026ndash;physician communication [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], physicians\u0026rsquo; awareness of symptoms, symptom management [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], self-management of quality of life (QOL), patient satisfaction [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], QOL [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and overall survival [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite increasing interest in the electronic collection of PROs using ePRO (electronic PRO) systems, such systems are not yet widely used in clinical practice. A major problem with the clinical use of PROs is lack of adherence [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] have shown that improvements in the online intervention system, such as intended usage frequency, application updates, and persuasive design, increase patient adherence to web-based interventions and ePROs. However, few studies have reported on patients\u0026rsquo; views on PRO adherence. Thus, qualitative research is required to understand the patient perspective on facilitators of and barriers to PRO adherence and to develop strategies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aimed to provide qualitative insights by identifying facilitators of and barriers to patient adherence to PROs via semistructured interviews with patients. Based on the identified facilitators and barriers, we propose interventions to improve patient adherence.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Sampling, recruitment, and eligibility criteria\u003c/h2\u003e \u003cp\u003eNine patients diagnosed with gynecological cancer and admitted for treatment at the Kyoto University Hospital between October 18 and 27, 2021, were interviewed in this study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The participants were recruited via convenience sampling. Although all participants had their first meetings with the interviewer (N.W), all participants knew the recruiter (N.H) well. Two patients declined to participate in this study due to poor physical condition. Written informed consent was obtained from all participants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCancer type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrimary or recurrence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTreatment status\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorpus cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAfter surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOvarian cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIC2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorpus cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIVB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePeritoneal cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMolecular targeting therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOvarian cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIVB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMolecular targeting therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChoriocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePeritoneal cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIC2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePeritoneal cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIVB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOvarian cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Data collection\u003c/h2\u003e \u003cp\u003eSemistructured interviews were conducted using an interview guide with open-ended questions related to PROs (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) in Japanese. The interview guide was developed using information on PROs obtained from the literature [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and included personal questions about the patient\u0026rsquo;s residence, family members living with the patient, job, hobbies, etc. Subsequent questions were focused on the cancer type, treatment status, side effects, and symptoms. Because this study aimed to identify facilitators of and barriers to patient adherence with PROs, we asked detailed questions regarding PRO records, medical examinations, and daily routines for managing physical conditions. Furthermore, open-ended questions were included to elicit information about patient health and well-being. The interview was conducted over Zoom or FaceTime in a private room for approximately 60 min by a nonmedical researcher who was familiar with semistructured interviews (N.W). In addition to the interviewer and patient, a nonmedical researcher (N.N) was in attendance. Following the nine interviews, we determined that no additional data would be needed, with categories and their relationships having been well developed. The protocol for this study was approved by the Kyoto University Graduate School and Faculty of Medicine Ethics Committee (C1458). All interviews were audio- and video-recorded with permission from the patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe lists of the questions in the semi-structured interview.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuestions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e1. About your profile\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo you have family members living with you?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhich city do you live in?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo you have any hobbies?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat type of cancer are you treating?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat kind of treatment are you receiving now?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat symptoms or side effects do you have now?