Esophageal cancer ranks seventh in incidence and sixth in mortality among all malignancies globally, with a higher prevalence in men, particularly those aged 60 to 70 years (1). In 2020, there were approximately 604,000 new cases and 544,000 deaths worldwide, with significant regional variations in incidence and mortality. The highest incidence rates were observed in Eastern Asia and Southern and Eastern Africa, driven by specific risk factors such as tobacco use, alcohol consumption, hot beverage intake, and indoor air pollution. Projections indicate that the global burden of esophageal cancer will increase by over 50% from 2020 to 2040, reaching nearly 1 million new cases annually (2).

Esophagectomy is the cornerstone of treatment for resectable esophageal cancer; however, it carries higher morbidity and mortality rates compared to other gastrointestinal surgeries (3, 4). Although esophagectomy is crucial for treating esophageal cancer, the surgical procedure may compress the lungs and damage thoracic muscles, leading to postoperative pulmonary complications such as respiratory dysfunction, atelectasis, and even respiratory failure. These complications can severely impair patients’ quality of life and hinder recovery, further complicating postoperative treatments (5, 6). Pulmonary morbidity is a common complication following esophagectomy, with recent studies reporting that it still occurs in 16 to 23% of cases despite improvements (4, 7–9). Pulmonary complications are also a major cause of hospital mortality and may independently predict poorer long-term survival (10, 11). Pulmonary rehabilitation plays a vital role in mitigating these postoperative complications. Through interventions such as respiratory function training and guided physical exercises, pulmonary rehabilitation can effectively improve lung function, alleviate breathing difficulties, and enhance exercise tolerance after surgery. Long-term, systematic respiratory training has been widely recognized for its ability to improve lung function and reduce the incidence of complications following thoracic surgeries, including esophagectomy, ultimately improving patients’ overall survival and quality of life. From this perspective, incorporating pulmonary rehabilitation into postoperative care is increasingly being emphasized in clinical practice (5, 12).

KAP (Knowledge, Attitude, and Practice) theory emphasizes that knowledge is the foundation for behavior change, while attitudes and beliefs serve as the driving force behind such changes (13). According to KAP theory, behavior change progresses through three stages: acquiring knowledge, forming attitudes and beliefs, and finally, adopting practices and behaviors (14). However, knowledge alone does not automatically lead to behavior change; it must first alter perceptions, which in turn drive behavioral adjustments (15).

China is among the top five countries with the highest incidence of esophageal cancer, with Linxian in Henan Province and Cixian and Shexian in Hebei Province reporting the highest incidence rates globally (1, 16). While esophagectomy remains a critical treatment for resectable esophageal cancer, the high rates of postoperative pulmonary complications greatly affect patient recovery and long-term survival (17, 18). Therefore, understanding the KAP of esophageal cancer patients regarding pulmonary rehabilitation training is essential for developing targeted educational and intervention strategies. Effective strategies could improve rehabilitation outcomes by enhancing lung function, reducing pulmonary complications, and improving the patients’ quality of life following surgery. Given the importance of this issue, research focusing on this population is crucial for informing clinical practice and optimizing rehabilitation approaches.

Currently, there is a lack of KAP studies specifically addressing pulmonary rehabilitation in this patient population. Unlike previous KAP studies in oncology, this research specifically targets pulmonary rehabilitation among esophageal cancer patients and employs both conventional statistical analyses and structural equation modeling (SEM) to elucidate the interrelationships among knowledge, attitudes, and practices. This design provides new insights into behavioral factors influencing rehabilitation engagement and offers an evidence base for developing targeted educational strategies in this high-risk surgical population. This study aimed to assess the KAP of esophageal cancer patients concerning pulmonary rehabilitation training.

Esophageal cancer patients demonstrated inadequate knowledge but maintained positive attitudes and proactive practices concerning pulmonary rehabilitation training. These findings suggest the need for targeted educational interventions to enhance patients’ knowledge, which may further strengthen their attitudes and practices in clinical settings.

