Attitudes and Coping Strategies toward Constipation in Individuals with Cancer: A Qualitative Study

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Methods: This qualitative study was conducted using a phenomenological design. Between February and June 2024, in-depth semi-structured interviews were conducted with 20 cancer patients experiencing constipation in the oncology unit of a hospital. Participants were also evaluated using a demographic information form and the Constipation Assessment Scale (CAS). Interviews were audio-recorded, transcribed verbatim, and analyzed using content analysis to identify emerging themes. Results: Four main themes were identified: physical effects, psychological effects, social and lifestyle impacts, and coping strategies. Physical effects included abdominal pain, bloating, fatigue, and mobility limitations. Psychological effects were expressed as irritability, stress, and feelings of helplessness. Social effects were described as reduced participation in daily activities and social withdrawal. Coping strategies included behavioral approaches such as fluid intake, fiber-rich diet, walking, and psychological strategies like positive thinking and family support. It was also found that some participants did not use any particular coping methods. Conclusion: This study revealed that constipation in individuals diagnosed with cancer causes significant effects not only physically but also psychologically and socially. Participants' experiences indicated a notable decline in quality of life due to constipation. The findings suggest that supportive care plans tailored to individual needs may be beneficial. Cancer Constipation Coping strategies Qualitative research Introduction Constipation is commonly defined as infrequent bowel movements or difficulty in defecation, often accompanied by symptoms such as excessive straining, incomplete evacuation, hard or lumpy stools, or the need for manual maneuvers, and in some cases, occurs without obvious symptoms [1, 2]. It is a prevalent symptom among patients with advanced-stage cancer and significantly impairs quality of life [1, 3]. The prevalence of constipation in this population is estimated to range between 30% and 80% [2, 4]. The incidence of constipation increases as cancer progresses, particularly due to the use of opioid analgesics and anticholinergic medications [1, 5]. The primary causes of constipation in cancer patients include medications (especially opioids), inadequate fluid intake, anorexia, and physical inactivity [1, 6]. When left untreated, constipation may lead to distressing symptoms such as nausea, vomiting, abdominal pain, and psychological stress, and even life-threatening complications such as bowel obstruction and perforation [2, 4, 6, 7]. Despite its serious consequences, constipation is often underrecognized and ineffectively managed by nurses in clinical practice [8]. This situation may exacerbate patients’ physical discomfort and psychological distress [1, 9]. In cases of opioid-induced constipation, lifestyle modifications such as the use of laxatives or stool softeners, increased fluid intake, fiber-rich diets, and enhanced physical activity are typically recommended [3, 10]. It is also essential to closely monitor patients to detect laxative-related side effects and other symptoms at an early stage [5–7]. As healthcare professionals who spend extensive time with patients and play a key role in identifying those at risk, nurses need to be knowledgeable about the assessment, causes, and management strategies of constipation in cancer patients [8]. They should also contribute to generating evidence-based data, facilitate knowledge sharing among healthcare providers, and promote interdisciplinary collaboration [5]. A limited number of studies have focused on the assessment of constipation in cancer patients, its causes, symptom burden, and management strategies [2, 5–7]. The primary aim of this study was to explore the attitudes and coping strategies of cancer patients toward constipation. Additional objectives included identifying the characteristics of patients experiencing constipation, the related physical and emotional consequences, the pharmacological and non-pharmacological strategies used for prevention and management, and the extent of healthcare service utilization in this context. Methods Study design This study adopted a phenomenological qualitative research design to explore cancer patients’ experiences with constipation, their attitudes toward it, and their coping strategies. Setting and participants The study was conducted between February and June 2024 in the oncology unit of a hospital in Türkiye. The study population consisted of patients receiving cancer treatment and experiencing constipation during this period. Participants were selected using purposive sampling. Inclusion criteria were being 18 years or older, orally fed, having no cognitive or physical conditions that would prevent communication, and meeting the Rome III diagnostic criteria for functional constipation (Table 1), with symptoms present intermittently or continuously in the past three months and having started at least six months earlier. Patients diagnosed with irritable bowel syndrome, gastrointestinal perforation, gastrointestinal bleeding, or gastrointestinal cancer were excluded from the study. Table 1. Rome III criteria It is important that these criteria have been observed within the last 12 months and have persisted for at least three consecutive months. Presence of at least two or more of the following: Straining during at least 25% of defecations Lumpy or hard stools in at least 25% of defecations Sensation of incomplete evacuation in at least 25% of defecations Sensation of anorectal obstruction/blockage in at least 25% of defecations Manual maneuvers to facilitate at least 25% of defecations Fewer than three defecations per week 2. Rare occurrence of loose stools without the use of laxatives 3. Insufficient criteria for irritable bowel syndrome Data collection In the study, a participant information form and the Constipation Assessment Scale (CAS) were used to describe patients’ socio-demographic characteristics and constipation status. In addition, semi-structured individual interviews were conducted to gain an in-depth understanding of patients’ experiences, impacts, and coping methods related to constipation. The interview form included five open-ended questions designed to facilitate participants' descriptions of their experiences. While the interview data formed the main basis of the study, the information obtained from the participant forms and the scale was used to better describe the participants' general characteristics and to provide contextual support for the findings. These data were not directly included in the analysis process of the interview content but were evaluated solely as supportive background information. All interviews were conducted face-to-face by the researcher in a private room within the hospital. Data collection continued until data saturation was achieved, meaning no new concepts or insights emerged in response to the research questions. A total of 20 patients participated in the study. Data collection tools Patient Information Form: The researchers developed this form to collect data on patients' socio-demographic and clinical characteristics. It includes items regarding age, gender, marital status, and educational level, as well as cancer-related variables such as cancer type, duration of cancer, duration of chemotherapy, and perceived health. Constipation Assessment Scale (CAS): The scale was originally developed by McMillan and Williams (1989). The Turkish validity and reliability study of the scale was conducted by Demir-Doğan and Aktuğ (2017). The scale consists of eight items and is scored between 0 and 16, with higher scores indicating more severe constipation. In the original study by McMillan and Williams, Cronbach's alpha was reported as 0.70, while Demir-Doğan and Aktuğ found it to be 0.78 [11]. Interview Form: The researchers developed a semi-structured interview form to explore patients’ experiences with constipation, the treatments they received, and their coping strategies. The form consisted of five open-ended questions: How does being constipated make you feel? Can you describe how constipation affects your daily life? What are the most common problems you experience when you are constipated? What do you do to cope with the problems caused by constipation? (What are your non-pharmacological approaches?) What do you do to prevent constipation? Data analysis Quantitative data were analyzed using the SPSS version 28.0 (Statistical Package for the Social Sciences). Descriptive statistics were used for frequency, percentage, mean, and standard deviation. The normality of data distribution was assessed using the Kolmogorov-Smirnov