A feasibility study using the RE-AIM framework: healthcare providers’ and community partners’ perceptions of a psychosocial intervention for Latino patient–caregiver dyads coping with advanced cancer

Abstract

Background

Patients with advanced cancer and their caregivers face significant psychosocial challenges, including distress, existential crises, and social isolation. Hispanic/Latino (H/L) communities experience disproportionate health disparities, exacerbating these challenges. Limited access to psychosocial care due to barriers, such as transportation and socioeconomic constraints, is especially evident among patients living in rural areas of Puerto Rico, where access to services is more restricted compared to metropolitan zones. These disparities underscore the need for culturally tailored interventions.

Objective

This study assesses the acceptability and refinement of the Caregivers-Patient Support for Latinx Coping with Advanced Cancer (CASA) intervention through the perspectives of healthcare providers and community partners. Using the RE-AIM framework, we examine the intervention’s Reach, Effectiveness, Adoption, Implementation, and Maintenance to enhance its impact and sustainability.

Methods

We conducted a qualitative study using Community-Based Participatory Research (CBPR), involving semi-structured interviews with 11 community partners and 10 healthcare providers actively involved in cancer care in Puerto Rico. Data were analyzed using a thematic content analysis within the RE-AIM framework to assess the feasibility, barriers, and facilitators of the intervention.

Results

Participants highlighted the relevance of the CASA intervention in addressing psychosocial needs, emphasizing the importance of integrating cultural values. Key facilitators included community engagement and telehealth, while barriers included patient resistance and logistical challenges. Recommendations included enhancing community partnerships and training.

Conclusion

The findings support CASA as a culturally tailored intervention that meets the unique needs of H/L patients and their caregivers. Community engagement and flexible implementation strategies are essential for its sustainability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-13794-3.

Background

Patients with advanced cancer and their caregivers face a wide range of psychosocial challenges that significantly impact their emotional and spiritual well-being [1]. These challenges include psychological distress and psychiatric disorders such as major depressive disorder and anxiety [1–3]. In addition to psychological distress, many patients experience existential crises, such as a loss of meaning, demoralization, and existential distress, which can profoundly impact their overall well-being [1]. Moreover, individuals diagnosed with cancer often experience social disconnection, which can manifest in isolation from family, friends, and the broader community [2]. Among Hispanic/Latino (H/L) communities, psychosocial challenges faced by cancer patients and caregivers are compounded by health disparities in cancer care.

Compared with other ethnic groups, H/L communities are disproportionately affected by lower quality of life, higher symptom burden, and worsened psychological well-being outcomes [4]. Within H/L communities, health disparities in cancer-related outcomes are due to limited access to care and psychosocial services [5]. Barriers to healthcare access include limited transportation, living in remote areas, physical limitations, heightened symptom burden, and financial constraints [5, 6]. Furthermore, the lack of culturally tailored psychosocial interventions further hinders access to appropriate care [5]. Therefore, to mitigate access barriers to psychosocial services, community-based, telehealth-delivered, and culturally tailored interventions are proposed as practical strategies to improve access and engagement [6–8].

Culturally tailored interventions demonstrate greater effectiveness in addressing the specific needs of H/L patients and caregivers by considering contextual factors and cultural values [9]. Core cultural values within H/L communities serve as protective factors against psychosocial challenges and disparities, and include social support, family, and spirituality. Spirituality-based coping and meaning making are prevalent among H/L individuals and are associated with physical and functional well-being in cancer patients [4, 10–12]. Family is another source of meaning and support for H/L patients. Patients have emphasized the significance of family as a source of meaning, the importance of communication with caregivers, and the role of family involvement in psychosocial treatments [10]. The cultural emphasis on social support within H/L communities extends beyond the family to encompass the broader community [5, 13]. H/L patients with advanced cancer and their caregivers often seek social support through community-based organizations and partners to access both practical and emotional support [8, 14].

The development of community-based psychosocial interventions becomes particularly relevant in light of the cultural values of H/L communities. Community partners, including faith-based leaders and nonprofit volunteers, could bridge the gap between healthcare services and the community, facilitating trust-building and leading to the engagement and sustainability of interventions [14]. Moreover, community partners are deeply embedded in their communities, placing them in a unique position to provide valuable insights into the specific needs of cancer patients and caregivers related to their condition. Alongside community partners, healthcare providers play a central role in the cancer journey, as they have direct and ongoing interactions with cancer patients and caregivers. This firsthand experience allows healthcare providers to be familiar with the values, practices, and barriers that influence the effectiveness and uptake of an intervention [15–18]. While community partners strengthen trust and accessibility, engaging healthcare providers can facilitate alignment of interventions with clinical care and ensure sustainability. Integrating both community partners and healthcare providers in the adaptation of culturally tailored interventions ensures cultural and clinical relevance, access, and sustainability within the contextual reality of H/L communities.

Recognizing the pressing need for culturally tailored interventions that address the unique psychosocial challenges of H/L patients with advanced cancer and their caregivers, our research team developed the Caregivers-Patient Support for Latinx Coping with Advanced Cancer (CASA) intervention [19, 20]. CASA is a culturally tailored psychological intervention designed to enhance spiritual well-being and communication between Latino patients and caregivers coping with advanced cancer (stages III and IV), integrating cultural values such as family and spirituality [19, 20]. The intervention consists of five manualized sessions that incorporate components from Meaning-Centered Psychotherapy, which emphasizes spirituality and meaning-making, and Couples Communication Skills Training, which promotes effective communication within the dyad. Sessions will be delivered via telehealth to address structural barriers, such as transportation and limited access to psychosocial services [19, 20]. Participants will be recruited through community partners. Further details on its CASA cultural adaptation and content area are presented in our previous work [19, 20]. This feasibility study builds on a prior cultural adaptation process to further refine the Implementation of CASA, guided by Community-Based Participatory Research (CBPR). Thus, we aim to examine healthcare providers’ and community partners’ perceptions of the CASA intervention, specifically concerning its Reach, Effectiveness, Adoption, Implementation, and Maintenance, using the RE-AIM framework. RE-AIM is a model of planning and evaluation that assesses the impact, efficacy, and sustainability of an intervention in real-world settings [21].

