Internet of Things-Enabled Pulmonary Rehabilitation for Advanced Lung Cancer Patients Receiving Chemotherapy: A Qualitative Study of Healthcare Professional and Patient Perspectives

Abstract

Objective

This study aimed to explore healthcare professionals’ and patients’ perceptions and experiences of Internet of Things (IoT)-enabled pulmonary rehabilitation (PR) among advanced lung cancer patients undergoing chemotherapy, to provide evidence-based references for the development and optimization of standardized, targeted IoT-based PR intervention programs for this patient population.

Methods

A qualitative descriptive design was adopted. Semi-structured one-on-one interviews were conducted with healthcare professionals and advanced lung cancer patients who received chemotherapy. The team discussion established the framework for a semi-structured interview focusing on the Restricted implementation, needs, vision, and implementation of IoT-enabled PR. All interview data were systematically collected, sorted, and analyzed thematically.

Results

A total of 18 healthcare professionals and 15 advanced lung cancer chemotherapy patients were enrolled in this study. The results revealed that PR implementation for patients with advanced lung cancer was generally neglected in clinical practice. Both participant groups exhibited insufficient professional cognition, prevalent misconceptions about pulmonary rehabilitation, and a lack of unified, standardized operating procedures for the clinical application of IoT-PR. Participants universally emphasized that individualized IoT-PR schemes and sustained social support were core guarantees of effective rehabilitation. Additionally, most participants held positive attitudes toward IoT-enabled PR, recognizing its unique advantages in improving rehabilitation convenience and providing comprehensive, whole-course rehabilitation guidance for patients.

Conclusion

Pulmonary rehabilitation for advanced lung cancer chemotherapy patients is currently underrecognized by both clinical staff and patients. The innovative IoT-enabled PR model integrates the hierarchical medical resources of tertiary hospitals, secondary hospitals, and community health institutions, enabling seamless integration of hospital- and home-based rehabilitation services, thereby complementing and expanding traditional offline PR modes. It is essential to strengthen professional publicity and education to improve cognition of IoT-PR, establish standardized and individualized rehabilitation protocols, and fully leverage the technical advantages of the IoT. These targeted improvements can effectively promote the standardized popularization and clinical application of PR in advanced lung cancer chemotherapy populations.

Introduction

Lung cancer is the leading cause of cancer-related death in China,¹ and it was estimated that in 2022, China recorded approximately 1.06 million new lung cancer cases and 733,300 deaths, respectively.² The lack of adequate means of early detection has led to the majority of lung cancer patients being diagnosed at an advanced stage. Due to the atypical early symptoms of lung cancer, about 30% of patients are diagnosed at an advanced stage, leading to limited treatment options.³ Despite novel targeted therapy emerging in recent decades, chemotherapy remained a cornerstone in the treatment of lung cancer for those patients with driver mutation-negative or targeted therapy failure.⁴ However, cytotoxic drugs inevitably brought out a short-term decline in physical function and multi-system dysfunction. They aggravated existing symptoms in lung cancer patients, such as shortness of breath, fatigue, pain, weight loss, etc,^5–7 leading to substantial deterioration in patients’ quality of life.

Pulmonary rehabilitation (PR) is a multidisciplinary intervention for patients with symptoms related to compromised pulmonary function, including exercise training, education, and behavioural changes. It is an evidence-based therapy for patients with respiratory disorders and is well established in COPD, pulmonary hypertension, and interstitial lung diseases.⁸ While for lung cancer, more and more evidence supported that PR therapy at home or hospital had a positive role in the lung cancer comprehensive treatments, and previous studies had shown that PR significantly alleviated clinical symptoms, improved physical functions, and enhanced muscle strength in lung cancer patients receiving chemotherapy.^9,10

Prevent complications, enhance physical function, restore self-confidence, improve quality of life, and facilitate patients’ societal reintegration.^11,12 Pulmonary rehabilitation also alleviates respiratory symptoms¹³ and improves quality of life.¹⁴ One study further demonstrated that pulmonary rehabilitation reduced dyspnea severity by 93%, decreased fatigue-related symptom intensity by 73%, and diminished pain levels by 74%.¹⁵ Moreover, it has been shown to be cost-effective for COPD and lung cancer.¹⁶ Accordingly, PR has been recommended as an important component of comprehensive care for patients with advanced lung cancer.¹⁷

Despite its clinical value, the implementation of PR in China remains limited. Previous studies have demonstrated that even among the core patient population with chronic obstructive pulmonary disease (COPD), the clinical implementation rate of pulmonary rehabilitation has remained consistently low.¹⁸ Highlighting a systemic gap in respiratory rehabilitation services. The situation in lung cancer is likely more difficult, particularly among advanced-stage patients who are not routinely referred to rehabilitation services. Existing PR services in China are predominantly concentrated in perioperative settings, while patients undergoing chemotherapy in the advanced stage often have limited access to structured rehabilitation support. Meanwhile, several studies focused on PR in peri- and post-operative lung cancer patients;¹⁴ there is limited research on patients with advanced-stage lung cancer.¹⁹

Multiple factors contribute to the underutilization of PR. Research demonstrates considerable heterogeneity in pulmonary rehabilitation knowledge among treating clinicians, which directly impairs patient engagement and referral adherence.^20,21 Similarly, barriers to home-based rehabilitation, inefficiencies in pulmonary rehabilitation services, suboptimal organisational structures, and insufficient awareness of pulmonary rehabilitation collectively contribute to low implementation rates.^22,23 These challenges highlight the need for innovative, scalable rehabilitation models that extend pulmonary rehabilitation beyond traditional hospital settings.

