Improvements in psychological distress in patients participating in a cooking programme following digestive cancer surgery: A retrospective, propensity score-matched pilot study

Abstract

Introduction:

This retrospective pilot study evaluated whether an Instrumental Activities of Daily Living intervention relieves psychological distress during hospital stays after digestive cancer surgery.

Methods:

In all, 24 patients were divided into two groups according to the experience of cooking programme during hospital stay (‘control group’, n = 11 and ‘cooking group’, n = 13) and both groups received usual postoperative care. The two groups were matched using propensity scores to reduce the potential for confounding factors. Outcome measures included psychological distress assessed by the Hospital Anxiety and Depression Scale and Basic Activities of Daily Living assessed by the Functional Independence Measure. Assessment time points were after surgical treatment and before discharge.

Results:

Propensity score matching generated nine pairs (‘control group’, n = 9 and ‘cooking group’, n = 9). The Functional Independence Measure improved in both groups (p = 0.008, r = 0.89) and the improvements in the Hospital Anxiety and Depression Scale were only found in the cooking group (p ⩽ 0.049, r ⩾ 0.66).

Conclusion:

We found significant improvement in Basic Activities of Daily Livings in both groups and additional improvements in psychological distress in the cooking group. These observations suggest that Instrumental Activities of Daily Living-based intervention could improve mental health in patients with cancer in their early postoperative period.

Introduction

Psychological distress in hospital environments is a common problem in cancer patients. Previous studies indicated approximately 30% of patients experience mental health problems during their hospital stay (Hammerlid et al., 1999; Keller et al., 2004). In-hospital stress is associated with a cancer diagnosis (Linden et al., 2012), increases during the treatment process (Sharma and Purkayastha, 2021) and results in poor mental well-being (Nordin et al., 2001).

Psychological distress is also associated with restrictions in Instrumental Activities of Daily Living (IADL) (Yoo et al., 2010). Reduced levels of participation in IADLs deprive patients of social roles and communication, leading to feelings of loss and subsequent psychological distress (Hong et al., 2021; Yoo et al., 2010). A fact worthy to note is that psychological distress related to IADLs is observed not only in community-dwelling cancer survivors, but also in patients in their early postoperative period of cancer surgery. Despite there being no real experience of IADL limitations, they often express concerns about restarting their home management activities before discharge (Sibbern et al., 2017).

These observations suggest there is a need to mitigate distress and promote self-confidence in IADLs in patients with early-stage cancer. However, the trend towards decreasing length of stay makes it challenging to provide IADL interventions in hospital settings (Carlsson et al., 2013). To our knowledge, it is only reported that an IADL-based intervention for cancer patients increased occupational performance and satisfaction in an acute hospital setting (Udovicich et al., 2020). To date, IADL interventions for mitigating psychological distress in the early postoperative period have not been adequately discussed.

The aim of the study was to evaluate the usefulness of an IADL intervention for relieving psychological distress in patients with cancer in the early postoperative period. We provided a cooking programme for patients who underwent digestive cancer surgery. Malnutrition and weight loss are common problems in digestive cancer patients (Baldwin et al., 2006), and diet-related issues are known as critical sources of distress (Locher et al., 2010). For these reasons, we hypothesized that the cooking programme in patients with digestive cancer may have a positive influence on mental health.

Methods

Study design

This pilot study is a retrospective analysis of routine patient data over a 2-year period (December 2016–January 2019). The study was approved by the ethics committee of the hospital, and the requirement to obtain informed consent was waived.

Participants

The patients’ data were collected from medical records in an acute hospital. The patients in the cooking group received a cooking programme as part of occupational therapy. Those who had similar characteristics but did not receive the cooking programme were set as controls. Both groups received usual postoperative care including comprehensive nursing care, rehabilitation therapy and nutrition counselling. Patients who already had functional decline before admission were excluded.

Interventions

The cooking programme was conducted in accordance with Kolb’s experiential learning theory (Morris, 2020). The theory is a four-stage learning model designed to facilitate new skill acquisition: concrete experience, reflective observation, abstract conceptualization and active experimentation. The framework has been applied to the intervention for cancer survivors, and positive outcomes were found in obtaining cancer-related self-efficacy (Li et al., 2013) and relieving cancer-related fatigue (Pritlove et al., 2020). In this study, we designed the cooking programme for providing the patients especially with an opportunity of self-understanding and self-efficacy. The patients conducted the cooking activity in the occupational therapy kitchen (Stage 1: concrete experience). The recipe was decided after discussion between each patient and an occupational therapist, and a dietitian checked whether the food could be problematic for the patients based on their digestion capacity and complications such as diabetes mellitus or hypertension. During the cooking activity, the occupational therapist supervised the patients’ cooking with minimal assistance. After cooking, the patients were asked to verbalize their sensory perceptions and emotional feelings experienced during the cooking activity (Stage 2: reflective observation). Finally, the occupational therapist gave feedback on some comments to help the patients to integrate their self-understanding and self-efficacy gained from the cooking activity into their postoperative life (Stage 3: abstract conceptualization). The cooking programme was approximately 1.5 hours in total. As necessary, their family members were allowed to observe the cooking programme. The active experimentation (Stage 4) was not included in this study because the programme was only set up during the hospital stay.

