Clinical implications
To increase the effectiveness of interventions, various recommendations
were made by the authors to guide either clinical practice or future
studies (see Table 3). Some recommendations were made regarding
important elements that should be included or considered, including
supporting participants’ self-efficacy, which is defined as an
individual’s self-judgment of their own abilities to execute certain
behaviours that determine the likelihood of a person engaging in or
avoiding certain behaviours [38]. Indeed, interventions that address
self-efficacy elements may increase children or survivors’ confidence in
their abilities to initiate and maintain healthy behaviours [28].
For example, it was found that with increased self-efficacy, children
with cancer are more likely to adopt and maintain regular PA [30].
Also, psychological variables are deemed important intervention targets
to improve quality of life [25]. For example, cognitive deficits
such as information processing problems should be addressed [29].
The engagement of families, especially parents is particularly important
[34]. Indeed, caregivers serving as role models of healthy eating
and exercise facilitate family changes [33]. Positive social
interactions and encouragement with the mentor was found to be
associated with greater adherence to healthy behaviours in one of the
studies; the authors therefore recommended enlisting the support of
parents or friends to provide additional social support to the CCS
[31]. Furthermore, authors support more frequent contact with the
interventionists as participants seem to need the continuing support on
the lifelong commitment to healthy behaviours to moderate the late
effects of therapy [27].
Another popular recommendation was to use targeted, individualized
programs and age-appropriate approaches, as they might be better than
standard or generic programs to increase the effects of the program
[21, 23, 25, 32]. Making the messages specific to the needs of young
cancer survivors would likely enhance their relevance as well as
increase the engagement and satisfaction of survivors with the content
[24].
Multimodal approaches have contributed to compliance and overall success
in reaching targeted outcomes [29]. Indeed, multimodal seemed
preferable to education only, as provision of information related to
adverse outcomes is necessary, but was found to be not sufficient to
produce significant changes in participants’ health outcomes [22].
Furthermore, the use of technology offers a feasible, relatively
low-cost alternative to more in-person intensive interventions in this
at-risk but sparse population because it can be distributed across time
and geography; however, personal contact also appeared to help
compliance with protocol and follow-up [29].
Finally, regarding the point over the course of treatment and
survivorship that interventions might be best implemented, Cox et al.
[27] concluded that it may not be feasible during early treatment
owing to the child’s responses to the disease and treatment. Indeed,
shortly after the diagnosis and following the participants through the
end of therapy may have resulted in the study participants and/or
parents being too sick and/or overwhelmed to complete the intervention
with the frequency and intensity necessary to improve function. They
suggested offering study participation at maintenance, in contrast to
within 10 days after diagnosis, so that parents and children will have
had a considerable period of time to adjust to the diagnosis and to have
hurdled the worst treatment and disease effects. Fear, anxiety,
symptoms, and overall well-being will no longer be the significant
threats that they were at diagnosis, thereby potentially facilitating
greater participation and commitment to the intervention. Another early
lifestyle intervention concluded that it was feasible, but that the
results did not show significant changes in the targeted outcomes
[34]. For survivors, it was found that trying to recruit after
treatment was difficult as families are often trying to forget their
cancer and hospital experiences and, similarly, too long after (e.g.
more than 3 years) was also difficult as families are likely to have
created a new normal. The average time since treatment ended for
participants recruited in their study was 1.96 years [33].
DISCUSSION
The present scoping review sheds light on the dominant areas of research
in terms of target population, intervention type, and outcomes for
complex interventions or multimodal programs targeting healthy
behaviours in children with cancer. Due to a paucity of studies, and the
heterogeneity of the studies included in this review, identifying the
best health promotion interventions or program is challenging. The
interventions typically focused on PA alone or in combination with other
health behaviours, the majority had a short duration (<6
months), and few conducted long-term assessments. Furthermore, no
studies included families of children younger than three years of age
and few recruited patients who were still undergoing treatment. There
are a lot of challenges that can be encountered in developing and
administering interventions with children who are severely ill, which
could explain why so little intervention effort has been made.
