Keywords

1 Introduction

Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells. There are many causes of cancer and many risk factors; some are nonmodifiable while some are modifiable, such as smoking. Cancer causes one in six deaths worldwide; the second leading cause of death after cardiovascular diseases [1]. The incidences of cancer globally are 23.4% in Europe, 13.3% in America, 7.3% in Africa, and 57.3% in Asia [2]. It is also estimated that one-in-five men and one-in-six women will develop cancer and one-in-eight men and one-in-eleven women will die from cancer [3]. It has been reported that cancer is the first or second cause of premature deaths in 100 countries worldwide [2]. The five most common cancers in males are lung, prostate, colorectal, stomach, and liver; and in females they are breast, colorectum, lung, cervix, and thyroid.

The global cancer burden is estimated at 18.1 million new cases and 9.6 million deaths in 2018 (ICRC 2018). In 2040, the global burden is expected to increase to 27.5 million new cases and 16.3 million deaths [4]. The increasing cancer burden is due to population growth and aging, economic and social development, unhealthy diet, physical inactivity, and changing lifestyles. It has been reported that cancer risk increases with age especially among age 65 years. According to the Human Development Index (HDI), there are 60% new cancer cases in high HDI compared to those in medium- and low-HDI countries [1, 5, 6].

2 Theoretical Frameworks Used in Cancer Health Promotion Research

Theoretical frameworks provide knowledge base for guiding intervention research. It is important that researchers understand the underpinnings of the various theories to enable appropriate selection for the study to be conducted. There are many theoretical frameworks sued in cancer research but only few examples are provided in this chapter. One example is the Salutogenic Model as a theory to guide health promotion which aims at moving people in the direction of the health end of the continuum [7]. As a Salutogenic orientation, the Sense of Coherence (SOC) construct emerges as a generalized orientation in facilitating the movement towards health [8, 9]. SOC is conceptualized as a global orientation to life experiences, including the degree to which life is viewed as comprehensible, manageable, and meaningful [9]. A meta-analysis by Winger and colleagues [10] found that SOC demonstrated significant negative associations with distress in cancer patients. Their analysis supported Antonovsky’s model of health that a high SOC suggests that cancer patients who view life as comprehensible, manageable, and meaningful experience less distress. In a systematic review Eriksson and Lindström [11] found that SOC is a health resource influencing quality of life.

The Transtheoretical Model of health (TTM) was developed by Proschaska and Verizer [12] who posited that health behavior change involves progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. It was postulated that behavior change is cyclic with some individuals regressing to earlier stages of readiness before behavior change is sustained. TTM-based interventions attempt to tailor the recommendations to a participant’s motivational readiness to change. Pinto [13] conducted the Moving Forward Trial, providing a home-based moderate-intensity physical activity program to determine its effects on physical activity fitness, mood, and physical symptoms in patients with breast cancer guided by TTM.

The Theory of Planned Behavior (TPB) is a social-psychological theory developed by Ajzen [14] to explain the link between attitudes and behaviors. It postulates that behavior is predicted by intention. According to this theory, human behavior is guided by behavioral, normative, and control beliefs. Interventions designed to change behavior can be directed to patients’ attitudes, subjective norms, and perceptions of behavioral control [15]. Jones and colleagues [16] applied the theoretical tenets of the TPB to understand the effects of two oncologist-based interventions on self-reported exercise in breast cancer survivors. The effects of the oncologists’ recommendations to exercise in patients with breast cancer was mediated by their attitude and positive intention thus supporting the tenets of TPB.

Social Cognitive Theories (SCT), behavior change is influenced by several interacting psychosocial, environmental, and behavioral factors on how a person makes choices. SCT was advanced by Bandura [17] from Social Learning Theory. SCT explains how people learn not only through their own experiences, but also by observing the actions of others and the results of those actions. Self-efficacy theory (SET) is a subset of Bandura’s social cognitive theory. Bandura defines self-efficacy as the individual’s perception of his or her ability to feel, think, motivate, and act to perform behaviors through four processes: (1) cognitive, (2) motivational, (3) affective, and (4) selection. SCT framework was used in a meta-analysis conducted by Graves [18] to evaluate the quality of life among patients with breast cancer. The results of this meta-analysis showed that using SCT-based interventions maximized improvement in overall quality of life (QOL) outcomes for adult cancer. Grimmett [19] examined the patterns of self-efficacy for managing illness-related problems among colorectal cancer patients in the 24 months following diagnosis. They found that there was an increase in self-efficacy mean score overtime. This study provided support of the positive association between self-efficacy and adaptation to cancer diagnosis and reduction of distress in patients with cancer.