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat concerns or burdens did you have as you proceeded with treatment?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e2. About recording PROs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow aware are you of changes or unusual changes in your physical condition?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIs there anything you do to notice changes in your physical condition?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat are some of the best things about taking care of your physical condition?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAre there any problems in managing your physical condition?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo you record your PRO?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat are some of the best things about recording your PRO?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAre there any problems in recording your PRO\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat functions do you require for self-monitoring and PRO?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat encourages you to recording your PRO?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat records would you like to see useful?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(For those who don't keep a record of PRO) why don't you record your PRO?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(For those who do not record PROs) What triggers or motivations would make you think you would record your PRO?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e3. About a daily life and QOL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026thinsp;\u0026minus;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat is the most difficult thing in parallel with treatment?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026thinsp;\u0026minus;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAre there any aspects of your daily life that you would like to improve?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIs there anything you have started doing since you started treatment for cancer?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat is the biggest discrepancy between the ideal and the current situation?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e4. About medical examination with a healthcare provider\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026thinsp;\u0026minus;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat is the usual process for medical interviews and examinations?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026thinsp;\u0026minus;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat do you usually talk about during medical interviews?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026thinsp;\u0026minus;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat is the good point of medical interviews?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIs there anything that you could not tell doctors in your routine medical interviews?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIs there anything that you feel uneasy or dissatisfied about in your routine medical interviews?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat do you feel comfortable to tell in a routine medical interview?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Data analysis\u003c/h2\u003e \u003cp\u003eAll interviews were audio recorded and transcribed. The researchers performed qualitative content analysis according to a previously established method [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The interviews were coded independently by two researchers (N.H and K.Y), and discrepancies were resolved by consensus. The adopted codes were clustered into meaningful categories based on differences and similarities. The codes and categories were entered into an Excel spreadsheet (WA, Microsoft Corporation) for analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Categories\u003c/h2\u003e \u003cp\u003eNine individuals consented to be interviewed. The content analysis revealed eight main categories related to patient adherence with PROs (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The eight categories and eight subcategories could be classified into five facilitators and five barriers, with two categories overlapping between them.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe lists of four problems related to sustainable self-management and three interventions to solve these problems\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubcategories\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdopting a healthier lifestyle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePerceiving the benefits of PRO recording\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImproved communication with health care providers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-management\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCumbersome nature\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnnecessary exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnxiety generated by recording\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesiring communication with the physician\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFear of cancer recurrence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of suitable format\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRelationship between physicians and patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHaving a trustful relationship with the physician\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor relationship with physicians\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderstanding functions and benefits of PRO recording\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Adapting a healthier lifestyle\u003c/h2\u003e \u003cp\u003eMany patients with cancer were committed to adopting good habits for their health\u0026rdquo; following their cancer diagnosis. Many tried to eat healthier, exercise more, and pay more attention to changes in their physical condition. Many patients are provided with notebooks by the hospital to record their PROs during chemotherapy; however, most preferred to record changes in their PROs in their own notebooks before and during chemotherapy.