The few studies published demonstrate that it is feasible to implement
these types of interventions or programs and that it can potentially
improve patient outcomes or healthy behaviours practises. Furthermore,
popular recommendations include the individualization of interventions,
the use multiple modalities and the engagement of families. The results
of this study are consistent with other reviews; one concluding that
diet and exercise interventions are feasible [39] and another one
that lifestyle technology-based interventions demonstrated high
feasibility and acceptability rates in the pediatric oncology and
survivors of childhood cancer populations [40]. Moreover, a recent
review of health behaviour in CCS interventions confirmed a gap in
interventions designed for younger cancer survivors (<8 years
of age) and that engaged parents, who are critical to child behaviour
change [41].
A crucial aspect in the evaluation of complex behavioural interventions
is the choice of outcome measures. Precise and reliable measures of both
behaviours targeted by the intervention and the health outcomes should
be included for a comprehensive evaluation of behavioural interventions.
Esbenshade and Ness [39] have suggested to pick out outcomes that
are reliable and reproducible as well as to standardize outcome measures
so that studies can be compared and combined. Furthermore, long-term
follow-up may be needed to determine whether the downstream effects on
the health outcome predicted by the change in behaviour occurred or
whether the short-term changes, such as the change in behaviour,
persisted [42]. Thus, implementing programs of longer duration
should be encouraged. Collecting data over an extended period of time
(e.g. more than 12 months after starting the intervention) would allow
clinicians or researchers to evaluate the long-term effects and benefits
of the interventions or program on outcomes such as quality of life,
which requires an extended period to respond the intervention compared
with other outcomes, for example levels of PA.
Consistent with the recommendations from Stern [33] and Zhang
[34] to engage families in behavioural interventions, a systematic
review that examined parental involvement in diet and PA studies in CCS
concluded that adding a parental component may improve health promotion
interventions for CCS [36]. Indeed, in their review, studies with no
or indirect parental involvement had lower amounts of success than
studies with direct parental involvement. Furthermore, as some research
has shown that parents remain involved in the healthcare of survivors
even into adulthood [43], parental involvement should be considered
throughout the continuum of care and regardless of the survivors’ age.
Parents of CCS are also known to experience psychosocial issues related
to the child’s cancer and treatment that can affect their family life
[44], such as being overprotective and restricting children from
participating in physical activities [45] or adopting a parenting
style that is associated with increased junk food consumption [46].
Therefore, addressing parenting practises and offering psychosocial
support or training to families may be beneficial for both parents and
children with cancer.
According to Short et al. [47], programs addressing the promotion of
health behaviours such as PA should be theory-based in order to maximise
effectiveness. Indeed, there is a growing recognition that theory-based
behaviour change interventions are more effective than approaches that
do not rely on theory [48]. Among other reasons, theory-based
interventions can help pinpoint what factors need to be considered
before developing a program or intervention, it can provide insight into
how to shape strategies to address these factors, and can provide
information on how or why the intervention works. The theoretical
framework that has been used the most in the field of pediatric oncology
is the Social Cognitive Theory (SCT) [49], which is a theory that
has shown particular promise also in the field of PA promotion for
breast cancer survivors [47]. However, the application of SCT or any
other theoretical framework to promote healthy behaviours in oncology is
still in its infancy and further research is needed to optimize their
use.
Interventions to change health behaviours such as adopting a healthy
diet and practicing frequent PA have huge potential to make a positive
impact on both the individual themselves and the overburdened healthcare
system [50]. Furthermore, there is growing evidence that
multiple-behaviour interventions promise to have much greater impact on
public health than single-behaviour interventions [51]. The key idea
that underpins behavioural change is to deliver interventions comprised
of various change-generating techniques in order to promote a change in
behaviour, which will subsequently have an effect on health outcomes.
The same rigorous experimental methods that have characterized
drug-based clinical treatments should be applied to those studies, which
is unfortunately not always the case. Indeed, methods must be devised to
measure what was previously thought to be unmeasurable and assessments
conducted in a reproducible and valid fashion, even for the measures of
subjective states [52].
Limitations from this review include the fact that this is a developing
field of research, with the oldest article published in 1999, with few
studies addressing the research question. The high variability in
intervention type and outcome measures across studies made comparison of
results difficult and meant we were not able to identify attributes of
studies that were effective. Furthermore, many of the included studies
had small sample sizes, biases and short follow-up duration. This review
underlines the need for further well-designed trials using standardized
outcome measures to be implemented in this population as well as the
gaps in the evidence base.