In recent years, the rapid development of digital health technologies has provided new opportunities to address these limitations. The Internet of Things (IoT) is a technological system that enhances connectivity between humans and objects and has been shown to facilitate innovative rehabilitation systems while advancing the field of e-health. IoT technology enables continuous physiological monitoring, real-time data transmission, personalised feedback, and remote clinical support, thereby providing novel rehabilitation solutions for home-based patients.^24,25 Compared with conventional telemedicine, IoT-enabled rehabilitation offers continuous data collection and personalised management, making it particularly suitable for long-term home-based pulmonary rehabilitation. As telemedicine continues to evolve, it has accumulated increasingly robust evidence regarding the efficacy of online psychological interventions, home-based remote monitoring, web- and computer-based smoking cessation programs, remote psychiatry services, home-based remote health management for diabetes, heart disease, and chronic obstructive pulmonary disease, as well as oncology interventions.²⁶ Recent systematic evidence demonstrates that remote rehabilitation significantly improves physical function, dyspnea, anxiety and depression, as well as quality of life in patients with chronic respiratory diseases and certain post-COVID conditions, with overall acceptable safety profiles.^27,28

Systematic reviews indicate that digital pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD) effectively promotes physical activity, enhances exercise capacity, detects disease progression, and improves quality of life.²⁹ Emerging evidence also suggests that IoT-enabled pulmonary rehabilitation is feasible, safe, and acceptable for patients undergoing lung cancer surgery, with potential benefits in improving exercise adherence, patient satisfaction, and programme completion. However, most studies have focused on perioperative populations, whereas evidence regarding patients with advanced lung cancer receiving chemotherapy remains extremely limited.³⁰

To better understand the behavioural factors influencing the implementation of IoT-enabled pulmonary rehabilitation, a theoretical framework is required to guide data collection and analysis. The Theoretical Domains Framework (TDF) is a comprehensive behavioural framework that integrates constructs from multiple behaviour change theories into 14 domains, including knowledge, skills, beliefs about consequences, intentions, social influences, and environmental context and resources.³¹ The TDF has been widely used in qualitative healthcare research to identify determinants influencing healthcare professionals’ and patients’ behaviours and to inform the development of implementation strategies.

Given that the successful implementation of Internet of Things (IoT)-enabled pulmonary rehabilitation largely depends on the knowledge, perceptions, motivation, and behavioural engagement of both healthcare professionals and patients, the TDF provides an appropriate framework for understanding the factors that may facilitate or hinder its adoption. Applying a behavioural perspective can help identify modifiable barriers and facilitators and support the development of tailored implementation strategies.

Despite the growing body of qualitative literature on barriers to pulmonary rehabilitation and digital rehabilitation approaches, little is known about how healthcare professionals and advanced lung cancer patients perceive IoT-enabled pulmonary rehabilitation and the factors that influence their willingness to adopt such programmes. Previous qualitative studies primarily focused on barriers to pulmonary rehabilitation among patients with chronic respiratory diseases or perioperative lung cancer populations. Therefore, guided by the Theoretical Domains Framework, this study aimed to explore healthcare professionals’ and patients’ perceptions, experiences, barriers, and facilitators regarding the implementation of IoT-enabled pulmonary rehabilitation, thereby providing evidence to support the design, optimisation, and future implementation of such interventions.

Methods

Design

This study used a descriptive phenomenological qualitative research methodology to collect data through one-on-one, face-to-face, semi-structured interviews. The data collection period was from 1 December 2023 to 30 March 2024, and a total of 33 valid interviews were completed. The semi-structured interview guide was developed based on a systematic review of the literature, discussions within the research team, and the Theoretical Domains Framework (TDF). The TDF informed the development of interview questions by guiding exploration of key behavioural determinants relevant to pulmonary rehabilitation and IoT-enabled rehabilitation, including participants’ knowledge and understanding of pulmonary rehabilitation, beliefs about its benefits and consequences, willingness to participate, perceived barriers and facilitators, social influences, and environmental and organisational factors affecting implementation. The specific interview framework is illustrated in Figure 1. To enhance the scientific rigor and feasibility of the outline, the research team conducted pre-interviews with two oncology patients; the data collected were used solely to refine the tool and were not incorporated into formal research analysis. After consolidating feedback from the pre-interview participants and incorporating revision suggestions from three senior nursing experts (with associate senior or higher titles), the interview outline was finalized through a literature review and team discussion.

Figure 1.

Semi-structured interview questions.

