This material is protected by U.S. copyright law. Unauthorized reproduction is prohibited.
To purchase reprints or request permission to reproduce, e-mail firstname.lastname@example.org.
A Model of Health Behavior to Guide Studies
of Childhood Cancer Survivors
Cheryl Lorane Cox, RN, PhD
Key Points . . .
Purpose/Objectives: To describe the Interaction Model of Client
Health Behavior (IMCHB) and its application to health promotion in
childhood cancer survivors.
➤ Survivors of childhood cancer engage in health-risk behaviors
Data Sources: Periodical literature about cancer survivors, health be-
at a rate comparable to or exceeding that of their healthy peers,
havior models, and the IMCHB.
despite their increased risks for treatment-related complications.
Data Synthesis: Childhood cancer survivors are at risk for various
late complications of treatment. The primary goal of intervention is the
➤ Documentation is limited or nonexistent regarding the ante-
modification of health-related behavior. Conceptual models that extend
cedents of participation in risk behaviors or health-protective
beyond health beliefs are needed to guide explanatory and intervention
behaviors for this vulnerable group.
studies in this group.
➤ New conceptual approaches that broadly consider intraper-
Conclusions: The IMCHB identifies background, cognitive, affective,
sonal and contextual determinants of health-related behavior
motivational, and contextual variables that explain health-related behav-
are needed to direct explanatory and intervention studies of
iors. The model defines the interactive and collective contributions of a
survivor, family, and provider to adherence to protocols, reduction of
childhood cancer survivors.
risk behavior, and promotion of health-protective behavior.
➤ The Interaction Model of Client Health Behavior has the po-
Implications for Nursing: This model may identify new determinants
tential to identify new targets for behavioral intervention.
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.
and well-being of cancer survivors given their treatment-related
risks. However, studies have documented that adolescent and
he rates of disease-free survival at five years for most
young adult survivors choose not to engage in these health-
childhood cancers now exceed 70%, and 1 in 900
promoting behaviors; instead, they practice high-risk behav-
adults from 2045 years of age in the United States is
iors (e.g., tobacco use, recreational drug use, unprotected
a childhood cancer survivor (Ries et al., 1999). An array of
sexual activity, alcohol consumption) at a rate equal to or
potential late effects of radiation therapy and chemotherapy
greater than that of their healthy peers (Corkery et al., 1979;
renders this population vulnerable to long-term health prob-
Haupt et al., 1992; Hollen & Hobbie, 1996; Tao et al., 1998;
lems, such as second cancers (Bhatia et al., 1996; Black,
Troyer & Holmes, 1988; Tyc, Hudson, & Hinds, 1999).
Straaten, & Gutjahr, 1998; Swerdlow et al., 1997), cardiovas-
Only recently have investigators begun to develop and test
cular problems (Green, Hyland, Chung, Zevon, & Hall, 1999;
interventions designed to reduce risk behavior and increase
Hudson et al., 1998; Hudson, Jones, Boyett, Sharp, & Pui,
health-protective behavior in young cancer survivors (Hudson
1997; Wolden, Lamborn, Cleary, Tate, & Donaldson, 1998),
et al., 2002). For the most part, these interventions have fo-
osteoporosis (Atkinson, Halton, Bradley, Wu, & Barr, 1998;
cused on changing survivors' beliefs about treatment-related
Hoorweg-Nijman et al., 1999; Vassilopoulou-Sellin et al.,
risks and the efficacy of health-protective behaviors in reduc-
1999), and obesity and its sequelae (e.g., hypertension, diabe-
ing those risks. Providers present risk and risk-modification
tes, dyslipidemia) (Oeffinger et al., 2001; Sklar et al., 2000;
Talvensaari, Lanning, Tapanainen, & Knip, 1996).
In the general population, sound dietary practices, breast
Cheryl Lorane Cox, RN, PhD, is an associate faculty member in the
and testicular self-examination, and aerobic and resistance
Department of Nursing Research at St. Jude Children's Research
exercise are behaviors known to reduce the risk of cardiovas-
Hospital in Memphis, TN. (Submitted October 2002. Accepted for
cular disease, diabetes, osteoporosis, obesity, and cancer (U.S.
publication April 15, 2003.)
Department of Health and Human Services, 2000). These self-
care behaviors are especially important to the long-term health
Digital Object Identifier: 10.1188/03.ONF.E92-E99
ONCOLOGY NURSING FORUM VOL 30, NO 5, 2003
information by combining patients' goal selection and a clas-
tion in sexual risk-taking behavior (Abel, Marion, & Sera-
sical health education approach. Survivors choose a behavior
phine, 1998), and self-determination in physical exercise
on which to focus (e.g., stopping smoking, initiating an aero-
(Eyler et al., 2002). Important intervention studies have used
bic exercise program), and behavior-specific information is
the IMCHB to examine enhancement of the health and well-
provided during the patient-provider encounter.
being of institutionalized elderly patients through choice and
This cognitive processing approach, which uses only
self-determination (Cox, Kaeser, Montgomery, & Marion,
knowledge to inform beliefs and attitudes, has shown limited
1991), initiation and maintenance of exercise in middle-aged
success in reducing health-risk behaviors or increasing health-
women (Wilbur, Chandler, & Miller, 2001), urinary inconti-
enhancing behaviors; therefore, survivors' behavioral choices
nence (Dougherty et al., 1998), and prevention of sexually
are likely to reflect factors other than beliefs and attitudes to-
transmitted diseases in populations at high risk (Marion,
ward their disease and knowledge about treatment-related
2002). Additional studies, guided by the IMCHB, currently
risks and risk modification. Multiple intrapersonal variables
are under way.
