Table 2.
Practices and perceived barriers or enablers to the provision of nutrition care for patients with cancer by Indonesian nutritionists and dietitians: survey questions addressing domains of the TDF mapped to the capability aspect of the COM-B system.
| Theoretical domain framework | All (n = 268) |
Nutritionists/dietitians | Geographical location | |||||
|---|---|---|---|---|---|---|---|---|
| Nutritionist (n = 181) | Dietitian (n = 86) | p-value | Metropolitan/large urban area (n = 140) | Regional or small city (n = 121) | Rural or remote (n = 6) |
p-value | ||
| Knowledge | ||||||||
| Awareness of publication, n (%) | ||||||||
| Hospital Nutrition Service Guidelines (Regulation of The Minister of Health of The Republic of Indonesia Number 78 of 2013) | 251 (93.7) | 167 (92.3) | 83 (96.5) | 0.184 | 126 (90.0) | 119 (98.3) | 6 (100) | 0.015 a* |
| International Dietetics and Nutritional Terminology (IDNT) Reference Manual: Standard Language for the Nutrition Care Process 4th Edition (2013) | 165 (61.6) | 113 (62.4) | 51 (59.3) | 0.624 | 91 (65.0) | 70 (57.9) | 4 (66.7) | 0.481 |
| eNCPT (2020) | 160 (59.7) | 98 (54.1) | 62 (72.1) | 0.005 | 85 (60.7) | 71 (58.7) | 4 (66.7) | 0.891 |
| ESPEN guidelines on nutrition in cancer patients | 120 (44.8) | 74 (40.9) | 45 (52.3) | 0.079 | 70 (50.0) | 49 (40.5) | 1 (16.7) | 0.102 |
| ESPEN practical guideline: Clinical Nutrition in cancer | 118 (44.0) | 71 (39.2) | 46 (53.5) | 0.028 | 67 (47.9) | 48 (39.7) | 2 (33.3) | 0.359 |
| Technical guidelines on adult Palliative patients with cancer (Ministry of Health) | 86 (32.1) | 51 (28.2) | 35 (40.7) | 0.041 | 54 (38.6) | 31 (25.6) | 1 (16.7) | 0.056 |
| The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines | 74 (27.6) | 40 (22.1) | 33 (38.4) | 0.005 | 45 (32.1) | 28 (23.1) | 1 (16.7) | 0.218 |
| Oncology Evidence-Based Nutrition Practice Guideline for Adults (Academy of Nutrition and Dietetics) | 42 (15.7) | 19 (10.5) | 22 (25.6) | 0.001 | 20 (14.3) | 20 (16.5) | 2 (33.3) | 0.431 |
| Position statement of cancer-related malnutrition and sarcopenia (Clinical Oncology Society of Australia) | 30 (11.2) | 10 (5.5) | 19 (22.1) | <0.001 | 18 (12.9) | 10 (8.3) | 2 (33.3) | 0.112 |
| I am not aware of these publications | 4 (1.5) | 4 (2.2) | 0 (0) | 0.309 | 4 (2.9) | 0 (0) | 0 (0) | 0.074 |
| Other | 13 (4.9) | 8 (4.4) | 5 (5.8) | 0.762 | 7 (5.0) | 6 (5.0) | 0 (0) | 0.855 |
| Skills | ||||||||
| Nutritional assessments that were routinely completed for patients with cancer, n (%) | ||||||||
| Anthropometry assessment | 246 (91.8) | 169 (93.4) | 77 (89.5) | 0.277 | 128 (91.4) | 113 (93.4) | 6 (100) | 0.652 |
| Biochemical data review | 237 (88.4) | 158 (87.3) | 78 (90.7) | 0.417 | 123 (87.9) | 111 (91.7) | 3 (50.0) | 0.006 b**, c*** |
| Nutrition-focused physical examination, including muscle and fat stores, fluid status, overall appearance | 191 (71.3) | 125 (69.1) | 65 (75.6) | 0.272 | 106 (75.7) | 81 (66.9) | 4 (66.7) | 0.283 |