test. The relationships between the CAS scores and variables, including age, duration of cancer, duration of chemotherapy, and perceived health status, were analyzed using Spearman correlation analysis. A significance level of p < 0.05 was considered statistically significant. Qualitative data were analyzed using inductive content analysis. All interviews were audio-recorded, transcribed verbatim, and manually coded by the researchers without software. Field notes and unstructured observations recorded during the study were also included in the analysis. Two researchers performed coding independently and then reviewed multiple times with intervals to ensure consistency. Themes and sub-themes were developed from the codes, and data matrices were created to display and interpret the findings. Each participant was anonymized using the letter "P" followed by a participant number (e.g., P1, P2). Limitations This study has several potential limitations. First, using a small sample size, which is typical in qualitative research, may raise concerns regarding the representativeness of the findings for the broader population of cancer patients experiencing constipation. However, this limitation was mitigated by the richness of the data and the purposive sampling approach applied until data saturation was achieved. Another limitation is that participants were selected from the researcher's own clinical setting, and individuals from diverse educational, ethnic, or racial backgrounds were not included, which limits the generalizability of the findings. Lastly, the study relied on participants' ability to recall and reflect on their past experiences, which may have introduced recall bias. Results The mean age of the cancer patients included in the study was 57.15 ± 15.58 years. In terms of socio-demographic characteristics, 85% of the participants were female, 80% were married, 50% were illiterate, 75% did not use laxatives, and 35% had been diagnosed with breast cancer. The average duration of cancer was 22.75 ± 25.11 months, and the mean duration of chemotherapy was 13.75 ± 10.92 months. The participants’ perceived health status score was 5.80 ± 1.90, and the mean CAS score was 9.10 ± 2.22 (Table 2). According to the Rome III criteria, all patients reported straining and excessive effort during at least 25% of defecations, lumpy or hard stools in at least 25% of defecations, a sensation of incomplete evacuation in at least 25% of defecations, and a sense of anorectal obstruction in at least 25% of defecations. Furthermore, 95% of participants reported a need for manual maneuvers to facilitate defecation in at least 25% of bowel movements and only rarely experienced soft stools without the use of laxatives. In addition, 60% of patients reported fewer than three bowel movements per week (Table 3). Table 2. Demographic and clinical characteristics of the patients (n = 20) Characteristic Frequency n Percent % Gender Male 3 15 Female 17 85 Marital status Married 16 80 Single 4 20 Education level Illiterate 10 50 Literate 2 10 Primary/Secondary school 3 15 High school graduate 3 15 Undergraduate/Postgraduate 2 10 Use of laxatives Yes 5 25 No 15 75 Type of cancer Breast cancer 7 35 Ovarian cancer 3 15 Brain cancer 1 5 Liver cancer 2 10 Bladder cancer 1 5 Esophageal cancer 1 5 Skin cancer 1 5 Cervical cancer 2 10 Bone cancer 1 5 Sarcoma 1 5 Mean ± SD Age (years) 57.15±15.58 Duration of cancer (months) 22.75±25.11 Duration of chemotherapy (months) 13.75±10.92 Perceived health status 5.80±1.90 CAS score 9.10±2.22 CAS: Constipation Assessment Scale; SD: Standard Deviation Table 3. Distribution of patient symptoms according to Rome III criteria Symptom n % Straining during at least 25% of defecations 20 100 Lumpy or hard stools in at least 25% of defecations 20 100 Sensation of incomplete evacuation in at least 25% of defecations 20 100 Sensation of anorectal obstruction in at least 25% of defecations 20 100 Need for manual maneuvers to facilitate at least 25% of defecations 19 95 Fewer than three defecations per week 12 60 Rare occurrence of soft stools without the use of laxatives 19 95 Table 4. Main themes, subthemes, and sample codes Main Theme Subtheme Sample Codes Physical effects Bodily symptoms Nausea, headache, abdominal pain, fatigue, bloating Mobility limitations Inability to walk, difficulty moving Psychological effects Emotional disturbances Irritability, stress, sadness Mental effects Negative thoughts Social and lifestyle effects Disruption of daily life Inability to go out, inability to do housework Social isolation Avoiding conversations, lack of enjoyment in life Coping strategies Nutritional and natural methods Drinking plenty of water, eating vegetables and fruits Behavioral methods Walking, taking a shower, cooking, engaging in art, passive behavior Psychological methods Thinking positively, spending time with family In this study, the qualitative data obtained from interviews with 20 patients were analyzed under four main themes: physical effects, psychological effects, social and lifestyle impacts, and coping strategies. Table 4 summarizes the identified main themes, corresponding sub-themes, and illustrative participant quotations. Theme 1: Physical effects Patients’ physical experiences were categorized under two sub-themes: bodily symptoms and mobility limitations. Reported symptoms included nausea, headache, abdominal pain, fatigue, and a sensation of bloating. Mobility limitations were described as difficulty walking and reduced overall physical capacity. Participants described constipation as an extremely uncomfortable experience, using various adjectives to convey the multidimensional nature of their suffering, such as "bloated," "blocked," "painful," "exhausting," and "tense." Some patient quotes included: "Constipation ruins me. It hits my stomach—I feel bloated and nauseous." (P2, P9) "I can’t walk—I feel paralyzed." (P18) "My stomach hurts. It’s like there’s a knot inside me." (P5) "I constantly feel tired. I don’t want to do anything. I don’t even want to get out of bed." (P13) These statements illustrate how constipation adversely affects patients’ daily functioning. Theme 2: Psychological effects This theme included two sub-themes: emotional disturbances and cognitive impacts . Emotional disturbances referred to irritability, stress, and sadness, while cognitive impacts involved persistent negative thoughts. Participants reported experiencing intense and complex emotional responses. They described a sense of inner discomfort, anxiety about toilet use, and frustration caused by the inability to defecate despite the constant urge. Quotes included: "I feel this inner discomfort I can't even describe." (P5) "I feel sad. I can’t enjoy life." (P6, P15, P12) "I yell at the people around me because of the pain—and then I regret it." (P11) "It’s destroying me. This situation is wearing me out." (P17) "I constantly feel like I need to go to the toilet, but nothing happens. It’s so frustrating." (P8) "I’m already ill (from cancer), and constipation just makes me feel even worse." (P12) Theme 3: Social and lifestyle impacts This theme was analyzed through two sub-themes: disruption of daily activities and social withdrawal . Participants expressed difficulty leaving the house, managing daily tasks, and maintaining social relationships. They reported that the constant need to use the bathroom discouraged them from participating in social life. Quotes included: "I can’t visit my children’s homes. My social life is over." (P11) "It always requires walking and being close to a bathroom… I can’t go out or leave the house." (P19) "My social interactions are decreasing. I don’t want to see anyone." (P9) "I can’t do the housework. My house is a mess." (P16) These statements highlight that constipation affects not only physical health but also patients’ ability to engage in social and daily life. Theme 4: Coping strategies Constipation significantly affects quality of life, prompting patients to develop various coping strategies. These were grouped under three sub-themes: dietary and natural remedies , behavioral methods , and psychological approaches . Sub-theme 1: Dietary and natural remedies Patients often used these methods both to relieve symptoms and for prevention. Common strategies included: Drinking plenty of water Consuming dried apricots, figs, persimmons, and olive oil Reducing solid foods Eating fruits, vegetables, and fiber-rich foods Avoiding spicy food Examples: "I drink lots of water every day." (P1, P3, P6...) "I eat dried figs or apricots—it helps me." (P3, P5, P7...) "I reduce heavy food intake to stay comfortable." (P2, P3, P6...) Sub-theme 2: Behavioral methods Participants used activities such as walking, hot compresses, taking showers, cooking, music, and screen time to relieve discomfort. Quotes included: "I walk for half an hour every day—it helps." (P8) "Warm