(e.g., perceived current and future health status, perceived
Although the IMCHB has guided explanatory and interven-
sense of self, developmental status, diagnosis and treatment
tion studies of a variety of health-related behaviors across the
experiences, affective responses to their disease and its treat-
life span, this model has not been tested among childhood
ment, demographic factors) that extend beyond health beliefs
cancer survivors. This article describes the concepts and con-
and attitudes may influence survivors' behavior choices.
structs that comprise the structure of the model and applies
Family, social, and healthcare contexts are equally impor-
them to young survivors of childhood cancer. In addition, the
tant influences on behavior (Gochman, 1997). Family and
ability of the model to direct descriptive studies and interven-
peer responses to survivors' disease and treatment and to their
tion trials targeted at behavioral change in this vulnerable
health-related behaviors may significantly influence whether
population will be addressed.
they follow prescribed or proscribed regimens. The prelimi-
Structure of the Interaction Model
nary findings of a recent qualitative study suggested that the
disease-related behavior of childhood cancer survivors is af-
of Client Health Behavior
fected strongly by providers' communication style, the rela-
The framework of the IMCHB (see Figure 1) incorporates
tionships between providers and patients, and the extent to
physical, social, cognitive, motivational, affective, and envi-
which providers recognize their patients' autonomy in choice
ronmental antecedents to health behavior. The model gives a
of behavior (Crom, Hinds, Gattuso, Tyc, & Hudson, 2002).
prominent contextual role to the provider or clinician in ef-
The inclusion and documentation of these intrapersonal and
fecting positive and negative health outcomes. The original
contextual variables in explanatory studies of childhood can-
empirical support for the concepts and their relationships in
cer survivors' health-related behaviors offer an opportunity to
the IMCHB is reported in detail elsewhere (Cox, 1982, 1984).
design risk-targeted, multifocal interventions to decrease the
Briefly, the model comprises three elements: client singular-
late complications of treatment.
ity (the unique intrapersonal and contextual configuration of
Prior Applications of the Interaction
the individual), client-professional interaction (the therapeu-
tic content and process that occurs between a clinician and pa-
Model of Client Health Behavior
tient), and health outcomes (the behavior or behaviorally re-
The Interaction Model of Client Health Behavior (IMCHB)
lated outcome subsequent to a client-professional interaction).
(Carter & Kulbok, 1995; Cox, 1982, 1984, 2000) was devel-
The basic assumptions of the model (described in detail in
oped to describe the multiple interacting antecedents of
Cox ) recognize the role of choice and self-determina-
health-protective and risk-taking behavior and to identify pro-
tion in health behavior, the ability of the clinician's interaction
vider behaviors that affect health outcomes. This model has
style and intervention approach to support or discourage health
served as the basis for a variety of health behavior studies in
behavior, and the dynamic impact of the client's singularity
which the uniqueness of each patient was used to explain vari-
ances in health outcomes. Studies have focused on adult
health behaviors, such as prenatal diagnostic testing (Cox &
Roghmann, 1984), smoking cessation (Solheim, 1989), em-
ployee fitness (Cox & Montgomery, 1991), health-promotion
behavior in military personnel (Troumbley & Lenz, 1992),
practitioner-patient interaction in prenatal care (Brown, 1992),
condom use among separated and divorced women (Marion
& Cox, 1996), and reproductive decision making (Read,
2002). The IMCHB has guided explanatory studies in pediat-
ric and adolescent health behavior, such as adolescent vio-
lence (DiNapoli, 2000), contraceptive use among adolescents
(Aruda, 2002), and children's health-promotion behaviors
(Farrand & Cox, 1993).
A number of instruments have been designed to measure
specific concepts within the IMCHB: self-determination in the
health behaviors of adults (Carter & Kulbok, 2002; Cox,
1985) and children (Cox, Cowell, Marion, & Miller, 1990),
Figure 1. Interaction Model of Client Health Behavior
satisfaction with care (Bear & Bowers, 1998), self-determina-
ONCOLOGY NURSING FORUM VOL 30, NO 5, 2003
profile on health outcomes. The model's working hypothesis
ever, they mainly serve as explanatory antecedents to the dy-
is that the potential for positive patient health outcomes in-
namic variables of client singularity. For example, a survivor
creases as the provider intervention or interaction is tailored
whose family has a limited income (demographic character-
to the uniqueness of each patient (i.e., background and cog-
istic), no health insurance (environmental resource), and
nitive, affective, and motivational manifestations).
members who fear the worst when a new symptom arises (so-
A reciprocal relationship (as noted in Figure 1) has been
cial influence) may decide (intrinsic motivation, as a dynamic
found between the dynamic variables of client singularity and
variable) against making an appointment for a follow-up
the four concepts that constitute the client-professional inter-
action element. Briefly, the intervention must address the
The background variables are assumed to be interrelated.
unique configuration of the client's singularity to maximize
Demographic characteristics certainly influence the cultural
positive health outcomes. Over time, the health outcomes el-
factors of social influence (e.g., racial, ethnic, and cultural
ement exerts a feedback effect that can influence both the
connections). Demographic characteristics and social influ-
background and dynamic variables of the client singularity
ence often are tied to health history, health status, and expe-
rience. Demographic characteristics and other background
The model was intended to accomplish two sequential pur-
variables are connected similarly to the availability and nature
poses: to guide the inclusion of client singularity variables in
of environmental resources.
studies that may explain health-related behaviors and their
Multiple interrelated indicators, such as those described by
associated health outcomes and to lead the design of interven-
the background variables, can make a conceptual model cum-
tions that target these identified variables.