3 Risk Protection Interventions to Reduce or Eliminate Exposure to Cancer-Producing Agents

Risk protection interventions can be targeted to mainly reduce or eliminate some types of cancer such as skin, breast, cervical, and colorectal cancers. Skin cancer is one of the most prevalent cancers worldwide among those with more sunlight exposure and can be prevented by protecting skin from excessive sun exposure. Detrimental effects of ultraviolet rays can be prevented by wearing thick clothing when exposed to sunlight, applying an appropriate sunscreen and avoiding artificial sources of ultraviolet rays for tanning.

Tobacco smoking causes many types of cancer and is a known risk factor for lung cancer. Several smoking cessation interventions have been implemented worldwide to curb this unhealthy behavior not only to prevent the risk of lung cancer but also to support patients who already have been diagnosed with lung cancer and undergoing treatment to cease smoking. An intervention involving a brief consultation with a nicotine dependence counsellor was used to help the patient develop an individualized treatment plan. The study showed that the 7-day point prevalence abstinence from tobacco at 6-month follow-up was 22% after adjusting for age, sex, and baseline cigarettes smoked per day [20]. The results in a study by Charlot [21] using an 8-week mindfulness-based smoking cessation intervention by a certified mindfulness trainer and tobacco treatment nurse specialist showed that there was a significant decrease in weekly cigarette intake from 75.1 cigarettes at baseline to 44.3 at 3 months. This 8-week intervention consisted of lessons on the effects of smoking, instructions for smoking cessation and guided instruction. Each participant received audio compact discs and manual on mind-body practices including meditation, body scan, and chair yoga (each 20 min in length) to facilitate home practice. Another study by Li [22] provided face-to-face individualized brief (15–30 min) risk communication to encourage patients with lung cancer to stop smoking. They hypothesized that participants in the intervention group would have a higher smoking cessation rates and have a reduced daily cigarette consumption by at least 50%. The intervention was followed by exhaled carbon monoxide level assessment. The risk communication component focused on the relationships between smoking and lung cancer diagnosis, treatment, and prognosis as a trigger to think about quitting. After 1 week, the experimental group received a booster intervention via telephone to assess the progress of and to identify difficulties faced by patients towards quitting and how to handle withdrawal symptoms. The results showed that the 268 patients with lung cancer had higher biochemically validated quit rate at the 6-month follow-up compared to the control group. The results found that at 6 weeks after treatment, the 7-day point prevalence smoking abstinence rate was 40% [22].

Mobile phone instant messaging apps (e.g., WhatsApp, Facebook Messenger, and WeChat) are popular and inexpensive alternatives to SMS for interactive messaging [23]. Advances in mobile technologies are also now being used for mobile phone-based interventions for smoking cessation. Wang [24] provided a 12-page self-help booklet on smoking cessation as well as chat-based smoking cessation support using WhatsApp mobile messaging twice a week for the first month, and once per week for the next 2 months by smoking cessation ambassadors. At 6 months follow-up the results showed that 77% of the 591 participants had significantly higher abstinence from smoking.

Breast cancer can be prevented through self-breast screening and improvements have been made to increase women’s awareness and attitudes towards the importance of screening for early detection of breast cancer. Promoting the attitude of the women toward breast cancer is largely influenced by their screening behaviors. Culture and ethnicity are also critical factors influencing women’s attitudes, beliefs, and access to health screening services [25]. Mirzaii [26] investigated the effects of breast cancer screening training based on the Systematic comprehensive Health Education and Promotion (SHEP) model on the attitudes and breast self-examination skills in 120 women in Iran. The three 2-h SHEP-based educational workshops using posters and images provided general explanation of breast structure, breast lumps and their features, risk factors and symptoms of breast cancer, and self-breast screening methods. Participants were asked to practice accordingly at 1-week interval between the first, second, and third workshops. The results showed the efficacy of the SHEP in promoting awareness, attitudes, and self-breast examination among the Iranian women.

Colorectal cancer is the third most common cancer worldwide and it is the second most common factor for death by cancer [27]. The timely and proper colorectal cancer screening is a leading factor to reduce incidence and consequences of this disease. Boogar [28] examined the moderating role of cancer-related health literacy and cancer-related empowerment in colorectal cancer screening using a comprehensive model in 366 participants. Using the Colorectal Screening Questionnaire and Health Education Impact Questionnaire, the results showed that higher perceived susceptibility and the cancer-related literacy was associated with lower defensive avoidance and had increased the tendency of patients to submit to colorectal screening tests [29]. Super [30] posited that both empowerment and reflection processes, which are interdependent, may be relevant for health promotion activities that aim to strengthen SOC. Low health literacy is associated with lack of knowledge about screening for cancer. Health care professionals should therefore knowledge about the benefits of cancer screening as patients’ perceived risk and health-promoting behavior such as regular medical check-ups and self-efficacy have been found to be positively correlated with adherence to colorectal screening [31]. The successful application of resources to deal with low literacy affecting adherence to screening for cancer is not only likely to have a positive influence on health but also creates consistent and meaningful life experiences that can positively reinforce SOC levels.