Outcomes

Socio-demographic and clinical characteristics were collected from medical records: age, sex, body mass index, cancer site, disease stage based on the Union for International Cancer Control tumor-node-metastasis classification and the type of surgical treatment.

The Japanese version of the Frenchay Activities Index (FAI) was used to assess pre-hospital IADL. It consists of 15 items, and the scores range from 0 (inactive) to 3 (highly active) with a maximum score of 45. The original version of the FAI was developed to assess social activity in stroke populations (Holbrook and Skilbeck, 1983), and the reliability and validity of the FAI in community-dwelling older people were also confirmed (Han et al., 2009).

The Hospital Anxiety and Depression Scale (HADS) was developed to assess psychological distress in outpatients (Zigmond and Snaith, 1983). It consists of 14 items, 7 for anxiety and 7 for depression. Each item is scored from 0 to 3 with a maximum score of 21 on each of the subscales. The HADS satisfied the reliability and validity in patients with cancer (Thomas et al., 2005). The optimal cut-off points for anxious and depressive states in hospitalized cancer patients have been reported to be 9/10 and 7/8, respectively (Annunziata et al., 2020).

Each patient’s Basic Activities of Daily Living (BADL) status was assessed by the Functional Independence Measure (FIM) (Keith et al., 1987). This consists of 13 motor and 5 cognitive items, and the scores range from 1 to 7, with a maximum score of 126 indicating total functional independence of BADLs. The reliability and validity of the FIM have been demonstrated (Kidd et al., 1995).

Data collection

We collected the data at two time points. Upon initial assessment after surgical treatment, the following variables were examined: socio-demographic characteristics, the pre-hospital FAI, the initial HADS and the initial FIM. Upon hospital discharge, the following variables were examined: the discharge HADS and the discharge FIM. The assessments were delivered within 72 hours after surgical treatment and no more than 72 hours before discharge, and the evaluators were occupational therapists who were familiar with using the measurements.

Statistical methods

We performed propensity score matching to reduce the potential for confounding factors (D’Agostino, 1998). A propensity score was estimated using logistic regression analysis with 1:1 patient matching. The variables included in the propensity score analysis were age, sex, disease stage, and the initial HADS anxiety and depression subscales scores. The choice to use these covariates was based on their putative confounding influence on the discharge HADS scores (Cardoso et al., 2016).

After adjusting for confounding factors through propensity score matching, we assessed the assumption of normality using the Shapiro–Wilk test and found the data were not normally distributed. As a result, non-parametric statistics were applied. The chi-square test or the Mann–Whitney U test was used to compare the two groups’ socio-demographic and clinical characteristics. Within-group analyses were performed using the Wilcoxon signed-rank test for the HADS and the FIM scores between different time points. The Mann–Whitney U test was used to compare the HADS and the FIM scores between the two groups. The allotment coordinator was not involved in any data analysis.

The effect size r was calculated for each outcome variable to index the magnitude of a performance difference. The effect size r is a large effect at 0.50, a moderate effect at 0.30 and a small effect at 0.10 (Cohen, 1988). Statistical analyses were performed using IBM SPSS for Windows, version 26. Significance was set at p < 0.05.

Results

Overall, 24 patients in the control group (n = 11) and the cooking group (n = 13) with sufficient data were included. Nine pairs were selected from the control and the cooking groups by propensity score matching.

Baseline socio-demographic and clinical characteristics are summarized in Table 1. The median ages of the control and cooking groups were 68.0 (interquartile range (IQR): 58.0–81.0) years with two males and seven females, and 68.0 (IQR: 65.0–69.0) years with one male and eight females, respectively. The baseline characteristics between the two groups did not differ significantly.

Table 1.

Baseline socio-demographic and clinical characteristics.

