A Model of Health Behavior to Guide Studies of Childhood Cancer Survivors

Cheryl Lorane Cox

ONF 2003, 30(5), E92-E99. DOI: 10.1188/03.ONF.E92-E99

Purpose/Objectives: To describe the Interaction Model of Client Health Behavior (IMCHB) and its application to health promotion in childhood cancer survivors.

Data Sources: Periodical literature about cancer survivors, health behavior models, and the IMCHB.

Data Synthesis: Childhood cancer survivors are at risk for various late complications of treatment. The primary goal of intervention is the modification of health-related behavior. Conceptual models that extend beyond health beliefs are needed to guide explanatory and intervention studies in this group.

Conclusions: The IMCHB identifies background, cognitive, affective, motivational, and contextual variables that explain health-related behaviors. The model defines the interactive and collective contributions of a survivor, family, and provider to adherence to protocols, reduction of risk behavior, and promotion of health-protective behavior.

Implications for Nursing: This model may identify new determinants of health-related behavior that can be targeted by specific inter- or intrapersonal interventions to protect the health of childhood cancer survivors and reduce their risk of late sequelae.

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    Abel, E., Marion, L., & Seraphine, A. (1998). The evaluation of motivation for sexual health among women. Western Journal of Nursing Research, 202, 166-179.

    Aruda, M. (2002). Predictors of unprotected sex for teens at pregnancy testing. Unpublished doctoral dissertation. University of Massachusetts, Lowell.

    Atkinson, S., Halton, J., Bradley, C., Wu, B., & Barr, R. (1998). Bone and mineral abnormalities in childhood acute lymphoblastic leukemia: Influence of disease, drugs and nutrition. International Journal of Cancer Supplement, 11, 35-39.

    Bear, M., & Bowers, C. (1998). Using a nursing framework to measure client satisfaction at a nurse-managed clinic. Public Health Nursing, 15(1), 50-59.

    Bhatia, S., Robison, L., Oberlin, O., Greenberg, M., Bunin, G., Fossati-Bellani, F., et al. (1996). Breast cancer and other second neoplasms after childhood Hodgkin's disease. New England Journal of Medicine, 334, 745-751.

    Black, P., Straaten, A., & Gutjahr, P. (1998). Secondary thyroid carcinoma after treatment for childhood cancer. Medical and Pediatric Oncology, 31, 91-95.

    Brown, S. (1992). Tailoring nursing care to the individual client: Empirical challenge of a theoretical concept. Research in Nursing and Health, 15, 39-46.

    Carter, K., & Kulbok, P. (1995). Evaluation of the Interaction Model of Client Health Behavior through the first decade of research. Advances in Nursing Science, 18(1), 62-73.

    Carter, K., & Kulbok, P. (2002). Motivation for health behaviours: A systematic review of the nursing literature. Journal of Advanced Nursing, 40, 316-330.

    Cockerham, W. (1997). Lifestyles, social class, demographic characteristics, and health behavior. In D. Gochman (Ed.), Handbook of health behavior research (pp. 253-264). New York: Plenum Press.

    Corkery, J.C., Li, F.P., McDonald, J.A., Hanley, J.A., Holmes, G.E., & Holmes, F.F. (1979). Kids who really shouldn't smoke. New England Journal of Medicine, 300, 1279.

    Cox, C. (1982). An interaction model of client health behavior: Theoretical prescription for nursing. Advances in Nursing Science, 5(1), 41-56.

    Cox, C. (1984). The individual as client. In J. Sullivan (Ed.), Directions for community health nursing (pp. 129-172). Boston: Blackwell Scientific.

    Cox, C. (1985). The health self-determinism index. Nursing Research, 34, 177-183.

    Cox, C. (2000). Response to patient-centered care: Understanding its interpretation and implementation in health care. Scholarly Inquiry for Nursing Practice: An International Journal, 14, 183-187.

    Cox, C. (2003). Explaining health and risk behavior in childhood cancer survivors. Grant funded by the ONS Foundation.

    Cox, C., Cowell, J., Marion, L., & Miller, E. (1990). The health self-determinism index for children. Research in Nursing and Health, 13, 237-246.

