Health-Promoting Lifestyle and Its Predictors in Adolescent Survivors of Childhood Cancer

Abstract

Background: Cancer survivors are at increased risk of long-term adverse effects related to the disease or treatment. Thus, it is important for cancer survivors to adopt a health-promoting lifestyle (HPL). This study aims to: (1) describe health behavior self-efficacy (HBSE) and HPL of adolescent survivors of childhood cancer, (2) examine the relationships between HBSE, HPL, and various demographic factors, and (3) identify determinants of HPL among adolescent survivors of childhood cancer. Method: A descriptive cross-sectional study was conducted with adolescent survivors of childhood cancer, ranged in age from 11 to 19 years (n = 82). Participants were recruited from pediatric oncology follow-up clinics at two medical centers in southern Taiwan. Data for each participant were collected from questionnaires assessing HBSE and HPL. Results: Only 61% of the adolescent survivors were considered as normal weight. The exercise was the lowest scoring HBSE subscale. Factors associated with better HPL included: education level, HBSE, well-being, and a healthy diet. Specifically, survivors diagnosed with cancer during adolescence exhibited significantly greater self-efficacy with stress management (F = 3.20, p = .04) compared with those diagnosed at pre-school ages. HBSE scores for well-being and a healthy diet were significant predictors of HPL, accounting for 43.8% of the total variance observed. Discussion: Our findings suggest that the age of diagnosis of childhood cancer significantly modulates the frequency of health-promoting behaviors of adolescent survivors. Thus, interventions designed to enhance adolescents’ well-being and the management of a healthy diet may enhance HPL in survivors of childhood cancer.

Keywords

adolescents childhood cancer survivors self-efficacy health-promoting lifestyle

Introduction

Adolescents have emerged as a distinct group that requires specialized cancer care due to their unique biophysical and psychosocial challenges (Eccles et al., 1993; He et al., 2004). Moreover, cancer type and treatment intensity are factors that may lead to both medical and psychological vulnerabilities (Bingen & Kupst, 2010; Diorio et al., 2018; Hsiao et al., 2018; Krawczuk-Rybak et al., 2018; Lupatsch et al., 2016; Nathan et al., 2018; Robison & Hudson, 2014). In general, the leading causes of morbidity and mortality in adolescent survivors of childhood cancer are related to behavior, with risky health behaviors linked to disability and disease later in life (Clarke & Eiser, 2007; Diorio et al., 2018; Grunbaum et al., 2000; Lown et al., 2008; Pugh et al., 2018). Hence, engagement in healthy behaviors as part of a healthy lifestyle is critical for preventing chronic disease and early mortality in adolescent survivors of childhood cancer (Kahe et al., 2004; Warner et al., 2016).

Health behavior self-efficacy (HBSE) is defined as an ability to maintain one's own health, initiate preventive health behaviors, and perform healthy behaviors (He et al., 2004; Pugh et al., 2018). Positive health behaviors include maintaining a healthy weight and diet, managing stress, and discontinuing smoking or intake of alcohol (Kazak et al., 2010). A higher frequency of healthy behavior has been shown to correspond with higher levels of HBSE (Becker et al., 1993; Kahe et al., 2004). Therefore, cancer survivors who learn self-care and health-promoting behaviors are more likely to adopt healthier behaviors and lifestyles (Kenzik et al., 2016; Quidde et al., 2016). It is commonly hypothesized that adolescent survivors of childhood cancer develop healthier lifestyles than their healthy peers due to their experiences with a life-threatening condition. However, no significant differences in physical status, psychological stress, or social experience were observed between adolescent survivors and their siblings when measured 5 years after cancer treatment (Mertens et al., 2008). Moreover, when Rebholz et al. (2012) compared the prevalence of health-related behaviors (i.e., tobacco, alcohol, and/or cannabis use, diet, exercise, and sun protection) between adolescent survivors of childhood cancer (aged: 20-35 years, n = 835) and matched controls from the general population (n = 1,670), they found that survivors engaged in a greater number of high-risk behaviors. The latter included health-compromising behaviors such as smoking and drinking (Butterfield et al., 2004; Carswell et al., 2008; Frobisher et al., 2010; Lown et al., 2008; Rebholz et al., 2012). Older survivors (11-33 years old) of childhood cancer were also more likely to smoke and to be obese, and were less likely to follow recommended diets and exercise compared with younger survivors (<18 years) (Demark-Wahnefried et al., 2005). Meanwhile, among adult survivors of cancer, self-efficacy has been shown to play a role in the maintenance of healthy lifestyles (Cortis et al., 2017; Mosher et al., 2013).