\u003c/p\u003e \u003cp\u003e\u0026ldquo;After my cancer diagnosis, I became more aware of changes in my physical condition and more attentive to my health than I had been before I was diagnosed. I keep taking care of changes in my physical condition and do stretches and massages.\u0026rdquo; (P2)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I became more attentive to changes in my physical health after my cancer diagnosis. I meditate and try to listen to my body. I try to record any changes in my physical condition that I feel.\u0026rdquo; (P8)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Perceiving the benefits of PRO recording\u003c/h2\u003e \u003cp\u003ePatients with high PRO adherence perceive benefits from recording them. There are two subcategories of benefits in this category. The first subcategory is improved communication with healthcare providers. Based on the PROs while out of the hospital, patients were able to explain their condition in detail to the healthcare provider. PROs can remind patients what they wanted to ask or what they intended to inform their healthcare providers. Patients indicated that using PROs while talking to healthcare providers ensured that patients were less likely to omit or forget a discussion point.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Since I have to see the doctor every three weeks, I wouldn\u0026rsquo;t be able to remember what happened during that time if I didn\u0026rsquo;t have the records. It gives me peace of mind knowing that the doctor who looked at my records knows I\u0026rsquo;m okay.\u0026rdquo; (P3)\u003c/p\u003e \u003cp\u003e\u0026ldquo;When I went to the hospital because of an upset stomach, it was easy to tell the doctor when the laxative was changed by looking at the records.\u0026rdquo; (P4)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I always show my records to the doctor so that I don\u0026rsquo;t forget to tell him what happened.\u0026rdquo; (P6)\u003c/p\u003e \u003cp\u003eThe second subcategory is self-management. In the case of concerning symptoms during chemotherapy, patients may check the record of a previous course to determine whether their symptoms are normal. Further, the records include information about medications; patients can thus consider whether any new symptoms are influenced by newly started medications.\u003c/p\u003e \u003cp\u003e\u0026ldquo;If I feel something is wrong with my health, I look at my previous record. I think records are important.\u0026rdquo; (P5)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I understand the cycle of physical changes caused by the side effects of chemotherapy.\u0026rdquo; (P8)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.4. Cumbersome nature\u003c/h2\u003e \u003cp\u003eRegardless of whether they record PROs, most patients find it \u0026ldquo;cumbersome\u0026rdquo; to maintain their PROs. Even patients with high PRO adherence reported that they sometimes forget to record their PROs when they are feeling very well or very sick.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I am too lazy to continue.\u0026rdquo; (P1)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think I will forget when I resume work.\u0026rdquo; (P2)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I forget when I\u0026rsquo;m feeling relatively well and very sick.\u0026rdquo; (P3)\u003c/p\u003e \u003cp\u003e\u0026ldquo;It\u0026rsquo;s a hassle.\u0026rdquo; (P4)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I recorded some information at the beginning of treatment, but it became tedious and I stopped.\u0026rdquo; (P6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I was given a notebook to record PROs, but I don\u0026rsquo;t keep it. It is clearly a hassle.\u0026rdquo; (P9)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.5. Unnecessary exercise\u003c/h2\u003e \u003cp\u003ePatients who do not record their PROs feel that recording them is unnecessary. If do not find any benefit in recording PROs, they feel that the exercise is not worthwhile.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I never looked back and felt it was necessary.\u0026rdquo; (P6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Side effects are always the same and I remember them myself, so I don\u0026rsquo;t need them.\u0026rdquo; (P9)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.6. Anxiety generated by recording\u003c/h2\u003e \u003cp\u003eMost patients feel anxious about exacerbation or recurrence of their disease while recording their symptoms. This anxiety can be classified into two subcategories. The first subcategory involves the desire to communicate with physicians. When a patient feels anxious about their symptoms while recording PROs, they try to communicate the symptoms to their physician. This subcategory is a facilitator of PRO adherence.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Whenever there is a change in my condition, I worry that I think it might be because I am relapsing. I think I need to tell my doctor about the symptoms I am concerned about. That is why I will record my symptoms.\u0026rdquo; (P3).