Methods

Study design

The ethical approval for the study procedures was obtained from the Ponce Research Institute Institutional Review Board (IRB#2403190180), ensuring compliance with the ethical standards. The research was guided by a Community-Based Participatory Research (CBPR) framework, ensuring that the research processes and outcomes were grounded in the lived experiences and priorities of the community [22]. This approach aimed to examine healthcare providers’ and community partners’ perceptions of the CASA intervention, specifically regarding its Reach, effectiveness, Adoption, Implementation, and Maintenance. Specifically, the study incorporated CBPR elements by: (1) engaging and training two community partners to serve as recruiters, thereby strengthening trust and cultural relevance in participant engagement; and (2) ensuring that findings were intended to directly inform future refinements to CASA to maximize acceptability and sustainability in real-world community and clinical settings. Moreover, this study builds on a previous project that evaluated and adapted the CASA intervention based on the perspectives of patients and caregivers, the intervention’s target population [20], thereby reinforcing the iterative process characteristic of CBPR designs. The team used data analysis following a deductive coding methodology informed by the RE-AIM framework. The RE-AIM framework encompasses five dimensions (Reach, Effectiveness, Adoption, Implementation, and Maintenance), providing a structured approach to assess and refine interventions by evaluating their impact across diverse contexts and populations [23].

The RE-AIM framework aims to guide planners, evaluators, and policymakers in the sustainable Implementation and evaluation of evidence-based interventions that are generalizable [24]. It focuses on five key steps to ensure comprehensive assessment and success. First, Reach refers to the representativeness of individuals participating in the intervention, as well as strategies to recruit participants. Effectiveness assesses the intervention’s impact on important outcomes, including potential adverse effects, quality of life, and economic considerations. Third, Adoption examines the number, proportion, and representativeness of settings and agents willing to implement the intervention. Fourth, Implementation ensures fidelity to the intervention protocol, consistency in delivery, and evaluates the costs and adaptations made during the process. Lastly, Maintenance determines whether the intervention becomes institutionalized into routine practice and whether its effects are sustained in the long term, typically six months or more [23]. Overall, the RE-AIM framework provides a structured approach to evaluating interventions, ensuring their success, scalability, and sustainability across various contexts [24].

Participants

The study included two participant groups: healthcare providers and community partners. Healthcare providers were oncologists or primary care specialists (e.g., physicians, nurses, hospice personnel), actively involved in patient care in Puerto Rico, treating more than 30 patients diagnosed with cancer. Community partners included in the study were community leaders, cancer survivors, or cancer support volunteers with active participation in cancer-related groups. Participants were recruited through two community partners from rural towns in Southern Puerto Rico, who had experience with cancer. These towns are geographically proximate but serve distinct catchment areas. While the specific municipalities of participants were not recorded in this project, the decision to focus on Southern Puerto Rico was informed by prior data indicating higher cancer incidence rates in this region compared to other areas of the island [25]. Community partners were trained in recruitment procedures at Ponce Health Sciences University (PHSU) to ensure effective participant recruitment. Recruitment strategies included referral from the two community partners, as well as snowball and convenience sampling. All participants completed a sociodemographic questionnaire, followed by a semi-structured interview. The interview was conducted with community partners (n = 11) and healthcare providers (n = 10) to assess perceptions of the CASA intervention regarding its Reach, effectiveness, Adoption, Implementation, and Maintenance. A minimum sample of 10 participants per group was established based on prior qualitative studies suggesting that a sample of 7 to 10 participants may be sufficient to achieve thematic saturation [26]. Each participant interviewed received $100 in recognition of their time and effort.

Data collection

The data collection for this study took place from May to August 2024, using a sociodemographic questionnaire and a one-time semi-structured interview. The sociodemographic questionnaire included questions about biological sex, age, employment, educational attainment, and marital status. The one-time semi-structured interview introduced information about the intervention to participants and elicited their feedback on the CASA intervention, specifically addressing all dimensions of the RE-AIM framework. Healthcare providers and community partners were interviewed separately. The research team designed and standardized the interviews (See Additional File 1), utilizing the RE-AIM framework to structure discussions around five critical dimensions: Reach, Effectiveness, Adoption, Implementation, and Maintenance. The principal investigator trained the research assistants in conducting semi-structured interviews based on her expertise. The interview protocol commenced with an overview of the study objectives, followed by a series of open-ended questions aimed at eliciting participants’ perspectives on the intervention design, feasibility, and potential for adaptation. Each interview had an average duration of 30 min and was conducted in person or over the phone, depending on participants’ availability and preference. To enhance the depth of the data collected, follow-up questions and prompts were employed when necessary to clarify responses and explore topics in greater detail. The flexible approach of a semi-structured interview facilitated the collection of rich, detailed data, capturing the nuanced and diverse experiences and insights of participants. Each interview, whether in person or by phone, was recorded and transcribed.

Data analysis

Recordings and transcriptions of the interviews were reviewed by the research team and analyzed using NVivo 14. The transcriptions were verified by a research assistant who was not responsible for the original transcription. The analysis combined inductive and deductive thematic content coding to ensure a comprehensive exploration of the data [27]. Descriptive statistics were performed to summarize the sociodemographic characteristics of the sample, providing essential context for the qualitative findings. The RE-AIM framework was employed as a guiding structure for deductive content analysis [21]. In the deductive content analysis, interview data were organized into predefined categories corresponding to the five dimensions of the framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). The framework provided an organizing structure to capture participants’ perceptions of CASA across its five domains. For this feasibility phase, Reach, Adoption, and Implementation were explored in terms of current acceptability, facilitators, and barriers, while Effectiveness and Maintenance were examined as anticipated outcomes and sustainability considerations since the intervention has not yet been implemented. This approach allowed us to align participant feedback with the RE-AIM dimensions while acknowledging the exploratory scope of this study. This approach ensured that the analysis aligned with the study’s objectives while allowing for systematic exploration of each domain [28]. The coding process involved multiple steps to enhance rigor and reliability. First, the recorded interviews were transcribed verbatim. Next, an initial round of coding was conducted independently by members of the research team to identify key themes. This was followed by group discussions to reconcile differences, refine the coding scheme, and achieve consensus on finalized codes. The qualitative codes used for the interviews included high acceptance, low acceptance, positive reaction, negative reaction, and unclear. NVivo 14 software was utilized to organize, code, and analyze qualitative data efficiently.