It is well recognized that unhealthy lifestyles have a negative impact on the quality of life and can lead to additional health problems (Kanera et al., 2016). While previous studies have focused on young adult (15-39 years) (Herts et al., 2017) or adult (Fong et al., 2018; Green et al., 2014; Holmes & Kroenke, 2004; Kanera et al., 2016; Somayaji et al., 2019) cancer survivors; adolescent survivors undergo more dynamic biological changes (Perry, 2012; Singleton, 2007) while also having a medical history of childhood cancer (Shin et al., 2019). Considering that cancer survivors are at increased risk of long-term adverse effects related to their disease and/or its treatment, they need to adopt health-promoting lifestyles (HPL). Therefore, the objectives of the present study were to: (1) describe the HBSE and HPL of adolescent survivors of childhood cancer, (2) examine the relationships between HBSE, HPL, and various demographic factors, and (3) identify determinants of HPL among adolescent survivors of childhood cancer.

Methods

A descriptive and correlational cross-sectional study of adolescent survivors of childhood cancer was conducted.

Sample and Data Collection

Subjects were enrolled from pediatric hematology/oncology outpatient clinics in southern Taiwan between March 2014 and June 2015. Inclusion criteria were: (1) adolescent survivors of childhood cancer, (2) aged between 11 and 19 years (based on the World Health Organization (WHO) definition of adolescence), (3) currently in remission, with completion of cancer treatment requiring at least another year, (4) an ability to communicate in Mandarin or Taiwanese, and (5) agreement to participate in this study. Subjects were excluded if developmental delays or psychiatric illnesses were diagnosed.

After receiving the approval from the institutional review boards of both hospitals, the first author contacted the director of pediatric hematology and oncology in each hospital and explained the purpose of the study. Participants and their legal guardians were approached at outpatient clinics after being informed by their doctors of the study. After informed consent was obtained, participants were asked to complete questionnaires and a demographic data sheet in a private and quiet environment. Compensation was provided to participants in the form of a gift equivalent to 100 Taiwan dollars (US$3-4).

Ethical Considerations

Before the study began, approval was obtained from the institutional review boards of two southern medical center hospitals. Completed questionnaires were anonymized and kept confidential. All data were de-identified and no personal identifying information was revealed.

Instruments

The demographic data collected included: specific cancer diagnosis, time since diagnosis, gender, family structure, perceived health status, duration of family interactions (i.e., how much time do you spend with your family each day?), smoking status (i.e., do you smoke? yes/no), drinking status (i.e., do you drink alcohol? yes/no), and body mass index (BMI) based on WHO definitions of the growth reference for children aged 5-19 years (WHO, 2020). Socioeconomic status (SES) was assessed by using the Hollingshead index of social position score (Hollingshead, 1957). A score for each participant was calculated based on their father's socioeconomic background (i.e., education and occupation) according to the formula: (education level index × 4) + (occupation index × 7). Higher scores correspond to lower SES (possible range: 11-55) (Hollingshead, 1957).