The results of this study show that while esophageal cancer patients demonstrated positive attitudes and proactive practices toward pulmonary rehabilitation training, their knowledge was notably inadequate. This finding is consistent with other studies, which have similarly reported low awareness, skepticism about the necessity, and limited acceptance of pulmonary rehabilitation among COPD patients in China (23). Additionally, there remains a significant gap in understanding and referral practices for pulmonary rehabilitation among Chinese respiratory physicians, further limiting access for patients with chronic respiratory diseases (24). The positive attitudes and proactive behaviors observed in this study suggest that patients are generally willing to engage in rehabilitation. However, the lack of knowledge may hinder them from fully benefiting from these programs. This gap between attitude and knowledge highlights the critical need for targeted educational interventions to ensure that patients are adequately informed and able to effectively participate in pulmonary rehabilitation. In addition to individual knowledge and socioeconomic disparities, difficulties in follow-up and limited accessibility to medical personnel may also hinder effective pulmonary rehabilitation among cancer patients. In real-world clinical settings, many patients have limited opportunities to communicate with their physicians due to short consultation times and heavy workloads in oncology departments. Consequently, important issues such as medication side effects, symptom management, and the rationale behind rehabilitation training are often insufficiently discussed. Establishing regular follow-up systems and enhancing doctor–patient communication could therefore be crucial to improving patients’ understanding, adherence, and overall participation in pulmonary rehabilitation programs. Furthermore, the rise of artificial intelligence–based medical platforms and telemedicine systems has greatly improved patients’ ability to follow up and understand their treatment processes. These technologies facilitate continuous communication between patients and healthcare providers, enhance access to educational resources, and enable personalized rehabilitation guidance even outside hospital settings. Such innovations have shown promising applications in esophageal surgery and postoperative care, providing new opportunities for improving patient outcomes (25–27).

The findings from correlation analysis, multivariate logistic regression, and SEM all indicate significant interconnections. These results were supported by the SEM analysis, which demonstrated that knowledge had a significant direct effect on attitude (β = 0.420, p < 0.001) and attitude on practice (β = 0.711, p < 0.001). However, the direct effect of knowledge on practice was not significant (β = 0.092, p = 0.073), suggesting that attitudes may act as a mediator between knowledge and practice. This highlights the importance of not only improving patients’ knowledge but also ensuring that their attitudes are aligned with evidence-based practices to encourage positive behavioral outcomes (28, 29). In this model, knowledge appears to influence practice primarily through its effect on attitudes rather than through a direct pathway. This finding suggests that simply increasing patients’ knowledge about pulmonary rehabilitation may not be sufficient unless it is accompanied by changes in their beliefs and motivation toward participation. Educational efforts that connect factual understanding with perceived personal benefit may therefore play a key role in strengthening this indirect pathway.

When examining the individual variables, several significant associations were identified. For gender, male patients exhibited significantly higher knowledge (p = 0.036) and attitude scores (p = 0.002) compared to female patients. However, no significant difference was found in practice scores (p = 0.135). This could indicate that while men may be more informed and maintain a positive outlook toward pulmonary rehabilitation, both genders face similar barriers when it comes to implementing these practices. Residence was another important factor, with urban and suburban patients scoring higher in knowledge (p < 0.001), attitude (p = 0.009), and practice (p < 0.001) compared to rural patients. This may be attributed to better access to healthcare resources and educational materials in urban and suburban areas. Rural patients often face challenges such as limited access to healthcare services and lower health literacy, which could explain their lower scores across all three dimensions (30, 31).

Educational level was strongly associated with KAP scores, where patients with higher education levels demonstrated significantly better knowledge (p < 0.001), attitudes (p < 0.001), and practices (p < 0.001). This is consistent with existing literature indicating that education is a key determinant of health literacy and health-related behaviors (32, 33). The multivariate logistic regression analysis supported this, showing that higher education was independently associated with better knowledge and attitudes, which subsequently influenced practice scores. Employment status also showed significant differences in all KAP dimensions. Employed and retired patients scored higher in knowledge (p = 0.001), attitude (p < 0.001), and practice (p = 0.004) compared to those in other employment categories. This could be due to greater social support and access to information among employed and retired individuals. Interestingly, multivariate analysis indicated that employment status was not an independent predictor of KAP outcomes, suggesting that other factors, such as income and education, might mediate these relationships (34, 35).

Monthly per capita income was another significant variable, with higher income being associated with better knowledge (p < 0.001), attitudes (p < 0.001), and practices (p < 0.001). This association was further confirmed by multivariate logistic regression, which showed that a monthly income of 2,000–5,000 yuan was independently associated with better knowledge (OR = 0.353, 95% CI: [0.143, 0.870], p = 0.024) and attitudes (OR = 2.848, 95% CI: [1.189, 6.823], p = 0.019). Higher income likely provides better access to healthcare resources, educational materials, and a supportive environment, facilitating better health outcomes (36).