water eases my abdominal pain." (P5) "Cooking distracts me." (P7) "I listen to music, paint, play the bağlama—it helps me focus elsewhere." (P1) "I spend time on my phone." (P14) Some used prescribed medications or herbal products. Four patients stated they did not use any coping strategies. Sub-theme 3: Psychological approaches Given constipation’s emotional impact, some participants reported using cognitive strategies, such as: "I try to think positively—I believe it will pass." (P4) "Spending time with my family relaxes me." (P12) These findings demonstrate that patients rely on a wide variety of coping strategies tailored to their personal preferences and lived experiences. Discussion This qualitative study explored the experiences of cancer patients with constipation, focusing on its physical, psychological, and social effects, as well as coping strategies. The findings reveal that constipation is not merely a physiological symptom but a multidimensional issue associated with emotional burdens, social limitations, and substantial declines in quality of life. The presence of symptoms consistent with Rome III criteria—such as straining, hard or lumpy stools, a sensation of incomplete evacuation, and anorectal blockage—among all participants underscores the prevalence and severity of the issue. Physically, patients reported a range of gastrointestinal symptoms such as abdominal pain, bloating, nausea, and fatigue. Functional limitations, including difficulty walking and reduced mobility, were also frequently described, affecting daily activities. The literature similarly identifies common symptoms accompanying constipation, including abdominal distension, rectal tears and fissures, hepatic or retroperitoneal pain, anorexia, nausea, vomiting, urinary retention, and confusion. However, it has also been noted that no universally accepted clinical definition of constipation exists for both patients and clinicians [ 4 ]. Effective constipation management requires regular assessment of patients, monitoring of bowel habits, and early identification of changes. Clinical recommendations systematically evaluate medical history, medications, dietary intake, fluid consumption, physical activity, comorbidities, and environmental factors. Physical examinations including abdominal assessment, perineal inspection, and digital rectal examination are also recommended [ 12 ]. Psychologically, the findings indicate that constipation has marked emotional consequences. Participants reported feelings of distress related to failed attempts at defecation, loss of control, and constant preoccupation with the urge to defecate. These experiences led to intense stress, irritability, sadness, and mental fatigue. Lin et al. (2024) found that the inability to expel waste can cause considerable emotional distress [ 7 ]. Similarly, Davies et al. (2020) noted that constipation negatively affects patients’ psychological well-being and reduces their quality of life [ 1 ]. These results clearly support the notion that constipation must be addressed not only as a physical disorder, but also in its psychosocial dimensions. The social and lifestyle findings showed that constipation restricts patients’ daily functioning and leads to social withdrawal. Most participants reported difficulties leaving home, performing household tasks, and maintaining social interactions. The unpredictability of bowel movements and the constant need for a nearby toilet contributed to isolation and reduced engagement with social life. These findings align with evidence-based guidelines that highlight the impact of chronic constipation on quality of life [ 13 ]. Participants employed a variety of strategies to manage constipation, which were categorized into three main groups: dietary approaches (e.g., increased fluid intake and high-fiber foods), behavioral methods (e.g., walking, distraction techniques), and psychological support (e.g., positive thinking, spending time with family). This suggests that patients play an active role in self-managing symptoms. Gao et al. (2019) confirmed that exercise is a feasible and effective method for managing constipation [ 14 ]. Zainordin et al. (2021) reported that increasing physical activity and reducing sedentary time helped alleviate constipation symptoms in cancer patients [ 15 ]. However, Nakano et al. (2018) found that while aerobic, resistance, and combined exercise programs improved symptoms like fatigue, pain, and insomnia, they had a neutral effect on constipation [ 16 ]. Complementary and alternative therapies also featured prominently in patients’ coping strategies. In a Turkish study, patients most frequently used phytotherapy to manage chemotherapy-induced constipation [ 17 ]. Furthermore, a meta-analysis reported that combined pharmacological and acupuncture therapies yielded promising outcomes for managing opioid-induced constipation [ 18 ]. Nevertheless, in patients with advanced cancer, lifestyle interventions (e.g., fiber intake and exercise) have shown limited effectiveness, especially for opioid-induced constipation, due to implementation challenges [ 1 ]. This highlights the continued need for robust evidence supporting non-pharmacological strategies. Nursing-led approaches have also demonstrated significant benefits in constipation management. Nurse-led care programs have improved symptoms such as constipation, insomnia, and financial burden [ 19 ]. Complementary interventions such as acupressure, abdominal aromatherapy massage, and self-management training have been particularly effective in improving quality of life in cancer patients [ 20 ]. In conclusion, the findings of this study underscore the necessity of adopting a multidisciplinary and holistic approach to constipation management in cancer care—one that integrates not only medical treatment, but also physical, psychological, and social dimensions. The literature emphasizes ensuring patient privacy and comfort, supporting proper defecation posture, promoting hydration and physical activity tailored to capacity, and implementing prophylactic measures before opioid initiation. Moreover, over-the-counter or homemade remedies should be critically evaluated for their potential interactions with prescribed treatments [ 12 ]. Conclusion and Recommendations This study revealed that constipation in individuals diagnosed with cancer is a multidimensional issue that extends beyond physical discomfort to encompass emotional distress and limitations in social life. The experiences of the participants indicated that constipation significantly diminishes quality of life and that patients develop various individual coping strategies to manage this condition. In this context, constipation should be assessed in physiological terms and with consideration for its psychological and social dimensions. Healthcare professionals should consider patients’ individual experiences and develop personalized, supportive interventions accordingly. Nutritional regulation, physical activity, and psychosocial support components should be integrated into care processes. Patient-centered and holistic approaches should be prioritized to ensure comprehensive and effective constipation management in cancer care. Declarations Acknowledgements The authors sincerely thank all the individuals with cancer who openly shared their experiences and participated in this study. Author contribution All authors contributed to the study conception and design. Material preparation and data collection were performed by DBA. The full manuscript was written by DBA, DAD, and AS, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Data availability The data that support the findings of this study are available from the corresponding author upon reasonable request. Due to the sensitive nature of the qualitative data, full transcripts cannot be publicly shared to protect participant confidentiality. Ethics approval and consent to participate Ethical approval for this study was obtained from the Mardin Artuklu University Non-Interventional Clinical Research Ethics Committee (Approval No: 2023/12-18; Date: 05.12.2023). Written permission was also obtained from the hospital where the study was conducted. Authorization was granted by the original authors for using the relevant scales. The administration of the survey took approximately 40–60 minutes. Participants were informed about the study's purpose and procedures, and written informed consent was obtained from each of them. The study was conducted by the principles of the Declaration of Helsinki. Consent to participate Consent to participate was obtained by the participants. Consent for publication Not applicable. Conflict of interest The authors declare that they have no competing interests. Financial interests The authors declare they have no financial interests. Financial Disclosure This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest No conflict of interest was declared by the authors. 