All researchers involved in the interviews received special training in the standardisation of semi-structured interviews to ensure consistency in the interview process, questioning protocols, and communication. All interviews were conducted with the written informed consent of the study participants, and audio recordings were kept throughout the interviews. The time and venue of the interviews were chosen by the respondents themselves, thereby ensuring the privacy and comfort of the interviews. Within 24 hours after the interview, two researchers (Jun Tian and Yuyao Chen) transcribed and cross-checked the audio recordings to ensure the authenticity and integrity of the text. Throughout the study, the Consolidated Criteria for Reporting Qualitative Research (COREQ) were followed.³²

Participants and Settings

Patients, doctors, and nurses were recruited using purposive sampling from a single healthcare centre. The inclusive criteria for patients were as follows: i. lung cancer patients diagnosed as stage III~IV according to the 8th edition of IASLC, ii. receiving chemotherapy or having previously received chemotherapy, iii. Age >18 years; IV. agreed to join the study. The exclusive criteria for patients are as follows: unable to cooperate with our interview. The inclusion criteria for doctors and nurses are specified in lung cancer healthcare; the exclusion criterion is < 1 year of experience in lung cancer.

Fifteen patients with advanced lung cancer on chemotherapy, 7 oncologists, and 11 oncology nurses were finally included in this study, and no study participant was dislodged or withdrew throughout the study. All respondents were interviewed independently only once, and interview lengths ranged from 20 to 45 minutes, with an average of 30 min. In this study, information saturation was used as the termination criterion for data collection, ie, data collection was discontinued when no new research themes emerged from the three consecutive interviews, when no new ideas were added to the content of the interviews, and when there was a high degree of repetition of previously coded information. The overall data collection period for this study was 4 months, which was sufficient to conduct qualitative mining and in-depth interpretation of respondents’ genuine feelings and caregiving experiences. However, this study collected only cross-sectional data over a single period, which may not reflect seasonal differences in patients’ physical symptoms, disease progression, and chemotherapy cycles, a limitation of this study.

In accordance with the COREQ requirements for qualitative research reports, this study fully disclosed the researchers’ identities, any inherent relationships with the research subjects, and the bias control strategy. The core researchers of this study, Tian Jun and Chen Yuyao, are both in-service clinical nurses in the same oncology department and work in the study’s data collection unit. Therefore, the research team had a routine clinical nurse-patient consultation relationship with the enrolled lung cancer patients, and had a colleague relationship with the interviewed healthcare workers in the same department and unit, which had the potential for information bias and interpretation bias due to inherent clinical thinking, interpersonal familiarity, and social expectation effects.

Reflexivity was maintained throughout the study. To mitigate the potential biases mentioned above and ensure the objectivity and credibility of the study, this research implemented a multi-dimensional quality control scheme: ①Prior to the interview, all participants must be fully informed that this is a purely academic study and that there are no right or wrong answers;patients’ responses would not affect the quality of their clinical treatment or care, and healthcare professionals’ answers would not impact their individual performance appraisals, thereby eliminating any tendency among respondents to provide answers designed to please the interviewer; ②The principle of interview separation was strictly enforced: researchers did not interview in-patients under their direct care, thereby avoiding any interview-guiding bias that might arise from familiarity with the nurse-patient relationship; ③A routine team reflection mechanism was established, with regular reflection meetings held throughout the study to proactively identify and correct any subjective interference in interview guidance, text interpretation and thematic coding resulting from the inherent experience of the clinical specialty; ④Adopt a coding model involving independent coding by two researchers, cross-verification and expert arbitration to avoid bias arising from the subjective judgements of a single individual; ⑤Through a member verification system, all preliminary analysis results are fed back to the interviewees for verification and correction, thereby maximising the accuracy of the interviewees’ true experiences and ensuring the authenticity and reliability of the research findings.

Data Analysis

We analysed our data according to a previous study.³³ In detail, two researchers (Xiang Liu and Zhenggang Zhu) independently performed the initial open coding. They identified and extracted meaningful statements regarding the attitudes and coping strategies of healthcare workers and patients towards PR knowledge. Recurring ideas were summarised, and open coding was conducted by presenting the respondents’ original words whenever possible. To resolve disagreements and achieve intercoder reliability, the two researchers first coded the data separately, then compared their coding results. Controversial codes were recorded, and the two researchers discussed each discrepancy. When consensus could not be reached through discussion, external expert opinions were sought to determine the final code. All coding discrepancies and resolution processes were documented. In the axial coding stage, the two researchers first summarised and synthesised the free nodes generated from open coding. Other research team members then proposed modifications individually. All revisions were discussed collectively until a consensus was reached, and the corresponding attributes were elaborated. In the selective coding stage, the relationships among the attributes were explored and established, forming core attributes that could uniformly cover all lower-level attributes. The core categories were thus identified. For data verification and to ensure the timeliness and authenticity of qualitative data, interviewers (Jun Tian and Yuyao Chen) transcribed all audio recordings verbatim within 24 hours of each interview. The transcribed texts were repeatedly cross-checked against the original audio files, and member checking was conducted further to verify the accuracy and completeness of the qualitative data. Representative participants, including two patients, one doctor, and two nurses, were invited to review their original interview transcripts. All participants confirmed that the transcribed content was consistent with their actual interview responses, and no revision suggestions were made. After completing preliminary thematic analysis, the aggregated research findings were further validated by both participants and coders to enhance the credibility and trustworthiness of the final results. The overall research process is illustrated in Figure 2.

