2.1. Study design and setting

The study employed a qualitative research design through individual semi-structured interviews between August 1, 2023, and September 30, 2023. To ensure confidentiality, interviews were conducted in a private and quiet space within the Alexandria University Faculty of Medicine (AUFM) Oncology Clinic in Alexandria, Egypt. Patients were approached for interviews while waiting for their appointments at the oncology clinic.

2.2. Conceptual framework

This study was situated within the Social Ecological Model (SEM) framework. The SEM emphasizes multiple levels of influence and supports the idea that behaviors both affect and are affected bidirectionally between the spheres [31]. Applying the SEM can provide a comprehensive understanding of the barriers and facilitators facing CRC patients through their journey from diagnosis to survivorship. Furthermore, the SEM helped structure our findings across the various levels of the model, including the individual, interpersonal, social context (culture/community), organization, and policy levels [32].

2.3. Study participants

The population of interest was Egyptian adults with a prior diagnosis of colorectal cancer (CRC) receiving treatment at the Alexandria University Oncology Clinic. Inclusion criteria included age of at least 30 years old at the time of diagnosis and having cognitive and physical capacity to provide informed consent and actively participate in the interviews.

Medical students trained as interviewers approached patients, provided an overview of the study using the Waiting Room Script, and completed an Eligibility Screener with interested patients. Those who met the study criteria were provided with an Information Sheet to ensure their understanding of the study. Once the patient verbally consented to participate, a time, date, and location for the interview were chosen based on the participant’s preference.

2.4. Interview duration and process

Individual semi-structured face-to-face interviews, lasting approximately one hour, were conducted with each participant. The interviews, which were audio recorded and conducted in Arabic, focused on the participants’ CRC journey, including pre-diagnosis, diagnosis, treatment, and their experiences with barriers and facilitators to achieving a healthy lifestyle. The Patient Interview Topic Guide was used to guide the interview process. Additionally, a hard copy of a Demographic Questionnaire was administered by the interviewer during the interview.

2.5. Ethical considerations and approval

The protocol for this study was approved by the Ethics Committee of the Faculty of Medicine, Alexandria University, Egypt (I.R.B. number: 00012098, date of approval 9 July 2023). The study was conducted in accordance with the ethical standards of the Declaration of Helsinki and ethical guidelines [33]. All participants were informed that their participation was voluntary, and written informed consent was obtained from all participants prior to the interviews. Participants were provided with an Information Sheet detailing the study objectives, procedures, and their rights. Interview recordings and demographic questionnaire responses were securely stored on a password-protected computer accessible only to the lead investigator to ensure data confidentiality.

2.6. Data analysis

Transcripts were analyzed using thematic analysis with NVIVO 11 to facilitate the coding process [34]. A three-stage process was implemented to ensure rigor in the analysis. First, a team of 4 investigators independently read the interview transcripts to identify codes and potential themes. Second, the investigators discussed and agreed upon coding categories to develop a code book. Third, the transcripts were re-read and coded by two independent coders according to the agreed-upon coding structure. Meetings were held during the coding process to address any discrepancies and ensure consistency. Codes were elevated to themes based on recurrence and depth, where the code represents a critical insight central to our research question. Data coding continued until thematic saturation was reached, defined as the point at which no new themes or insights were identified. Finally, the investigators organized the themes into facilitators and barriers across levels of the SEM, including individual, interpersonal, social context (culture/community), organization, and policy levels.

3.1. Perceived barriers

3.2. Perceived facilitators

4.1. Perceived barriers

One key finding from the diagnosis phase is that more than half of the participants presented at advanced cancer stage 3 or 4 with metastases, indicating significant diagnostic delays. Studies report an estimated survival of 26 months for stage 2 CRC, and a median overall survival being 2 years [16,36]. The reasons for this phenomenon, suggested by our data and the literature, span the SEM levels.

Individual-level barriers to diagnosis identified in this study included the patient’s lack of awareness and perceiving initial symptoms as minor, leading to complications, mainly rectal bleeding and intestinal obstruction. Similar barriers are established in the literature [37–39], highlighting the urgent need to raise public awareness to counteract denial, fatalism, and coping behaviors. Furthermore, fear of colonoscopy and perceived fear of pain, lack of privacy, and embarrassment also delayed diagnosis, with patients often seeking care only after worsening symptoms or physician encouragement, consistent with previous themes in the literature [40–43].