\u003c/p\u003e \u003cp\u003eThe second subcategory is fear of cancer recurrence. When a patient feels anxious about their symptoms, they stop recording PROs because want to avoid this anxiety. This subcategory is a barrier to PRO adherence.\u003c/p\u003e \u003cp\u003e\u0026ldquo;It is better to stay positive. I don\u0026rsquo;t want it to be stressful. I think it\u0026rsquo;s stressful to record PROs when I\u0026rsquo;m not doing well.\u0026rdquo; (P9)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.7. Lack of suitable format\u003c/h2\u003e \u003cp\u003ePatients who exhibit high adherence with recording PROs on forms handed to them at hospitals and other institutions are stressed by their uniform format. For example, the remarks column is small, the column to record the symptoms that doesn\u0026rsquo;t appear to the patient is disturbing, and it is difficult to rate the intensity of symptoms on a scale of 1 to 10. For this reason, in addition to the notebook handed to them at the hospital, some patients prefer to write freely in a diary or blog.\u003c/p\u003e \u003cp\u003e\u0026ldquo;With a notebook, space is limited.\u0026rdquo; (P2)\u003c/p\u003e \u003cp\u003e\u0026ldquo;The remarks column is too small.\u0026rdquo; (P4, 8)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I would like to have space to write down oral medications.\u0026rdquo; (P7)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.8. Relationships between physicians and patients\u003c/h2\u003e \u003cp\u003eThis category contains two contradicting subcategories. The first is having a trustful relationship with the physician. When the relationship between physicians and patients is trustful, patients adhere to the treatment and lifestyle recommended by their physicians and adopt a proactive approach toward their treatment. A virtuous cycle ensues when patients continue to record PROs although they consider it cumbersome. They perceive benefits, such as improved communication and self-management, which further encourages them to continue to maintain records. This subcategory is considered a facilitator.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I can have a casual conversation with my doctor, such as \u0026lsquo;Did you go on a trip?\u0026rsquo;. When I was struggling with my diet, my doctor arranged for me to receive nutritional guidance\u0026hellip;I keep recording my symptoms because my doctor checks them.\u0026rdquo; (P5)\u003c/p\u003e \u003cp\u003e\u0026ldquo;My doctor is a very good doctor. He suggested me to increase my enjoyment, and I consciously increased the number of things I enjoy and reported them. Not only did he talk to me about my illness, but he also improved my environment, including my long-term care insurance, and I was able to discuss everything with him\u0026hellip;I keep recording my symptoms because my doctor told me to do so.\u0026rdquo; (P8)\u003c/p\u003e \u003cp\u003eThe second subcategory is poor relationship with the physician. Under these circumstances, even if the PRO record is recommended, the patient will not record it because they think it is cumbersome and unnecessary. This results in no change in communication with the physician, lack of a trustful relationship, and, in some cases, the patient takes no active role in the treatment and often seeks a second opinion. This subcategory is considered a barrier.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Frequent changes of doctors are stressful. Some doctors are businesslike in their attitude and I cannot communicate with them. I am thinking of going for a second opinion. I recorded some information at the beginning of treatment, but it became tedious and I stopped.\u0026rdquo; (P6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I don\u0026rsquo;t even know who my doctor is. I was given a notebook to record PROs, but I don\u0026rsquo;t keep it. It is clearly a hassle.\u0026rdquo; (P9)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.9. Understanding functions and benefits of PRO recording\u003c/h2\u003e \u003cp\u003eThis category has two subcategories. The first subcategory is an additional benefit of recording PROs. Patients who do not routinely record their PROs indicate that they might do so if it had a function beyond simply recording them. For example, patients would like to be alerted when their recorded PRO requires medical attention or self-care. As discussed above, many patients feel anxious when recording their PROs. They are reassured when a medical decision about their symptoms is immediately available after recording their PROs. This subcategory is considered a facilitator.\u003c/p\u003e \u003cp\u003e\u0026ldquo;If it had an alert feature that told me \u0026lsquo;This is unusual\u0026rsquo;, I might record a PRO.\u0026rdquo; (P6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;When symptoms are severe, it is difficult to know how to get better even if I only record the symptoms. I would like you to suggest self-care.\u0026rdquo; (P8)\u003c/p\u003e \u003cp\u003eThe second subcategory is awareness of the benefits. It is difficult for patients to imagine how recording their PROs improves their QOL or prolongs overall survival. In fact, many patients may be willing to record PROs if it improves their prognosis. This subcategory is also considered a facilitator.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I would record it if it would help me recover faster.\u0026rdquo; (P1)\u003c/p\u003e \u003c/div\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eEight categories were identified regarding patient adherence with PROs, and these categories were grouped into facilitators and barriers. To our knowledge, this is the first report to identify the facilitators of and barriers to PRO adherence from the perspective of patients.