Interestingly, significant differences in KAP were not observed across marital status, smoking, or alcohol consumption for practice scores, despite differences in knowledge and attitudes. For example, regular smokers had higher knowledge (p = 0.023) and attitude (p = 0.005) scores compared to non-smokers, yet no significant difference was observed in practice scores (p = 0.105). This lack of difference in practice might be attributed to external factors such as limited access to resources or support for behavioral changes, suggesting that improving knowledge alone may not be sufficient to translate into better practices without addressing these underlying barriers (37).

The distribution of responses across the knowledge, attitude, and practice dimensions indicates several areas where esophageal cancer patients exhibit inadequate understanding, particularly regarding the principles and importance of pulmonary rehabilitation. A significant portion of the patients were unclear about key aspects of pulmonary rehabilitation, such as its components, intensity, and the necessity for personalization based on specific health conditions. For instance, nearly half of the patients were unfamiliar with the importance of moderate to high-intensity training during pulmonary rehabilitation, and many did not recognize that rehabilitation could continue effectively outside of a hospital setting. These findings are consistent with similar studies in which patients often show limited understanding of complex medical regimens, leading to suboptimal engagement and outcomes (38). On the other hand, the attitude and practice dimensions revealed generally positive responses, with the majority of patients expressing interest and willingness to participate in rehabilitation, although a small subset harbored misconceptions or doubts about its effectiveness.

Given these knowledge gaps, targeted educational interventions are essential. First, tailored educational materials should be developed to clearly explain the specific benefits of pulmonary rehabilitation, emphasizing the role of high-intensity training and the flexibility of performing these exercises outside the hospital. These materials could include visual aids, simplified language, and practical examples that resonate with patients’ everyday experiences. In addition, hands-on workshops or interactive sessions led by healthcare professionals could enhance patient understanding and retention of this information (39–41).

Considering the significant disparities observed in knowledge across different demographic groups, specific strategies should be implemented to address these gaps. For example, rural patients and those with lower educational levels demonstrated notably poorer knowledge scores. For these groups, community-based programs that leverage local healthcare workers could be particularly effective. Such programs might include home visits or small group sessions that offer personalized education and support, thereby overcoming barriers related to health literacy and access. Moreover, employing digital platforms like mobile apps tailored to deliver bite-sized, easy-to-understand information on pulmonary rehabilitation could reach a broader audience, particularly among younger or tech-savvy patients (42, 43).

To improve the more challenging aspects, such as the misunderstanding about the necessity of strict adherence to rehabilitation plans, motivational interviewing techniques could be integrated into routine care. This approach has been shown to effectively change health behaviors by aligning the intervention with patients’ personal values and goals (44, 45). Additionally, addressing concerns related to the potential for harm or the perceived burden of rehabilitation on family dynamics should be a priority. Structured family counseling sessions, where both patients and their families receive clear guidance on the benefits and practical aspects of rehabilitation, could alleviate these concerns and foster a supportive environment.

This study has several limitations. First, as a cross-sectional study, it captures only a snapshot of the participants’ KAP at a single point in time, limiting the ability to assess changes over time or causality. Future research may include longitudinal or interventional designs to explore how knowledge, attitudes, and practices evolve over time and to examine whether targeted educational measures can lead to measurable behavioral improvements. Second, the data were collected using self-reported questionnaires, which may introduce response bias, particularly in sensitive areas such as smoking and alcohol consumption. Because the responses were self-reported, some participants might have provided socially desirable answers or understated certain behaviors. Although the questionnaire included a control item to identify inconsistent responses, self-reporting bias cannot be completely ruled out. Third, the study was conducted at a single cancer hospital, which may limit the generalizability of the findings to other populations or settings. Because the participants were all recruited from one institution, the findings should be interpreted with some caution. Differences in healthcare resources, patient education, and rehabilitation practices in other regions may lead to somewhat different outcomes. Future studies involving several centers could help verify whether these patterns hold in broader contexts.

In conclusion, esophageal cancer patients demonstrated inadequate knowledge, positive attitudes, and proactive practices concerning pulmonary rehabilitation training. These findings highlight the need for targeted educational interventions to enhance patients’ knowledge, which may further strengthen their attitudes and practices toward pulmonary rehabilitation, ultimately improving their overall treatment outcomes.