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Clin Epidemiol 13:907–919. https://doi.org/10.2147/CLEP.S324193 Cheng X, Wei S, Zhang H, et al (2018) Nurse-led interventions on quality of life for patients with cancer: A meta-analysis. Medicine (Baltimore) 97:e12037. https://doi.org/10.1097/MD.0000000000012037 Nakano K, Kanno Y, Kajiwara K, et al (2025) Nursing support for constipation in patients with cancer: A scoping review. J Palliat Med 28:115–122. https://doi.org/10.1089/jpm.2024.0071 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-7023245","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498986257,"identity":"d7d35a8c-6b38-4532-9b64-6f7112c61b40","order_by":0,"name":"Derya Bıçak Ayık","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYDCCA1BSgr0BSBtYkKKFB8QykCBFi0QCiEGEFr7jvc8kftTckZec+fzqhh8FEgz87d0JeLVInjluJtlz7JnhbOmcsps9QIdJnDm7Aa8WgxtpbBI8bIcT5KRz0m7wALUYSOQS0HL/GZvkn39ALZJn0m7+IUrLDTY2ad62wwnSEuzHbhNlC9BsZmvZvmeGM3ty2G7LGEjwEPQL3/FjjDfffLsjL3H8+LObb/7YyPG39+LXAgQs0LjgMQCThJSDAPMHCM3+gBjVo2AUjIJRMAIBALSeSt6y5yibAAAAAElFTkSuQmCC","orcid":"","institution":"Mardin Artuklu University","correspondingAuthor":true,"prefix":"","firstName":"Derya","middleName":"Bıçak","lastName":"Ayık","suffix":""},{"id":498986260,"identity":"6a6e432b-ee95-4479-954c-3e982ce3860c","order_by":1,"name":"Ayşe Serpici","email":"","orcid":"","institution":"Bursa Uludağ University","correspondingAuthor":false,"prefix":"","firstName":"Ayşe","middleName":"","lastName":"Serpici","suffix":""},{"id":498986262,"identity":"ef7c576e-9531-4663-af48-0efa04d90cc9","order_by":2,"name":"Derya Akça Doğan","email":"","orcid":"","institution":"Bursa Uludağ University","correspondingAuthor":false,"prefix":"","firstName":"Derya","middleName":"Akça","lastName":"Doğan","suffix":""}],"badges":[],"createdAt":"2025-07-01 19:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7023245/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7023245/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96769653,"identity":"28d82d7f-a033-49a9-8893-c1fe2ef220be","added_by":"auto","created_at":"2025-11-25 23:38:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":957938,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7023245/v1/8992f8bf-3d47-496d-865f-21778dbe743e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAttitudes and Coping Strategies toward Constipation in Individuals with Cancer: A Qualitative Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eConstipation is commonly defined as infrequent bowel movements or difficulty in defecation, often accompanied by symptoms such as excessive straining, incomplete evacuation, hard or lumpy stools, or the need for manual maneuvers, and in some cases, occurs without obvious symptoms [1, 2]. It is a prevalent symptom among patients with advanced-stage cancer and significantly impairs quality of life [1, 3]. The prevalence of constipation in this population is estimated to range between 30% and 80% [2, 4]. The incidence of constipation increases as cancer progresses, particularly due to the use of opioid analgesics and anticholinergic medications [1, 5].\u003c/p\u003e\n\u003cp\u003eThe primary causes of constipation in cancer patients include medications (especially opioids), inadequate fluid intake, anorexia, and physical inactivity [1, 6]. When left untreated, constipation may lead to distressing symptoms such as nausea, vomiting, abdominal pain, and psychological stress, and even life-threatening complications such as bowel obstruction and perforation [2, 4, 6, 7].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite its serious consequences, constipation is often underrecognized and ineffectively managed by nurses in clinical practice\u0026nbsp;[8]. This situation may exacerbate patients\u0026rsquo; physical discomfort and psychological distress [1, 9].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn cases of opioid-induced constipation, lifestyle modifications such as the use of laxatives or stool softeners, increased fluid intake, fiber-rich diets, and enhanced physical activity are typically recommended [3, 10]. It is also essential to closely monitor patients to detect laxative-related side effects and other symptoms at an early stage\u0026nbsp;[5\u0026ndash;7].\u003c/p\u003e\n\u003cp\u003eAs healthcare professionals who spend extensive time with patients and play a key role in identifying those at risk, nurses need to be knowledgeable about the assessment, causes, and management strategies of constipation in cancer patients\u0026nbsp;[8]. They should also contribute to generating evidence-based data, facilitate knowledge sharing among healthcare providers, and promote interdisciplinary collaboration [5].\u003c/p\u003e\n\u003cp\u003eA limited number of studies have focused on the assessment of constipation in cancer patients, its causes, symptom burden, and management strategies [2, 5\u0026ndash;7]. The primary aim of this study was to explore the attitudes and coping strategies of cancer patients toward constipation. Additional objectives included identifying the characteristics of patients experiencing constipation, the related physical and emotional consequences, the pharmacological and non-pharmacological strategies used for prevention and management, and the extent of healthcare service utilization in this context.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adopted a phenomenological qualitative research design to explore cancer patients\u0026rsquo; experiences with constipation, their attitudes toward it, and their coping strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted between February and June 2024 in the oncology unit of a hospital in T\u0026uuml;rkiye. The study population consisted of patients receiving cancer treatment and experiencing constipation during this period. Participants were selected using purposive sampling. Inclusion criteria were being 18 years or older, orally fed, having no cognitive or physical conditions that would prevent communication, and meeting the Rome III diagnostic criteria for functional constipation (Table 1), with symptoms present intermittently or continuously in the past three months and having started at least six months earlier. Patients diagnosed with irritable bowel syndrome, gastrointestinal perforation, gastrointestinal bleeding, or gastrointestinal cancer were excluded from the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eRome III criteria\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 604px;\"\u003e\n \u003cp\u003eIt is important that these criteria have been observed within the last 12 months and have persisted for at least three consecutive months.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 604px;\"\u003ePresence of at least two or more of the following:\u003cul\u003e\n \u003cli\u003eStraining during at least 25% of defecations\u003c/li\u003e\n \u003cli\u003eLumpy or hard stools in at least 25% of defecations\u003c/li\u003e\n \u003cli\u003eSensation of incomplete evacuation in at least 25% of defecations\u003c/li\u003e\n \u003cli\u003eSensation of anorectal obstruction/blockage in at least 25% of defecations\u003c/li\u003e\n \u003cli\u003eManual maneuvers to facilitate at least 25% of defecations\u003c/li\u003e\n \u003cli\u003eFewer than three defecations per week\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 604px;\"\u003e\n \u003cp\u003e2. Rare occurrence of loose stools without the use of laxatives\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 604px;\"\u003e\n \u003cp\u003e3. Insufficient criteria for irritable bowel syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the study, a participant information form and the Constipation Assessment Scale (CAS) were used to describe patients\u0026rsquo; socio-demographic characteristics and constipation status. In addition, semi-structured individual interviews were conducted to gain an in-depth understanding of patients\u0026rsquo; experiences, impacts, and coping methods related to constipation. The interview form included five open-ended questions designed to facilitate participants\u0026apos; descriptions of their experiences.\u003c/p\u003e\n\u003cp\u003eWhile the interview data formed the main basis of the study, the information obtained from the participant forms and the scale was used to better describe the participants\u0026apos; general characteristics and to provide contextual support for the findings. These data were not directly included in the analysis process of the interview content but were evaluated solely as supportive background information.