Figure 2.

Flow diagram.

Results

Our study interviewed 15 patients with advanced lung cancer receiving chemotherapy, 7 doctors, and 11 nurses who met the inclusion and exclusion criteria. The detailed information of the participants is shown in Table 1. The themes between healthcare professionals and patients were very similar. Therefore, a synthesis of themes exploring current pulmonary rehabilitation practice and perceptions of incorporating pulmonary rehabilitation-related conversations into care was presented. Three themes with ten sub-themes emerged: current situation (four sub-themes), needs and vision (three sub-themes), and implementation (three sub-themes).

Table 1.

Participant Demographic Characteristics at Time of Interview

Patients Demographic (n = 15)	Mean (Range)/Number of Participants
Age	62.13 (43–80)
Gender
Male	12
Female	3
Time since diagnosis (years)	2.47 (1–6)
Stage at diagnosis (same as current stage)
IIIA-C	8
IV	7
Education
Primary schools	2
Completed secondary (year 9)	6
Senior high school	4
University	3
Insurance
Workers’ medical insurance	10
New rural cooperative medical insurance	5
Healthcare professionals (n = 18)
Age	35.44 (26–51)
Time at healthcare service (years)	12.44
Gender
Male	4
Female	14
Role category
Doctor	7
Nurse	11
Highest level of education
Bachelor’s degree	11
Master’s degree	3
Doctoral degree	4

Current Situation

Cognitive Differentiation

Respiratory physicians in this department showed a high level of awareness of pulmonary rehabilitation (PR): five of the seven doctors reported that they would communicate with rehabilitation physicians to help patients in need.

D1: I would open a consultation with the rehabilitation department for the patient, and then work out a PR program with the rehabilitation doctors.

In contrast, the two trainee doctors rotating through the department had a shallow understanding, stating that they had only heard of PR at large academic conferences but had never implemented it. The nurses’ group (eight of 11 nurses) had a poorer understanding than the doctors and believed that implementing PR would increase their workload.

N1: I wouldn’t initiate the mission because the patient didn’t take the initiative to ask us, and the patient was discharged a day after chemotherapy.

Six nurses explicitly cited work overload, and there was no appraisal system for PR in the department. A negative case emerged: one attending physician (D7) admitted never having considered PR for lung cancer patients.

D7: Never thought about this aspect of pulmonary rehabilitation. My knowledge of PR is limited to traumatic brain injury, sputum evacuation, and infections. I have never thought that oncology patients can do PR. There is no special preaching and explanation for patients with lung cancer.

D3 similarly stated: No contact with PR, and I have never heard of PR.

This differentiation between respiratory attendings, trainee doctors, and nurses suggests that knowledge and implementation of PR vary substantially by provider role and experience.

Lack of a Standard Platform for Implementing Assessments

When asked about people’s attitudes towards PR, 12 out of 18 healthcare workers and 8 out of 15 patients said they lacked a standardised and systematic platform for it.

N7: They are not skilful in their propaganda process and do not have systematic knowledge and information on the PR mission. Create systematic and comprehensive information.

N3: People as a whole don’t pay attention to it, and the hospital doesn’t provide a relevant learning platform. Everyone is very busy during working hours, and healthcare workers themselves don’t have comprehensive knowledge of PR, nor do they have systematic mastery of it. How to teach patients when you don’t have much mastery yourself.

D5: Nowadays, people pay a lot of attention to the popularisation of science and get it from various ways, but there is no formal way to get useful information. The reason it cannot be adhered to is that people do not know how to do it, and it is not standardised.

Emphasising Treatment Over Rehabilitation

Our results show that both health workers and patients emphasised drug therapy over rehabilitation, especially respiratory rehabilitation. All seven physicians and 12 of the 15 interviewed patients framed anti-cancer drug therapy as the unequivocal primary clinical intervention for advanced lung cancer, with PR viewed as a secondary, optional add-on. For instance,

D7: I know that PR is important, but I think for lung cancer patients, we should give priority to drug therapy.

And patients could not totally recognise the importance of this.

P13 said, I think that drug is much more important than rehabilitation, and I am not sure that I can get benefits from it, especially suffering from pain and vomiting after chemotherapy.

Poor Patient Willingness

During chemotherapy cycles, patients tended to be reluctant to participate in pulmonary rehabilitation exercises because they felt worried about the side effects of chemotherapy, and PR could not relieve them or even aggravate them.

N3 said that: For those patients with remote metastasis, because of the discomforts the diseases bring about, they are intolerant of drug therapy, let alone PR

And patients

P1: I felt very uncomfortable after chemotherapy, and I do not want to move at all.,

P11: I occasionally took oxygen inhalation and walked around for a few hours a day, while apart from these, I would not like to take jogging, hiking or yoga…

P9 initially expressed a fatalistic view: My condition is so advanced that whether I take action or not it’s the same, I’m going to face death eventually and it’s going to end up that way, so it doesn’t matter if I do pulmonary rehabilitation or not.