Results

Sociodemographic information

Eleven community partners and 10 healthcare providers completed the interview, with a total of 21 participants. Most of the community partners reported an age range of 51 to 60 years; the majority were female (73%), married (64%), and Latino (100%). Similarly, most of the healthcare providers reported an age range of 51 to 60 years; the majority were female (90%), married (50%), and Latino (100%). Regarding the healthcare providers, the majority were nurses (50%; 30% clinicians, and 20% general nurses), followed by oncologists (30%). Table 1 provides more detailed information regarding sociodemographic characteristics.

Table 1.

Sociodemographic information

Characteristics	Participants; n (%)
	Community Partners (n = 11)	Healthcare providers (n = 10)
Age range
31–40 years	2 (18%)	2 (20%)
41–50 years	-	3 (30%)
51–60 years	3 (27%)	5 (50%)
60 years or older	6 (55%)	-
Sex
Female	8 (73%)	9 (90%)
Male	3 (27%)	1 (10%)
Marital Status
Married	7 (64%)	5 (50%)
Single	3 (27%)	4 (40%)
Divorced	1(9%)	1 (10%)
Educational Level
High School	1(9%)	-
Associate degree	1(9%)	-
College degree	1 (9%)	7 (70%)
Master’s degree	7 (64%)	-
Doctoral degree	1 (9%)	3 (30%)
Role
Community Partner	11 (100%)	-
Social Worker	-	2 (20%)
Generalist nurse	-	2 (20%)
Clincians nurse	-	3 (30%)
Doctor (oncologist or hematologist)	-	3 (30%)
Employment status:
Unemployed	6 (55%)	-
Part-Time worker	-	1 (10%)
Full-Time worker	5 (45%)	9 (90%)
Years of work experience
1 year	1 (9%)	-
2 years	1(9%)	1 (10%)
3 years	1(9%)	-
5 years	-	2 (20%)
6 years	-	1 (10%)
10 years or more	8 (73%)	6 (60%)

Participants offered direct and reflective responses to illustrate their acceptance and reaction to the intervention content and implementation strategies. These responses provided concrete feedback on the intervention and implementation strategies. The interviews ranged from 15 to 54 min, with an average duration of 30 min. During the interview, participants shared their opinions, experiences, and suggestions regarding the intervention and the implementation strategies, including exploratory factors, barriers, and facilitators to Implementation. Participants offered vivid and descriptive examples of cases and situations encountered in their communities and clinical practice. Five main interrelated themes were created: (1) Reach, (2) Effectiveness, (3) Adoption, (4) Implementation, and (5) Maintenance.

Reach

Three subthemes emerge from the reach theme: (1) Acceptance of the intervention objective, (2) Acceptance of community partners as recruiters, and (3) Implementation barriers. Participants generally expressed high acceptance (18 reactions) and positive reactions (6 responses) toward the overall goal of the intervention, emphasizing its relevance to community needs. The Reach theme focused on participants’ understanding and acceptance of the intervention’s objectives, as well as the role of community partners in recruitment. Participants generally supported the intervention, emphasizing its potential value for patients and caregivers. According to the participants, the intervention would benefit both families and patients, and its Implementation would be vital (e.g., “I think it is essential, right, because one always thinks of the cancer patient as the person who is most affected,” provider 05). The positive reaction was attributed to the participants’ vivid experiences, highlighting the importance of this intervention (e.g., “As a survivor and as a caregiver, it is important to be able to understand this aspect, this concept of spirituality,” community partner 01, see Table 2.1).

Table 2.1.

Participants’ responses to the acceptance of the CASA intervention

Theme: Reach
Subtheme	Codes	Verbatims
Acceptance of Objective	High Acceptance (n = 18)	“Well, I understand that it would be good because, obviously, if it is going to be done with people other than family and so on, then it would be… a great support for the patients and caregivers.” (community partner 11) “I think it is extremely important, right, because one always thinks of the cancer patient as the person who is most affected, but in reality, an intervention is a necessity for both.” (provider 05)
	Positive Reaction (n = 6)	“As a survivor and as a caregiver, it is important to be able to understand this aspect, this concept of spirituality. For me, to be able to support myself, and for others, any intervention or strategy that you can give me to be able to handle this diagnosis and this person who has this diagnosis, will help me. People fall down as soon as they hear the first news. It is important to have information about what they can use.” (community partner 01) “I have worked with hospice patients as well, and I have obviously worked with cancer in these terminal stages, when the patient is already close to dying in 6 months or less, and I have seen the great need that exists when family members are exhausted, when they are alone, when it is only one patient with one family member, and the need in terms of emotional and spiritual support is enormous…” (provider 07)

Note: n represents the number of participants whose responses correspond to that code

Participants also reported high acceptance of community partners as potential recruiters (e.g., “Very well, because as leaders, they know where the need is…”, provider 09). Some of the discussed implementation barriers were related to patients’ and caregivers’ resistance, with participants reporting that patients may refuse the intervention (e.g., “And the biggest barrier here would be the patient and the caregiver, who refuse to participate in the process,” community partner 08). Another barrier participants reported was transportation (e.g., “So, there are many problems that are linked to that, the transportation problems,” community partner 03). Table 2.2 presents detailed examples of reach-related themes.

Table 2.2.

Participants’ responses to the community partners as recruiters and barriers to the intervention