	Control group (n = 9)	Cooking group (n = 9)	p
Age, year, median (IQR)	68.0 (58.0–81.0)	68.0 (65.0–69.0)	0.689
Sex, number, male/female	2/7	1/8	1.000
BMI, kg/m2, median (IQR)	21.1 (20.5–22.5)	23.4 (21.4–24.0)	0.070
Pre-hospital FAI, score, median (IQR)	27.0 (21.5–35.0)	30.0 (27.0–35.0)	0.499
Cancer site, number (colon/stomach/rectum/cecum)	2/7/0/0	5/2/1/1	–
Disease stage, number, early/advanced	3/6	3/6	1.000
Surgical treatment, number, laparotomy/laparoscopy	8/1	8/1	1.000
Amount of occupational therapy received, minutes, median (IQR)	200 (180–280)	240 (160–260)	0.929
Amount of physical therapy received, minutes, median (IQR)	160 (140–180)	180 (80–320)	0.562
The cooking program from surgery, days, median (IQR)	–	8.0 (7.0–10.0)	–
Length of stay, days, median (IQR)	16.0 (15.0–23.0)	15.0 (11.0–18.0)	0.155

BMI: body mass index; FAI: Japanese version of Frenchay Activities Index; IQR: interquartile range.

During the hospital stay, both groups received a similar length of occupational and physical therapy. The duration of the cooking programme from surgery was 8.0 (IQR: 7.0–10.0) days in the cooking group. No significant difference was detected in the length of stay.

Table 2 shows the results of comparisons within and between the two groups. In the within-group analyses, both groups showed significant improvements in the FIM total and motor scores with a large effect size (p = 0.008, r = 0.89). In contrast, the HADS anxiety and depression subscale scores showed significant improvements only in the cooking group with a large effect size (p ⩽ 0.049, r ⩾ 0.66). Intergroup comparisons showed that the cooking group gained additional improvements in the HADS depression subscale score with a large effect size (p = 0.024, r = 0.53).

Table 2.

Summary of outcome measurements at baseline and discharge.

	Control group (n = 9)				Cooking group (n = 9)				Control group versus Cooking group
	Baseline	Discharge	p	r	Baseline	Discharge	p	r	Baseline		Discharge
									p	r	p	r
HADS, score, median (IQR)
Anxiety	7.0 (5.0–8.0)	4.0 (4.0–5.0)	0.091	0.57	8.0 (4.0–9.0)	4.0 (3.0–5.0)	0.035	0.66	0.789	0.06	0.622	0.12
Depression	6.0 (4.0–9.0)	5.0 (4.0–5.0)	0.089	0.56	9.0 (3.0–10.0)	3.0 (2.0–3.0)	0.049	0.70	0.965	0.01	0.024	0.53
FIM, score, median (IQR)
Total	48.0 (48.0–48.0)	113.0 (112.0–120.0)	0.008	0.89	48.0 (48.0–48.0)	120.0 (118.0–124.0)	0.008	0.89	1.000	0.00	0.214	0.29
Motor	13.0 (13.0–13.0)	79.0 (78.0–85.0)	0.008	0.89	13.0 (13.0–13.0)	85.0 (84.0–89.0)	0.008	0.89	0.539	0.15	0.183	0.31
Cognitive	35.0 (35.0–35.0)	35.0 (34.0–35.0)	0.655	0.15	35.0 (34.0–35.0)	35.0 (35.0–35.0)	0.317	0.33	0.655	0.11	0.695	0.09

Values in bold indicate a significant difference.

FIM: Functional Independence Measure; HADS: Hospital Anxiety and Depression Scale; IQR: interquartile range.

Discussion

The FIM total scores improved in both groups and the improvements in the HADS anxiety and depression scores were only found in the cooking group.

A major finding of the present study is the improvement in the HADS depression score after the cooking programme. The risk of depression can be increased in the early postoperative period of cancer surgery (Matsushita et al., 2005). Indeed, in the initial HADS, 12 of 24 patients (7 in the control group and 5 in the cooking group) in our study indicated scores above the clinical threshold, supporting that hospitalized patients tend to feel lonely and alienated from a healthy life (Clarke et al., 2018). Given that there was no difference in the baseline characteristics between the two groups, one possible underlying mechanism of decreased depression in the cooking group may be positive emotional changes obtained during the process of the cooking programme. The rich sensory stimulation from cooking, for example, creates positive emotions such as happiness and relaxation (Güler and Haseki, 2020). Completing and tasting the meal increases satisfaction, resulting in building confidence (Lavelle et al., 2017). In truth, patients in our study also expressed their positive emotions while performing and reviewing the cooking task with the occupational therapist and/or their family members. Thus, it is reasonable to assume that these physical, psychological and psychosocial benefits of cooking contributed to mitigating depression.