    Cox, C., Kaeser, L., Montgomery, A., & Marion, L. (1991). Quality of life nursing care: An experimental trial in long-term care. Journal of Gerontological Nursing, 17(4), 6-11.

    Cox, C., & Montgomery, A. (1991). Fitness and absenteeism in hospital workers: Clarifying the connection. Journal of Occupational Health Nurses, 39, 189-198.

    Cox, C., & Roghmann, K. (1984). Empirical test of the interaction model of client health behavior. Research in Nursing and Health, 7, 275-285.

    Crom, D., Hinds, P., Gattuso, J., Tyc, V., & Hudson, M. (2002). Female survivors of Hodgkin disease: Perceived vulnerability to breast cancer and compliance with health promotion recommendations. Unpublished manuscript.

    Deci, E., & Ryan, R. (1985). Intrinsic motivation and self-determination in human behavior. New York: Plenum Press.

    Deci, E., & Ryan, R. (2002). Handbook of self-determination research. Rochester, NY: University of Rochester Press.

    DiNapoli, P. (2000). A contextual analysis of adolescent violence using the Interaction Model of Client Health Behavior. Unpublished doctoral dissertation. University of Massachusetts, Lowell.

    Dougherty, M., Dwyer, J., Pendergast, J., Tomlinson, B., Boyington, A., Vogel, W., et al. (1998). Community-based nursing: Urinary continence care for older rural women. Nursing Outlook, 46, 233-244.

    Eyler, A., Wilcox, S., Matson-Koffman, D., Evenson, K.R., Sanderson, B., Thompson, J., et al. (2002). Correlates of physical activity among women from diverse racial/ethnic groups. Journal of Women's Health and Gender-Based Medicine, 11, 239-253.

    Farrand, L., & Cox, C. (1993). Determinants of positive health behavior in middle childhood. Nursing Research, 42, 208-213.

    Gochman, D. (Ed.). (1997). Handbook of health behavior research. New York: Plenum Press.

    Green, D., Hyland, A., Chung, C., Zevon, M., & Hall, B. (1999). Cancer and cardiac mortality among 15-year survivors of cancer diagnosed during childhood or adolescence. Journal of Clinical Oncology, 17, 3207-3215.

    Haupt, R., Byrne, J., Connelly, R., Mostow, E., Austin, D., Holmes, G., et al. (1992). Smoking habits in survivors of childhood and adolescent cancer. Medical and Pediatric Oncology, 20, 301-306.

    Hollen, P., & Hobbie, W. (1996). Decision making and risk behaviors of cancer-surviving adolescents and their peers. Journal of Pediatric Oncology Nursing, 13, 121-133.

    Hoorweg-Nijman, J., Kardos, G., Roos, J., van Dijk, H., Netelenbos, C., Popp-Snijders, C., et al. (1999). Bone mineral density and markers of bone turnover in young adult survivors of childhood lymphoblastic leukaemia. Clinical Endocrinology, 50, 237-244.

    Hudson, M., Jones, D., Boyett, J., Sharp, G., & Pui, C. (1997). Late mortality of long-term survivors of childhood cancer. Journal of Clinical Oncology, 15, 2205-2213.

    Hudson, M., Poquette, C., Lee, J., Greenwald, C., Shah, A., Luo, X., et al. (1998). Increased mortality after successful treatment for Hodgkin's disease. Journal of Clinical Oncology, 16, 3592-3600.

    Hudson, M., Tyc, V., Srivastava, D., Gattuso, J., Quargnenti, A., Crom, D., et al. (2002). Multi-component behavioral intervention to promote health protective behaviors in childhood cancer survivors: The protect study. Medical and Pediatric Oncology, 39, 2-11.

    Kovac, J., Patel, S., Peterson, R., & Kimmel, P. (2002). Patient satisfaction with care and behavioral compliance in end-stage renal disease patients treated with hemodialysis. American Journal of Kidney Diseases, 39, 1236-1244.

    Kulbok, P., & Cox, C. (2002). Dimensions of adolescent health behavior. Journal of Adolescent Health, 31, 394-400.

    Marion, L. (2002). Sexually transmitted disease prevention intervention in African-American women. Grant funded by the National Institutes of Health and the National Institute of Nursing Research.