The HBSE questionnaire was adapted from a health self-efficacy measure which was designed to assess the perception of children and adolescents regarding their ability to implement various health-promoting behaviors (Becker et al., 1993; Huang, 2007). The HBSE questionnaire contains 24 items in four subscales: healthy diet, exercise, well-being, and health accountability (Huang, 2007). Respondents are asked to indicate how well they perform with respect to engaging in health-related behaviors on a 5-point Likert scale, with answers ranging from 1 (never) to 5 (always). Overall scoring for the HBSE questionnaire ranged from 24 to 120. Both reliability and validity of the HBSE questionnaire have been verified (Huang, 2007). Cronbach's alpha for the HBSE questionnaire in the present study was 0.74-0.87.

The HPL questionnaire contains 35 items and 6 subscales (nutrition, exercise behaviors, stress management, interpersonal support, health behaviors, and self-achievement) (Huang, 2007). Respondents are asked to rate their frequency of performing each item on a scale ranging from 1 (never) to 5 (always). Reliability (Cronbach's alpha was 0.71-0.83) and validity of the HPL were previously examined (n = 811) (Huang, 2007). In this study, Cronbach's alpha for the HPL questionnaire was 0.78-0.89.

Data Analysis

SPSS 19.0 software was used for data collection and analysis. Data were analyzed descriptively or inferentially, depending on the research question. Demographic, HBSE, and HPL data were reported as mean (M), standard deviation (SD), and percentage values. Pearson's correlation coefficient (r) was used to estimate relationships among continuous variables, while r² was used to estimate the proportion of variance in the HPL. Values of r > 0.6 were defined as strong, values ranging from 0.2 to 0.59 were defined as moderate, and values <0.2 were defined as weak. Analysis of variance followed by Bonferroni post-hoc testing was used to identify significant differences between pairs. Multiple regression was used to test the significance of predictors of HPL. All variables were examined for normality and homoscedasticity to avoid a multi-collinearity effect (Tabachnick & Fidell, 2007). P-values <.05 were considered to indicate a statistically significant difference.

Results

Participants’ Characteristics

All 82 subjects who were approached for this study were enrolled. The demographic and clinical characteristics of these participants are listed in Tables 1 and 2, respectively. More than half of the participants were male (54.9%), lived with their nuclear family (79.3%), and had a history of leukemia (51.8%). In addition, most of the participants indicated that they did not smoke (96.3%) or drink alcohol (93.9%). Nearly half (46.3%) of the participants were diagnosed with cancer at a pre-school age (<7 years old). BMI z score/percentile values were used to evaluate weight status, rather than absolute BMI values because an increase in BMI is a normal aspect of adolescent development and also varies by gender. According to this measure, 61% of the participants were considered normal weight, 17.1% were overweight, and 12.2% were obese. Self-perceived “poor” health status was reported by 3.7% of the participants.

Table 1.

Demographic Characteristics of the Participants (n = 82).

Variable	N	%
Gender
Male	45	54.9
Female	37	45.1
Family structure
Nuclear	65	79.3
Stem	13	15.8
Extended	1	1.2
Single parent	3	3.7
Intergenerational	0
SES
Low	9	11.0
Middle	56	68.3
High	17	20.7
Self-perceived health status
Excellent	9	11.0
Very good	31	37.8
Good	25	30.5
Fair	14	17.1
Poor	3	3.7
Smoking
Yes	3	3.7
No	79	96.3
Alcohol use
Yes	5	6.1
No	77	93.9
Interaction with family, days
1-2 h	6	7.3
Over 2 h	76	92.7
BMI
Severe thinness	4	4.9
Thinness	4	4.9
Normal	50	61.0
Overweight	14	17.1
Obese	10	12.2

Note. SES = socioeconomic status; BMI = body mass index.

Table 2.

Clinical Characteristics of Participants (n = 82).