| Dietary intake assessment | 255 (95.1) | 171 (94.5) | 83 (96.5) | 0.558 | 132 (94.3) | 118 (97.5) | 5 (83.3) | 0.157 |
| Malnutrition assessment using a validated tool | 149 (55.6) | 96 (53.0) | 53 (61.6) | 0.187 | 81 (57.9) | 65 (53.7) | 3 (50.0) | 0.766 |
| The presence of nutrition impact symptoms related to cancer | 203 (75.7) | 135 (74.6) | 68 (79.1) | 0.423 | 111 (79.3) | 88 (72.7) | 4 (66.7) | 0.404 |
| Effect of specific treatments and prescribed medications | 134 (50) | 85 (47.0) | 49 (57.0) | 0.126 | 79 (56.4) | 52 (43.0) | 2 (33.3) | 0.067 |
| Nutritional intake through tube feeding (if relevant) | 214 (79.9) | 140 (77.3) | 73 (84.9) | 0.152 | 115 (82.1) | 95 (78.5) | 4 (66.7) | 0.560 |
| Quality of life | 147 (54.9) | 94 (51.9) | 53 (61.6) | 0.137 | 80 (57.1) | 64 (52.9) | 3 (50.0) | 0.764 |
| Other | 20 (7.5) | 8 (4.4) | 12 (14.0) | 0.006 | 15 (10.7) | 5 (4.1) | 0 (0) | 0.103 |
| Confidence in providing nutrition care | ||||||||
| Conduct a nutritional assessment of a patient with cancer and identify main signs/symptoms related to malnutrition | 8 (7–9) | 8(7–9) | 9 (8–10) | 0.006 | 9 (8–10) | 8 (7–9) | 7.5 (7–8.5) | 0.003 d* |
| Provide nutrition diagnosis and identify problem-etiology-sign/symptoms within individual patients | 8 (7–9) | 8(7–9) | 8 (8–10) | 0.067 | 9 (8–10) | 8 (7–9) | 8 (7–8.5) | 0.013 e* |
| Provide several nutritional recommendations to address the identified nutritional problem | 8 (8–9) | 8 (8–9) | 8 (9–10) | 0.023 | 9 (8–9.25) | 8 (7–9) | 8 (8–8.5) | 0.007 f* |
| Provide nutritional recommendations to support better nutritional status for patients, considering patient preferences | 8 (8–9) | 8 (8–9) | 9 (8–10) | 0.071 | 9 (8–10) | 8 (7–9) | 8 (8–8.5) | 0.007 f* |
| Provide nutritional recommendations for discharged patients for formula drink (if clinically indicated and preferred) with instructions on how to prepare it | 8 (8–9) | 8 (7–9) | 9 (8–10) | 0.058 | 9 (8–10) | 8 (7–9) | 8 (6.5–9.25) | <0.001 g* |
| Evaluate and monitor a patient’s nutritional status at each follow-up visit | 8 (7–9) | 8 (7–9) | 8 (8–9) | 0.266 | 8 (8–10) | 8 (7–9) | 8 (7–8.5) | <0.001 g* |
| Provide basic nutritional advice (e.g., high energy, high protein diet education) for patients with cancer | 9 (8–10) | 9 (8–10) | 9 (8–10) | 0.894 | 9 (8–10) | 8 (8–9) | 8 (7.75–9.25) | 0.007 a* |
| Provide nutritional recommendations for patients with a feeding tube | 8 (8–9) | 8 (7–9) | 9 (8–10) | 0.017 | 9 (8–10) | 8 (7–9) | 8 (7.75–9.25) | <0.001 g* |
| Troubleshoot individual nutrition impact symptoms and provide recommendations for my patients with cancer | 8 (8–9) | 8 (7–9) | 9 (8–9.5) | 0.033 | 9 (8–10) | 8 (7–9) | 8 (7.75–9.25) | <0.001 g* |
| Memory, attention and decision processes | ||||||||
| Publication used for practice, n (%) | ||||||||
| Hospital Nutrition Service Guidelines (Regulation of The Minister of Health of The Republic of Indonesia Number 78 Of 2013) | 234 (87.3) | 162 (89.5) | 71 (82.6) | 0.112 | 119 (85.0) | 110 (90.9) | 5 (83.3) | 0.333 |
| eNCPT (2020) | 142 (53.0) | 87 (48.1) | 55 (64.0) | 0.015 | 79 (56.4) | 60 (49.6) | 3 (50.0) | 0.536 |