4 Health Promotion Interventions to Reduce the Effects of Cancer Diagnosis

A cancer diagnosis is associated with high levels of distress, a multifactorial unpleasant emotional experience in 35–45% of patients with cancer [32]. It causes fear, uncertainty above recovery, and suffering not only to the patients with cancer but also to their families, as life situation changes suddenly affecting the family unit. Although many studies have been conducted using the Salutogenic theory of SOC and its three components of meaningfulness, manageability, and comprehensibility, Ozanne and Graneheim [33] focused their study on the comprehensibility component of SOC when patients’ symptoms appeared and diagnosis was confirmed. They found that whether they comprehend or not, the 27 participants felt uncertain before the diagnosis, they lost their foothold during the diagnosis and lived in fear after the diagnosis. The results highlighted that it takes time to find comprehensibility and health professionals should provide support and information to both patients and spouses to answer their questions. Depression is a comorbidity of cancer and more so if the patients is diagnosed with late stage of cancer with metastasis. SOC has long been recognized as an important factor in the psychological adjustment to cancer and a protective factor for depression. Aderhold [34] examined if SOC and post-traumatic growth (coping, struggling or thriving) were predictors of depression in 252 patients in Germany since being diagnosed with cancer. They found that posttraumatic growth (PTG) is a significant predictor of depressive symptoms 1 year after the cancer diagnosis; the higher PTG levels the lower patients’ levels of depressive symptoms. They also found that high levels of SOC predicted low levels of depressive symptoms. Patients’ experience of having cancer and survival may enhance a feeling of personal strength and a sense of self-efficacy which could be protective psychological factors. Therefore, interventions should promote SOC in patients with cancer by creating a supportive environment for them to be able to reflect on problems faced since diagnosis, focusing on the positive changes they experience and strengthening their coping resources.

5 Health Promotion Interventions to Reduce the Effects of Cancer Treatment

Once diagnosis is confirmed and staged, patients undergo specific treatment according to protocols. The treatment modalities are surgery, chemotherapy, radiotherapy, hormone therapy, immune therapy, and/or targeted therapy. No matter what cancer treatment patients receive, they experience various treatment side effects impacting their overall QoL. Cancer and cancer-related treatments trigger such symptoms like pain, insomnia, nausea, and vomiting, chemotherapy-induced peripheral neuropathy, and sexual dysfunction which may lead to psychological symptoms such as stress, depression and anxiety [35]. Overcoming the psychological effects of cancer treatment require patients with cancer to have a clear concept of coping ability to conceptualize their diagnosis and treatment as meaningful, manageable and comprehensible which are the three components of SOC [8].

Fatigue, a subjective feeling of weariness, tiredness or lack of energy, is the most common unmanaged symptom in patients undergoing chemotherapy or radiotherapy which leads to decreased physical daily activity during treatment. Exercise has been shown to be effective in decreasing fatigue and improving activity tolerance in patients during chemotherapy [36, 37]. A study that showed the effectiveness of exercise was conducted by Mock et al. [38] using the walking exercise intervention in female concurrently with the duration of 4–6 weeks of chemotherapy or 6 weeks of radiotherapy. The exercise was conducted at the clinical site and taught by trained staff using the exercise prescription developed by the exercise physiologist which was individualized for each participant based on age, level of physical fitness, and type of cancer treatment. The walking intervention consisted of an initial 10–15 min sessions and 5–6 sessions per week and increased to 30 min per session, 5–6 weeks per week according to their exercise tolerance and responses to treatment. The women were asked to keep diaries of their daily exercise activity. Velthuis [39] conducted a multicentre randomized controlled trial in 150 breast and 150 colon cancer patients undergoing cancer treatment. The intervention was 18-weeks supervised group exercise program and significant beneficial effects of the exercise were visible during cancer treatment, adherence was moderate to excellent and few adverse events occurred.