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Facilitators\u003c/h2\u003e \u003cp\u003e \u003cem\u003eIn this study, the following five facilitators were identified: Adopting a healthier lifestyle, Perceiving the benefits of PRO recording, Desiring communication with the physician, Having a trustful relationship with the physician, and Understanding functions and benefits of PRO recording\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOne study reported that many patients with cancer adopted a healthier lifestyle after diagnosis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Patients with gynecologic malignancies exhibit stronger consciousness regarding a healthy lifestyle after cancer treatment compared with before treatment, determined using the Healthy Lifestyle Consciousness Index scale [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This semistructured interview\u0026ndash;based study revealed that patients with gynecologic malignancies were more attentive to changes in their own physical condition and documented changes early after the start of cancer treatment.\u003c/p\u003e \u003cp\u003eBy showing their records when talking to healthcare providers about their physical condition, patients with cancer acquire the ability to communicate their condition without forgetting anything. Even if they feel anxious while recording PROs, they are reassured when their physicians make decisions about their treatment based on the records. Improved communication has been previously reported as a benefit of PRO records [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Patients who maintained good communication with their physicians also had a trustful relationship with them, positive attitude toward treatment, and continued practice of recording PROs, which led to even better communication with their physicians and generated a virtuous cycle. It has been previously reported that good patient\u0026ndash;physician communication builds trustful relationships [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], improves medication adherence [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and may result in good treatment outcomes.\u003c/p\u003e \u003cp\u003eSelf-administration, another benefit of PRO records identified in this study, is an important factor. Previous reports identified that recording and monitoring PROs improved self-efficacy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Moreover, patients with higher self-efficacy could build more trustful relationships with their physicians [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and ensure higher adherence to medications [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Here, similar virtuous cycles were observed in which patients who perform self-management using PRO records showed increased self-efficacy, resulting in higher adherence to PROs during their medical care.\u003c/p\u003e \u003cp\u003ePatients are unlikely to benefit from simply recording their PROs. When alerts are issued or self-care is suggested based on the PROs, patients will perceive a concrete benefit, thus yielding good adherence. These features were included and developed into ePRO to form eRAPID [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], which reported high adherence [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough recording PROs was reported to prolong overall survival [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and improve QOL [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], these favorable effects are not widely known among physicians or patients with cancer. Explaining the benefits of PRO records to patients could ensure high adherence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Barriers\u003c/h2\u003e \u003cp\u003e \u003cem\u003eIn this study, the following five barriers were identified: Cumbersome nature, Unnecessary exercise, Fear of cancer recurrence, Lack of suitable format, and Poor relationship with the physician\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAlmost all patients in this study considered that recording PROs was cumbersome. Patients who benefited from recording PROs were able to continue to record them although they considered this exercise cumbersome. In contrast, patients who did not perceive any benefit in PRO recording considered it \u0026ldquo;cumbersome\u0026rdquo; and \u0026ldquo;unnecessary\u0026rdquo; and finally stopped. The same was reported for medication adherence in patients with hypertension and diabetes; in these patients, lack of patient comprehension regarding the need for treatment was considered a barrier to PRO adherence [19; 20].\u003c/p\u003e \u003cp\u003eFear of cancer recurrence was also a barrier to PRO adherence. Similarly, it has been reported that patients with breast cancer who have high fear of cancer recurrence are less likely to engage in healthy behavior [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. As discussed above, recording PROs is perceived as part of a healthy lifestyle for patients with cancer. High fear of cancer recurrence also decreases PRO adherence.\u003c/p\u003e \u003cp\u003eIn the present study, we observed that patients with poor relationships with physicians were reluctant and showed little interest in their condition and treatment. Similarly, adherence to medication was reported to be low in cases of poor patient\u0026ndash;physician relationships [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Moreover, poor patient\u0026ndash;physician relationships are associated with greater fear of cancer recurrence [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A vicious cycle is created in which a poor patient\u0026ndash;physician relationship further decreases PRO adherence due to increased fear of cancer recurrence.