Variable	Frequency	%
Diagnosis
Leukemia	42	51.8
Brain tumor	7	8.6
Lymphoma	12	14.8
Osteosarcoma	13	16.0
Other	8	8.8
Years since diagnosis
0-5	21	25.6
6-10	43	52.4
>10	18	22.0

Variable	M	SD
M age at diagnosis (years)	7.99	4.01
Pre-school (<7)	4.48	1.82
School (7-11)	8.91	1.05
Adolescence (>11)	13.33	1.91
M age (year)	15.11	2.73

Note. M = mean; SD = standard deviation.

HBSE and HPL

Results from the HBSE and HPL questionnaires are presented in Table 3. The highest scoring subscale of the HBSE was health accountability (M = 3.58, SD = 0.76), followed by healthy diet (M = 3.45, SD = 0.62) and well-being (M = 3.39, SD = 0.82). The highest scoring subscales of the HPL were interpersonal support (M = 3.67, SD = 0.74), nutrition (M = 3.66, SD = 0.58), and self-achievement (M = 3.46, SD = 0.83). On both scales, the exercise-related subscales received the lowest scores.

Table 3.

HBSE and HPL Scores for Adolescent Survivors of Childhood Cancer, Compared Across Age at Diagnosis (n = 82).

Scale subscale	No. items	All survivors			Age at diagnosis						F	p	Post hoc
		All survivors			Pre-school^a (n = 38)		School^b (n = 23)		Adolescence^c (n = 21)
		Range	M	SD	M	SD	M	SD	M	SD
HBSE	24	2.1-4.8	3.41	0.57	3.35	0.49	3.36	0.60	3.57	0.67	1.13	.33
Healthy diet	6	2.3-5.0	3.45	0.62	3.36	0.61	3.38	0.55	3.67	0.68	1.90	.16
Exercise	6	1.5-5.0	3.22	0.67	3.17	0.69	3.13	0.61	3.35	0.72	0.67	.52
Well-being	6	1.5-5.0	3.39	0.82	3.33	0.84	3.43	0.73	3.47	0.90	0.23	.79
Healthy accountability	6	2.2-4.8	3.58	0.76	3.52	0.68	3.48	0.81	3.78	0.81	1.04	.36
HPL	35	1.9-4.7	3.45	0.60	3.33	0.51	3.51	0.63	3.59	0.68	1.60	.21
Nutrition	7	2.4-4.7	3.66	0.58	3.59	0.58	3.74	0.63	3.73	0.52	0.66	.52
Exercise behaviors	6	1.2-5.0	3.22	0.75	3.10	0.77	3.22	0.76	3.44	0.66	1.45	.24
Stress management	6	1.8-5.0	3.45	0.74	3.24	0.59	3.55	0.78	3.71	0.86	3.20	.04	3 > 1
Interpersonal support	6	2.2-5.0	3.67	0.74	3.55	0.67	3.76	0.73	3.79	0.87	0.94	.39
Self-achievement	5	1.6-5.0	3.46	0.83	3.38	0.78	3.54	0.84	3.52	0.94	0.32	.73
Healthy behaviors	5	1.6-4.8	3.21	0.70	3.09	0.60	3.28	0.79	3.38	0.75	1.26	.29

Note. M = mean; SD = standard deviation; HBSE = health behavior self-efficacy; HPL = health-promoting lifestyle.

<7 years old.

7-11 years old.

>11 years old.

Relationships Between HBSE, Demographic Factors, and HPL

HPL stress management scores significantly differed among the three age groups evaluated according to age at diagnosis (<7 years old, 7-11 years old, and >11 years old) (F = 3.20, p < .04). Post hoc testing revealed that an adolescent age at the time of diagnosis (i.e., >11 years old) was associated with better stress management than a diagnosis at a pre-school age (i.e., <7 years old). Additionally, a moderate positive correlation was observed between the HPL and HBSE scores (Pearson's r value: 0.363-0.642; all p < .01). Among the HBSE subscale scores, those for diet, exercise, well-being, and accountability represent 18.0% (r = 0.424), 13.2% (r = 0.363), 41.2% (r = 0.642), and 20.5% (r = 0.453), respectively, of the HPL score variation. Survivors who completed higher levels of education received better HPL scores (r = 0.273, p < .05), such that education accounted for 7.5% of the variation in HPL. In contrast, HPL scores were not significantly related to age (r = 0.174), BMI (r = 0.071), gender (r = 0.093), years since diagnosis (r = 0.003), economic status (r = −0.076), perceived health status (r = 0.206), or interaction with family (r = −0.023).