bersome. However, because the IMCHB was developed to
guide clinical practice through research, the model attempts to
articulate all potentially important direct and indirect concep-
tual classes of correlates of health-promoting and risk behav-
This element of the model comprises two different sets of
factors: background variables (e.g., gender, religion, health
If the background variables that are most important in iden-
history) and dynamic variables (e.g., motivation, knowledge,
tifying individuals at risk or in explaining individuals' cogni-
fear). These variables can be defined and measured in terms
tive appraisal, motivation, or affective responses are identi-
of many different factors. Together, these sets of factors can
fied, interventions can be tailored specifically to them. For
define the uniqueness of every young cancer survivor (client
example, interventions that target young male and female sur-
singularity) at a given point in time on the basis of intraper-
vivors separately may be optimal if sex is strongly explana-
sonal and socioenvironmental contextual characteristics.
tory of a given health behavior or is a strong determinant of
Background Variables of Client Singularity
the dynamic variables of client singularity (Farrand & Cox,
1993). A recent study demonstrated distinctive patterns be-
Factors such as demographic characteristics, social influ-
tween adolescent cultural and ethnic groups and risk-taking
ence (e.g., culture, religion, peer influences, social network,
behaviors; consequently, interventions may need to be tai-
social support), previous healthcare experiences (e.g., health
lored specifically to cultural and ethnic survivor groups to
history, developmental status, objective health data), and en-
maximize their impact (Kulbok & Cox, 2002).
vironmental resources (e.g., access to health care, barriers to
health care, personal resources) are relatively static variables
Dynamic Variables of Client Singularity
at any single point in time (i.e., the time at which the patient-
Cognitive appraisal, affective response, and motivation are
provider encounter occurs). Selected background variables
may change over time, but such change tends to be subtle. For
dynamic variables (see Figure 1 and Table 1). These variables
would be affected by an intervention more immediately than
example, a young survivor's treatment history and response to
would background variables (which tend to be more static)
that treatment remain relatively stable as perceived experi-
ences within a given developmental stage. The impact of the
(Wilbur, Miller, Chandler, & McDevitt, 2003). Cognitive
change in these background variables on motivated behavior,
appraisal comprises such factors as patient knowledge, beliefs,
and attitudes toward the illness and treatment. These factors
in most cases, will not be immediate because health-promot-
ing and health-risking behaviors are largely under the control
(knowledge, beliefs, and attitudes) correspond to those previ-
of the patients.
ously used in studies of interventions in childhood cancer
Unique to survivors of pediatric cancer are the influences of
survivors (Hudson et al., 2002). Affective response factors are
developmental status. Developmental status is treated as a
based on emotion and ultimately contribute to behavioral de-
background variable within the IMCHB in that, at any given
cision making. Fear, anxiety, anger, joy, sadness, and uncer-
point in time, a child's developmental status is an important
tainty can be very strong predictors of behavior that are inde-
consideration in explaining health behavior. The inclusion of
pendent of other cognitively based variables (attitudes,
developmental status within the background variables cat-
knowledge, and beliefs) (Deci & Ryan, 2002).
egory does not imply that it is a static variable; indeed, over
Motivation in the IMCHB is defined according to the con-
time, developmental status will change. Although interven-
cept of intrinsic and extrinsic motivation derived from the
tions to modify behavior must incorporate an understanding
Theory of Self-Determination (Deci & Ryan, 1985). Briefly,
of a child's development, developmental status itself is not
the motivation for a behavior is based on two major operative
altered by the intervention, thus making developmental status
factors: the content of a patient's behavioral goals (intrinsic
a stable rather than a modifiable model characteristic.
versus extrinsic) and the regulatory processes (autonomous
Background variables are posited to have a direct influence
versus controlled) through which these goals are pursued.
on some health outcomes (e.g., sex and income may weakly
Both content and process affect goal-directed behavior (Deci
predict adherence or utilization) (Cockerham, 1997); how-
& Ryan, 2002).