Nausea and vomiting are the most common side effects of chemotherapy [40]. Without appropriate antiemetic intervention, chemotherapy-induced nausea and vomiting can lead to dehydration, electrolyte disorder, malnutrition, and can negatively affect patients’ adherence to treatment as well as quality of life [41]. Acupoint therapies have been recommended as a complementary intervention to prevent chemotherapy-induced nausea and vomiting by the National Institute of Health [42]. Acupoint therapies including acupuncture, acupressure, acupoints injection, massage, and moxibustion which are safe medical procedures have shown promising intervention for the management of chemotherapy-induced nausea and vomiting [43]. Auricular acupressure, another innovative health promotion intervention in preventing and treating nausea and vomiting in patients with cancer, was also used before chemotherapy which has been recognized by the Federal Nursing Council in its 197/97 resolution as being an acceptable professional role of nurses [44]. Eghbali [45] placed the ear seed on the pinna on each ear for 5 day and asked the patients to press the ear seeds for 3 min three times a day in the morning, noon and night during the chemotherapy cycle. Their study found that auricular therapy led to a decrease in the number and intensity of nausea and vomiting in both the acute and delayed phases in the experimental group and suggested that nurses can use this pressure technique as a complementary nonpharmacological, inexpensive, and noninvasive relief of chemotherapy-induced nausea and vomiting.

Chemotherapy-induced peripheral neuropathy (CIPN) is another symptom experienced by patients with cancer who are undergoing chemotherapy [46]. It is a progressive, prolonged, and often irreversible side effect of many chemotherapeutic agents and affects 30–40% of patients undergoing treatment [47]. CIPN affects the peripheral sensory and/or motor systems and causes numbness, pain, burning, tingling, heat and hyperalgesia, and mechanical allodynia, as well as reduced motor function [47]. It has been reported that CIPN may continue to worsen after chemotherapy as 68% of patients with cancer still experience the problems in the first month and 30% in the sixth month after chemotherapy [48, 49]. There is no effective treatment in preventing or managing CIPN, but complementary therapies have been reported to improve the symptoms of CIPN such as acupuncture, foot bath, massage, reflexology, sensorimotor training as well as Chinese, Korean, and Japanese herbal medicines [50]. However, further research is needed to examine the effects of herbal medicine on its efficacy, safety, and cost-effectiveness.

Sexual dysfunction during treatment of early-stage cervical and endometrial cancer has been reported as the most distressing side effect of cancer treatment. The negative effects of chemotherapy result in threats to the women’s sexual identity, self-esteem, intimacy, and the end of reproductive capacity. Psychoeducational intervention has been found to significantly improve frequency of coital activity, reduce fear about intercourse, and improve sexual knowledge. For example, Brotto [51] recruited 22 women with gynaecological cancer with sexual dysfunction and asked them to self-report their response to the 3-min neutral and 4-min erotic audiovisual film using the Film Scale. The Film Scale [52] was administered during the sexual arousal assessments that assessed perception of genital sexual arousal, subjective sexual arousal, autonomic arousal, anxiety, positive affect, and negative affect. Items were rated on a 7-point Likert scale from 1 (not at all) to 7 (intensely). Psychoeducational intervention consisting of three 60-min sessions targeting sexual arousal complaints and how to troubleshoot these difficulties was conducted. A combination of information about progressive relaxation, mindfulness, becoming organismic, and making marriage work in a manual was also given to the patients. The results showed significant improvement in women’s sexual response, mood, and quality of life [51].

Another innovative health promotion intervention to improve the psychological well-being and quality of life of patients with cancer by lessening of side effects from chemotherapy is the use of art therapy. A study by Bozcuk [53] involving 48 patients attending the outpatient chemotherapy unit in Turkey participated in the painting art therapy using watercolors for 6 weeks. Group discussions were conducted on the symbolic nature of their paintings, and expression of feelings and thoughts. The results showed that art therapy in the form of water-color painting improved their global quality of life and reduced depression through sharing and discussing problems, feelings and thoughts thus enabled coping with their negative feelings about their cancer diagnosis and treatment. Huss and Samson [54] conducted a study to explore the connection between art therapy and SOC in patients their families dealing with cancer. As a health promoting strategy, the participants drew images causing their stress. In a group discussion, participants explained the image to the group and the group then discussed the meaning, manageability, and comprehensiveness components that could help cope with stress. The study provided evidence that methods in creating meaning through art therapy enhanced the patients’ SOC by integrating the three components to overcome their stress about cancer diagnosis and treatment.