\u003c/p\u003e\n\u003cp\u003eAll interviews were conducted face-to-face by the researcher in a private room within the hospital. Data collection continued until data saturation was achieved, meaning no new concepts or insights emerged in response to the research questions. A total of 20 patients participated in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection tools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Information Form:\u0026nbsp;\u003c/strong\u003eThe researchers developed this form to collect data on patients\u0026apos; socio-demographic and clinical characteristics. It includes items regarding age, gender, marital status, and educational level, as well as cancer-related variables such as cancer type, duration of cancer, duration of chemotherapy, and perceived health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConstipation Assessment Scale (CAS):\u0026nbsp;\u003c/strong\u003eThe scale was originally developed by McMillan and Williams (1989). The Turkish validity and reliability study of the scale was conducted by Demir-Doğan and Aktuğ (2017). The scale consists of eight items and is scored between 0 and 16, with higher scores indicating more severe constipation. In the original study by McMillan and Williams, Cronbach\u0026apos;s alpha was reported as 0.70, while Demir-Doğan and Aktuğ found it to be 0.78 [11].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterview Form:\u0026nbsp;\u003c/strong\u003eThe researchers developed a semi-structured interview form to explore patients\u0026rsquo; experiences with constipation, the treatments they received, and their coping strategies. The form consisted of five open-ended questions:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eHow does being constipated make you feel?\u003c/li\u003e\n \u003cli\u003eCan you describe how constipation affects your daily life?\u003c/li\u003e\n \u003cli\u003eWhat are the most common problems you experience when you are constipated?\u003c/li\u003e\n \u003cli\u003eWhat do you do to cope with the problems caused by constipation? (What are your non-pharmacological approaches?)\u003c/li\u003e\n \u003cli\u003eWhat do you do to prevent constipation?\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data were analyzed using the SPSS version 28.0 (Statistical Package for the Social Sciences). Descriptive statistics were used for frequency, percentage, mean, and standard deviation. The normality of data distribution was assessed using the Kolmogorov-Smirnov test. The relationships between the CAS scores and variables, including age, duration of cancer, duration of chemotherapy, and perceived health status, were analyzed using Spearman correlation analysis. A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003eQualitative data were analyzed using inductive content analysis. All interviews were audio-recorded, transcribed verbatim, and manually coded by the researchers without software. Field notes and unstructured observations recorded during the study were also included in the analysis. Two researchers performed coding independently and then reviewed multiple times with intervals to ensure consistency. Themes and sub-themes were developed from the codes, and data matrices were created to display and interpret the findings. Each participant was anonymized using the letter \u0026quot;P\u0026quot; followed by a participant number (e.g., P1, P2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several potential limitations. First, using a small sample size, which is typical in qualitative research, may raise concerns regarding the representativeness of the findings for the broader population of cancer patients experiencing constipation. However, this limitation was mitigated by the richness of the data and the purposive sampling approach applied until data saturation was achieved.\u003c/p\u003e\n\u003cp\u003eAnother limitation is that participants were selected from the researcher\u0026apos;s own clinical setting, and individuals from diverse educational, ethnic, or racial backgrounds were not included, which limits the generalizability of the findings.\u003c/p\u003e\n\u003cp\u003eLastly, the study relied on participants\u0026apos; ability to recall and reflect on their past experiences, which may have introduced recall bias.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age of the cancer patients included in the study was 57.15 \u0026plusmn; 15.58 years. In terms of socio-demographic characteristics, 85% of the participants were female, 80% were married, 50% were illiterate, 75% did not use laxatives, and 35% had been diagnosed with breast cancer. The average duration of cancer was 22.75 \u0026plusmn; 25.11 months, and the mean duration of chemotherapy was 13.75 \u0026plusmn; 10.92 months. The participants\u0026rsquo; perceived health status score was 5.80 \u0026plusmn; 1.90, and the mean CAS score was 9.10 \u0026plusmn; 2.22 (Table 2).\u003c/p\u003e\n\u003cp\u003eAccording to the Rome III criteria, all patients reported straining and excessive effort during at least 25% of defecations, lumpy or hard stools in at least 25% of defecations, a sensation of incomplete evacuation in at least 25% of defecations, and a sense of anorectal obstruction in at least 25% of defecations. Furthermore, 95% of participants reported a need for manual maneuvers to facilitate defecation in at least 25% of bowel movements and only rarely experienced soft stools without the use of laxatives. In addition, 60% of patients reported fewer than three bowel movements per week (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eDemographic and clinical characteristics of the patients (n = 20)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eIlliterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eLiterate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003ePrimary/Secondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eHigh school graduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eUndergraduate/Postgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUse of laxatives\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of cancer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eBreast cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eOvarian cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eBrain cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eLiver cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eBladder cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eEsophageal cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eSkin cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eCervical cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eBone cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eSarcoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u0026plusmn;\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cp\u003e57.15\u0026plusmn;15.58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDuration of cancer (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cp\u003e22.75\u0026plusmn;25.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDuration of chemotherapy (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cp\u003e13.75\u0026plusmn;10.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePerceived health status\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cp\u003e5.80\u0026plusmn;1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCAS score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 349px;\"\u003e\n \u003cp\u003e9.10\u0026plusmn;2.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCAS: Constipation Assessment Scale; SD: Standard Deviation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Distribution of patient symptoms according to Rome III criteria\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 425px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003cstrong\u003eSymptom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eStraining during at least 25% of defecations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eLumpy or hard stools in at least 25% of defecations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eSensation of incomplete evacuation in at least 25% of defecations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eSensation of anorectal obstruction in at least 25% of defecations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eNeed for manual maneuvers to facilitate at least 25% of defecations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eFewer than three defecations per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 425px;\"\u003e\n \u003cp\u003eRare occurrence of soft stools without the use of laxatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eMain themes, subthemes, and sample codes\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain Theme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubtheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Codes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eBodily symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eNausea, headache, abdominal pain, fatigue, bloating\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eMobility