Needs and Vision

Patient Ideas and Needs

After explaining the benefits of PR to patients, the interviewees inquired about their thoughts and needs on PR. 10 of 15 patients changed their expressed willingness. Their initial reluctance was not fixed but responsive to information.

P9, who had earlier said she was going to die anyway,

responded differently after a nurse explained that PR could help maintain basic physical function and alleviate breathlessness:

I didn’t know PR could make breathing easier. The nurse told me that even simple movements like arm raises and sitting on the bedside count as rehabilitation. She said it might not cure me, but it could help me feel less suffocated and keep my muscles from wasting. If it really helps me feel less suffocated, maybe I should give it a try. At least it might make my remaining days more bearable.

Another patient (P5) described a stepwise process:

At first, I thought exercise was useless because chemotherapy already drained me. But after the doctor explained that gentle movements are also a form of PR, I started with five minutes a day. Now I can do ten minutes without feeling worse. Knowing that I don’t have to do intense exercise made me less scared.

Patients also expressed preferences for light, mild exercises.

P2 said: …PR can make me breathe freely, and I will try to stretch my upper limbs regularly, and try to dance every day…I think light or mild exercise is more suitable for me.

P7: I will take PR at home. I think I will try running every morning, and I think swimming is good for the lungs and for my chest, but I would not like to do running and swimming during chemotherapy.

Simplicity and convenience were essential:

P10: It should be simple and convenient, and no special recovery instructions required.

Transformation of Rehabilitation Models

Through interviews, it was found that both healthcare professionals and patients hope to implement PR at home rather than be discharged and have PR interrupted.

N2: Chemotherapy patients spend more time at home, so home-based rehabilitation has become an important trend. How to ensure consistency between in-hospital and out-of-hospital PR is a key focus of our consideration.

In fact, many patients hope to continue receiving attention from healthcare professionals after discharge.

P1: I need one-on-one guidance from healthcare professionals at home because I only stay in the hospital for a few days, and most of my time is spent at home. I would be very grateful if healthcare professionals could teach me how to perform PR at home.

D1: We need to inform patients that active rehabilitation is more effective than passive rehabilitation and encourage them to participate throughout the PR process actively. Of course, we also need many clinical cases, and even utilise technological tools to assist patients in implementing PR, as this would be more persuasive.

Diverse Social Supports

We found that during the PR process, diverse social supports from family, health workers, patients, and the communities were necessary for patients.

P2: If someone, doctors or nurses, could lead us to take PR motions, I think it would be a great help.

P11: My husband and my neighborhood are always encouraging me to do some exercise, and I think they can give me sufficient support in PR.

D2: Patients can learn about PR from each other, and it is much more effective; moreover, Social workers and communities can provide the necessary facilities, equipment, and guidance of PR for the patients.

Health workers, family, and community support provided facilities assistance and spiritual encouragement.

Implementation

Systematic PR Plans

PR is not limited to rehabilitation exercises but also includes assessment, follow-up, feedback, etc.,³⁴ Given that there is no standard PR process for advanced lung cancer, all healthcare workers and patients agreed on the importance of systematic PR plans.

D5: In my opinion, there should be a standard process first and study guides, or through a group lesson given by a teacher who has learnt the system, then we can do as the protocol.

D7: PR is a complex treatment method, when we take PR into practice, patients, doctors, nurses and rehabilitation therapist should be assembled to develop a suitable plan, including evaluation by certain scales, detailed and step-by-step approach of rehabilitation exercise, and the equipment and facilities needed in PR.

P6: “I do believe in a standard process, it is important, because a standard process will ensure effects of PR, and avoid errors in the rehabilitation”.

Outpatient Digital Pulmonary Rehabilitation

Outpatient settings are the core clinical scenario for PR in patients undergoing chemotherapy for lung cancer. Providing continuous and effective PR management for outpatients has long been a significant challenge for clinicians. Five doctors and four nurses endorsed digital solutions.

D4: A user-friendly PR app can be adopted to establish a communication bridge between medical staff and patients, addressing the current situation where patients discontinue PR upon discharge, and expanding the scope of doctors’ monitoring of patients’ health management.

D1: In this AI era, doctors can use IoT devices and data to create personalised rehabilitation prescriptions for out-of-hospital patients, including medication, exercise, smoking cessation, nutrition, and psychological support. Online interventions or patient communication can be conducted to adjust rehabilitation plans.

One dissenting view emerged: a senior nurse (N6) expressed concern that “not all elderly patients can use smartphones or apps; we might exclude the most vulnerable group if we rely too much on digital tools”. This counterpoint highlights the need for hybrid models. Furthermore, one patient (P4) stated: “I don’t trust online procedures; I’m afraid of being scammed out of my money, and I’d much rather have a nurse ring me directly.” With all the high-tech stuff around these days, it’s hard for me to tell what’s real and what is not.” These negative examples indicate that digital solutions have not been universally accepted.

