Health-promoting behaviors of thyroid cancer survivors
The average score for health-promoting behaviors among thyroid cancer patients was 2.67/4.00. Among the sub-areas of health-promoting behavior reported by thyroid cancer survivors in this study, exercise was the lowest at 2.36 points, and stress management was the second lowest at 2.46 points. This was similar to the findings among breast cancer patients, whose scores were lowest for stress management and second lowest for exercise . Thyroid cancer survivors are considered to have a low score in the exercise area because the proportion of women in that population is three times higher than that of men . In the study of patients with colorectal cancer, women reported having lower physical activity than men . In addition, the results of previous comparisons of the degree of exercise between cancer patients and healthy adults show that cancer patients do not exercise regularly .
The proportion of thyroid cancer patients in Korea is 53.1% in their 40s and 50s, and 57.9% of the thyroid cancer survivors in this study reported having a job . In fact, patients with thyroid cancer are reported to have a shorter leave of absence and lower unemployment rate than patients with other types of cancer . Therefore, exercise interventions that can accommodate work life are needed for survivors in their 40s and 50s. Women in their 40s and 50s who have survived thyroid cancer need to take steps to prevent osteoporosis in preparation for menopause because taking thyroid hormones raises the risk of osteoporosis . Therefore, it is necessary to develop an exercise program for preventing osteoporosis that thyroid cancer survivors can follow easily at home.
Factors influencing health-promoting behavior by survival stage
The factors affecting the use of health-promoting behavior among thyroid cancer survivors differed by survival stage. Fear of recurrence and symptoms influenced health-promoting behavior only in the extended stage, and age was associated with health-promoting behavior only in the permanent stage. Social support was found to be a variable influencing health-promoting behavior in all stages of survival, and social support was low in the permanent stage.
The acute stage is a period of active treatment, and it is necessary to promote self-efficacy and encourage health-promoting behavior through social support. A cancer diagnosis can be a motivation to change health behaviors . Motivation is important in changing health behaviors, so it is important to strengthen motivation in the early stages [34, 35]. In the acute stage, medical staffs should learn about each patient's health behaviors and plan for change with them together.
As survivors at the extended stage return to work after finishing treatment, they engage in relatively fewer health-promoting behaviors, so active education is needed to strengthen their commitment to health-promoting behavior . As shown by this study, in the extended stage, it is necessary to focus on managing the symptoms and fear of recurrence caused by radioactive iodine treatment. In this study, high symptom scores dose-dependently correlated with low health-promoting behavior scores. Previous studies also found that physical symptom experience reduced health-promoting behavior . A study of health-promoting behavior among middle-aged women found that more severe menopausal symptoms correlated with low health-promoting behavior . Patients with thyroid cancer need continuous intervention for their symptoms because fatigue persists for a long time after treatment . The results of this study also show that in the extended stage, symptoms interfere with health promotion. Nurses should thus help patients acquire skills to cope with symptoms, such as fatigue, that interfere with health promotion and provide positive feedback to encourage them to continue their health behaviors.
Among thyroid cancer survivors in the extended stage, a high fear of recurrence correlated with a high use of health-promoting behaviors. This is a principle of the health belief model, which is based on an awareness of the risks of disease and the value of preventive health behavior . However, fears of recurrence need to be approached carefully because a high fear of recurrence carries a high level of patient anxiety . Previous studies have shown that providing information about benefits more effectively motivates health behaviors than focusing on potential losses . Therefore, the fear of recurrence needs to lead to effective health behavior through an emphasis on the benefits of health behavior and accurate information. Providing a variety of health promotion programs could help patients overcome the fear of recurrence.
Patients with thyroid cancer who have received radioactive iodine treatment more than once reported high health-promoting behavior scores in this study, which is consistent with higher health-promoting behavior scores in breast cancer patients who received chemotherapy . In a previous study, the severity of disease awareness in patients with thyroid cancer correlated with the number of radioactive iodine treatments, and patients who received radioactive iodine treatment more than once were thought to have attempted to improve their health by recognizing the severity of their disease .
A program for continuous health promotion should be developed for patients in the permanent stage of survival, with interventions offered to increase self-efficacy and social support. Stages of thyroid cancer are divided according to age, and at diagnosis, patients over 55years of age have a higher cancer stage and a worse prognosis . Among respondents in the permanent stage, health-promoting behavior was high in survivors older than 60, possibly because they perceived the risk of thyroid cancer. Therefore, education is needed to encourage health-promoting behavior among survivors in their 40s and 50s. The number of online users in their 40s and 50s is high, and in this study, 54% of respondents said that they accessed the online community every day . In recent years, e-health applications and healthcare education using mobile phones have been spotlighted and reported to have positive effects [43, 44]. In the permanent stage of survival, intervals between outpatient visits are long, so it would be helpful to develop an online healthcare program to provide disease-related information and encourage regular exercise.
This study has confirmed that self-efficacy and social support are factors that influence health promotion, as shown in Pender's health promotion model, and that the fear of recurrence and symptoms also influence cancer survivors' participation in health-promoting behaviors. With the development of medical technology and improvements in the long-term cancer survival rate, cancer is becoming a disease that requires long-term management. Interventions that vary with the stage of survival will help to improve the use of health-promoting behavior among cancer survivors.
Most of the data collected in this study came from patients who responded through the online community, and it is difficult to rule out the possibility that people who frequently access the online community work harder to promote health than those who access the online community less often or not at all. In addition, this study compared groups of thyroid cancer survivors in the acute, extended, and permanent survival stages, and the characteristics of those groups might have differed in meaningful ways. Because this study was cross-sectional, it did not consider the passage of time. Therefore, interpretations should be made with care when comparing the three groups. In the future, longitudinal cohort studies are needed to identify changes in health-promoting behavior.