Theme: Reach
Subtheme	Codes	Verbatims
Community partners recruitment	High Acceptance (n = 17)	“It would be good because the patient, perhaps, if the community leader refers them, it is because the patient obviously had to have given the authorization and has to have the trust of that patient. Well, it would be good in that aspect because they already have a different sort of trust.” (community partner 10) “Very well, because as leaders they know where the need is… in the neighborhood, they are always attentive to their people. The best resource would be community leaders who have a lot of information about their environment and who need help and who don’t.” (provider 09)
CASA Implementation Barriers	Patients, Caregivers, and Family Resistance (n = 7)	“And the biggest barrier here would be the patient and the caregiver, who refuse to participate in the process.”  (community partner 08) “Willingness to talk because they don’t see it as an option to solve their problems. It’s the only barrier that I could…” (provider 01)
	Modality (n = 6)	“Technology mastery is going to be a key element. I don’t know if it should be inclusive, but it has to be evaluated.”  (community partner 01) “All of these things, but it all depends on whether the patient has internet access and whether it is compatible. There could be many factors that could mean that the intervention does not reach the patient as easily as a phone call.” (provider 05)
	Access (n = 6)	“I really find… barriers, for example, that they are not under control, external barriers, depending on the telephone line or the light, things like that, to get them there. But not barriers for the person to start, time can be one.” (community partner 04) “And the one who knocks on the doors and calls them is the family member, let it be the family member first. For example, I have had the experience that, to me, patients have told me, family members have told me, I have gone to seek help, and they say, ‘I can’t give you this information’ or ‘I can’t offer you help because it has to be the patient per se’. Look, sometimes the patient can’t, either because of the symptoms of the chemo or because the cancer doesn’t allow it, and they can’t get there, then they are inhibited, the family member is refused service because they are not the patient.” (provider 03)
	Transportation (n = 4)	“So there are many problems that are linked to that, the transportation problems.” (community partner 03) “Some vehicles cannot transport… transportation is very important, like a barrier.” (provider 07)
	Patient’s Health Condition (n = 3)	“Other barriers can be, well, like the patient’s physical condition, right, the health condition.” L01 “If we go to the more clinical aspect, the barrier that cancer patients with head and neck cancer have is verbal communication. This patient does not take much medication because it puts their breathing at risk.” (provider 03)

Note: n represents the number of participants whose responses correspond to that code

Effectiveness

Six subthemes emerge from the effectiveness theme: (1) Effectiveness of Session 1: Introduction to Meaning and History of Cancer, (2) Effectiveness of Session 2: Identity and Communication Strategies, (3) Effectiveness of Session 3: Creative Sources of Meaning, (4) Effectiveness of Session 4: Experiential Sources of Meaning, (5) Effectiveness of Session 5: Transitions, and (6) Perception of not yet implement CASA effectiveness. The effectiveness theme reflects anticipated rather than observed effectiveness, capturing expectations of potential impact based on participants’ professional and community experience, regarding each session and the overall intervention in achieving its goals (e.g., improving health behaviors and increasing access to care). Participants’ responses were categorized both in terms of acceptance (high/low) and reaction (positive/adverse), allowing us to distinguish between explicit endorsement of CASA and affective responses. Regarding the general effectiveness of the CASA intervention, participants expressed high acceptance (19 reactions) and positive reactions (2 reactions), emphasizing that the intervention would help to improve patients’ quality of life. Participants also reported high acceptance toward session 1, highlighting the essential aspect of talking and understanding the cancer diagnosis from patients’ and caregivers’ points of view (e.g., “I think it is imperative that people really talk about the diagnoses and understand what is happening, that they themselves talk about what that diagnosis means for everyone in the family, this is extremely important and that is where expectations are significant,” provider 05, see Table 3.1).

Table 3.1.

Participants’ responses to the effectiveness of the overall CASA intervention and session 1

Theme: Effectiveness
Subtheme	Codes	Verbatims
Effectiveness of not yet implemented CASA intervention	High Acceptance (n = 19)	“I find it interesting because they obviously cover everything, keeping in mind the feelings of the person, not only the patient, but also the caregiver, and obviously the entire external part.”  (community partner 11) “So, I think this kind of intervention is very fair and necessary.” (provider 05
	Positive Reaction (n = 2)	“Well, look, I would like to congratulate you because sometimes we are unaware of the studies that are being done … but that you are looking for a meaningful life in this moment that is so important in life, well, I think that is exceptional.” (community partner 11) “It’s very good because you intervene, you guide…” (provider 01)
Effectiveness of the Session 1	High Acceptance (n = 12)	“I think the first session is key to defining how far we are going to go…” (community partner 01) “No, I love it. I think it is extremely important that people really talk about the diagnoses and understand what is happening, that they themselves talk about what that diagnosis means for everyone in the family, this is extremely important and that is where expectations are really important.” (provider 05)
	Positive Reaction (n = 6)	“You have the diagnosis, to start an introduction” (community partner 02) “That is extremely important. I believe that this would be part of the basis for being able to start a quality-of-life intervention with that patient.” (provider 06)

Note: n represents the number of participants whose responses correspond to that code

According to the participants, integrating communication strategies in Session Two is vital, as it is key to communicating effectively with others (e.g., “Because it would obviously be the basis for working with others,” Community Partner 04). Regarding the effectiveness of Session 3, which focused on the creative source of meaning, participants highlighted its importance in helping them focus on roles and tasks that both patients and caregivers can perform in their new circumstances. (e.g., “I imagine that it will help a lot to… especially to the patient, to know that they’re productive, that they can do something,” community partner 11). See Table 3.2 for participants’ perceptions of the effectiveness of each session and the overall CASA intervention.

Table 3.2.

Participants’ responses to the effectiveness of CASA intervention session 2 and 3

Theme: Effectiveness
Subtheme	Codes	Verbatims
Effectiveness of Session 2	High Acceptance (n = 9)	“Because it would obviously be the basis for working on the others.” (community partner 04) “Also very good because as I was explaining to you, there are many patients that arrive with the diagnosis and are very reluctant to talk.” (provider 09)
	Positive Reaction (n = 3)	“Well, I think that, sometimes I realize it from what the caregivers or the patient tell you, because of these communication strategies, I don’t know if it’s because of closeness, habit, routine, sometimes not… I mean, there are frictions, or one part doesn’t understand the other and they think it’s something… for example, a child who takes care of mom or dad who is sick in an advanced state, they tell you “it’s that I think they lack love perhaps because I don’t communicate with them” because they leave… I don’t know if it’s resisting or if… like they learn to communicate…” (community partner 11) “Everyone has to understand a little bit, right, sometimes we expect the caregiver to do everything and sometimes the caregiver can’t. And it’s important for them to understand these expectations from the beginning to see how they can then get more help.” (provider 05)
Effectiveness of Session 3	High Acceptance (n = 10)	“I imagine that it will help a lot to… especially to the patient, to know that they’re productive, that they can do something. Because often here we get so much out of wanting to take care of them and protect them so much that we almost assume that… they have nothing to contribute.” (community partner 11) “Well, that sounds really interesting. I find it incredible that you’re looking for the patient to be able to take back certain things.” (provider 07)
	Positive Reaction (n = 6)	“Tasks are important, that assignment that is offered to the caregiver and the patient, because from there they can cover many things, other situations that need to be handled.” (community partner 05) “I think so, if you talk about it from the beginning or if you talk about it from the moment you can’t, I think that things have more meaning and people lose, there is always a real feeling of guilt for not being able to do everything you can for that patient, but if you talk about it from the beginning I think that things are resolved and in the end there are fewer misunderstandings and bad feelings between the two parties.” (provider 05)