limitations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eInability to walk, difficulty moving\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychological effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eEmotional disturbances\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eIrritability, stress, sadness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eMental effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eNegative thoughts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial and lifestyle effects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eDisruption of daily life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eInability to go out, inability to do housework\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eSocial isolation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eAvoiding conversations, lack of enjoyment in life\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoping strategies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eNutritional and natural methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eDrinking plenty of water, eating vegetables and fruits\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eBehavioral methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eWalking, taking a shower, cooking, engaging in art, passive behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003ePsychological methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 264px;\"\u003e\n \u003cp\u003eThinking positively, spending time with family\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIn this study, the qualitative data obtained from interviews with 20 patients were analyzed under four main themes: physical effects, psychological effects, social and lifestyle impacts, and coping strategies. Table 4 summarizes the identified main themes, corresponding sub-themes, and illustrative participant quotations.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eTheme 1: Physical effects\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003ePatients\u0026rsquo; physical experiences were categorized under two sub-themes: bodily symptoms and mobility limitations. Reported symptoms included nausea, headache, abdominal pain, fatigue, and a sensation of bloating. Mobility limitations were described as difficulty walking and reduced overall physical capacity.\u003c/p\u003e\n\u003cp\u003eParticipants described constipation as an extremely uncomfortable experience, using various adjectives to convey the multidimensional nature of their suffering, such as \u003cem\u003e\u0026quot;bloated,\u0026quot; \u0026quot;blocked,\u0026quot; \u0026quot;painful,\u0026quot; \u0026quot;exhausting,\u0026quot;\u003c/em\u003e and \u003cem\u003e\u0026quot;tense.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome patient quotes included:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;Constipation ruins me. It hits my stomach\u0026mdash;I feel bloated and nauseous.\u0026quot;\u003c/em\u003e (P2, P9)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I can\u0026rsquo;t walk\u0026mdash;I feel paralyzed.\u0026quot;\u003c/em\u003e (P18)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;My stomach hurts. It\u0026rsquo;s like there\u0026rsquo;s a knot inside me.\u0026quot;\u003c/em\u003e (P5)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I constantly feel tired. I don\u0026rsquo;t want to do anything. I don\u0026rsquo;t even want to get out of bed.\u0026quot;\u003c/em\u003e (P13)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese statements illustrate how constipation adversely affects patients\u0026rsquo; daily functioning.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eTheme 2: Psychological effects\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis theme included two sub-themes: \u003cstrong\u003eemotional disturbances\u003c/strong\u003e and \u003cstrong\u003ecognitive impacts\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e Emotional disturbances referred to irritability, stress, and sadness, while cognitive impacts involved persistent negative thoughts.\u003c/p\u003e\n\u003cp\u003eParticipants reported experiencing intense and complex emotional responses. They described a sense of inner discomfort, anxiety about toilet use, and frustration caused by the inability to defecate despite the constant urge.\u003c/p\u003e\n\u003cp\u003eQuotes included:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I feel this inner discomfort I can\u0026apos;t even describe.\u0026quot;\u003c/em\u003e (P5)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I feel sad. I can\u0026rsquo;t enjoy life.\u0026quot;\u003c/em\u003e (P6, P15, P12)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I yell at the people around me because of the pain\u0026mdash;and then I regret it.\u0026quot;\u003c/em\u003e (P11)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;It\u0026rsquo;s destroying me. This situation is wearing me out.\u0026quot;\u003c/em\u003e (P17)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I constantly feel like I need to go to the toilet, but nothing happens. It\u0026rsquo;s so frustrating.\u0026quot;\u003c/em\u003e (P8)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I\u0026rsquo;m already ill (from cancer), and constipation just makes me feel even worse.\u0026quot;\u003c/em\u003e (P12)\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003e\u003cstrong\u003eTheme 3: Social and lifestyle impacts\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis theme was analyzed through two sub-themes: \u003cstrong\u003edisruption of daily activities\u003c/strong\u003e and \u003cstrong\u003esocial withdrawal\u003c/strong\u003e. Participants expressed difficulty leaving the house, managing daily tasks, and maintaining social relationships.\u003c/p\u003e\n\u003cp\u003eThey reported that the constant need to use the bathroom discouraged them from participating in social life.\u003c/p\u003e\n\u003cp\u003eQuotes included:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I can\u0026rsquo;t visit my children\u0026rsquo;s homes. My social life is over.\u0026quot;\u003c/em\u003e (P11)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;It always requires walking and being close to a bathroom\u0026hellip; I can\u0026rsquo;t go out or leave the house.\u0026quot;\u003c/em\u003e (P19)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;My social interactions are decreasing. I don\u0026rsquo;t want to see anyone.\u0026quot;\u003c/em\u003e (P9)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I can\u0026rsquo;t do the housework. My house is a mess.\u0026quot;\u003c/em\u003e (P16)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese statements highlight that constipation affects not only physical health but also patients\u0026rsquo; ability to engage in social and daily life.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eTheme 4: Coping strategies\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eConstipation significantly affects quality of life, prompting patients to develop various coping strategies. These were grouped under three sub-themes: \u003cstrong\u003edietary and natural remedies\u003c/strong\u003e\u003cstrong\u003e, behavioral methods\u003c/strong\u003e, and \u003cstrong\u003epsychological approaches\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eSub-theme 1: Dietary and natural remedies\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003ePatients often used these methods both to relieve symptoms and for prevention. Common strategies included:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDrinking plenty of water\u003c/li\u003e\n \u003cli\u003eConsuming dried apricots, figs, persimmons, and olive oil\u003c/li\u003e\n \u003cli\u003eReducing solid foods\u003c/li\u003e\n \u003cli\u003eEating fruits, vegetables, and fiber-rich foods\u003c/li\u003e\n \u003cli\u003eAvoiding spicy food\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eExamples:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I drink lots of water every day.\u0026quot;\u003c/em\u003e (P1, P3, P6...)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I eat dried figs or apricots\u0026mdash;it helps me.\u0026quot;\u003c/em\u003e (P3, P5, P7...)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I reduce heavy food intake to stay comfortable.\u0026quot;\u003c/em\u003e (P2, P3, P6...)\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003e\u003cstrong\u003eSub-theme 2: Behavioral methods\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eParticipants used activities such as walking, hot compresses, taking showers, cooking, music, and screen time to relieve discomfort.\u003c/p\u003e\n\u003cp\u003eQuotes included:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I walk for half an hour every day\u0026mdash;it helps.