ONCOLOGY NURSING FORUM VOL 30, NO 5, 2003
Table 1. Correspondence of the Interaction Model of Client Health Behavior Labels With Descriptors Relevant
to Childhood Cancer Survivors
Childhood Cancer Survivor Descriptors
Unique intrapersonal and contextual configuration of
an individual based on background variables, mo-
tivation, cognitive appraisal, and affective response
ˇ Background variables
Relatively nonmodifiable influences on health behavior
Age, education, race or ethnicity, family income
Variation in amount and consistency (religiosity; fam-
Social factors that affect health behaviors
ily, peer, and cultural influences)
Diagnosis and treatment history or experience, re-
Previous healthcare experience
Health history (objective and subjective), current
sponse to treatment, dexamethasone levels
physiologic health status, and developmental status
Availability of informational, people, financial, and
Access to oncology providers, other providers, insur-
ance, transportation, and informational resources
geographic resources to facilitate health behavior
ˇ Dynamic variables
Modifiable targets for intervention
Emotional response to a health concern
Fears about the future, health, fertility, and interactions
with peers, family, and teachers; depression; anxiety
over loss of contact with oncology providers and ad-
equacy of generalist's care
Intrinsic or extrinsic motivation, self-determination
Feelings of competency related to disease course, treat-
ment, or new behaviors; health behaviors based on
intrinsic (self-determined) versus extrinsic (nonself-
Cognitive representation of a health concern
Knowledge; attitudes; beliefs about health, cancer,
treatment, and health behaviors
The extent to which the provider attends to a client's
singularity and tailors the intervention approach to
ˇ Affective support
The process of attending to a client's level of emotional
The bond with the survivor, acknowledgement of
arousal and building an affiliative bond with the client
survivor's feelings about disease and treatment
ˇ Provision of health information
The process of providing useful health information to
Timing, content, quantity, method of delivery, valida-
tion of learning
The process of creating a healthcare climate that is
ˇ Decisional control
Supporting a survivor to participate in his or her own
supportive of autonomy rather than controlling
healthcare decision making, avoiding controlling
Therapeutic skills of the provider
The ability of the provider to tailor the intervention to
ˇ Professional or technical competencies
the uniqueness of each survivor
Health behavior or health state that is behaviorally
The extent to which an individual seeks out and uses
Follow-up appointments, participation in support
ˇ Healthcare utilization
available healthcare resources
Physiologic, psychological, social health, and well-
Fitness levels, well-being measures
ˇ Health status indicators
Disease progression, stabilization as a function of
Symptoms, fatigue, appetite, quality of life
ˇ Problem-severity indicators
measures of disease or treatment sequelae
Extent to which a patient engages in care regimens,
Use of sunscreen, takes prescribed medications
ˇ Adherence to the recommended care
behaviors, or treatments that are necessary to en-
sure optimal health
Client's appraisal of adequacy of a provider's re-
Perceived adequacy of care, satisfaction measures
ˇ Satisfaction with care
sponse to a healthcare problem and extent to which
the patient's expectations are or are not met
The dynamic client singularity variables (i.e., motivation,
might act on her knowledge (cognitive appraisal) that not all
cognitive appraisal, and affective response) influence one an-
breast masses are cancerous. This leads to the self-determined
other. Attitudes, knowledge, and beliefs (factors of cognitive
intrinsic goal (motivation) to seek evaluation to reduce her
appraisal) contribute to motivation and emotions (affective re-
anxiety (affective response).
sponse). Similarly, emotions can influence motivation and
Although cognitive appraisal, motivation, and affective re-
beliefs. For example, consider a young cancer survivor who
sponse all are cognitively based, the IMCHB proposes that
recently discovered a mass in her breast. The discovery gen-
the behavioral impact of each of these constructs can be very
erates overwhelming fear of recurrent or new disease (affec-
different, thus creating the need for conceptual specificity
tive response); this fear, in turn, generates a fear-controlled
and distinction. The IMCHB conceptually separates and de-
goal not to seek medical attention (motivation). Alternatively,
fines each of the concepts to enable the development of
another young female survivor on making the same discovery
more focused interventions. Use of the model to pinpoint the
ONCOLOGY NURSING FORUM VOL 30, NO 5, 2003
descriptive factors that explain young survivors' health-re-
of competency, self-determination, and responsibility for their
lated behaviors would allow for interventions targeted at these
own health care. Decisional control describes the extent to
factors. The greater the precision with which an intervention
which the healthcare climate is supportive of autonomy or is
is targeted to the multiple explanatory contributing factors of
controlling. During treatment, survivors have limited oppor-
a behavior, the greater the likelihood that the intervention will
tunities to participate fully in their care; after they gain "sur-
vivor status," they may seek opportunities to exert their deci-
The importance of paying attention to the uniqueness of
sional control, even if that control means participating in
each patient was supported in a recent focus group study of
health-risking behaviors. Adolescents, in particular, look for
young female survivors of childhood cancer. When asked
opportunities to gain control. The more their autonomy in
what providers could do to support survivors' health-protec-
decision making is supported, the less likely they are to be-
tive behaviors, they responded resoundingly and unani-
have in a reactive manner and the more open they are to mak-
mously, "Listen to my story." They wanted providers to lis-
ing positive health choices. Over time, they internalize the
ten to and address their fears, their specific knowledge
responsibility for health-protective behaviors.
deficits, and internal and external factors that supported or ne-
Professional or technical competencies refer to the ability of
gated positive health behaviors (Crom et al., 2002). These
a provider to interact with a client in ways that are appropri-
young patients articulated their need for providers to recog-
ate to the client's singularity and appreciation of the patient's
nize their singularity and to address that singularity in inter-
technical versus interpersonal needs in light of the healthcare
actions and interventions. This study was conducted without
problem. For example, the newly hospitalized child who is in
any knowledge of the IMCHB, yet the patient data strongly
crisis, being managed by protocol, and minimally responsive
support multiple concepts within the model.
to external stimuli has needs that are different from those of
the adolescent childhood cancer survivor whose greatest
therapeutic need is skilled behavioral assessment and inter-
vention. With the former, provider skills are oriented very
Four factors define the client-professional interaction ele-
much to the physiologic and technical aspects of care; with the
ment: affective support, provision of health information, de-
latter patient, skills are needed that can facilitate patient deci-
cisional control, and professional or technical competencies.
sion making relative to new behaviors to support health. Skills
Affective support means attending to a survivor's level of
and abilities at both extremes are important. Behavioral as-
emotional arousal and building an affiliative bond with the
sessment and intervention skills are as important as acute care
client (Cox, 1984). These two aspects of affective support are
technologic intervention skills. A single provider may not be
related in complex ways (see Cox  for a more detailed
expert in both areas but should be able to recognize the need
discussion) and have particular relevance to childhood cancer
for a given intervention and find appropriate resources to meet
survivors. During treatment, pediatric patients with cancer
a patient's needs.
develop very strong bonds with their oncology care providers.
