Using the COM-B framework to elucidate facilitators and barriers of home-based pulmonary rehabilitation adherence among elderly lung cancer survivors in China: a qualitative study

Pulmonary rehabilitation (PR) adherence is strongly associated with the recovery outcomes of elderly lung cancer survivors (ELCSs). Evidence-based recommendations suggest that continuous PR is crucial for reducing the burden of lung cancer, improving the quality of life and increasing the survival rate of patients; however, many elderly patients who have survived lung cancer aren’t positive about PR adherence, and the reasons behind these challenges have not been fully elucidated. This study aimed to gain insight into the facilitators and barriers to home-based PR adherence among ELCSs in China. A qualitative descriptive study was conducted at a tertiary general hospital and a specialized pulmonary hospital in China from December 2024 to April 2025 within the framework of the Capability, Opportunity, and Motivation-Behaviour (COM-B) model. Purpose sampling was used to recruit ELCSs. Face-to-face semistructured interviews were conducted to elucidate the facilitators and barriers to home-based PR adherence, and directed content analysis was used to extract themes. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to report the study results. A total of 20 eligible ELCSs participated in the study. Six main categories, including 9 facilitators and 12 barriers for the home-based PR of elderly patients who survived lung cancer, were identified on the basis of the COM-B model. The facilitators of home-based PR adherence among ELCSs included capability factors (subjective self-regulation strategies and established exercise habits), opportunity factors (personalized and flexible rehabilitation management, accessibility of rehabilitation resources, and positive social support networks), and motivation factors (perceived rehabilitation benefits, positive coping attitudes towards illness, high exercise self-efficacy and intrinsic motivation for rehabilitation). Barriers included capability factors (physical limitations and symptom burden, knowledge deficits regarding PR, lack of self-discipline in rehabilitation, and insufficient exercise endurance), opportunity factors (inadequate supervision and follow-up guidance, unmet social support needs, environmental constraints and heavy financial burdens), and motivation factors (negative emotions, disease stigma, rehabilitation avoidance tendencies, and unpleasant exercise experiences). This research provides detailed insight into the development and implementation of home-based PR adherence intervention strategies for elderly patients who survived lung cancer. By combining the COM-B model, this study provides strong evidence that active behavioural change strategies are needed for ELCSs to increase their participation in home-based PR. Different and complex factors related to ELCSs can affect their adherence to home-based PR. Symptom management, knowledge enhancement, awareness promotion, social support optimization, infrastructure improvement, supervision system development, community rehabilitation support, quality resource provision through multiple channels, and smart health care service advancement are essential for improving the evidence system to increase home-based PR adherence and effectiveness.