Note: n represents the number of participants whose responses correspond to that code

Additionally, participants expressed their perception of Session 4 and its effectiveness and relevance since it allows patients and caregivers to connect through their experiences, such as beauty, love, and humor (e.g., “I think it is fundamental because those are the things that perhaps the same illness cannot take away from me, that the pain cannot take away from me, it cannot take away material things from me, the ability to move, that is not true, that remains within each one of us,” community partner 11). Finally, toward the last session, participants shared their perceptions and examples regarding sessions that they connected with during the interviews (e.g., “I remember that I recently read a book by Romano Guardini, “The Stages of Life,” and he talked about the true transition of each stage, and I imagine that it is important to be able to continue living,” community partner 11, See Table 3.3).

Table 3.3.

Participants’ responses to the effectiveness of CASA intervention session 2 and 3

Theme: Effectiveness
Subtheme	Codes	Verbatims
Effectiveness of Session 4	High Acceptance (n = 9)	“At that stage, I think it is fundamental because those are the things that perhaps the same illness cannot take away from me, that the pain cannot take away from me, it cannot take away material things from me, the ability to move, that is not true, that remains within each one of us.” (community partner 11) “Excellent, it’s very well distributed.” (provider 04)
	Positive Reaction (n = 5)	“Kissing my granddaughter.” (community partner 01) “Well yes, I think it’s essential, wow, I think it’s like I told you, for me leaving a legacy, leaving… being able to say look, we did all this together and we made it true, gives a lot of meaning to life, it gives both of them closure, more than anything else. So I think it’s something I love because I think no one talks about it, everyone thinks about it and wants to do it, but in reality, no one talks about it.” (provider 05)
Effectiveness of Session 5	High Acceptance (n = 9)	“Very good too, yes, because they are, like, stages.” (community partner 11) “It’s essential, and I think it’s great that you’re doing this because there’s a lot of emotional and spiritual support needed in this country.” (provider 07)
	Positive Reaction (n = 6)	“I remember that I recently read a book by Romano Guardini, “The Stages of Life,” and he talked about the true transition of each stage, and I imagine that it is important to be able to continue living.” (community partner 11) “And all the interventions you mentioned, we have that type of patient every day, they are definitely very necessary… It is a consolation that it could be greatly improved; what you are presenting to me is spectacular.” (provider 06)

Note: n represents the number of participants whose responses correspond to that code

Adoption

Two themes emerge from the Adoption theme: (1) Facilitators in referral through community partners, and (2) Intervention Modality. The adoption theme focused on community partners as the patient’s referral and the telephone modality of the intervention. Most participants emphasized the importance of community partners’ characteristics when discussing the Adoption of the referral intervention, noting that preferences for specific groups—such as community leaders, health professionals, and specific populations—could influence their willingness to participate (e.g., “Those who like this because there are people, community leaders, health professionals”, community partner 05). Training was identified as a key facilitator, with many participants highlighting the need for thorough preparation to ensure community partners were equipped to implement the intervention effectively (e.g., “you must prepare well the people who will work with them,” community partner 08). Participants reported the need to disseminate and create a successful campaign for the intervention to reach people who may benefit (e.g., “Make a good campaign that reaches those older people,” provider 07; see Table 4.1).

Table 4.1.

Participants’ responses to the adoption of CASA intervention

Theme: Adoption
Subtheme	Codes	Verbatims
Facilitators in referral through community partners	Trainings (n = 7)	“So, I think you have to prepare well the people who are going to work with them.” (community partner 08) “Make a good campaign that reaches those older people. For example, there are campaigns against bullets in the air, suicide prevention, but what… I have never seen a campaign like this one, where we encourage you to talk and vent. We’re going to bring help to your home by calling this number, and we’ll help you find a way to talk and vent. They give numbers for “call here for…” in reality. If you feel that way, then call the PAZ line. That is all one sees, and they do not emphasize it; mental health is not given priority in this country.” (provider 07)
	Characteristics of Community Partners (n = 3)	“Those who like this, because there are people, community leaders, health professionals, there are populations that they don’t like to work with… If, for example, I don’t like working with cancer patients, because it causes me a lot of emotional pain, I shouldn’t.” (community partner 05)

Note: n represents the number of participants whose responses correspond to that code

Regarding the telephone modality, most participants (n = 10) expressed high acceptance, with some indicating that phone or video calls would be a convenient and effective way to deliver the intervention (e.g., “it would be perfect by phone or video call,” community partner 5). However, eight participants voiced concerns, citing the modality’s impersonal nature as a barrier to engagement (e.g., “The phone makes it more impersonal,” community partner 06). These findings suggest that while there is broad support for a telephone-based approach, customization of the referral process, careful consideration of community partner characteristics, and training needs will be crucial for successful Adoption. Table 4.2 presents detailed examples of participants’ responses regarding the modality of the CASA intervention.

Table 4.2.

Participants’ responses to the modality of CASA intervention

Theme: Adoption
Subtheme	Codes	Verbatims
Intervention Modality: Telephone	High Acceptance (n = 10)	“Well, if you already have the patient as a resource, I see that it would be perfect by phone or video call.” (community partner 05) “Yes, I understand that people will accept it much more easily than if you have to take them to an office or go visit them or perform the intervention in a place where they do not feel so comfortable.” (provider 05)
	Low Acceptance (n = 8)	“The phone makes it more impersonal” (community partner 06) “The telephone method could work when there is a skilled caregiver, because otherwise, it is a bit complex.” (provider 06)

Note: n represents the number of participants whose responses correspond to that code

Implementation

The implementation theme focused on other patient referrals, community partners’ referral barriers, alternative modalities, and promotional strategies. Most participants suggested that medical personnel make referrals to the intervention (e.g., “Other good resources for referrals are oncologists, oncologists’ offices where they provide treatments and where they do studies and mammograms,” community partner 06; “doctors,” provider 09). Specifically, they suggested that nurses make the referral (e.g., “the nurses who work with these cancer patients,” provider 05). Additionally, participants noted that it is beneficial to inform nonprofit organizations about the intervention, particularly those that provide services to the cancer community (e.g., “Nonprofit organizations or those that provide services to the community,” provider 02). Participants reported that anyone who may know someone with cancer could be a good referral resource (e.g., “Anyone who knows, I think everyone in this country knows a cancer patient,” community partner 08). More specifically, they suggested spiritual leaders (e.g., “A pastor can have more effect, so perhaps within those community partners, including a pastor, the church has a lot of weight,” community partner 01; “churches are even more of facilitators,” provider 07) and hospices (e.g., “hospice services,” community partner 05; “hospices could be an excellent referral source as well,” provider 06). See Table 5.1 for participants’ perceptions regarding the Implementation of the CASA intervention.