Decreased HADS anxiety score suggests another benefit of the cooking programme. Although both anxiety and depression present emotional distress, there is a fundamentally different aspect between these two symptoms. Whereas depression reflects a loss of pleasure or interest in activities in the past and present, anxiety mainly reflects future concerns (Smarr and Keefer, 2011). In other words, anxiety may be related to future self-management at home after hospital discharge. To cope with anxiety in hospital settings, verbal or written information on physical activity, digestive symptoms and nutrition is provided (Sibbern et al., 2017). However, these information dissemination approaches do not always lead to behaviour modification due to the nature of one-sided information sharing (Mcmurray et al., 2007) and information overload (Bapat et al., 2017). To enhance self-management post-discharge, the experience of occupational engagement needs to be considered in addition to these conventional information provisions. For example, a study comparing the usefulness of an approach in people with mental illness found a significant increase in self-management in patients who participated in a programme compared to those who were only given a brochure (Alegría et al., 2014). In our study, all participants were provided with verbal and printed information, and the cooking group participants were additionally provided with the experience of occupational engagement. Consistent with the previous study (Alegría et al., 2014), we assume that the cooking programme was useful in promoting patients’ confidence in self-management, and as a result, their anxious feeling was relieved.

The Kolb’s experiential learning theory (Morris, 2020) provided a framework to design a cooking programme in the acute care setting. Patient–healthcare provider cooperation is an essential element in building patient-centred goals (Visser and Wysmans, 2010). However, the trend towards decreasing hospital length of stay makes it challenging to provide ample time for patient–staff communication regarding postoperative life (Carlsson et al., 2013). To respond to this challenge, we adopted the Kolb’s experiential learning theory in the cooking programme. First, the occupational therapist took time before the programme to listen to patients’ concerns about cooking under minimal professional advice. This supportive attitude played an important role in facilitating patients’ participation in the cooking programme after surgery (concrete experience) and building rapport between the patients and the occupational therapist in a short period of time. Second, right after completing the cooking task, the patients look back on the overall process of the experience. At this stage, their reflections were shared with the occupational therapist and/or their family member. Verbalizing experience in a supportive environment increased self-understanding and self-efficacy (reflective observation). Lastly, the occupational therapist gave feedback to the patients to identify strategies for flexible problem-solving. For example, when a female patient looked back that she had experienced fatigued during cooking, she was advised to use a microwave or ask her spouse for support as energy conservation techniques. This helped the patients have a new idea of reconstructing their healthy lives and social roles (abstract conceptualization). Using the consecutive intervention, we could develop a framework for successful IADL-based intervention in the acute hospital setting.

The total FIM scores were significantly improved in both groups, indicating that all patients reached their pre-hospital level of independence. Of note, the cooking group gained the same level of BADLs as the control group even though BADL and IADL interventions were provided in parallel. In hospital settings, it is considered desirable to start IADL interventions after obtaining BADLs independence (Okamoto et al., 2014). This hierarchical arrangement is based on the Rasch model, suggesting effective functional recovery can be prompted by providing less difficult activities first (Glenny, 2012). In patients with stroke, for example, feeding, grooming and toileting are first treated in occupational therapist intervention, followed by dressing and bathing. IADL tasks such as meal preparation and home management are positioned at a higher level than BADLs (Hsueh et al., 2004). However, our result implied that various perspectives on the BADLs structure need to be taken into consideration when making rehabilitation strategies. In cancer patients, independent self-care is maintained until the last month before death (Seow et al., 2011). In other words, the patients in the early postoperative stage have potential BADLs ability even if there is a temporary decline in BADLs due to postoperative rest. Considering this characteristic of patients with cancer, it is reasonable to assume that creating an opportunity for a high-level task in acute hospital settings is essential to facilitate early independence in BADLs and IADLs.

Limitations

Several limitations of the present study should be acknowledged. Firstly, the patients’ data were collected from a single facility. This may affect the generalizability of the study findings. Secondly, the study was non-randomized and had a small sample size due to the nature of a retrospective pilot study. Another limitation was the risk of co-interventions. We cannot exclude the possibility that pharmacological treatment influenced the results. In addition, short-term improvements in psychological distress in the cooking group could be due to the time following the surgery. Furthermore, while the HADS scores in the cooking group improved with a large effect size, the p-values were only just below the 0.05 cut-off, and this could be due to chance. Lastly, the present study did not include the active experimentation stage of Kolb’s experiential learning theory. Further studies including the active experimentation stage and long-term follow-up may clarify the longer-term effects of the cooking programme.

Conclusion

We found significant improvement in BADLs in both groups and additional improvements in psychological distress in the cooking group. These observations suggest that IADL-based intervention could improve mental health in patients with cancer in their early postoperative period. To clarify the effectiveness of the cooking programme, appropriately powered prospective studies are required.

Key findings

• The cooking programme relieved psychological distress during hospital stays after digestive cancer surgery.

• IADL-based intervention could be useful in mental healthcare in postoperative patients with cancer.

What the study has added

This study assessed a cooking programme after digestive cancer surgery. The programme has the potential to improve mental healthcare services in acute hospital settings.