6 Health Promotion Interventions to Support Survivorship and Palliation

Although cancer has been considered as a global public health issue, with continuing improvement in cancer treatment, more individuals diagnosed with cancer are surviving with the disease [55]. Patients who are alive 5 years after the cancer diagnosis and treatment are referred to as survivors. However, although intensive treatments can improve long-term survival, the emotional and physical demands of the diagnosis and treatment experience of cancer survivors are substantial. Several health promotion interventions have been developed, implemented and evaluated to overcome the physiological and psychological problems experienced by cancer survivors. For example, reports found that exercise improves breast cancer survivors’ physical and psychological functioning, reduce the risk of cancer recurrence, second primary cancers, as well as prolong survival [56]. Simple, effective, and inexpensive physical activity interventions for cancer survivors can also improve quality of life and reduce the risk of early mortality. An example of intervention to empower survivors was a 12-week home-based walking intervention to breast cancer survivors [57]. The intervention also consisted of telephone counselling of breast cancer survivors to set their goals to walk three times per week for 20–30 min for the first 4 weeks, walking four times a week for 30–40 min for the next 3 weeks followed by walking five times per week for 30–40 min for 5 weeks. Minutes-by-minutes activity was measured by providing them with pedometer (portable device that counts the number of steps) as well as actigraphy (monitors movement and sleep-wake cycle) and self-report of the walking log. The results showed that the survivors had increased their activity levels as well as improved their quality of life [57].

Nutritional deficiencies are also common problems associated with cancer diagnosis and should be corrected during the survivorship period. Pierce [58]examined the effectiveness of telephone counseling to promote dietary change in the intervention from baseline to 12 months in 2970 breast cancer survivors in the Women’s Healthy Eating and Living (WHEL) Study. Individualized telephone counselling with monthly cooking classes and monthly newsletters were provided by qualified counsellors and nutritionists. Each cooking class featured a nutrition theme to promote adherence and understanding of the intervention dietary pattern and gave women an opportunity to taste new foods and learn to prepare recipes. The newsletters featured research updates, nutrition information and recipes to help motivate women to adopt and maintain the intervention dietary pattern. At 12 months, the intervention group reported a significantly increased daily vegetables, fruits, and fiber intake.

Qigong is a Chinese mind-body integrative exercise used to prevent and cure ailments, to improve health and energy levels through regular practice [59]. Two clinical trials suggested its effectiveness in prolonging the life of cancer patients: (1) a study by Hong [60] involving 24 patients with advanced gastric cancer showed that Qigong was an effective nursing intervention to reduce fatigue, difficulty of daily activities and some chemotherapy side effect such as nausea, vomiting, and stomatitis, and (2) an RCT study by Wang [61] including 62 patients with late stage cancer also showed that Qigong plus chemotherapy had extended the tumor-free and better quality of their survival. However, the health promotion effectiveness of Qigong needs to be further evaluated in more rigorous clinical trials.

Another health promoting intervention to support survivorship was the use of mindfulness-based psychoeducation for cancer survivors (MindCAN) which is a psychoeducation program to help cancer survivors learn essential cancer-related knowledge; and to recognize and manage stress, thoughts, and emotions more effectively [62]. Contents of the MindCAN program was adapted from Mindfulness-Based Stress Reduction (MBSR) involving 8 weekly group-based program encompassed two components: Education and Mindfulness Practice. Each session lasted 90 min. Weekly education topics included: introducing mindfulness, recognizing and managing cancer-related stress, dealing with cancer-related symptoms and treatments, promoting mindful calmness and composure, powerful mind, mindful communication, mindful living, building your mindful lifestyle, and consolidating mindfulness practice. Mindfulness practices included: mindful breathing, body scan, mindful eating, standing and walking meditations, mindful emotions, let go of thoughts, loving-kindness medication and STOP breathing space [63]. Furthermore, participants shared their experiences with group members on their journey toward survivorship. A qualitative study involving 15 cancer patients was conducted to examine the patients’ perception towards MindCAN. A thematic analysis suggested five major themes including: (1) heightened awareness of self, (2) enriching body experiences through mindfulness practice, (3) cultivating powerful minds and positive emotions, (4) integrating mindfulness to daily life, and (5) embracing interpersonal mindfulness. Furthermore, most participants perceived that MindCAN helped them feel more relaxed, and that they better managed stress, unhealthy thoughts, and emotions [62, 64].

Many children are also diagnosed with cancer and undergo similar treatments as adults. Advances in cancer treatment and cancer treatment efficacy have also improved the prognosis of childhood cancer and long survivorship period [65]. However, childhood cancer survivorship has shown declining levels of physical activity mainly due to fatigue and reduced physical strength and endurance as well parental view that children must take more rest [65]. In the past two decades, there has been an increase in the promotion of regular physical activity among childhood cancer survivors as it enhances their physical and psychological well-being [66]. There has been an increase in the use of adventure-based training to promote the psychological well-being of primary school children which can be used also in childhood cancer survivors [67]. For example, a 4-day integrated adventure-based training and health education program in the day-camp centre was conducted by 2 professional adventure-based trainers in 71 Hong Kong childhood cancer survivors. The results showed that the intervention promoted increased levels of physical activity, self-efficacy, and QoL in childhood cancer survivors [68].