    Marion, L., & Cox, C. (1996). Condom use and fertility among divorced and separated women. Nursing Research, 45, 110-115.

    Oeffinger, K., Buchanan, G., Eshelman, D., Denke, M., Andrews, T., Germak, J., et al. (2001). Cardiovascular risk factors in young adult survivors of childhood acute lymphoblastic leukemia. American Journal of Pediatric Hematology/Oncology, 23, 424-430.

    Read, C. (2002). Reproductive decisions of parents of children with metabolic disorders. Clinical Genetics, 61, 268-276.

    Ries, L., Smith, M., Gurney, J., Linet, M., Tamra, T., Young, J., et al. (Eds.). (1999). Cancer incidence and survival among children and adolescents: United States SEER Program 1975-1995 [NIH Publication No. 99-4649]. Bethesda, MD: National Cancer Institute.

    Roberts, K. (2002). Physician-patient relationships, patient satisfaction, and antiretroviral medication adherence among HIV-infected adults attending a public health clinic. AIDS Patient Care and STDs, 16(1), 43-50.

    Sklar, C., Mertens, A., Walter, A., Mitchell, D., Nesbit, M., O'Leary, M., et al. (2000). Changes in body mass index and prevalence of overweight in survivors of childhood acute lymphoblastic leukemia: Role of cranial irradiation. Medical and Pediatric Oncology, 35, 91-95.

    Solheim, K. (1989). The smoking cessation process. Journal of Holistic Nursing, 7(1), 26-33.

    Swerdlow, A., Barber, J., Horwich, A., Cunningham, D., Milan, S., & Omar, R. (1997). Second malignancy in patients with Hodgkin's disease treated at the Royal Marsden Hospital. British Journal of Cancer, 75, 116-123.

    Talvensaari, K., Lanning, M., Tapanainen, P., & Knip, M. (1996). Long-term survivors of childhood cancer have an increased risk of manifesting the metabolic syndrome. Journal of Clinical Endocrinology and Metabolism, 81, 3051-3055.

    Tao, M., Guo, M., Weiss, R., Byrne, J., Mills, J., Robison, L., et al. (1998). Smoking in adult survivors of childhood acute lymphoblastic leukemia. Journal of the National Cancer Institute, 90, 219-225.

    Troumbley, P., & Lenz, E. (1992). Application of Cox's interaction model of client health behavior in a weight control program for military personnel: A preintervention baseline. Advances in Nursing Science, 14(4), 65-78.

    Troyer, H., & Holmes, G. (1988). Cigarette smoking among childhood cancer survivors. American Journal of Diseases in Children, 142, 123-124.

    Tyc, V., Hudson, M., & Hinds, P. (1999). Health promotion interventions for adolescent cancer survivors. Cognitive and Behavioral Practice, 6, 128-136.

    U.S. Department of Health and Human Services. (2000). Healthy people 2010. Washington, DC: Government Printing Office.

    Vassilopoulou-Sellin, R., Brosnan, P., Delpassand, A., Zietz, H., Klein, M., & Jaffe, N. (1999). Osteopenia in young adult survivors of childhood cancer. Medical and Pediatric Oncology, 32, 272-278.

    Wilbur, J., Chandler, P., & Miller, A. (2001). Measuring adherence to a women's walking program. Western Journal of Nursing Research, 23, 8-24.

    Wilbur, J., Miller, A.M., Chandler, P., & McDevitt, J. (2003). Determinants of physical activity and adherence to a 24-week home-based walking program in African American and Caucasian women. Research in Nursing and Health, 26, 213-224.

    Williams, G., Cox, E., Hedberg, V., & Deci, E. (2000). Extrinsic life goals and health-risk behaviors in adolescents. Journal of Applied Social Psychology, 30, 1756-1771.

    Williams, G., Freedman, Z., & Deci, E. (1998). Supporting autonomy to motivate patients with diabetes for glucose control. Diabetes Care, 21, 1644-1651.

    Wolden, S., Lamborn, K., Cleary, S., Tate, D., & Donaldson, S. (1998). Second cancers following pediatric Hodgkin's disease. Journal of Clinical Oncology, 16, 536-544.