Table 5.1.

Participants’ responses to the implementation of CASA intervention

Theme: Implementation
Subtheme	Codes	Verbatims
Other Patient Referral	Medical Services (n = 14)	“Another good resource for referrals is oncologists, oncologists’ offices, and where they provide treatments and where they do studies and mammograms.” (community partner 06) “The doctor too, the doctors who are… the oncologists who see the majority of patients who are diagnosed with cancer.”  (provider 09)
	Organizations (n = 12)	“It is also good for nonprofit organizations to know this.” (community partner 02) “Yes, nonprofit organizations or those that provide services to the community.” (provider 02)
	Others / Other Person (n = 9)	“I think anyone who knows, I think everyone in this country knows a cancer patient.”  (community partner 08) “The same family itself, friends.”  (provider 9)
	Spiritual leaders (n = 4)	“So perhaps within those community leaders, including a pastor, the church has a lot of weight.” (community partner 01) “A lot of times churches are even more of facilitators.” (provider 07)
	Hospice (n = 4)	“Hospice services.”  (community partner 05) “But hospices could be an excellent referral source as well.” (provider 06)
	Oncology Nurses (n = 3)	“The nurses who work with these cancer patients, right? It’s important, right, because they know better than anyone what these patients are going through.”  (provider 05)
	Support Groups (n = 2)	“In my case, I know people who have support groups, and perhaps those support groups could also be a source for finding participants.” (community partner 04)

Note: n represents the number of participants whose responses correspond to that code

Barriers reported by participants in community partners making the referral included lack of knowledge, communication, financial and personal vulnerability, and resistance. Other modalities reported by participants included in-person home visits (n = 11) and hybrid (n = 3), defined as a combination of in-person and telephone-based delivery. Regarding the promotion, participants reported the need to engage potential participants through social media, outreach activities, radio, and TV; see Table 5.2 for illustrative verbatim comments. These insights underline the need for a multifaceted approach that leverages both medical and community-based referral networks, addresses key barriers, and utilizes diverse promotional strategies to ensure the intervention reaches its intended audience.

Table 5.2.

Participants’ responses to the implementation of CASA intervention

Theme: Implementation
Subtheme	Codes	Verbatims
Community Partners Referral Barriers	Lack of Knowledge (n = 6)	“We are here, we are going to select according to some criteria, some characteristics, because everything that is this type of thing, you know, attracts our attention, but not everyone has the skills. Because it also requires certain knowledge, so that could work.” (community partner 01) “It is, I think, if the referral source is community leaders, then perhaps the scope of the correct diagnostic information is truly the sample we are looking for.” (provider 06)
	Communication (n = 6)	“Well, the barrier may be the way in which it is said. I understand that the patient is going to receive help, but if the community leader is not empathetic, how will he convey the message? It is not that he has to; perhaps it can be a barrier. It may be that I am doing it with good intentions, but it is not the best way to communicate it; then the patient will create resistance.” (community partner 10) “Well, look, I think that no, well, the most difficult barrier is always delivering the information.” (provider 05)
	Financial (n = 5)	“Sometimes we don’t have enough money to help them, and we depend a lot on what we do … I understand that what affects us the most is the aspect of financing, of money.” (community partner 02) “Barriers can be economic necessity.” (provider 07)
	Personal Vulnerability (n = 4)	“It’s not healthy for that person to be around. If, for example, I don’t like working with cancer patients, because it causes me a lot of emotional pain, I shouldn’t…” (community partner 05) “Well, a barrier could be that the person does not want to receive services, because one can guide them, but if the person does not want to, it could be a barrier. Because many people do not accept what is happening, or they do not want to bother them, or they do not want someone…” (provider 02)
	Resistance (n = 3)	“That the patient wants to receive it.” (provider 04)
	Stigma (n = 2)	“Because they think that is only for people who say… some people say, ‘but I’m not crazy” (provider 04)
Other modalities	In person: Home visits (n = 11)	“To the patient’s home” (community partner 02) “As I told you, bringing them help to the house, I know that it is not always possible, but yes, bringing help to the house.” (provider 07)
	In person: Not Specific (n = 3)	“Obviously, the traditional way, which is in person.” (community partner 04) “In person because that’s where you have the best visual experience, because I can tell you a lot of things, but you’re not seeing your perspective, you can say ‘look, she’s saying this, but I notice she’s worried’.” (provider 01)
	Hybrid (n = 3)	“Well, one visit, if the patient agrees, visits… It doesn’t have to be everything, but one or two visits are not a bad thing.” (community partner 05)
	In person: Groups (n = 2)	“Instead of doing it individually, I would carry it out as a group, and a group of no more than 10 or 12 people” (community partner 08)
	In person: Other facilities (n = 2)	“You can look for facilities in areas that provide facilities so you can meet them there.” (community partner 01)
Promotions	Social Media (n = 9)	“I understand that you also use social media tools to engage the public. To ensure participation.” (community partner 04) “In the same way, you know, if you put it on social media” (provider 05)
	Activities (n = 3)	“For example, there are campaigns against bullets in the air, for suicide prevention, but what… I have never seen a campaign to talk, to vent, that we’re going to bring the help to your home, call this number, and we will come to you so that you can talk and vent.” (provider 07)
	Radio (n = 2)	“Through the radio, if you ask for the necessary permits, you can go to the radio.” (community partner 06)
	TV (n = 2)	“All doctors have a television; they can make a short video, 5 to 6 minutes long, that talks about the workshop, leaving the time there for contact so that they can be more interested.” (community partner 07)

Note: n represents the number of participants whose responses correspond to that code