\u003c/p\u003e \u003cp\u003eThe lack of a suitable form was also a barrier to PRO recording, but this issue did not cause patients to quit recording PROs. Similarly, the use of a mobile application to improve medication adherence enhanced usability and was effective, but its effect on medication adherence remains unclear [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Interventions\u003c/h2\u003e \u003cp\u003eBased on the facilitators and barriers extracted in this study, we identified four interventions that could contribute to increased adherence to PRO recording. The first is patient education. Patients who do not currently record PROs regarded them as \u0026ldquo;cumbersome\u0026rdquo; and \u0026ldquo;unnecessary\u0026rdquo;; however, they indicated that they would record PROs if it indicated a favorable prognosis. Although recording PROs was reported to prolong overall survival [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and improve QOL [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], these favorable effects are not widely known among physicians or patients with cancer. Educating patients with cancer regarding the effects of recording PROs could result in better adherence to PRO recording.\u003c/p\u003e \u003cp\u003eSecond, PROs should be recorded to serve as a communication tool with healthcare providers and self-management. Patients with gynecologic cancer would like to communicate better with their physicians. As previously reported, recording PROs can improve patient\u0026ndash;physician communication [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Patients can continue to record their PROs because they benefit from improved communication with their healthcare providers by referring to their PROs, explaining the progression of their symptoms, and showing the relationship between their medications and symptoms. Summary and graphical functions can display the time course of symptoms and abnormal data in PROs for easy understanding, thus resulting in improved communication with healthcare providers [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and higher PRO adherence. Patients also continue recording PROs owing to the benefit of self-management. Patients should review their symptom records from previous doses, particularly because symptoms during chemotherapy are cyclical. Other features that can further support PRO adherence include the facility to monitor or review their symptom reports over time, which is useful for self-management [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and may ensure better adherence.\u003c/p\u003e \u003cp\u003eThird, a personalized format is desirable. Six of nine patients documented information on medications, vaccination dates, etc., in their notes. Free space provided for notes may increase patient satisfaction. The free-text feature was generally valued highly in previous reports [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In addition, ePRO created an easy-to-record format by placing symptoms related to medical conditions or treatments at the top of the list. Previous reports have also suggested that personalized intervention content afforded higher PRO adherence [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A user-friendly format also induced higher adherence.\u003c/p\u003e \u003cp\u003eFourth, providing information according to the contents of the record is important. Some patients were anxious and stressed about their symptoms, causing them to stop recording PROs altogether. Previous reports have indicated that providing appropriate information regarding medical conditions and symptoms can help reduce anxiety [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Therefore, the ability to obtain recommendations for self-care and medical consultation based on the PROs recorded by patients recorded resolved their concerns and resulted in high adherence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.4. Limitations\u003c/h2\u003e \u003cp\u003eThis study had several limitations. First, the study was conducted at a single institution with nine participants. The results cannot be generalized to all patients with cancer. However, all interviews were coded independently by two researchers, and discrepancies were resolved by consensus. Following the nine interviews, we determined that no new data was needed, with categories and their relationships being well developed. Second, the participants were patients undergoing cancer treatment and were in less than perfect physical condition, which may have caused volunteer bias. Although it is difficult to generalize these results to all cancer patients, including those who have completed treatment, patients under treatment are the most important targets for PRO recording. A third limitation was the reliability and generalizability of qualitative data. However, the two researchers independently agreed that data saturation was achieved after the ninth interview, and there was consensus regarding the categories and subcategories that emerged. To the best of our knowledge, this study is the first to identify the factors responsible for patients\u0026rsquo; inability to continuously record PROs.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. CONCLUSIONS","content":"\u003cp\u003eAdopting a healthier lifestyle, perceiving the benefits of PRO recording, desiring communication with the physician, having a trustful relationship with the physician, and understanding functions and benefits of PRO recording are facilitators of adherence with PROs. Cumbersome nature, unnecessary exercise, fear of cancer recurrence, lack of suitable format, and poor relationship with the physician are barriers. Interventions contributing to PRO adherence include patient education, PROs as a communication and self-management tool, personalized forms, and provision of information based on the content of the record. These results can help design future ePROs to ensure higher adherence.