Table 3.
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 opportunity 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 | ||
| Social influences | ||||||||
| Emotional support | ||||||||
| I can rely on my nutrition/dietetic colleagues for emotional support in providing nutrition care to my patients with cancer | 8 (8–9) | 8 (8–9.25) | 8 (8–9) | 0.441 | 9 (8–9.5) | 8 (8–9) | 8 (7.75–10) | 0.722 |
| I can rely on my oncology team colleagues for emotional support in providing nutrition care to my patients with cancer | 8 (8–9) | 8 (7–9) | 8 (8–9) | 0.324 | 8 (8–9) | 8 (7–9) | 7.5 (7–10) | 0.418 |
| Environmental context and resources | ||||||||
| Support available to manage a patient with cancer, n (%) | ||||||||
| Peers | 214 (79.9) | 149 (82.3) | 64 (74.4) | 0.133 | 110 (78.6) | 101 (83.5) | 3 (50.0) | 0.149 |
| Mentor | 40 (14.9) | 31 (17.1) | 9 (10.5) | 0.154 | 22 (15.7) | 18 (14.9) | 0 (0) | 0.572 |
| Supervisor | 58 (21.6) | 43 (23.8) | 14 (16.3) | 0.164 | 37 (26.4) | 21 (17.4) | 0 (0) | 0.047 |
| Specialist oncology medical professionals | 143 (53.4) | 91 (50.3) | 51 (59.3) | 0.167 | 83 (59.3) | 59 (48.8) | 1 (16.7) | 0.039 |
| Medical professionals | 156 (58.2) | 106 (58.6) | 49 (57.0) | 0.806 | 73 (52.1) | 78 (64.5) | 4 (66.7) | 0.119 |
| Nursing team | 191 (71.3) | 124 (68.5) | 66 (76.7) | 0.165 | 95 (67.9) | 95 (78.5) | 1 (16.7) | 0.003 i**, d*** |
| Local hospital nutritionists and dietitians, doctors, or nurses (only select this if you do not work in a hospital) | 96 (35.8) | 75 (41.4) | 21 (24.4) | 0.007 | 56 (40.0) | 35 (28.9) | 5 (83.3) | 0.009 d*** |
| Online forums | 50 (18.7) | 26 (14.4) | 24 (27.9) | 0.008 | 33 (23.6) | 16 (13.2) | 1 (16.7) | 0.097 |
| Interest group email listings | 11 (4.1) | 6 (3.3) | 5 (5.8) | 0.337 | 7 (5.0) | 4 (3.3) | 0 (0) | 0.613 |
| Other | 11 (4.1) | 5 (2.8) | 6 (7.0) | 0.105 | 7 (5.0) | 4 (3.3) | 0 (0) | 0.613 |
| Barriers to providing nutrition care for patients with cancer, n (%) | ||||||||
| The time required to provide nutrition care for these patients exceeds my capacity | 105 (39.2) | 67 (37.0) | 38 (44.2) | 0.262 | 57 (40.7) | 46 (38.0) | 2 (33.3) | 0.864 |
| Lack of training in the area of patients with cancer | 203 (75.7) | 139 (76.8) | 64 (74.4) | 0.671 | 91 (65.0) | 107 (88.4) | 5 (83.3) | <0.001 g* |
| Training during working | 85 (31.7) | 56 (30.9) | 29 (33.7) | 0.648 | 47 (33.6) | 36 (29.8) | 2 (33.3) | 0.801 |
| Lack of multidisciplinary team support experienced in managing patients with cancer | 94 (35.1) | 63 (34.8) | 31 (36.0) | 0.843 | 47 (33.6) | 45 (37.2) | 2 (33.3) | 0.826 |
| Insufficient handover from referring medical professionals | 55 (20.5) | 34 (18.8) | 20 (23.3) | 0.395 | 32 (22.9) | 21 (17.4) | 1 (16.7) | 0.529 |
| Working with patients with cancer makes me anxious and stressed | 15 (5.6) | 10 (5.5) | 5 (5.8) | 1.000 | 8 (5.7) | 5 (4.1) | 1 (16.7) | 0.379 |
| Limited access to up-to-date research and guidelines on managing patients with cancer | 115 (42.9) | 75 (41.4) | 40 (46.5) | 0.434 | 61 (43.6) | 51 (42.1) | 3 (50.0) | 0.917 |
| Insufficient resources and tools for effective nutrition counseling | 104 (38.8) | 74 (40.9) | 30 (34.9) | 0.347 | 49 (35.0) | 53 (43.8) | 2 (33.3) | 0.334 |
| Lack of clear guidelines for the nutritional management of patients with cancer | 58 (21.6) | 43 (23.8) | 15 (17.4) | 0.242 | 25 (17.9) | 31 (25.6) | 2 (33.3) | 0.252 |
| Limited nutrition/dietetic staff | 131 (48.9) | 92 (50.8) | 39 (45.3) | 0.403 | 68 (48.6) | 60 (49.6) | 3 (50.0) | 0.986 |
| Frequent staff rotation | 61 (22.8) | 46(25.4) | 15 (17.4) | 0.147 | 35 (25.0) | 26 (21.5) | 0 (0) | 0.165 |
| Lack of equipment resources, e.g., computer access, electronic medical record | 55 (20.5) | 36 (19.9) | 19 (22.1) | 0.677 | 28 (20.0) | 26 (21.5) | 1 (16.7) | 0.928 |
| Difficult procedures for reimbursement of training fees | 58 (21.6) | 39 (21.5) | 19 (22.1) | 0.919 | 32 (22.9) | 26 (21.5) | 0 (0) | 0.218 |