Internet-Based/Digital Rehabilitation Healthcare

Internet-based digital healthcare has achieved solid evidence in PR. Transportation difficulties, insufficient rehabilitation resources, and other health problems often impede the use of traditional face-to-face PR methods. Patients, therefore, need more efficient, sustainable, and convenient PR technology. Five of 15 patients explicitly refused traditional telephone follow-ups, stating that, due to their busy work schedules, healthcare staff rarely had time to listen to patients’ detailed concerns, merely offering perfunctory greetings and superficial routine inquiries.

P8: It’s good to set up a small video public account and teach people how to do it by posting videos and lessons online every day. There is a professor in your hospital who sends out health medicine videos every day. I watch them every day. Don’t call, there’s no point in calling, or set up a WeChat group and send small WeChat videos.

P12: Create a hospital mini-program. Enter the patient’s ID number, click into the personal center, which has doctor’s orders, such as reviewing blood routine after a week, which also has exercise punch cards, so that the patient can click in and stick to the punch card to urge the patient.

Beyond convenience, patients valued specific IoT-enabled functions.

P12 elaborated: The punch card makes me feel like someone is watching my progress. Otherwise, I would easily give up. Also, if the app could show my daily step count and remind me when I have been inactive for too long, that would help me stay on track.

Another patient (P3) noted:

I would like a function that records my breathing rate and tells me whether I am performing the exercises correctly. Watching a video is not enough—I need feedback on my technique.

N3 highlighted data extraction as a key benefit for remote monitoring: When patients are discharged, they can continue exercising using video tutorials and connected devices that extract patient data. This allows me to monitor them from home and gives me peace of mind knowing that I won’t miss a deteriorating case.

Thus, what patients and nurses valued most in digital PR was not just convenience, but accountability through progress tracking, real-time feedback on exercise performance, data-driven remote monitoring, and the psychological reassurance of being supervised even from a distance.

Discussion

This qualitative study, involving patients with advanced lung cancer, physicians, and nurses from a tertiary cancer centre in China, revealed three key findings. First, pulmonary rehabilitation (PR) in this population remains pervasively neglected, a phenomenon driven by multi-layered barriers spanning patient misconceptions, healthcare provider knowledge deficits, and systemic absence of standardized protocols. Second, despite this neglect, all stakeholder groups acknowledged the potential value of PR and expressed conditional openness to technology-supported home-based models, primarily because chemotherapy patients spend most of their treatment intervals outside hospital settings. Third, participants’ attitudes toward digital PR were markedly ambivalent: while convenience and real-time monitoring were viewed as attractive, substantial concerns about platform credibility, digital accessibility, and inadequate professional supervision tempered their enthusiasm. Together, these findings suggest that addressing PR underutilisation in advanced lung cancer requires not merely technological innovation, but fundamental improvements in PR awareness, service standardization, and sustainable oversight mechanisms. The findings of this study can be interpreted through the lens of the Theoretical Domains Framework (TDF). Several identified themes correspond closely to key TDF domains. Insufficient awareness and understanding of pulmonary rehabilitation among healthcare professionals and patients reflected deficits in the Knowledge domain. The common perception that pharmacological treatment should take precedence over rehabilitation corresponded to Beliefs about Consequences. Reluctance to participate in pulmonary rehabilitation during chemotherapy reflected challenges related to Intentions and behavioural motivation. The importance of support from healthcare professionals, family members, peers, and communities highlighted the influence of Social Influences. Furthermore, the lack of standardized rehabilitation pathways, insufficient training opportunities, and limited rehabilitation resources reflected barriers within the Environmental Context and Resources domain. Together, these findings suggest that future implementation strategies should target multiple behavioural determinants simultaneously to improve the adoption and sustainability of IoT-enabled pulmonary rehabilitation.

The pervasive neglect of PR in advanced lung cancer identified in our interviews aligns with and extends prior epidemiological observations. The reported PR utilisation rate of only 0.8% in COPD populations in China³⁵ suggests that respiratory rehabilitation remains a low-priority area across pulmonary diseases, with lung cancer representing an even more overlooked subgroup. Secondly, knowledge of PR among PR among healthcare providers was poor. A survey of about 10,000 nurses indicated that knowledge of PR among nurses, including those in the respiratory department, was far from satisfactory.³⁶ For physicians, limited knowledge and awareness of PR were associated with barriers to implementing PR in pulmonary disease management.³⁷ In addition, the lack of a standard process might impede doctors from popularising knowledge of PR.³⁸ Thirdly, we found that, apart from limiting physical activities due to patient discomfort, the mistaken belief among patients and health workers that drug treatments outweigh rehabilitation adversely affected the application of PR, which could be an important factor influencing the willingness to practice PR. Only through improvements in PR knowledge among health workers, changes in PR conception among patients, and the establishment of a standard process for PR of advanced lung cancer can the situation of PR in advanced lung cancer be enhanced in China.