| International Dietetics and Nutritional Terminology (IDNT) Reference Manual: Standard Language for the Nutrition Care Process 4th Edition (2013) | 141 (52.6) | 100 (55.2) | 40 (46.5) | 0.182 | 76 (54.3) | 62 (51.2) | 3 (50.0) | 0.878 |
| Technical guidelines on adult Palliative patients with cancer (Ministry of Health) | 69 (25.7) | 42 (23.2) | 27 (31.4) | 0.153 | 41 (29.3) | 27 (22.3) | 1 (16.7) | 0.378 |
| ESPEN guidelines on nutrition in cancer patients | 100 (37.3) | 57 (31.5) | 42 (48.8) | 0.006 | 65 (46.4) | 35 (28.9) | 0 (0) | <0.001 h*, b** |
| ESPEN practical guideline: Clinical Nutrition in cancer | 84 (31.3) | 52 (28.7) | 31 (36.0) | 0.227 | 55 (39.3) | 29 (24.0) | 0 (0) | 0.003 a* |
| ASPEN Nutrition Guidelines for Adult Head and Neck Cancer: Protocol | 57 (21.3) | 30 (16.6) | 26 (30.2) | 0.010 | 36 (25.7) | 21 (17.4) | 0 (0) | 0.061 |
| Oncology Evidence-Based Nutrition Practice Guideline for Adults (Academy of Nutrition and Dietetics) | 31 (11.6) | 13 (7.2) | 17 (19.8) | 0.002 | 19 (13.6) | 12 (9.9) | 0 (0) | 0.438 |
| Position statement of cancer-related malnutrition and sarcopenia (Clinical Oncology Society of Australia) | 16 (6.0) | 3 (1.7) | 12 (14.0) | <0.001 | 10 (7.1) | 6 (5.0) | 0 (0) | 0.625 |
| I am not aware of these publications | 5 (1.9) | 5 (2.8) | 0 (0) | 0.179 | 4 (2.9) | 1 (0.8) | 0 (0) | 0.412 |
| Other | 14 (5.2) | 11 (6.1) | 3 (3.5) | 0.559 | 7 (5.0) | 6 (5.0) | 1 (16.7) | 0.447 |
| Behavioral regulation | ||||||||
| Preference for referral to a more experienced nutritionist or dietitian | ||||||||
| If I receive a referral for an adult patient with cancer who is malnourished, I prefer to refer to a nutritionist or dietitian with more experience in this area | 7 (5–9) | 7.5 (5–9) | 7 (5–8) | 0.196 | 7 (5–9) | 7 (5–8) | 9 (6.5–10) | 0.124 |
| If I receive a referral for an adult patient with cancer who has comorbidities, e.g., diabetes, I prefer to refer to a nutritionist/dietitian with more experience in this area | 7 (5–9) | 8 (5–9) | 7 (5–8) | 0.189 | 8 (5–9) | 7 (5–8) | 9.5 (7.25–10) | 0.047 |
eNCPT, electronic Nutrition Care Process Terminology; IDNT, International Dietetics and Nutritional Terminology; ESPEN, European Society for Parenteral and Enteral Nutrition; ASPEN, American Society for Parenteral and Enteral Nutrition; * significant difference is between participants working in metropolitan/large urban areas and regional/small cities; ** significant difference is between participants working in metropolitan/large urban areas and rural/remote; *** significant difference is between participants working in regional/small cities and rural/remote; a p = 0.008; b p = 0.034; c p = 0.014; d p = 0.003; e p = 0.012; f p = 0.005; g p < 0.001; h p = 0.004; Participants indicated level of agreement for each statement, 0 = ‘strongly disagree’, 10 = ‘strongly agree’; Numbers were described as median (interquartile range/IQR) from a 10-point Likert scale of agreement. Bold indicates p < 0.05.