Cancer also have long-term and lasting adverse effects on the psychological well-being and neurocognitive functioning of childhood cancer survivors. Dietz [65] provided a weekly 45-min lesson on musical training for 52 weeks among 60 children aged 5–8 years. These children were survivors with brain tumor; the program aimed to transform their lives and instill positive values through music. Training was conducted by a group of professional musicians of the nongovernment Music Children Foundation in Hong Kong. One-to-one musical training was conducted by qualified orchestral performers at the participants’ homes. The participants were assigned a specific musical instrument to learn based on their interests as well as their fine motor skills and expiratory function which were assessed by the training musician. Training began at the lowest level up to the highest level where children were able to play an entire music. The results showed that children brain tumor survivors reported statistically significant fewer depressive symptoms, higher levels of self-esteem and better quality of life.

Many patients with advanced-stage cancer will only require palliative care and thus will continue to live with the cancer and cancer treatment-related symptoms such as fatigue, paraesthesia and dysesthesias, chronic pain, anorexia, insomnia, limbs oedema, and constipation [69]. For patients with advanced-stage cancer, one option is to provide effective care through pain relief and palliative care. Sometimes, surgery, chemotherapy and radiotherapy are also effective measures for effective palliative care especially for pain relief. Living with persistent pain is always associated with poor life satisfaction and is one of the factors that cause comorbidity and mortality [70]. When cancer patients experience persistent pain, this has negative influence on their well-being. In cancer survivors, pain treatment needs to meet the expectation. Opioids is still the major drug used. In view of the risks of overuse of opioids and the balance between the positive benefit to the survivors, this creates a real challenge to the health care system and the health care providers. The psychological effect of pain is an inner emotional experience of suffering in patients with cancer. As a result of being sick, palliative care patients begin to question the meaning of life and death. As such the salutogenic framework is useful in helping palliative care patients to find meaning and enable them who are living in this difficult situation to have better health and well-being [71]. Roditi and Robinson [72] suggested that promoting SOC in cancer survivors can help empower them to deal with, and acquire new meaning of persistent pain. Other nonpharmacological interventions such as massage, acupuncture, mind and body techniques are evidence-based interventions that can be used to relieve cancer pain, as these techniques are inexpensive, safe, and have no side effects [73]. Promoting palliative care aside from helping patients to feel comfortable by providing pain relief also need psychological and spiritual support. Health promoting interventions are also important. A longitudinal study by Park [74] on survivors of various cancers found that meaning-making efforts were related to less distress through meanings made to their negative emotions which corresponds to Antonovsky’s SOC three tenets. Persons with palliative phase of cancer and their families experience low hope, anxiety, and symptoms of depression. In an observational, cross-sectional multiple study Mollenberg [75] found that both the patients and their families with stronger SOC were associated with higher hope, lower anxiety, and symptoms of depression. Health professional should strive to assess patients and families who have low SOC and offer support to promote their comprehensibility, manageability, and meaningfulness during the palliative phase of cancer.

7 Mindfulness Interventions for Psychological Health of Patients with Cancer

Promoting overall psychological health of patients with cancer has been a focus of much research and one of the promising and innovative health promoting intervention is the use of mindfulness-based training among people with cancer [32, 76]. The concept of mindfulness was derived from the term “Sati,” which has its original root from Theravada Buddhism. Mindfulness refers to awareness, which can be achieved through focusing and sustaining attention on the current moment on purpose with a nonjudgmental attitude [77, 78]. Mindfulness practice, including formal and informal meditations, are main approaches to cultivate the mindfulness levels among individuals. The formal mindfulness practice requires a person to perform regular meditations for a certain time period (such as body scan), whereas informal practice signifies how persons integrate awareness or “cautious attention” in their daily life activities (such as mindful eating and mindful walking). During the mindfulness practice, the individuals would be able to: (a) recognize the full range of their internal and external experiences, (b) regulate their attention and energy levels, and (c) connect to people around them [78]. People with high levels of mindfulness pay their attention on the current tasks and activities, disengage from unhealthy beliefs, thoughts and/or emotions, and maintain emotional balance and psychological well-being [77]. Mindfulness practice encompasses seven attitudinal foundations, including acceptance, beginner’s mind, letting go, nonjudging, nonstriving, patience, and trust [78]. Mindfulness interventions were developed for people with physical and psychological conditions. Subsequently, those interventions have been applied to patients with cancer. Examples of the program are MBSR, MBCT, and MBCR, all of which are explained in the following.