Regarding ideas for implementing PR in lung cancer, our results revealed the need for a standardised process and personalised, targeted instruction. Many studies focused on post- or pre-operation PR, such as symptom-limited aerobic exercise, breathing exercises, shoulder and arm exercises, and educational sessions conducted to improve quality of life and ameliorate symptoms after operation.³⁹ Also, several studies have found that PR, such as breathing exercises, can improve lung function, reduce symptoms, and enhance quality of life for patients.^40,41 However, given that PR is a multidimensional intervention, assessment and implementation toolkits are still needed to guide PR practice in advanced lung cancer. We also identified that patients need customised PR services and social support. On account of the heterogeneity of advanced lung cancer, such as different symptoms, physical fitness, treatment plan, and tolerance degree, an individualised PR plan is more applicable to these patients. Before telerehabilitation and a home-based personal plan, a comprehensive evaluation was a prerequisite.⁴² While social support from informal carers and peer support may help maximise the utilisation of PR,²⁶ our interview results suggest that the benefits of social support may be attributable to motivational encouragement and behavioural assistance.

Participants held dual attitudes toward intelligent PR technologies, involving both positive expectations and practical concerns. Home-based, IoT-assisted PR was widely regarded as a promising approach to address insufficient continuity of in-hospital rehabilitation, and participants consistently called for standardised, systematic service mechanisms to support reliable digital PR delivery. Clinicians and nurses particularly highlighted that most chemotherapy patients spend the majority of their recovery time at home, leading to strong practical demand for continuous, accessible off-hospital rehabilitation guidance. From the patient perspective, post-discharge professional follow-up was identified as the most urgent unmet need. Empirically, home-based PR has been shown to improve rehabilitation adherence, quality of life, and respiratory symptoms among populations with chronic lung disease.⁴³ With the advent of artificial intelligence and the era of big data in the medical field, Wearable biosensing devices enable continuous, objective data collection, thereby supporting the assessment of PR in chronic respiratory diseases.^44,45 More advanced sensors and devices can be used for human safety monitoring.⁴⁶ Through such technologies, patients at home could engage in real-time monitoring of their own health data and early warning systems; IoT-based sensing systems could facilitate remote monitoring and alarm functions, with data transmitted to rehabilitation service providers to guide PR accordingly.⁴⁷

Indeed, our results showed that internet-based PR was more attractive due to its convenience compared with the traditional PR process in a medical centre. Moreover, we found that the advantages of internet-based PR were not only convenience, but also the multi-dimensional communication it provides. During the chemotherapy interval, patients could get various PR information, including videos, animations, articles, and give feedback to PR healthcare providers at home, which has been proven to be effective in COPD.⁴⁸ Also, internet-based PR can improve the self-management of lung function at home.⁴⁹ In recent years, internet-based technology has facilitated the application of PR. A meta-analysis indicated that internet-based PR increased compliance among patients with chronic lung disease. However, there was probably little to no difference between internet-based PR and conventional PR.⁵⁰ A seemingly contradictory finding that our qualitative findings can reasonably resolve, participants did not merely ask for “online access” to rehabilitation materials—they specifically demanded credible information sources, individualised prescription adjustment, and real-time professional oversight. Standalone internet platforms, which often deliver generic exercise videos or static educational content, may fulfil the “access” need but fail to address these deeper requirements for supervision and responsiveness. Thus, the modest clinical effect of existing internet-based PR may stem not from the irrelevance of technology, but from the inadequacy of current implementations in meeting stakeholders’ expectations for quality assurance and personalised support. Our findings suggest that future digital PR models should prioritise interactive professional engagement, dynamic progress monitoring, and individualised feedback over one-way information dissemination. This suggests that technological accessibility alone cannot drive rehabilitation effectiveness; instead, service standardization, continuous professional oversight, and structured hierarchical support are indispensable components currently lacking in digital PR models.

Building on participants’ expressed needs for continuous home-based follow-up and standardised rehabilitation guidance, a multi-tiered collaborative service framework may represent a promising avenue for future service design. Such a framework would need to address three foundational conditions identified in our study: standardised workflows to guide PR delivery across care settings, dedicated platforms to facilitate coordination and data sharing, and enhanced PR awareness among all healthcare providers through structured training. Structurally, this direction aligns with the principles of “primary care as the first point of contact,” “two-way referrals,” and “coordination between different levels”, emphasised in China’s tiered healthcare reform, and is also consistent with policies such as long-term prescriptions and remote guidance.^51,52 Our findings indicate that foundational conditions, standardised workflows, dedicated platforms, and enhanced PR awareness are prerequisites for any tiered implementation. Future research should therefore engage healthcare staff and patients in co-design, followed by feasibility testing and prospective trials to assess clinical effectiveness and cost-effectiveness before large-scale translation.

Limitations

There were still some limitations in our study: Firstly, our study is single-centre-based research, but as a typical lung cancer centre in a top hospital in China, the results are representative. Secondly, participants in our studies were limited to health workers specialised in lung cancer in a comprehensive hospital; doctors and nurses in primary care centres or other departments were not reached. Thirdly, the cross‑sectional design captures perceptions at a single time point and does not assess changes across chemotherapy cycles or seasons. Importantly, while participants expressed enthusiasm for digital PR solutions, the specific IoT‑based multi‑tiered architecture proposed in earlier drafts of this discussion has not been validated by participants and should be regarded as a hypothesis‑generating proposal rather than an evidence‑based finding. Future research should involve patients, caregivers, and clinicians in co‑designing such systems, followed by rigorous feasibility and efficacy trials. Although data saturation was achieved, the relatively small sample size and single-centre design may limit the transferability of the findings.