Factors within the element of client-professional interaction
After completion of therapy, patients often are returned to
influence one another. The relationship component of affec-
generalist providers for continuing care and follow-up. The
tive support is the primary foundation on which all other in-
loss of relationships with oncology care providers and worry
tervention and interaction factors are built. Even the most
that the generalists may not provide adequate cancer follow-
advanced therapies and elaborate health education programs
up can be powerful determinants of subsequent behavioral
can be unsuccessful without effective communication, the
ability to deliver a message of caring and concern, and atten-
The provision of health information to cancer survivors can
tion to a patient's affective response. For example, a 16-year-
be examined from multiple perspectives: the nature (specific
old boy post-treatment for acute lymphocytic leukemia who
versus abstract) and content (the message) of information pro-
is depressed (affective response) by the impact of his disease
vided, the manner in which the information is conveyed (writ-
and its treatment may not be attentive to provider recommen-
ten, audio, video, or one-on-one interaction), the affective
dations relative to exercise and diet to decrease his risks for
state of patients when the information is offered, and the
treatment-related problems. Failure to address his affective
quantity of information provided. Health information varies in
response may result in his noncompliance with therapeutic
type and function. Some health information is useful in in-
health-protective recommendations. Alternatively, recogni-
forming survivors' cognitive appraisal (e.g., didactic content
tion of his affective state (affective support); pharmacologic
on treatment-related complications and risks). Other health in-
treatment of depression, if needed; and information that helps
formation can be used to promote intrinsic motivation (e.g.,
him cope with his concerns about his disease (health informa-
positive feedback on survivor-initiated health-protective be-
tion) may enhance his adherence to treatment.
havior). Some information can focus on altering the affective
Decisional control is related strongly to affective support
response (e.g., specific information about how a treatment
and provision of health information. In a healthcare climate
will feel to lessen patient anxiety).
that is supportive of autonomy, providers can assist young
Decisional control conceptually represents providers' rec-
cancer survivors on many levels. Providers can aid survivors
ognition of patients' ability to participate in decision making
to become aware of their health-related behaviors, help to for-
related to their own health care. Although most healthcare
mulate standards against which survivors can compare their
professionals would insist patients' input into healthcare de-
behavior and set goals, foster a sense of self-efficacy that
cision making is normative, it still is often overlooked as a
stresses survivors' capacity to make decisions about their
specific intervention strategy (Gochman, 1997). Providers can
health, assist survivors to see the relationship between their
limit patients' sense of control by failing to provide useful in-
behaviors and specified outcomes, and help survivors to un-
formation and using coercive tactics (e.g., provider addresses
derstand what can and cannot be changed about their health
parents versus patients). These factors reduce patients' sense
ONCOLOGY NURSING FORUM VOL 30, NO 5, 2003
status. By supporting survivors' self-determination, this ap-
Generally, health behavior studies, for reasons of practicality,
proach ultimately strengthens survivors' feelings of self-effi-
are limited to one or two outcome measures.
cacy and promotes the internalization of responsibility for
Healthcare utilization refers broadly to the use of health re-
sources as a health-promoting behavior. The concept can be
The client-professional interaction or intervention is dictated
operationalized to measure survivors' independent access of
by survivors' singularity profiles. The patient-provider encoun-
health information sources to inform their decisions or mea-
ter can provide many clues that can help to guide the interven-
sure self-referred or professional-referred use of formal or
tion approach. Clearly, what survivors know and believe (cog-
informal healthcare services (e.g., frequency of visits, type
nitive appraisal) and survivors' emotional state (affective
and nature of services sought).
response) are targets for intervention in terms of affective sup-
Health status indicators conceptually represent the full spec-
port and the provision of health information. The need for au-
trum of clinical health outcomes (e.g., weight, objective and
tonomy can be assessed simply by asking survivors how they
subjective health status, laboratory measures, well-being).
relate to a care provider, to what extent they want to be involved
Studies may seek to use self-report health status measures,
in decision making, and to what extent they are willing to be full
physiologic or laboratory data (hematology and immunology
participants in their care.
data), or standardized measures of affective or cognitive states
Survivors constantly offer clues to their sense of efficacy and
(depression, anxiety, or problem-solving abilities).
competency related to their illness and treatment. The extent to
Problem-severity indicators can be used to evaluate pro-
which survivors initiate questions and want information about
gression of disease, stabilization of disease, return of function,
progress and setbacks is a clear indicator of whether they want
and other end points. This category of variables enables the
an active role in their care and whether they feel competent to
development of outcome measures that are based less on
make choices (Deci & Ryan, 2002). Such behavior is highly
measures of disease and more on measures of the sequelae of
indicative of an intrinsically motivated survivor. Such survi-
disease or its treatment (e.g., fatigue, quality of life, appetite,
vors, when they need to stop smoking and begin an aerobic
control of nausea).
exercise regimen, are more likely to respond to an autonomy-
Adherence to the recommended care regimen is the extent
supportive intervention strategy ("I personally would like to see
to which the survivor engages in those behaviors or treatments
you stop smoking and begin an exercise program; however, that
that are necessary to ensure optimal health. Actual behavior
is your choice. If you decide you would like some help to do
(e.g., frequency of aerobic exercise sessions per week), indi-
both or either of these things, I am here to help you.") than one
cators of adherence (e.g., pill counts, dexamethasone assays),
in which the provider is controlling ("You should stop smok-
and congruency measures (the correspondence between rec-
ing and start exercising."). Conversely, when survivors indicate
ommended and actual behavior) represent the types of mea-
overtly or covertly that they prefer that the provider be the de-
surable adherence outcomes.
cision maker, interventions that emphasize closer contact and
Satisfaction with care directly reflects the content of the
external reinforcement from the provider (e.g., more frequent
provider's interaction or intervention and sensitivity to the
visits, regular telephone contact) are appropriate.
client's singularity. Although it is not a behavioral measure,
satisfaction with care is a strong indicator of subsequent be-
havior (Kovac, Patel, Peterson, & Kimmel, 2002; Roberts,
2002). Satisfaction with care is linked very closely to whether
The element of health outcomes consists of healthcare uti-
patients follow a therapeutic protocol, use care options as sug-
lization, health status indicators, problem-severity indicators,
gested, and implement suggested health behaviors.
adherence to recommended care regimens, and satisfaction
with care. The broad array of behaviorally related conceptual
Extending the Boundaries of Survivor
outcomes allows the specification of a measured outcome that
is sufficiently sensitive to the explanatory singularity factors
and to the variables manipulated as part of an intervention.