Additionally, the stigma and embarrassment surrounding colonoscopy and digital rectal exam created a significant psychological barrier to early diagnosis. This is well-documented in studies, particularly those situated in conservative societies [44]. Poverty further restricted diagnostic access due to high costs in the private sector and a lack of equipment in accessible primary care clinics. These findings align with existing literature that individuals from LMICs face substantial cost and accessibility barriers to screening, resulting in late-stage diagnoses [45].

At the interpersonal level, the peer fear of colonoscopy among family and friends impacted patients. This aligns with findings from other studies that highlighted the lack of support from family and friends as a barrier to the uptake of colonoscopy [41].

Within the health service organization, barriers included misdiagnoses, poor preparation for procedures, and insufficient patient education. This lack of physician screening recommendations and misdiagnosis is heavily reported in the region [18,46,47], emphasizing the need for better physician communication to address patients’ concerns and promote CRC screening.

At the policy level, we found a frequent lack of the application of screening protocols, particularly in rural areas. Long referral-to-diagnosis times also contributed to late-stage CRC diagnoses at tertiary care hospitals. Despite the availability of Egyptian screening guidelines, a nationwide survey reported that only 2.3% of screening-eligible participants were referred for CRC screening [18]. Similarly, Bateman et al. found that many Egyptian physicians reported screening only high-risk or symptomatic patients [47]. Therefore, training providers and expanding healthcare facilities, mobile units, and telemedicine is essential to improve timely diagnosis and treatment [48].

During treatment, chemotherapy side effects such as poor appetite, neuropathy, and back pain were individual-level barriers that limited participants’ ability to maintain physical activity and a balanced diet. This is consistent with previous findings on chemotherapy-related functional decline [49,50]. Managing a colostomy further impaired quality of life through leaks, social isolation, and challenges with diet and physical activity. This aligns with previous studies reporting that individuals with a colostomy face significant difficulties and limitations in daily living activities, employment, and well-being [51,52]. Furthermore, poverty and employment loss, particularly in physically demanding jobs, added further treatment burdens, aligning with studies that highlight the socioeconomic challenges of cancer care in Egypt, where most patients are living in poverty [53,54].

Within the health service organization, our study identified insufficient patient education and a lack of structured programs for diet and physical activity. Although physicians advised against prolonged bed rest and emphasized eating well, detailed plans or referrals to nutritionists and physiotherapists were missing. This corroborates with the results of previous studies that highlight the lack of physician recommendations regarding what form of physical activity patients should engage in and limited access to exercise counseling as major barriers to following physical activity guidelines [49,55]. Other studies identified that malnutrition among CRC patients may worsen health and limit the effectiveness of treatments [25,56,57]. Implementing nutrition therapy during treatment is critical to enhance patient adherence to diet recommendations, prevent side effects, and shorten recovery time [58].

In the social context (culture/community), unsupportive work environments, cultural and religious beliefs, and cancer stigma present challenges for most participants. Physically demanding jobs were often unsuitable for patients, particularly for those with colostomies, further complicating their ability to maintain a stable income. Additionally, fear of colostomy leaks disrupts religious practices, such as prayer, compounding psychological distress. The lack of community-based programs to educate employers and promote inclusive hiring practices leaves many patients feeling isolated and unsupported, underscoring the need for societal changes to reduce stigma and reintegrate patients into the workforce [59].

After treatment, unemployment remained common. One patient reported being jobless for over three years post-diagnosis. There is a significant need for rehabilitation programs and social security support for cancer survivors [60].

4.2. Perceived facilitators

At the diagnosis phase, resilience was a key individual-level facilitator among participants. Faith and acceptance of one’s destiny, influenced by religious teachings and practices within the community, were major coping mechanisms with diagnosis acceptance and treatment, consistent with previous studies that highlight the role of religious beliefs in coping with cancer [61,62]. However, mental health struggles are sometimes seen as a weakness in faith in the Arab culture and religious norms, where expressing negative emotions or discussing mental health is often taboo [63,64]. This highlights the importance of integrating Psychosocial support and culturally sensitive mental health counseling alongside spiritual resilience.

During treatment, participants demonstrated a positive general perception of healthy behaviors, particularly healthy diet and physical activity. Physical activity was often viewed as the ability to carry out daily tasks, with walking being the only exercise mentioned, believing it helped them better tolerate treatment and recover more effectively. This is consistent with previous studies showing that even moderate levels of physical activity can improve cancer treatment outcomes, reduce fatigue, and enhance overall quality of life [65]. At the interpersonal level, many participants highlighted the emotional and practical support they received from family, friends, and peers as a key facilitator in their journey toward treatment and recovery. Further, knowing a cancer survivor motivated patients to adhere to treatment and lifestyle recommendations. This social support has been widely recognized in the literature as a crucial determinant of health outcomes, particularly for cancer patients [66].