Predictors of HPL

To identify important predictors of adolescent HPL, variables that exhibited a significant association with HPL were analyzed with multiple regression. The HBSE subscales of healthy diet and well-being accounted for 43.8% of the total HPL score variance (Table 4). The predictive equation of adolescent HPL was 52.473 + (2.431 × well-being) + (1.208 × healthy diet).

Table 4.

Predictors of Health-Promoting Lifestyle in Adolescent Survivors of Childhood Cancer (n = 82).

Model predictor	β	Beta	R ²	F	P
Model 1			0.403	53.906	<.001
Constant	69.794
HBSE well-being	2.809	.634
Model 2			0.438	30.839	<.001
Constant	52.473
HBSE well-being	2.431	0.549
HBSE healthy diet	2.431	0.208

Note. HBSE = health behavior self-efficacy; β = nonstandardized regression coefficient; Βeta = standardized regression coefficient; R² = coefficient of determination.

Discussion

In the present study, factors associated with HPL were examined in adolescent survivors of childhood cancer. HBSE was found to be significantly correlated with HPL, and exercise-related subscales of the HBSE and HPL questionnaires received the lowest scores. It has been demonstrated that regular exercise can increase the quality of life and enhance self-esteem and confidence in body image (Meuleners et al., 2002). Established guidelines recommend that healthy children and adolescents aged 6-17 years should perform 60 min of physical activity each day, with muscle-strengthening physical activity performed at least 3 days a week (Department of Health and Human Services, 2018). For youth older than 17 years of age, between 150 and 300 min of moderate-intensity activity should be performed each week (DHHS, 2018). Meanwhile, few pediatric patients are recommended exercise by their physicians (Ross et al., 2018), and supervised exercise programs are not routinely implemented in the clinical setting (Beulertz et al., 2016; Götte et al., 2014; Su et al., 2018). Physical, psychological, and organizational barriers to exercise which exist among pediatric cancer patients have the potential to create habits that may persist even after treatment has ended (Götte et al., 2014).

The results of the present study suggest that obesity in adolescent survivors of childhood cancer is a matter of concern regarding their lifelong health-related behaviors. Among our participants, 17.1% were considered overweight and 12.2% were obese. These percentages are higher than the averages reported for healthy adolescents in Asian countries, where the rate of overweight and obese are 14.6% and 8.6%, respectively (Mazidi et al., 2018). In a longitudinal childhood cancer survivor study spanning 26 pediatric oncology centers in the United States and Canada, the BMI of 1,451 adult survivors and 2,167 same-sex siblings was assessed (Garmey et al., 2008). The prevalence of obesity was higher than average for both survivors and siblings, although the survivors had higher obesity rates than their siblings (13.5% vs. 7.5%). Previous research has demonstrated that being overweight and obese is related to an increased risk of cancer recurrence and mortality for pediatric cancer survivors older than 10 years (Saenz et al., 2018). Hence, weight management via targeted counseling for physical activity and diet needs to be initiated as early as possible. In addition, exercise behavior is strongly influenced by family and peers (Schultz et al., 2007). As a result, the feasibility of exercise education, such as implementing exercise into daily hospital routines or home activities, is recommended during treatment and immediately following treatment. Furthermore, the targets of such education should include both patients and their parents. Previous studies have indicated that factors such as gender, family structure, economic status, interaction time with families, and time since diagnosis can be predictive of healthy lifestyles (Arroyave et al., 2008; Carswell et al., 2008; Gilliam et al., 2012; Mertens et al., 2014; Rebholz et al., 2012).