The outcomes are not limited to behavior, although behavior
The IMCHB can improve childhood cancer care and research
certainly is implied in each of the outcomes, and can be mea-
efforts in two ways. First, the conceptual breadth of the model
sured directly or indirectly as a function of any of the out-
will allow the generation of new questions incorporating new
comes. For the most part, health outcomes are related logi-
concepts, variables, and relationships heretofore unexamined.
cally and conceptually. The relationships among outcome
For example, in previous studies of cancer survivors (Hudson
measures, however, may or may not be interrelated, depend-
et al., 2002), after an education intervention, girls demonstrated
ing on the specific operationalization of the outcome and the
more knowledge than boys about the risks associated with their
context in which it is being evaluated. For example, common
cancer and its treatment. Increased knowledge, however, did
sense would dictate that satisfaction with care could be related
not lead to behavior modification. The IMCHB would be a
to whether someone would adhere to a recommendation or
useful guide for the design of studies that include multiple ques-
use services in the future; similarly, adherence to a regimen
tions about what modifies the knowledge and behavioral out-
may have a definitive impact on the severity of healthcare
come link, such as to what extent is increased knowledge me-
problems or clinical health status indicators. Although the
diated by other demographic or social influence variables?
potential for these interrelationships exists, theoretically, it
Does fear or anxiety (affective response) modify the assimila-
cannot be put forward as universal for all health outcomes
tion and application of knowledge positively or negatively? Are
across all contexts. For that reason, health outcomes are pre-
knowledge and affect associated with an adolescent's motiva-
sented as a collective with the potential for interrelationship;
however, those relationships are not specified a priori or in the
The IMCHB can be used to guide the formulation of ques-
absence of a healthcare problem and context under study.
tions about the connections among affective response, moti-
ONCOLOGY NURSING FORUM VOL 30, NO 5, 2003
vational orientation, and behavioral outcomes. How much do
motivation and affect predict health-related behavior? Does
A wide variety of measures are available throughout the
fear of treatment-related complications contribute to an extrin-
medical, nursing, and psychosocial literature to address the
sic motivational orientation and thereby increase participation
multifocal concepts within the IMCHB. Similarly, analytical
in health-risking behaviors? Healthy adolescents whose par-
strategies such as structural equation modeling and confirma-
ents are supportive of autonomy participate less in health-risk-
tory structural factor analysis lend themselves well to the ex-
ing behaviors (Williams, Cox, Hedberg, & Deci, 2000), and
amination of models containing multiple variables with inter-
diabetic patients whose healthcare providers are supportive of
active moderating and mediating effects on dependent
autonomy rather than controlling are more adherent to thera-
measures. Such strategies allow for examination of the struc-
peutic regimens (Williams, Freedman, & Deci, 1998). Could
ture of the IMCHB as a whole and estimation of its ability to
home and healthcare contexts be influential in determining
explain behavior. The IMCHB is being used to direct a pro-
survivors' health behavior motivation and subsequent health-
gram of research targeted at explaining health promotion and
risk reduction in survivors of pediatric cancers. A currently
Second, the IMCHB can be used to test whether client sin-
funded study will examine the ability of the IMCHB to spe-
gularity variables explain the health-risk and health-protective
cifically identify targets for intervention and reevaluate the
behaviors of childhood cancer survivors and how these mul-
impact of a previously tested intervention using reconfigured
tiple variables are related (direct or indirect influences, medi-
behavioral outcome measures (Cox, 2003). These studies are
ating or modifying influences). This information can be used
preliminary to intervention studies that will focus on support-
to clearly define intervention strategies for cancer survivors.
ing positive health-protective behaviors in young survivors.
Intervention approaches broader than didactic health educa-
In summary, the IMCHB offers a conceptual structure that
tion may be indicated. If the healthcare climate (client-profes-
can support explanatory studies and intervention trials in the
sional interaction) is found to be predictive of health behav-
childhood cancer survivor population. This broader concep-
ior in this population, then interactions that are tailored to the
tual framework has the potential to reveal new explanatory
motivational orientation of survivors should be highly effec-
variables for health-protective and health-risk behaviors. In-
tive in changing behavior. If social influences (parent-survi-
terventions that target these variables can promote behavioral
vor interaction) predict behavior, then interventions that
changes that advance survivors' health and well-being while
modify parent-survivor interaction related to health-risk be-
reducing their risk of late sequelae.
haviors may be useful. If affective responses to cancer and its
treatment are related to the motivational orientation of adoles-
cents, then interventions that directly address emotional con-
Author Contact: Cheryl Lorane Cox, RN, PhD, can be reached at
cerns and thereby mediate the motivational response are indi-
email@example.com, with copy to editor at rose_mary@earth
Abel, E., Marion, L., & Seraphine, A. (1998). The evaluation of motivation
and health behavior. In D. Gochman (Ed.), Handbook of health behavior
for sexual health among women. Western Journal of Nursing Research,
research (pp. 253264). New York: Plenum Press.
