Research report: Swallowing exercise adherence in patients with head and neck cancer based on the dual-process model: a qualitative study

A qualitative study of 18 patients with head and neck cancer found that adherence to swallowing exercises emerged from interactions between automatic processes and reflective appraisal, rather than from a purely rational decision to follow treatment. Patients’ exercise experiences, habitual cues and routines, and emotional support mainly reflected system 1 processes, while reflections on dysphagia, available medical-service resources, benefits and risks, and discrepancies between expectations and perceived effects reflected system 2 processes. The descriptive qualitative study, published in Supportive Care in Cancer , examined patients who had experience with swallowing exercises.

Researchers purposively recruited participants from a nursing rehabilitation clinic at Hubei Cancer Hospital in China between May and September 2024. They conducted semistructured interviews and analyzed the transcripts using combined deductive and inductive content analysis. Data collection continued until both code saturation and meaning saturation were achieved, and agreement for 20% of transcripts assessed by two coders was substantial, with a Cohen’s kappa of 0.79.

The analysis identified seven themes. Exercise experience, habitual exercise cues and routines, and emotional support were classified primarily as system 1 processes. Reflective appraisal of dysphagia, consideration of medical-service resources, weighing benefits and risks, and the gap between expectations and effects were classified primarily as system 2 processes.

The findings therefore linked adherence to both immediate patterns of behavior and patients’ conscious assessment of their condition, resources, and possible outcomes. Cross-system interactions added a dynamic element to the findings. The study reported that immediate bodily and emotional responses were continually reshaped by reflective appraisal, contextual resources, and perceived progress.

In other words, patients’ assessments could affect how they interpreted immediate experiences, while situational conditions and perceptions of progress could influence reflective judgment. Adherence was thus understood as a changing product of interacting automatic and reflective processes. Emotional support was one of the themes associated with system 1 processes, indicating that support from other people formed part of the context in which exercises were performed.

The study also identified the consideration of medical-service resources as a reflective factor, showing that patients evaluated the services surrounding their care when thinking about exercise adherence. These findings should not be interpreted as evidence that any particular support strategy improves swallowing outcomes, because the study did not test such an intervention. The authors’ clinical-relevance section proposed combining habit-supportive cues and affective support with education, expectation management, accessible follow-up, and individualized goal setting.

They suggested that clinicians could anchor exercises to stable daily cues, involve family members as proximal habit coaches, offer flexible or abbreviated protocols for working patients, and provide motivational interviewing and tele-rehabilitation support to reduce uncertainty and sustain adherence. These are recommendations derived from the qualitative findings rather than results from a clinical trial of the proposed approaches. The study’s scope was limited by its design and setting.

It included 18 patients from one rehabilitation clinic in China, all of whom had experience with swallowing exercises. The findings describe reported processes behind adherence; they do not establish that the same patterns hold for every person with head and neck cancer or measure changes in swallowing function, treatment response, or survival. The research was also intended to explore mechanisms, not to demonstrate that swallowing exercises produce clinical benefits.

Overall, the study presents swallowing-exercise adherence as a context-sensitive process shaped by routines, emotional support, conscious appraisal, service resources, expectations, and perceived effects. For rehabilitation teams, that distinction points to a broader view of support, one that considers both the conditions surrounding daily exercise and the judgments patients make about their difficulties and progress.

Subject of Research: Factors influencing swallowing-exercise adherence among patients with head and neck cancer

Article Title: Swallowing exercise adherence in patients with head and neck cancer based on the dual-process model: a qualitative study

Article References: Liu, Y., Liu, S., Hu, L., Jia, J., Wang, Y., Lin, H., Zou, L., & Shi, L. (2026). Swallowing exercise adherence in patients with head and neck cancer based on the dual-process model: a qualitative study. Supportive Care in Cancer, 34(11), Article 1134. https://doi.org/10.1007/s00520-026-11360-z

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11360-z

Keywords: head and neck cancer, swallowing exercises, exercise adherence, dual-process model, qualitative research, rehabilitation, health behavior, patient support, Swallowing, exercise, adherence, patients