The participants who were diagnosed with cancer at a pre-school age scored the lowest on the stress management subscales compared to the participants diagnosed with cancer during adolescence. It should be noted that only 25.6% (n = 21) of our participants were diagnosed during adolescence. As a result, only a small number of survivors were analyzed, thereby limiting our ability to interpret and generalize this finding. Second, participants with higher education levels exhibited better HPL. This finding is consistent with the results of previous studies which have shown that cancer survivors with a high school education or less were significantly less likely to report discussing strategies to improve health and exercise (Kenzik et al., 2016). Hence, further studies need to be conducted with larger samples to recommend interventions for the early identification of vulnerable groups to enhance stress management in adolescent survivors of childhood cancer.

Our findings identified that well-being and a healthy diet served as significant predictors of HPL. HBSE well-being, a psychological factor influenced by personal beliefs that promote a sense of control, explained 40.3% of the total HPL variance. This finding is consistent with the notion that self-efficacy is a causal psychological mechanism for engaging HPL among adolescent survivors of childhood cancer (Herts et al., 2017; Parks et al., 2018). However, the experience of childhood cancer and its treatment often adversely impacts the psychosocial well-being of adolescent survivors (Vuotto et al., 2015). For example, adolescent survivors of childhood cancer frequently report feeling alienated by their classmates and suffering from decreased academic performance (Beulertz et al., 2016; Su et al., 2018). In addition, a healthy diet is considered to play an important role in cancer risk. It has been proposed that certain foods may reduce the risk of cancer recurrence (Hsiao et al., 2018; Love et al., 2013). Guidelines currently recommend a diet rich in fruits, vegetables, and whole grains, which is accompanied by decreased intake of sugars and sugar-sweetened beverages (Holman & White, 2011). However, adolescent survivors of childhood cancer have described barriers to meeting daily recommendations (Murphy-Alford et al., 2019). Furthermore, there is a gap between recommendations and individual realities. Hence, further research is needed to develop interventions that will strengthen perceived HBSE well-being and a healthy diet so that adolescents will successfully engage in HPL.

Limitations

This cross-sectional, questionnaire-based study had a small sample size. In addition, given that self-efficacy is a continual learning process, and that dynamic changes can occur at different stages of life, the predictors of HPL identified here should be cautiously interpreted. Thus, further studies are needed to better understand the dynamics of HBSE and HPL throughout the various stages of life.

Conclusions and Implications

Adolescent survivors of childhood cancer reported lower self-efficacy with regard to exercise in the present study. However, survivors who were diagnosed with cancer at pre-school ages had significantly less self-efficacy with regard to diet and stress management than survivors diagnosed later in adolescence. Significant correlations were observed between education level and HBSE and HPL. In addition, HBSE scores for well-being and healthy diet emerged as significant predictors of HPL. Further studies need to be conducted with larger samples to confirm which factors are predictive of engagement in HPL. Once confirmed, these factors could be used to develop interventions aimed at improving self-efficacy and HPL for adolescent survivors of childhood cancer.

Footnotes

Acknowledgments

The authors gratefully acknowledge the time and energy contributed by participants.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Li-Min Wu

Author Biographies

Yi-Jung Huang, RN, has been a clinical nurse for 17 years. Currently, she is a school nurse for 10 years in Kaohsiung Municipal Sinsing senior high school and committed to health promotion.

Shu-Li Lee, RN, PhD. is an assistant professor in School of Nursing, Kaohsiung Medical University. She is dedicated to adolescents with chronic disease.

Li-Min Wu, RN, PhD. is a professor and director in school of Nursing, Kaohsiung Medical University, and Adjunct Research Fellow, Department of Medical Research, Kaohsiung Medical University Hospital. She is devoted to pediatric cancer care and research.

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