Corkery, J.C., Li, F.P., McDonald, J.A., Hanley, J.A., Holmes, G.E., &
Aruda, M. (2002). Predictors of unprotected sex for teens at pregnancy test-
Holmes, F.F. (1979). Kids who really shouldn't smoke. New England Jour-
ing. Unpublished doctoral dissertation. University of Massachusetts,
nal of Medicine, 300, 1279.
Cox, C. (1982). An interaction model of client health behavior: Theoretical
Atkinson, S., Halton, J., Bradley, C., Wu, B., & Barr, R. (1998). Bone and
prescription for nursing. Advances in Nursing Science, 5(1), 4156.
mineral abnormalities in childhood acute lymphoblastic leukemia: Influence
Cox, C. (1984). The individual as client. In J. Sullivan (Ed.), Directions for
of disease, drugs and nutrition. International Journal of Cancer Supple-
community health nursing (pp. 129172). Boston: Blackwell Scientific.
ment, 11, 3539.
Cox, C. (1985). The health self-determinism index. Nursing Research, 34,
Bear, M., & Bowers, C. (1998). Using a nursing framework to measure cli-
ent satisfaction at a nurse-managed clinic. Public Health Nursing, 15(1),
Cox, C. (2000). Response to patient-centered care: Understanding its interpre-
tation and implementation in health care. Scholarly Inquiry for Nursing
Bhatia, S., Robison, L., Oberlin, O., Greenberg, M., Bunin, G., Fossati-Bel-
Practice: An International Journal, 14, 183187.
lani, F., et al. (1996). Breast cancer and other second neoplasms after child-
Cox, C. (2003). Explaining health and risk behavior in childhood cancer sur-
hood Hodgkin's disease. New England Journal of Medicine, 334, 745751.
vivors. Grant funded by the ONS Foundation.
Black, P., Straaten, A., & Gutjahr, P. (1998). Secondary thyroid carcinoma
Cox, C., Cowell, J., Marion, L., & Miller, E. (1990). The health self-determin-
after treatment for childhood cancer. Medical and Pediatric Oncology, 31,
ism index for children. Research in Nursing and Health, 13, 237246.
Cox, C., Kaeser, L., Montgomery, A., & Marion, L. (1991). Quality of life
Brown, S. (1992). Tailoring nursing care to the individual client: Empirical
nursing care: An experimental trial in long-term care. Journal of Geron-
challenge of a theoretical concept. Research in Nursing and Health, 15, 39
tological Nursing, 17(4), 611.
Cox, C., & Montgomery, A. (1991). Fitness and absenteeism in hospital work-
Carter, K., & Kulbok, P. (1995). Evaluation of the Interaction Model of Cli-
ers: Clarifying the connection. Journal of Occupational Health Nurses, 39,
ent Health Behavior through the first decade of research. Advances in Nurs-
ing Science, 18(1), 6273.
Cox, C., & Roghmann, K. (1984). Empirical test of the interaction model of
Carter, K., & Kulbok, P. (2002). Motivation for health behaviours: A system-
client health behavior. Research in Nursing and Health, 7, 275285.
atic review of the nursing literature. Journal of Advanced Nursing, 40, 316
Crom, D., Hinds, P., Gattuso, J., Tyc, V., & Hudson, M. (2002). Female sur-
vivors of Hodgkin disease: Perceived vulnerability to breast cancer and com-
Cockerham, W. (1997). Lifestyles, social class, demographic characteristics,
pliance with health promotion recommendations. Unpublished manuscript.
ONCOLOGY NURSING FORUM VOL 30, NO 5, 2003
Roberts, K. (2002). Physician-patient relationships, patient satisfaction, and
Deci, E., & Ryan, R. (1985). Intrinsic motivation and self-determination in
antiretroviral medication adherence among HIV-infected adults attending
human behavior. New York: Plenum Press.
a public health clinic. AIDS Patient Care and STDs, 16(1), 4350.
Deci, E., & Ryan, R. (2002). Handbook of self-determination research. Roch-
Sklar, C., Mertens, A., Walter, A., Mitchell, D., Nesbit, M., O'Leary, M., et
ester, NY: University of Rochester Press.
al. (2000). Changes in body mass index and prevalence of overweight in
DiNapoli, P. (2000). A contextual analysis of adolescent violence using the
survivors of childhood acute lymphoblastic leukemia: Role of cranial irra-
Interaction Model of Client Health Behavior. Unpublished doctoral disser-
diation. Medical and Pediatric Oncology, 35, 9195.
tation. University of Massachusetts, Lowell.
Solheim, K. (1989). The smoking cessation process. Journal of Holistic Nurs-
Dougherty, M., Dwyer, J., Pendergast, J., Tomlinson, B., Boyington, A.,
ing, 7(1), 2633.
Vogel, W., et al. (1998). Community-based nursing: Urinary continence
Swerdlow, A., Barber, J., Horwich, A., Cunningham, D., Milan, S., & Omar,
care for older rural women. Nursing Outlook, 46, 233244.
R. (1997). Second malignancy in patients with Hodgkin's disease treated
Eyler, A., Wilcox, S., Matson-Koffman, D., Evenson, K.R., Sanderson, B.,
at the Royal Marsden Hospital. British Journal of Cancer, 75, 116123.
Thompson, J., et al. (2002). Correlates of physical activity among women
Talvensaari, K., Lanning, M., Tapanainen, P., & Knip, M. (1996). Long-term
from diverse racial/ethnic groups. Journal of Women's Health and Gender-
survivors of childhood cancer have an increased risk of manifesting the
Based Medicine, 11, 239253.
metabolic syndrome. Journal of Clinical Endocrinology and Metabolism,
Farrand, L., & Cox, C. (1993). Determinants of positive health behavior in
middle childhood. Nursing Research, 42, 208213.
