Author: Ria Joseph
Joseph, Ria, 2024 Optimising referral practices to dietary and exercise services for cancer survivors, Flinders University, College of Nursing and Health Sciences
Terms of Use: This electronic version is (or will be) made publicly available by Flinders University in accordance with its open access policy for student theses. Copyright in this thesis remains with the author. You may use this material for uses permitted under the Copyright Act 1968. If you are the owner of any included third party copyright material and/or you believe that any material has been made available without permission of the copyright owner please contact copyright@flinders.edu.au with the details.
Cancer survivors often experience short and long-term challenges to physical and psychological health, financial, and social or family functioning that limit their ability to maintain a healthy lifestyle. As such, there is an increased need for effective dietary and exercise interventions. These interventions can prevent, reduce, or reverse numerous physical and psychosocial effects of cancer and its treatment, including through their impact on other coexisting chronic medical conditions, such as cardiovascular disease or obesity. For cancer survivors to access specialised dietary and exercise care in Australia, cancer survivors need to be referred to dietitians and exercise professionals by their specialist team. Even though there is strong evidence in the literature that dietary and exercise interventions are essential and beneficial for optimising outcomes for cancer survivors, the current system of care does not comprehensively facilitate quality, systematised health-system responses to provide cancer survivors with seamless access to dietary and exercise services. Therefore, this doctoral research aimed to ultimately provide guidance to optimise dietary and exercise referral practices for cancer survivors in Australia across the survivorship trajectory.
An integrative review was conducted to examine the perspectives of medical and nurse health professionals on their roles in providing referrals to cancer survivors. Although medical and nursing professionals agree they have an important role in providing guidance and referrals for exercise and dietary services, there is a lack of role clarity regarding their roles and responsibilities with regards to providing dietary and exercise advice to cancer survivors, and a lack of standardised referral pathways to facilitate referral practices. A four-round Delphi study was then conducted to inform the development of essential elements to provide guidance to medical and nursing health professionals regarding dietary and exercise care and referrals for cancer survivors. These essential elements were distributed to a panel to establish consensus by rating the importance of each statement. The Delphi consensus study produced 24 essential element statements. The implementation of these essential elements may experience challenges that affect the extent to which they become embedded and scaled-up due to the complexity of the health system. Thus, pre-implementation work is an important element to identify factors contributing to the implementation of essential elements. Accordingly, a systems-thinking workshop based on the World Health Organisation (WHO) health system building blocks was conducted with six facilitated focus groups, including consumers, cancer specialists, researchers and representatives of peak bodies, Cancer Council and Cancer Australia. Through the systems-thinking workshop, cognitive maps demonstrated inter-related factors that can influence referral practices across the WHO health system building blocks. Furthermore, using a systems-thinking approach enabled the identification of fifteen strategies related to the WHO health system building blocks at a policy level; to further advance practices in medical and nursing health professionals’ guidance and referrals for exercise and dietary services. Overall, this doctoral research resulted in the development of a consensus framework of essential elements to guide practice as well as a causal loop diagram complemented with strategies at a policy level. This doctoral research provides valuable guidance regarding the optimisation of dietary and exercise referral practices in Australia, as well as supporting medical and nursing health professionals to do so. Future implementation research is needed to confirm the findings of this doctoral research in other samples, further refine the essential elements and tailor intervention strategies to be used in different healthcare settings. More research will also ensure successful translation at the micro- (persons and clinician level), meso- (organisational level) and macro- (policy and system level).
Keywords: cancer care, diet, exercise, referral practices, health system, systems thinking
Subject: Public Health thesis
Thesis type: Doctor of Philosophy
Completed: 2024
School: College of Nursing and Health Sciences
Supervisor: Raymond Chan