\u0026quot;\u003c/em\u003e (P8)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;Warm water eases my abdominal pain.\u0026quot;\u003c/em\u003e (P5)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;Cooking distracts me.\u0026quot;\u003c/em\u003e (P7)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I listen to music, paint, play the bağlama\u0026mdash;it helps me focus elsewhere.\u0026quot;\u003c/em\u003e (P1)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I spend time on my phone.\u0026quot;\u003c/em\u003e (P14)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSome used prescribed medications or herbal products. Four patients stated they did not use any coping strategies.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eSub-theme 3: Psychological approaches\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eGiven constipation\u0026rsquo;s emotional impact, some participants reported using cognitive strategies, such as:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;I try to think positively\u0026mdash;I believe it will pass.\u0026quot;\u003c/em\u003e (P4)\u003c/li\u003e\n \u003cli\u003e\u003cem\u003e\u0026quot;Spending time with my family relaxes me.\u0026quot;\u003c/em\u003e (P12)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese findings demonstrate that patients rely on a wide variety of coping strategies tailored to their personal preferences and lived experiences.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study explored the experiences of cancer patients with constipation, focusing on its physical, psychological, and social effects, as well as coping strategies. The findings reveal that constipation is not merely a physiological symptom but a multidimensional issue associated with emotional burdens, social limitations, and substantial declines in quality of life. The presence of symptoms consistent with Rome III criteria\u0026mdash;such as straining, hard or lumpy stools, a sensation of incomplete evacuation, and anorectal blockage\u0026mdash;among all participants underscores the prevalence and severity of the issue.\u003c/p\u003e\u003cp\u003ePhysically, patients reported a range of gastrointestinal symptoms such as abdominal pain, bloating, nausea, and fatigue. Functional limitations, including difficulty walking and reduced mobility, were also frequently described, affecting daily activities. The literature similarly identifies common symptoms accompanying constipation, including abdominal distension, rectal tears and fissures, hepatic or retroperitoneal pain, anorexia, nausea, vomiting, urinary retention, and confusion. However, it has also been noted that no universally accepted clinical definition of constipation exists for both patients and clinicians [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Effective constipation management requires regular assessment of patients, monitoring of bowel habits, and early identification of changes. Clinical recommendations systematically evaluate medical history, medications, dietary intake, fluid consumption, physical activity, comorbidities, and environmental factors. Physical examinations including abdominal assessment, perineal inspection, and digital rectal examination are also recommended [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePsychologically, the findings indicate that constipation has marked emotional consequences. Participants reported feelings of distress related to failed attempts at defecation, loss of control, and constant preoccupation with the urge to defecate. These experiences led to intense stress, irritability, sadness, and mental fatigue. Lin et al. (2024) found that the inability to expel waste can cause considerable emotional distress [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Similarly, Davies et al. (2020) noted that constipation negatively affects patients\u0026rsquo; psychological well-being and reduces their quality of life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These results clearly support the notion that constipation must be addressed not only as a physical disorder, but also in its psychosocial dimensions.\u003c/p\u003e\u003cp\u003eThe social and lifestyle findings showed that constipation restricts patients\u0026rsquo; daily functioning and leads to social withdrawal. Most participants reported difficulties leaving home, performing household tasks, and maintaining social interactions. The unpredictability of bowel movements and the constant need for a nearby toilet contributed to isolation and reduced engagement with social life. These findings align with evidence-based guidelines that highlight the impact of chronic constipation on quality of life [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e Participants employed a variety of strategies to manage constipation, which were categorized into three main groups: dietary approaches (e.g., increased fluid intake and high-fiber foods), behavioral methods (e.g., walking, distraction techniques), and psychological support (e.g., positive thinking, spending time with family). This suggests that patients play an active role in self-managing symptoms. Gao et al. (2019) confirmed that exercise is a feasible and effective method for managing constipation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Zainordin et al. (2021) reported that increasing physical activity and reducing sedentary time helped alleviate constipation symptoms in cancer patients [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, Nakano et al. (2018) found that while aerobic, resistance, and combined exercise programs improved symptoms like fatigue, pain, and insomnia, they had a neutral effect on constipation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Complementary and alternative therapies also featured prominently in patients\u0026rsquo; coping strategies. In a Turkish study, patients most frequently used phytotherapy to manage chemotherapy-induced constipation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Furthermore, a meta-analysis reported that combined pharmacological and acupuncture therapies yielded promising outcomes for managing opioid-induced constipation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Nevertheless, in patients with advanced cancer, lifestyle interventions (e.g., fiber intake and exercise) have shown limited effectiveness, especially for opioid-induced constipation, due to implementation challenges [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This highlights the continued need for robust evidence supporting non-pharmacological strategies.\u003c/p\u003e\u003cp\u003eNursing-led approaches have also demonstrated significant benefits in constipation management. Nurse-led care programs have improved symptoms such as constipation, insomnia, and financial burden [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Complementary interventions such as acupressure, abdominal aromatherapy massage, and self-management training have been particularly effective in improving quality of life in cancer patients [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn conclusion, the findings of this study underscore the necessity of adopting a multidisciplinary and holistic approach to constipation management in cancer care\u0026mdash;one that integrates not only medical treatment, but also physical, psychological, and social dimensions. The literature emphasizes ensuring patient privacy and comfort, supporting proper defecation posture, promoting hydration and physical activity tailored to capacity, and implementing prophylactic measures before opioid initiation. Moreover, over-the-counter or homemade remedies should be critically evaluated for their potential interactions with prescribed treatments [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion and Recommendations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study revealed that constipation in individuals diagnosed with cancer is a multidimensional issue that extends beyond physical discomfort to encompass emotional distress and limitations in social life. The experiences of the participants indicated that constipation significantly diminishes quality of life and that patients develop various individual coping strategies to manage this condition.