Conclusion

Through the quality study, we found that both patients and healthcare workers overlooked PR in advanced lung cancer, and that a lack of knowledge, misconceptions, and an absence of standard processes hindered its implementation. Apart from overcoming the above disadvantages, a personalised PR plan and the use of Internet-based technology could improve the situation of PR in advanced lung cancer. Integrating information technology within and beyond hospitals, based on the Internet of Things (IoT), is a challenge that all medical institutions are currently considering and striving to address. Nevertheless, consistent with participants’ feedback in our empirical findings, the large-scale adoption and sustainable implementation of IoT-enabled PR services still face prominent practical challenges. Notably, the study cohort spans a wide age range, from 43 to 80 years, with a mean age of 62 years. A considerable proportion of elderly patients experience notable digital divides and limited technological literacy, which constitute core obstacles to the widespread adoption of smart home-based pulmonary rehabilitation. Elderly patients often lack the skills to operate intelligent monitoring and rehabilitation equipment. They may also have limited ability to understand and follow remote rehabilitation guidance, potentially reducing adherence to and effectiveness of IoT-based PR interventions.

Despite these existing limitations, the integrated application of hospital-community-home information technology via the Internet of Things (IoT) remains an inevitable trend and key research focus for modern medical institutions to optimize chronic disease rehabilitation management. Accordingly, based on the findings of this qualitative study, we propose that future studies should develop and evaluate a comprehensive IoT-based pulmonary rehabilitation information management platform embedded within a tertiary hospital-secondary hospitals-community hospitals-home-based rehabilitation consortium model. This platform adopts standardized communication protocols, wearable physiological signal detection technology, and advanced architectural design. It strictly adheres to standardized clinical practice pathways to form a full-cycle PR service system that covers in-hospital treatment and out-of-hospital community and home rehabilitation. The platform can build systematic and standardized health data archives for patients, providing high-quality, reliable clinical data to support precise clinical decision-making and individualized rehabilitation management. Further targeted optimization for elderly patients’ digital adaptation needs will be required in subsequent platform iterations and promotion to mitigate digital divide barriers. Details are shown in Figures 3 and 4.

Figure 3.

Implementation status of pulmonary rehabilitation across tiered healthcare institutions within the medical alliance.

Figure 4.

IOT-Enabled Pulmonary Rehabilitation.

Implications for Rehabilitation

As an emerging healthcare service model, the “Internet of Things + Pulmonary Rehabilitation” framework establishes a four-stage pulmonary rehabilitation system for patients with advanced lung cancer undergoing chemotherapy, which aligns with the tiered rehabilitation model proposed in China. It can provide patients with adequate health education and management, enhance their exercise tolerance, and improve their quality of life. This article outlines three key points.

Enhancing awareness of pulmonary rehabilitation among healthcare workers and lung cancer patients, along with implementing standardized training, are crucial measures to promote its development. Both healthcare professionals and advanced-stage lung cancer patients in China generally exhibit low awareness of pulmonary rehabilitation. Additionally, resources and development in this field are unevenly distributed, with high-quality resources predominantly concentrated in large tertiary hospitals, while primary-level hospitals often lag. This limits patients’ rehabilitation options.

The application of IoT technology in pulmonary rehabilitation is a new opportunity: Using IoT to establish a “smart pulmonary rehabilitation” model enables remote monitoring, personalized program delivery, online education, and communication platforms. This overcomes transportation barriers, enhances patient compliance, and serves as an effective means to achieve integrated “hospital-community-home” management.

Establish a novel model of tiered collaborative medical alliance for pulmonary rehabilitation: This requires forming a pulmonary rehabilitation medical consortium led by tertiary hospitals, linking primary care facilities and households. By integrating multidisciplinary teams and implementing standardized training, remote consultations, and two-way referrals, this model ensures consistent quality and comprehensive expansion of pulmonary rehabilitation services.

Ethics Approval

The Ethics Committee of the Xiangya Hospital of Central South University (number 202312250) reviewed and approved this project. All procedures were conducted in accordance with the Declaration of Helsinki and relevant national regulations on biomedical research involving human subjects. Informed consent was obtained from all participants before enrollment, and data were anonymized to protect participant privacy. To protect participant privacy, all direct identifiers (names, contact details, and institutional affiliations) were removed during transcription. In the results section, participants are referred to by alphanumeric codes (eg, D1, N1, P1) solely to facilitate readers’ comprehension of the thematic analysis. The full, de-identified transcripts are stored separately from the code–identifier linkage key, which is password-protected and accessible only to the research team. This ensures that no individual participant can be re-identified from the published data or from the stored materials without authorized access.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

All authors of this study declare that they have no conflicts of interest relating to this study. Some authors are affiliated with the same hospital and share an institutional connection, which may lead to non-financial conflicts of interest or professional hierarchy bias. However, the study design, data collection, statistical analysis, interpretation of results, and manuscript preparation were all based on objective data and predefined research methods and were not unduly influenced by institutional affiliations, professional relationships, or factors related to professional hierarchy. All authors have reviewed and confirmed the above statement on conflicts of interest.