7.1 Mindfulness-Based Stress Reduction (MBSR)

The first mindfulness program was developed at the University of Massachusetts Medical Centre’s stress reduction clinic for people who experienced pain and stress [78]. The group-based MBSR contains 8 weekly sessions, each one lasts two and a half hours. A 1-day retreat is also included, and participants are asked to perform daily mindfulness practice for 30–45 min. Topics for each week include: (1) simple awareness, (2) attention and the brain, (3) dealing with thoughts, (4) stress: responding versus reacting, (5) dealing with difficult emotions or physical pain, (6) mindfulness and communication, (7) mindfulness and compassion, and (8) conclusion: developing a practice of your own [79]. Participants also learn different mindfulness practices such as meditation, body scan, loving kindness, and yoga [79]. In the field of oncology, specific breast cancer MBSR has been implemented. Studies showed that the mindfulness improved physical symptoms (fatigue and interference) [80], emotional problems (depression, anxiety, fear of occurrence), and QoL in patients with breast cancer [81, 82].

7.2 Mindfulness-Based Cognitive Therapy (MBCT)

MBCT is a group-based program originally created as a relapse-prevention treatment for patients with depression [83]. Participants would learn to be more aware of their physical sensations, thoughts and emotions from moment to moment and then respond to unpleasant sensations, thoughts and emotions in more skillful approaches [84]. It is perceived that people with full awareness would have more freedom and choices whilst those in an autopilot mode often engage in unhealthy habits, which may trigger negative moods [84]. MBCT, with much influence from MBSR, contains 8 weekly sessions. For each week, the topics are: (1) Awareness and automatic pilot, (2) Living in our heads, (3) Gathering the scattered thoughts, (4) Recognizing aversion, (5) Allowing/Letting be, (6) Thoughts are not fact & Relapse signature, (7) How can I best take care of myself, and (8) Maintaining and extending new learning [84]. Similar to MBSR, various mindfulness practices are introduced encompassing raisin exercise, body scan practice, mindfulness of the breath, sitting meditation, and mindful walking. Home practices are required whereby participants do daily practice of mindfulness guided by provided CDs. Two RCTs involving participants diagnosed with cancer revealed that MBCT improved mindfulness, depression, anxiety, distress, and QoL in comparisons to control participants [85, 86]. Among women with breast cancer, participants in the MBCT group reported significantly lower pain intensity, nonprescription pain medication use, and function disability, and greater quality of life, posttraumatic growth, and self-management compared to the control group [87, 88].

7.3 Mindfulness-Based Cancer Recovery (MBCR)

MBCR is offered to people with cancer as a healing practice, which enables them to enrich their daily life, cope with cancer-related symptoms and treatments, improve an immune system, reduce harmful effects of stress hormones and thus enhance QoL [89]. Mindfulness is represented in two categories: Big-M and Little-m [90]. The former signifies living in the world mindfully whereas the latter represents allocating certain time slots to practice mindfulness [89]. Adapted from MBSR, MBCR comprises 90-min, 8-week intervention sessions, a weekend retreat and home practice. Weekly themes entails: (1) mindfulness attitudes, (2) stress responding versus reacting, (3) mindful movement, (4) balancing breath, (5) stories we tell ourselves (trouble mind), (6) meditation with imagery, (7) a Day of Silence, and (8) deepening and expanding [89]. Certain contents are incorporated into MBCR, including coping with cancer-related symptoms (such as pain, insomnia and fear of reoccurrence) and cognitive coping strategies. Participants are instructed to practice mindful breathing, body scan, sitting meditation, yoga, mindful walking, and mountain and loving kindness meditation. Empirical evidence showed that, in comparison with control groups, MBCR reduced stressed symptoms and mood disturbance [91] and enhanced QoL and post-traumatic growth among distressed breast survivors [92].

7.4 Innovation: Technology-Based Mindfulness Interventions

Traditional face-to-face mindfulness programs are beneficial in terms of preventing and reducing physical and psychological symptoms among people with cancer [93]. However, there are some challenges concerning the traditional method of learning. Specifically, some patients may have limited mobility due to cancer-related fatigue and pain, geographical distance and program schedule and setting. As such, technology-based platforms (such as internet and mobile phone) may be the alternatives as they help overcome challenges encountered by traditional face-to-face programs.

A mobile phone mindfulness-based stress reduction intervention for breast cancer was examined among 15 breast cancer survivors in USA [94]. A single-group, quasi-experimental design was implemented. The MBSR was created to deliver 6 weekly, 2-h intervention sessions through iPad. Weekly modules covered formal meditative techniques (sitting and walking meditation, body scan and Hatha yoga) and informal meditation (integrating mindfulness into daily life). Participants practiced formal and informal mindfulness for 15–45 min and recorded the practice on the iPad. Results indicated improvement in psychological symptoms (stress, anxiety and depression), health status (fatigue), QoL, and cognitive abilities (mindfulness and cognitive functioning) [94].