Maintenance

Maintenance themes were divided into two subthemes: (1) CASA implementation facilitators and (2) Community partners’ referral to psychological services. The maintenance theme focused on key facilitators and barriers related to sustaining the intervention and ensuring continuous referrals to psychological services in the future, once CASA is implemented. The identified facilitator by participants includes doctor or health department referrals (e.g., “the doctor or health department refers them to us or they come to me, then I will call you, and the leader will be the one to call and refer them,” community partner 10) and working with hospice social workers (e.g., “The area of hospice, social work and spiritual counseling would be two disciplines that would be of great help for this project because it is practically what they work on,” provider 06). Also, participants reported as facilitators exposure (e.g., “knocking on doors in communities to link positive actions towards the project you have,” community partner 03), collaboration (e.g., “As I told you, communication with the doctors, with the health department of the municipality,” community partner 09) and dissemination (e.g., “it’s like when you want to sell something, it’s not that you’re going to sell the project but that you can present it to the patient in a way in which you tell them: this is a great benefit that you’re going to have, in which you’re going to benefit in this x or y way,” community partner 10). On the other hand, the participants suggest that for Maintenance, we need to continue with the education (e.g., “it’s all about education…,” community partner 10) and modality flexibility (e.g., “there should be flexibility so that the person, the patient, and the caregiver can select how they can do it, and finish,” community partner 04). Participants also reported the idea of a directory of resources that the patient can call to obtain information (e.g., “A directory of resources that the patient can call to obtain information,” community partner 07). See Table 6.1 for participants’ perceptions of the maintenance-related theme.

Table 6.1.

Participants’ responses to the maintenance of CASA intervention

Theme: Maintenance
Subtheme	Codes	Verbatims
CASA Implementation Facilitators	External Referral (n = 10)	“The doctor or health department refers them to us, or they come to me, then I will call you, and the leader will be the one to call and refer them.” (community partner 10) “In the area of ​​hospice, social work, and spiritual counseling would be two disciplines that would be of great help for this project because it is practically what they work on, obviously at a simpler level.” (provider 06)
	Exposure (n = 5)	“It is participation, what you are doing, seeking active participation, knocking on doors in communities to link positive actions towards the project you have.” (community partner 03)
	Education (n = 4)	“Well, it’s all about education…” (community partner 10) “Education, educate, we must educate people.” (provider 08)
	Dissemination (n = 3)	“Yes, for example, it’s like when you want to sell something, it’s not that you’re going to sell the project but that you can present it to the patient in a way in which you tell them: this is a great benefit that you’re going to have, in which you’re going to benefit in this x or y way.” (provider 10)
	Modality Flexibility (n = 3)	“There should be the facility to use perhaps tools like the one we are using now, telemedicine, or if they are in person as well. There should be flexibility so that the person, the patient, and the caregiver can select the way in which they can do it, and finish.” (community partner 04)
	Additional Resources (n = 2)	“A directory of resources that the patient can call to obtain information.” (community partner 07)

Note: n represents the number of participants whose responses correspond to that code

However, a primary barrier to maintaining the intervention was potential resistance from individuals who do not want to receive services despite guidance and support being available (e.g., “if the person doesn’t want to, that could be a barrier,” provider 02). These findings underscore the importance of ongoing engagement, adaptability, and educational initiatives to sustain the intervention’s success while addressing resistance to participation. Table 6.2 presents participants’ illustrative quotes related to maintenance themes.

Table 6.2.

Participants’ responses to the maintenance of CASA intervention

Theme: Maintenance
Subtheme	Codes	Verbatims
Community Partners Referral to Psychological Services	Barriers (n = 7)	“Well, the patient comes, well, denial, or the caregiver, when the caregiver has authorization or some kind of control over a patient, says, ‘No, you are not going to participate in that’.” (community partner 01) “If the person doesn’t want to receive services, because you can guide them, but if the person doesn’t want to, it could be a barrier.” (provider 02)

Note: n represents the number of participants whose responses correspond to that code

Discussion

This feasibility study examines the potential impact and sustainability of the Caregivers-Patient Support for Latinx Coping with Advanced Cancer (CASA) intervention from the perspective of healthcare providers and community partners. Guided by the REAIM framework, we explored dimensions of Reach, Effectiveness, Adoption, Implementation, and Maintenance to identify key recommendations for refining CASA. By considering the perspective of healthcare providers and community partners who work hands-on in cancer-related contexts, this study contributes unique insights into how CASA can be sustained in real-world community and clinical settings.

Based on the Reach theme, participants supported the CASA’s objectives and its potential to address the psychosocial needs of Latino patients and caregivers. This strong acceptance highlights the intervention’s cultural and contextual relevance, suggesting its feasibility for future Implementation. This conclusion supports findings that establish the critical role open communication, one of the CASA intervention goals, plays for both patients and caregivers in their journey of coping with cancer as a dyad [29] —it can reduce caregiver burden [30] and improve the physical and mental health of patients and caregivers alike [31]. At the same time, participants identified essential barriers to Reach, including transportation and patient resistance. These findings align with previous studies on H/L populations, which have identified structural barriers and reluctance to seek psychosocial support as recurring obstacles to care [32, 33]. This underscores the need for CASA to integrate flexible delivery methods and proactive engagement strategies, including strengthening outreach and leveraging community organizations.

Moreover, regarding the potential effectiveness of CASA, participants also highlighted the acceptance of the overall program and its sessions. These findings demonstrate that participants not only perceived the content of CASA as effective in general but also found specific session content to be meaningful and relevant. Similarly, our previous research with patients and caregivers on the CASA adaptation process reflects the high acceptance of the intervention content [20]. In terms of the Adoption dimension, participants strongly supported the role of community partners as referral agents but stressed the importance of proper training to ensure effective engagement. This finding suggests that before implementing CASA, we need to develop a training focused on recruitment to ensure community partner engagement with patients and caregivers. This is essential since structured training has been shown to improve referral practices and cultural competence in community-based interventions [38]. Consequently, the Adoption of the intervention raises several aspects that also influence participants’ access to the intervention. One of these aspects, for example, is the dissemination of the intervention through broad campaigns, particularly to reach older populations.