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epatient-reported outcome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQOL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003equality of life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eePRO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eelectronic patient-reported outcome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by Kyoto University Graduate School and Faculty of Medicine, Ethics Committee (December/27\u003csup\u003eth\u003c/sup\u003e/2019 /\u0026nbsp;C1458). Informed consent was obtained from all participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eAll participants have given their consent for the publication of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eDue to data protective restrictions, additional data are not available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This work was supported by the Suzuken Memorial Foundation and MIRAI2021 GAP grant. DUMSCO Incorporated provided financial support for conducting interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u003c/strong\u003e\u003cstrong\u003es\u0026rsquo;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003econtributions:\u0026nbsp;\u003c/strong\u003eNozomi Higashiyama: Conceptualization, Formal analysis, Investigation, Data Curation, Writing - Original Draft, Ken Yamaguchi: Conceptualization, Formal analysis, Investigation, Data Curation, Writing - Original Draft, Supervision, Funding acquisition, Naofumi Wakabayashi: Conceptualization, Methodology, Writing \u0026ndash; Review \u0026amp; Editing, Ayami Koike: Writing \u0026ndash; Review \u0026amp; Editing, Yoshihide Inayama: Writing \u0026ndash; Review \u0026amp; Editing, Yosuke Yamamoto: Methodology, Writing \u0026ndash; Review \u0026amp; Editing, Koji Yamanoi: Resources, Writing \u0026ndash; Review \u0026amp; Editing, Mana Taki: Writing \u0026ndash; Review \u0026amp; Editing, Ryusuke Murakami: Writing \u0026ndash; Review \u0026amp; Editing, Junzo Hamanishi: Resources, Writing \u0026ndash; Review \u0026amp; Editing, Noriyoshi Nishiike: Writing \u0026ndash; Review \u0026amp; Editing, Project administration, Funding acquisition, and Masaki Mandai: Writing \u0026ndash; Review \u0026amp; Editing, Project administration\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eNot applicable\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHowell D, Molloy S, Wilkinson K, Green E, Orchard K, Wang K, Liberty J. 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Breast Cancer Res Treat. 2008;112(Suppl 1):5\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10549-008-0077-3\u003c/span\u003e\u003cspan address=\"10.1007/s10549-008-0077-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"PRO (Patient- Reported Outcome), Advance Directive Adherence, User-Centered Design, Patient-Centered Care, Physician-Patient Relations","lastPublishedDoi":"10.21203/rs.3.rs-4446052/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4446052/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackgroud:\u003c/h2\u003e \u003cp\u003eThe systematic monitoring of patients based on patient-reported outcomes (PROs) has positive effects on patient\u0026ndash;physician communication, symptom management, and quality of life; however, a major problem with PRO recording is the lack of adherence. The factors that affect patient adherence with PRO recording remain unclear. This study aimed to provide qualitative insights by identifying facilitators of and barriers to PRO adherence in patients with gynecological cancer.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData were collected from nine patients diagnosed with gynecological cancer and admitted for treatment at the Kyoto University Hospital via semistructured interviews. Interviews were audiotaped and transcribed verbatim. Coding and qualitative content analysis of the transcripts were completed by two independent researchers.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEight categories, including five facilitators and five barriers to PRO adherence, were identified. The five facilitators were \u0026ldquo;adopting a healthier lifestyle,\u0026rdquo; \u0026ldquo;perceiving the benefits of PRO recording,\u0026rdquo; \u0026ldquo;desiring communication with the physician,\u0026rdquo; \u0026ldquo;having a trustful relationship with the physician,\u0026rdquo; and \u0026ldquo;understanding functions and benefits of PRO recording.\u0026rdquo; The five barriers were \u0026ldquo;cumbersome nature,\u0026rdquo; \u0026ldquo;unnecessary exercise,\u0026rdquo; \u0026ldquo;fear of cancer recurrence,\u0026rdquo; \u0026ldquo;lack of suitable format,\u0026rdquo; and \u0026ldquo;poor relationship with the physician.\u0026rdquo;\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSuitable interventions to improve adherence to PROs may enable patient-centered care by enhancing facilitators of and eliminating barriers to such adherence.\u003c/p\u003e","manuscriptTitle":"Facilitators of and barriers to continued recording of patient-reported outcomes based on qualitative interviews of patients with gynecological cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-03 13:10:26","doi":"10.21203/rs.3.rs-4446052/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5424c8d1-2a22-485a-9eef-33191e425315","owner":[],"postedDate":"June 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-29T09:15:39+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-03 13:10:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4446052","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4446052","identity":"rs-4446052","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}