| A part-time nutritionist/dietitian position | 17 (6.3) | 11 (6.1) | 6 (7.0) | 0.779 | 7 (5.0) | 8 (6.6) | 2 (33.3) | 0.021 j** |
| Inappropriate salary according to qualification and experience | 33 (12.3) | 22 (12.2) | 11 (12.8) | 0.883 | 21 (15.0) | 11 (9.1) | 1 (16.7) | 0.326 |
| Distance to work from home is too far | 8 (3.0) | 6 (3.3) | 2 (2.3) | 1.000 | 7 (5.0) | 1 (0.8) | 0 (0) | 0.095 |
| Implementing a new licensing system (Law of The Republic of Indonesia Number 17, 2023 and Circular Letter Number HK.02.01/MENKES/6/2024) | 26 (9.7) | 21 (11.6) | 5 (5.8) | 0.136 | 17 (12.1) | 9 (7.4) | 0 (0) | 0.317 |
| Other | 7 (2.6) | 3 (1.7) | 4 (4.7) | 0.217 | 4 (2.9) | 3 (2.5) | 0 (0) | 0.836 |
| Enablers to providing nutrition care for patients with cancer, n (%) | ||||||||
| The time required to provide nutrition care for these patients is adequate | 144 (53.7) | 98 (54.1) | 46 (53.5) | 0.920 | 74 (52.9) | 67 (55.4) | 3 (50.0) | 0.903 |
| Easy/comfortable access to training | 172 (64.2) | 117 (64.6) | 55 (64.0) | 0.913 | 86 (61.4) | 84 (69.4) | 2 (33.3) | 0.118 |
| Day off for training – workload covered while training | 95 (35.4) | 61 (33.7) | 34 (39.5) | 0.352 | 47 (33.6) | 46 (38.0) | 2 (33.3) | 0.751 |
| Support from an experienced multidisciplinary team in managing patients with cancer is available | 141 (52.6) | 95 (52.5) | 45 (52.3) | 0.980 | 78 (55.7) | 61 (50.4) | 2 (33.3) | 0.432 |
| Dietitian referrals are available in a timely manner | 49 (18.3) | 30 (16.6) | 19 (22.1) | 0.276 | 31 (22.1) | 17 (14.0) | 1 (16.7) | 0.236 |
| Working with patients with cancer keeps me motivated | 105 (39.2) | 64 (35.4) | 40 (46.5) | 0.081 | 57 (40.7) | 42 (34.7) | 5 (83.3) | 0.047 k*** |
| Easy/comfortable access to up-to-date research and guidelines on managing patients with cancer | 105 (39.2) | 68 (37.6) | 36 (41.9) | 0.502 | 48 (34.3) | 56 (46.3) | 0 (0) | 0.007 l*, b*** |
| Adequate resources and tools for effective nutrition counseling | 116 (43.3) | 75 (41.4) | 41 (47.7) | 0.337 | 54 (38.6) | 60 (49.6) | 2 (33.3) | 0.177 |
| Clear hospital guidelines for nutrition care for patients with cancer | 123 (45.9) | 81 (44.8) | 41 (47.7) | 0.654 | 59 (42.1) | 60 (49.6) | 4 (66.7) | 0.286 |
| Adequate nutrition/dietetic staff. | 122 (45.5) | 81 (44.8) | 41 (47.7) | 0.654 | 63 (45.0) | 57 (47.1) | 2 (33.3) | 0.777 |
| No staff rotation (retain expertise) | 46 (17.2) | 33 (18.2) | 13 (15.1) | 0.529 | 32 (22.9) | 14 (11.6) | 0 (0) | 0.017 m* |
| Adequate equipment resources, e.g., computer access, electronic medical records. | 116 (43.3) | 52 (28.7) | 31 (36.0) | 0.227 | 44 (31.4) | 38 (31.4) | 1 (16.7) | 0.717 |
| Simple procedures for reimbursement of training fee | 43 (16.0) | 28 (15.5) | 14 (16.3) | 0.865 | 18 (12.9) | 22 (18.2) | 3 (50.0) | 0.037 n** |
| A full-time nutritionist/dietitian posit | 50 (18.7) | 33 (18.2) | 17 (19.8) | 0.764 | 31 (22.1) | 18 (14.9) | 1 (16.7) | 0.318 |
| Appropriate salary according to qualification and experience | 64 (23.9) | 43 (23.8) | 20 (23.3) | 0.928 | 32 (22.9) | 28 (23.1) | 3 (50.0) | 0.365 |
| Reasonable distance to work from home | 32 (11.9) | 21 (11.6) | 10 (11.6) | 0.995 | 15 (10.7) | 15 (12.4) | 2 (33.3) | 0.243 |
| Other | 5 (1.9) | 2 (1.1) | 3 (3.5) | 0.332 | 2 (1.4) | 3 (2.5) | 0 (0) | 0.737 |
| Resources for managing nutrition care | ||||||||
| I have adequate and accessible resources for managing nutrition care for patients with cancer (e.g., education materials, training, office space, access to electronic medical records, access to nutrition care forms) | 8 (7–9) | 8(7–9) | 8(7–9.5) | 0.683 | 8(8–10) | 8(7–9) | 8.5(8–9.25) | 0.212 |
Bold indicates p < 0.05. *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; b p = 0.034;d p = 0.003; g p = <0.001; i p = 0.018; j p = 0.045; k p = 0.026; l p = 0.048; m p = 0.017; n p = 0.039; 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.