A 10-week, internet-based group intervention was developed with elements from MBSR and cognitive-behavioral stress management for ovarian cancer survivors in USA [95]. Participants logged in to a web platform to access weekly a videoconference, relaxation and meditation practice (such as deep breathings mindfulness meditation, and guided relaxation and visualization) and journal to record daily reflection. Session topics encompassed awareness of stressors and strengths, automatic thoughts, rational thoughts, acceptance, social support, effective communication, anger, meaning of life, and wrap up. The study revealed that the internet-based program was highly usable and acceptable with moderate feasibility for ovarian cancer survivors [95].

In the Netherlands, a pilot single-group study tested the effects of a 9-week, internet-based, therapist-guided, individual MBCT (iMBCT) on fatigue among cancer survivors [96]. Each week, patients would log in to the website, read information specific for mindfulness, write down their experiences in the log boxes and practice mindfulness using audio files. On an agreeable day of the week, the therapist would reply to the patients’ log and guide them through the program. An online forum allowed participants to share their experiences on mindfulness practice. Patients who attended the iMBCT reported significant reduction in fatigue severity and distress [96].

In Denmark, researchers created an internet-delivered MBCT program (iMBCT) for breast and prostate cancer survivors [97]. In this RCT, cancer survivors included those who completed primary treatments at least 3 months until 5 years. Potential participants were randomized into either an intervention (receiving iMBCT) or control group (receiving care-as-usual). The iMBCT program comprised 8 weekly modules with written materials, audio-guided exercise, examples of cancer-specific patients and videos. Participants were required to submit a weekly training diary to their therapist, who would provide comments each week. Nine therapists, who received MBCT training, involved in such tasks. Findings suggested that patients in both MBCT and iMBCT groups had long-term reduction in psychological and distress; and long-term increase in positive mental health and mental health-related QoL [98].

In Canada, researchers conducted an RCT to test the “synchronous” or “real time” online MBCR on distressed cancer survivors [99]. The online MBCR encompasses eight 2-h weekly sessions with a didactic approach, live group interaction, online 6-h retreat and home practice (hatha yoga, qigong movement and sitting, walking, and loving-kindness meditations). During the mindfulness sessions, all participants interacted in real time with the therapist and other group members. The home practice was achieved through guided recordings and videos. The program demonstrated feasibility and effectiveness in reducing stress, mood disturbances, enhancing mindfulness and spirituality [76]. Similarly, another study in Canada revealed the effectiveness of the real time online MBCR on cancer survivors. Age and gender differences were documented whereby younger participants reported greater improvement in stress, spirituality, and nonreactivity (one component of mindfulness); and men reported greater posttraumatic growth [99]. Results indicated that participants in the iMBCT group had significant improvement in anxiety.

Another pilot study in USA was carried out to test a Headspace application (a self-paced commercial program) via website or smart phone [100]. The 8-week program comprised a 30-days foundation course (basic mindfulness meditation) followed by condition-specific sessions (stress, anxiety, sleep and acceptance). Each session took 10–20 min encompassing a short lecture video and progressive audio instruction. The Headspace helped reduce distress, depression, anxiety, and improved mental health and quality of sleep among cancer patients with active cancer treatments and their caregivers [100].

8 Chapter Summary

Cancer is a global concern as the incidence rates of cancer continue to increase despite new treatment modalities. The number of cancer survivors are also on the rise prolonging their life beyond the 5-year period. From being aware of the risk for cancer to results of screening, definitive diagnosis, undergoing treatment and survivorship, patients experience physiological as well as psychological ill health and reduced well-being. There are growing health promotion strategies to support patients with cancer. Most of these interventions focused on increasing patients’ knowledge, attitudes, and behaviors in changing their lifestyle as well as managing the problematic and debilitating treatment-related symptoms they continue to experience as cancer survivors. The Salutogenic model of health and specifically the SOC has been widely and effectively used in health promotion interventions. It is suggested that health care professionals use these evidence-based interventions appropriately within their sociocultural context. Table 17.1 provides a summary of health promoting interventions presented in this chapter.

Table 17.1 Summary of health promotion interventions for cancer patients
Full size table

Take Home Messages

  • Cancer patients have reduced psychological well-being and increased stress, anxiety, and depressive symptoms.

  • The Salutogenic health theory that focuses on the origins of health and psychological well-being can be used to guide health promotion interventions in patients with cancer.

  • A high SOC reflects a coping capacity of cancer patients to deal with everyday life stressors and consists of three elements: comprehensibility, manageability, and meaningfulness.

  • Innovative health promotion interventions such as art therapy, auricular therapy, mindfulness, web-based instant messaging, physical exercise, psychoeducational manuals, and other nonpharmacological therapies are needed to strengthen SOC in patients with cancer.