\u003c/p\u003e\u003cp\u003eIn this context, constipation should be assessed in physiological terms and with consideration for its psychological and social dimensions. Healthcare professionals should consider patients\u0026rsquo; individual experiences and develop personalized, supportive interventions accordingly. Nutritional regulation, physical activity, and psychosocial support components should be integrated into care processes. Patient-centered and holistic approaches should be prioritized to ensure comprehensive and effective constipation management in cancer care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors sincerely thank all the individuals with cancer who openly shared their experiences and participated in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation and data collection were performed by DBA. The full manuscript was written by DBA, DAD, and AS, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request. Due to the sensitive nature of the qualitative data, full transcripts cannot be publicly shared to protect participant confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Mardin Artuklu University Non-Interventional Clinical Research Ethics Committee (Approval No: 2023/12-18; Date: 05.12.2023). Written permission was also obtained from the hospital where the study was conducted. Authorization was granted by the original authors for using the relevant scales. The administration of the survey took approximately 40\u0026ndash;60 minutes. Participants were informed about the study\u0026apos;s purpose and procedures, and written informed consent was obtained from each of them. The study was conducted by the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent to participate was obtained by the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no financial interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial Disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflict of interest was declared by the authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDavies A, Leach C, Caponero R, et al (2020) MASCC recommendations on the management of constipation in patients with advanced cancer. Support Care Cancer 28:23\u0026ndash;33. https://doi.org/10.1007/s00520-019-05016-4\u003c/li\u003e\n\u003cli\u003eWang P-M, Hsu C-W, Liu C-T, et al (2019) Effect of acupressure on constipation in patients with advanced cancer. Support Care Cancer 1\u0026ndash;6. https://doi.org/10.1007/s00520-019-4655-1\u003c/li\u003e\n\u003cli\u003eQi S, Lai H, Zhang Y, et al (2018) Chinese herbal medicine for opioid induced constipation in cancer patients. Medicine (Baltimore) 97:. https://doi.org/10.1097/MD.0000000000012594\u003c/li\u003e\n\u003cli\u003eMoschen AR, Sammy Y, Marjenberg Z, et al (2022) The underestimated and overlooked burden of diarrhea and constipation in cancer patients. Curr Oncol Rep 24:861\u0026ndash;874. https://doi.org/10.1007/s11912-022-01267-3\u003c/li\u003e\n\u003cli\u003eWickham RJ (2017) Managing Constipation in Adults With Cancer. J Adv Pract Oncol 8:149\u0026ndash;161\u003c/li\u003e\n\u003cli\u003eDzierżanowski T, Mercadante S (2022) Constipation in cancer patients an update of clinical evidence. Curr Treat Options Oncol 23:936\u0026ndash;950. https://doi.org/10.1007/s11864-022-00976-y\u003c/li\u003e\n\u003cli\u003eLin J-N, Xie W-T, Yang Y-Y, et al (2024) Living with constipation and communication taboos surrounding constipation among older adults: An interpretive phenomenology analysis study. Geriatr Nur (Lond) 58:266\u0026ndash;273. https://doi.org/10.1016/j.gerinurse.2024.05.020\u003c/li\u003e\n\u003cli\u003eLarkin PJ, Cherny NI, La Carpia D, et al (2018) Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. Ann Oncol 29:iv111\u0026ndash;iv125. https://doi.org/10.1093/annonc/mdy148\u003c/li\u003e\n\u003cli\u003eHasson F, Muldrew D, Carduff E, et al (2020) \u0026lsquo;Take more laxatives was their answer to everything\u0026rsquo;: A qualitative exploration of the patient, carer and healthcare professional experience of constipation in specialist palliative care. Palliat Med 34:1057\u0026ndash;1066. https://doi.org/10.1177/0269216319891584\u003c/li\u003e\n\u003cli\u003eKeller MS, Jusufagic A, Spiegel BMR (2019) Patient and provider differences in the treatment of opioid-induced constipation: a qualitative study. BMC Gastroenterol 19:182. https://doi.org/10.1186/s12876-019-1097-7\u003c/li\u003e\n\u003cli\u003eDemir Doğan M, Aktuğ C (2017) Validity and reliability of the Turkish version of constipation assessment scale in nursing students. Eurasian J Fam Med 6:72\u0026ndash;76\u003c/li\u003e\n\u003cli\u003eLarkin PJ, Cherny NI, La Carpia D, et al (2018) Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. Ann Oncol 29:iv111\u0026ndash;iv125. https://doi.org/10.1093/annonc/mdy148\u003c/li\u003e\n\u003cli\u003eIhara E, Manabe N, Ohkubo H, et al (2025) Evidence-based clinical guidelines for chronic constipation 2023. Digestion 106:62\u0026ndash;89. https://doi.org/10.1159/000540912\u003c/li\u003e\n\u003cli\u003eGao R, Tao Y, Zhou C, et al (2019) Exercise therapy in patients with constipation: a systematic review and meta-analysis of randomized controlled trials. Scand J Gastroenterol 54:169\u0026ndash;177. https://doi.org/10.1080/00365521.2019.1568544\u003c/li\u003e\n\u003cli\u003eZainordin NH, A. Karim N, Shahril M, Abd Talib R (2021) Physical activity, sitting time, and quality of life among breast and gynaecology cancer survivors. Asian Pac J Cancer Prev 22:2399\u0026ndash;2408. https://doi.org/10.31557/APJCP.2021.22.8.2399\u003c/li\u003e\n\u003cli\u003eNakano J, Hashizume K, Fukushima T, et al (2018) Effects of aerobic and resistance exercises on physical symptoms in cancer patients: A Meta-analysis. Integr Cancer Ther 17:1048\u0026ndash;1058. https://doi.org/10.1177/1534735418807555\u003c/li\u003e\n\u003cli\u003eToygar İ, Yeşilbalkan \u0026Ouml;U, K\u0026uuml;rk\u0026uuml;tl\u0026uuml; M, Aslan A (2020) Complementary and alternative medicines used by cancer patients to cope with chemotherapy-induced constipation. Complement Ther Clin Pract 39:101108. https://doi.org/10.1016/j.ctcp.2020.101108\u003c/li\u003e\n\u003cli\u003eHan C, Liu Y, Fan H, et al (2021) Acupuncture relieves opioid-İnduced constipation in clinical cancer therapy \u0026ndash; A meta-analysis and systematic review. Clin Epidemiol 13:907\u0026ndash;919. https://doi.org/10.2147/CLEP.S324193\u003c/li\u003e\n\u003cli\u003eCheng X, Wei S, Zhang H, et al (2018) Nurse-led interventions on quality of life for patients with cancer: A meta-analysis. Medicine (Baltimore) 97:e12037. https://doi.org/10.1097/MD.0000000000012037\u003c/li\u003e\n\u003cli\u003eNakano K, Kanno Y, Kajiwara K, et al (2025) Nursing support for constipation in patients with cancer: A scoping review. J Palliat Med 28:115\u0026ndash;122. https://doi.org/10.1089/jpm.2024.0071\u003c/li\u003e\n\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":"Cancer, Constipation, Coping strategies, Qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-7023245/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7023245/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e This study aimed to examine the attitudes and coping strategies of cancer patients toward constipation using a qualitative approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This qualitative study was conducted using a phenomenological design. Between February and June 2024, in-depth semi-structured interviews were conducted with 20 cancer patients experiencing constipation in the oncology unit of a hospital. Participants were also evaluated using a demographic information form and the Constipation Assessment Scale (CAS). Interviews were audio-recorded, transcribed verbatim, and analyzed using content analysis to identify emerging themes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Four main themes were identified: physical effects, psychological effects, social and lifestyle impacts, and coping strategies. Physical effects included abdominal pain, bloating, fatigue, and mobility limitations. Psychological effects were expressed as irritability, stress, and feelings of helplessness. Social effects were described as reduced participation in daily activities and social withdrawal. Coping strategies included behavioral approaches such as fluid intake, fiber-rich diet, walking, and psychological strategies like positive thinking and family support. It was also found that some participants did not use any particular coping methods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This study revealed that constipation in individuals diagnosed with cancer causes significant effects not only physically but also psychologically and socially. Participants' experiences indicated a notable decline in quality of life due to constipation. The findings suggest that supportive care plans tailored to individual needs may be beneficial.\u003c/p\u003e","manuscriptTitle":"Attitudes and Coping Strategies toward Constipation in Individuals with Cancer: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-18 14:58:22","doi":"10.21203/rs.3.rs-7023245/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":"fbd3cbba-1ba9-40da-bd0c-0c446cd10a11","owner":[],"postedDate":"August 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-25T23:38:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-18 14:58:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7023245","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7023245","identity":"rs-7023245","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}