Tao, M., Guo, M., Weiss, R., Byrne, J., Mills, J., Robison, L., et al. (1998).
Gochman, D. (Ed.). (1997). Handbook of health behavior research. New
York: Plenum Press.
Smoking in adult survivors of childhood acute lymphoblastic leukemia.
Journal of the National Cancer Institute, 90, 219225.
Green, D., Hyland, A., Chung, C., Zevon, M., & Hall, B. (1999). Cancer and
Troumbley, P., & Lenz, E. (1992). Application of Cox's interaction model of
cardiac mortality among 15-year survivors of cancer diagnosed during
client health behavior in a weight control program for military personnel:
childhood or adolescence. Journal of Clinical Oncology, 17, 32073215.
Haupt, R., Byrne, J., Connelly, R., Mostow, E., Austin, D., Holmes, G., et al.
A preintervention baseline. Advances in Nursing Science, 14(4), 6578.
Troyer, H., & Holmes, G. (1988). Cigarette smoking among childhood can-
(1992). Smoking habits in survivors of childhood and adolescent cancer.
cer survivors. American Journal of Diseases in Children, 142, 123124.
Medical and Pediatric Oncology, 20, 301306.
Tyc, V., Hudson, M., & Hinds, P. (1999). Health promotion interventions for
Hollen, P., & Hobbie, W. (1996). Decision making and risk behaviors of can-
adolescent cancer survivors. Cognitive and Behavioral Practice, 6, 128136.
cer-surviving adolescents and their peers. Journal of Pediatric Oncology
U.S. Department of Health and Human Services. (2000). Healthy people 2010.
Nursing, 13, 121133.
Washington, DC: Government Printing Office.
Hoorweg-Nijman, J., Kardos, G., Roos, J., van Dijk, H., Netelenbos, C., Popp-
Vassilopoulou-Sellin, R., Brosnan, P., Delpassand, A., Zietz, H., Klein, M.,
Snijders, C., et al. (1999). Bone mineral density and markers of bone turn-
& Jaffe, N. (1999). Osteopenia in young adult survivors of childhood can-
over in young adult survivors of childhood lymphoblastic leukaemia. Clini-
cer. Medical and Pediatric Oncology, 32, 272278.
cal Endocrinology, 50, 237244.
Wilbur, J., Chandler, P., & Miller, A. (2001). Measuring adherence to a
Hudson, M., Jones, D., Boyett, J., Sharp, G., & Pui, C. (1997). Late mortal-
women's walking program. Western Journal of Nursing Research, 23, 8
ity of long-term survivors of childhood cancer. Journal of Clinical Oncol-
ogy, 15, 22052213.
Wilbur, J., Miller, A.M., Chandler, P., & McDevitt, J. (2003). Determinants
Hudson, M., Poquette, C., Lee, J., Greenwald, C., Shah, A., Luo, X., et al.
of physical activity and adherence to a 24-week home-based walking pro-
(1998). Increased mortality after successful treatment for Hodgkin's dis-
gram in African American and Caucasian women. Research in Nursing and
ease. Journal of Clinical Oncology, 16, 35923600.
Health, 26, 213224.
Hudson, M., Tyc, V., Srivastava, D., Gattuso, J., Quargnenti, A., Crom, D.,
Williams, G., Cox, E., Hedberg, V., & Deci, E. (2000). Extrinsic life goals and
et al. (2002). Multi-component behavioral intervention to promote health
health-risk behaviors in adolescents. Journal of Applied Social Psychology,
protective behaviors in childhood cancer survivors: The protect study.
Medical and Pediatric Oncology, 39, 211.
Williams, G., Freedman, Z., & Deci, E. (1998). Supporting autonomy to mo-
Kovac, J., Patel, S., Peterson, R., & Kimmel, P. (2002). Patient satisfaction
tivate patients with diabetes for glucose control. Diabetes Care, 21, 1644
with care and behavioral compliance in end-stage renal disease patients
treated with hemodialysis. American Journal of Kidney Diseases, 39, 1236
Wolden, S., Lamborn, K., Cleary, S., Tate, D., & Donaldson, S. (1998). Sec-
ond cancers following pediatric Hodgkin's disease. Journal of Clinical
Kulbok, P., & Cox, C. (2002). Dimensions of adolescent health behavior.
Oncology, 16, 536544.
Journal of Adolescent Health, 31, 394400.
Marion, L. (2002). Sexually transmitted disease prevention intervention in
African-American women. Grant funded by the National Institutes of Health
For more information . . .
and the National Institute of Nursing Research.
Marion, L., & Cox, C. (1996). Condom use and fertility among divorced and
separated women. Nursing Research, 45, 110115.
➤ Candelighters Childhood Cancer Foundation
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
➤ National Childhood Cancer Foundation
Hematology/Oncology, 23, 424430.
Read, C. (2002). Reproductive decisions of parents of children with metabolic
➤ The Children's Cause
disorders. Clinical Genetics, 61, 268276.
Ries, L., Smith, M., Gurney, J., Linet, M., Tamra, T., Young, J., et al. (Eds.).
(1999). Cancer incidence and survival among children and adolescents:
Links can be found using ONS Online at www.ons.org.
United States SEER Program 19751995 [NIH Publication No. 99-4649].
Bethesda, MD: National Cancer Institute.
ONCOLOGY NURSING FORUM VOL 30, NO 5, 2003