In the social context (culture/community), NGOs also facilitated treatment access. The healthcare system in Egypt is multifaceted, involving a wide range of public, private, and non-governmental entities that contribute to the management, financing, and delivery of medical care. NGOs and faith-based charities improve healthcare access and cancer care in both urban and rural areas through donations and services focused on raising awareness, prevention, early detection, and patient support [67,68].

Moreover, the free treatment policies at tertiary care educational hospitals were highlighted as a crucial facilitator. These provided access to urgent surgeries, chemotherapy, and oncology care funded by the government for uninsured patients. This quick transition allowed for timely consultations with oncologists and initiation of treatment compared with longer intervals experienced in developed countries [69–71]. Participants received treatment supported by government funds, indicating the accessibility and affordability of cancer care in Egypt. This is especially significant in Egypt, where the notably high poverty rate is at 29.7%, and the main healthcare financing source is out-of-pocket (OOP) expenditures, representing more than 60% of total health expenditures [72,73]. This finding highlights the importance of government support in ensuring equitable access to cancer treatment.

4.3. Recommendations and implications

The findings of this study highlight the urgent need for culturally tailored policy reforms, addressing barriers and facilitators to CRC diagnoses and treatment in Egypt.

To address diagnostic delays and late-stage CRC presentation, Egypt must implement culturally adapted and accessible CRC screening programs, particularly in rural areas. In 2022, Nawwar et al, developed a theory-based intervention promoting CRC screening via the low-cost, user-friendly guaiac fecal occult blood test (gFOBT) kit, distributed in a primary care unit in Egypt [74]. Following this study, the country's 100 Million Healthy Lives Campaign adopted the more sensitive fecal immunochemical test (FIT) for CRC screening, with colonoscopies covered for positive cases under the national insurance scheme [75]. However, FIT should be fully integrated into the health system, with mandatory training for healthcare providers to follow CRC screening guidelines. Healthcare providers also need medical education focused on recognizing early CRC signs, screening guidelines, and prevention methods. A study by Khamess et al. (2023) showed that training medical students as Health Champions significantly improved their knowledge of CRC risks, screening, and treatments, suggesting this model for broader integration into Egyptian medical curricula [76]. Public health campaigns may benefit from collaborating with religious leaders, NGOs, community organizations, and media to raise awareness about CRC symptoms, promote screening, and reduce stigma around colonoscopy [77]. Engaging religious and community leaders can positively impact health behaviors among religiously conservative communities and disseminate culturally appropriate messages [78].

In treatment settings, healthcare providers should be trained to communicate effectively about treatment plans, symptom management, lifestyle changes, and Psychosocial support. It would also be beneficial for oncology care to include structured programs on diet and physical activity, with referrals to nutritionists and physiotherapists to enhance recovery and quality of life. Peer support groups for individuals undergoing treatment and post-treatment in hospitals and community centers can provide emotional support, share coping strategies, and reduce feelings of isolation. Furthermore, NGOs are critical in helping patients navigate the healthcare system, access treatment, and cope with socioeconomic challenges. Moreover, government policies that provide financial support, rehabilitation, and employment reintegration for cancer patients and survivors would be important. Survivorship programs should include ongoing mental health support, community reintegration, and partnerships with NGOs to facilitate holistic care. Additionally, further research into low-income groups and gender-specific barriers would provide valuable insights for developing targeted interventions.

4.4. Strengths and limitations

To the authors’ knowledge, this is the first qualitative study to explore the CRC patient’s journey in Egypt. Our study is distinguished by its method of performing in-person interviews with patients, which gave us valuable insights into their experiences and needs. It also addressed an important gap in knowledge about the role of diet and physical activity in Egyptian CRC patients’ treatment and shed light on the barriers and facilitators to adopting a better lifestyle during and after cancer treatment.

On the other hand, this study has limitations to note. We used a convenience sample from one center, which may limit the transferability due to the broader demographic and socioeconomic diversity present within Egypt. However, the study was conducted in one of the main tertiary care hospitals located in Alexandria, the second largest city in the country, which serves a wide and diverse patient population. Additionally, semi-structured interviews rely on participants’ subjective experiences and emotions. Unlike anonymous questionnaires, patients in in-person interviews may tend to express more positive aspects of their experience than negative ones; however, we tried to address that by providing questions and repeating them in different formats to obtain more comprehensive and clear answers. Throughout the study, dominance and recalcitrance did not appear to be problematic.