Regarding modality, telephone delivery was generally viewed as convenient and feasible, though some participants expressed concern about its impersonal nature. This finding suggests that while digital modalities can address access barriers, providing multiple options—including telephone, video, and in-person delivery—may be necessary to optimize patient engagement, which participants also reported. Integrating flexible modalities may enhance engagement in other settings and help overcome these availability and accessibility barriers [34]. In relation to other referral pathways, participants identified a diverse range of referral sources, including oncologists, nurses, hospices, nonprofit organizations, and faith-based leaders. These recommendations are consistent with evidence that fostering collaborative partnerships among researchers, healthcare providers, policymakers, and community partners ensures that interventions are culturally appropriate, responsive, and sustainable [30]. Barriers for community partner referrals, such as a lack of knowledge and communication challenges, highlight the importance of providing orientation and ongoing support. Participants also recommended complementary outreach not only through social media, but also on the radio and television, which is particularly relevant for older populations who may encounter barriers when engaging through digital platforms alone [35].

Based on feedback from healthcare providers and community partners, it is evident that community engagement plays a pivotal role in the success of the CASA intervention. Prior research highlights that community-based interventions in psychosocial support programs are more effective when local partners actively participate in their Implementation [36]. Community-based approaches have been shown to enhance access to culturally sensitive support services and improve overall well-being among Latino cancer patients and their families [37]. In future Implementation, the intervention should continue to leverage community partners as referral agents, while providing targeted training to ensure they are adequately prepared to make referrals. Effective training programs should encompass cultural competence, communication strategies, and strategies for addressing patient resistance, as previous studies suggest that tailored training enhances the success of community-based healthcare interventions [38]. This structured training approach can improve trust and ensure that referrals are made in a culturally sensitive manner, increasing patient engagement.

Finally, participants underscored that sustaining CASA would require strong community–clinical partnerships, flexibility in delivery, and continued education. Recommendations such as embedding referrals within medical and hospice systems, developing a resource directory, and promoting collaboration align with findings that institutional integration and accessible resources are crucial for long-term Maintenance. However, persistent patient resistance remains a key challenge, suggesting that normalization of psychosocial support and ongoing educational efforts will be essential for sustaining engagement. Moreover, the role of community partners, spiritual leaders, and hospice workers would be crucial, as other authors have found that community and spiritual partners can develop strong and deep connections within their communities, making them trusted figures who influence community members [39].

The insights gained from this study will directly inform refinements to CASA before it is pilot-tested with patient–caregiver dyads. Specific priorities include strengthening outreach strategies, prioritizing engagement of influential community partners, expanding flexible delivery modalities, and developing structured training programs for providers and partners. Moreover, it is essential to explore the efficacy of various implementation strategies, such as leveraging digital platforms or optimizing community-based training, which can provide valuable insights into how to scale the intervention effectively across different settings. Furthermore, future research should examine barriers to patient engagement in greater depth, particularly the psychological and cultural factors contributing to resistance, as well as strategies to mitigate them. Understanding these dynamics will enhance patient participation and optimize the outcomes of interventions. These steps align with recommendations from prior studies on Latino cancer care, which emphasize the importance of culturally tailored, community-driven approaches for sustainability [37, 40]. Moreover, following the CBPR framework, the next step will be to consult these findings with a Community Advisory Board composed of healthcare providers, community partners, caregivers, patients, and members of the research team. This process will ensure that the recommendations emerging from this study are validated and refined by those most directly affected, thereby reinforcing the iterative and participatory nature of CASA’s development, consistent with the CBPR framework.

Limitations of the study

Despite its valuable insights, this study has several limitations. First, the data collected is self-reported feedback, which introduces the potential for response bias, mainly due to social desirability or participants’ perceptions of researchers’ expectations. Additionally, the study employed a deductive analysis approach, which, while appropriate for exploring predefined themes, may have limited the ability to identify unanticipated insights that could emerge from an inductive approach. However, we employ the deductive method because it aligns with the study’s objectives for structured evaluations of intervention frameworks, such as RE-AIM. Future research could complement this approach with inductive methods to capture emergent themes and deepen understanding. Another limitation is the small sample size of healthcare providers, particularly given the inclusion of diverse professional roles (e.g., oncologists, nurses, hospice personnel), which may have limited subgroup-specific saturation. Nonetheless, all providers in this study were actively engaged in oncology care, ensuring that their perspectives were grounded in direct experience with cancer patients and caregivers. Additionally, in this study, we evaluated dimensions such as Effectiveness and Maintenance, as well as future vision, since the intervention has not yet been implemented. Further investigation into other dimensions of the RE-AIM framework, such as long-term Maintenance and its impact on health outcomes, will be crucial for assessing the sustained effectiveness of the intervention.

Conclusion

This study provides significant insights into refining and implementing a psychosocial intervention for cancer patients and their caregivers, framed within the RE-AIM framework. The feedback from community partners and healthcare providers highlights the intervention’s strengths and challenges, providing valuable guidance for refining its delivery and improving its sustainability. By addressing barriers such as patient resistance and logistical difficulties and by leveraging community engagement and flexible modalities, the intervention has the potential to make a meaningful impact on the well-being of cancer patients and their families. Further research will be essential to build on these findings and ensure the intervention’s long-term success across diverse populations.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CASA

Caregivers-Patient Support for Latinx Coping with Advanced Cancer intervention

RE-AIM

Reach, Effectiveness, Adoption, Implementation, and Maintenance

CBPR

Community-Based Participatory Research

H/L

Hispanic/Latino

Author contributions

N.T-B. carried out the study conception and design. All authors (N.T-B., S.T-M., C.A-B., A.L-L., N.R-T., and L.R-R.) performed the material preparation and data collection. Moreover, N.T-B., S.T-M., C.A-B., A.L-L, and N.R-T. Conducted the analysis. N.T-B. wrote the first draft of the manuscript, and all authors (N.T-B., S.T-M., C.A-B., A.L-L, N.R-T., and L.R-R.) contributed to writing different sections and providing feedback on previous versions. All authors read and approved the final manuscript.

Funding

This study was funded by the National Institutes on Minority Health and Health Disparities U54 MD007579 (START and Recruitment Core) and U54 MD007579-S3 and the National Cancer Institute (NCI) K08CA279242, U01CA290613, and U54CA163071.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The ethical approval for the study procedures was obtained from the Ponce Research Institute Institutional Review Board (IRB#2403190180). This study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all subjects involved in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.