Skip to main content Accessibility help

Recovering function and surviving treatments are primary motivators for health behavior change in patients with head and neck cancer: Qualitative focus group study

  • Melissa Henry (a1) (a2), Ala Bdira (a1), Maria Cherba (a2) (a3), Sylvie Lambert (a1), Franco A. Carnevale (a1) (a4), Christina MacDonald (a2), Michael Hier (a1) (a2), Anthony Zeitouni (a1) (a4), Karen Kost (a1) (a4), Alex Mlynarek (a1) (a2) (a4), Martin Black (a1) (a2), Zeev Rosberger (a1) (a2) and Saul Frenkiel (a1) (a2)...



Against medical advice, head and neck cancer (HNC) patients have been shown to continue to smoke and misuse alcohol post-diagnosis and treatment. This study aimed to better understand the barriers to and facilitators of health behavior change (HBC) in HNC patients.


We conducted nine focus groups following a standard protocol. Eligible patients were diagnosed less than three years previously with a primary HNC and selected using maximum variability sampling (gender, age, cancer stage, smoking, and alcohol misuse). Thematic analysis was conducted using NVivo 10 software.


Participants were mostly men (79%), 65 years of age (SD = 10.1), and married/common-law (52%, n = 15). Mean time from diagnosis was 19 months (SD = 12.3, range = 5.0–44.5), and most had advanced cancer (65.5%, n = 19). Participants provided a larger than anticipated definition of health behaviors, encompassing both traditional (smoking, drinking, diet, exercise, UV protection) and HNC-related (e.g., dental hygiene, skin care, speech exercises, using a PEG, gaining weight). The main emerging theme was patient engagement, that is, being proactive in rehabilitation, informed by the medical team, optimistic, flexible, and seeking support when needed. Patients were primarily motivated to stay proactive and engage in positive health behaviors in order to return to normal life and reclaim function, rather than to prevent a cancer recurrence. Barriers to patient engagement included emotional aspects (e.g., anxiety, depression, trauma, demoralization), symptoms (e.g., fatigue, pain), lack of information about HBC, and healthcare providers' authoritarian approach in counseling on HBC. We found some commonalities in barriers and facilitators according to behavior type (i.e., smoking/drinking/UV protection vs. diet/exercise).

Significance of Results:

This study underlines the key challenges in addressing health behaviors in head and neck oncology, including treatment-related functional impairments, symptom burden, and the disease's emotional toll. This delicate context requires health promotion strategies involving close rehabilitative support from a multidisciplinary team attentive to the many struggles of patients both during treatments and in the longer-term recovery period. Health promotion in HNC should be integrated into routine clinical care and target both traditional and HNC-related behaviors, emphasizing emotional and functional rehabilitation as key components.


Corresponding author

Address correspondence and reprint request to: Melissa Henry, Jewish General Hospital, 3755 Cote Sainte-Catherine Rd, Pavilion H, Room H-366, Montreal, Quebec, Canada, H3T 1E2. E-mail:


Hide All
Babor, T. & Kadden, R.M. (2005). Screening and interventions for alcohol and drug problems in medical settings: What works? The Journal of Trauma: Injury, Infection, and Critical Care, 59(3), S80S87.
Beckjord, E.B., Rutten, F., Arora, N.K., et al. (2008). Information processing and negative affect: Evidence from the 2003 Health Information National Trends Survey. Health Psychology, 27(2), 249257.
Bjorklund, M., Sarvimaki, A. & Berg, A. (2008). Health promotion from the perspective of individuals living with head and neck cancer. European Journal of Oncology Nursing, 12(1), 2634.
Bultz, B.D., Waller, A., Cullum, J., et al. (2013). Implementing routine screening for distress, the sixth vital sign, for patients with head and neck and neurologic cancers. Journal of the National Comprehensive Cancer Network, 11, 12491261.
Canadian Cancer Society (2011). Canadian cancer statistics 2011. Toronto: Canadian Cancer Society. Available from
Canadian Partnership Against Cancer (2012). Screening for distress, the 6th vital sign: A guide to implementing best practices in person-centered care. Available from,
Carpenter, C.J. (2010). A meta-analysis of the effectiveness of health belief model variables in predicting behavior. Health Communication, 25(8), 661669.
Cherpitel, C.J. (2000). A brief screening instrument for alcohol dependence in the emergency room: The RAPS4. Journal of Studies on Alcohol, 61, 447449.
Ciccolo, J.T. & Busch, A.M. (2014). Behavioral interventions to enhance smoking cessation: A summary of current evidence. American Journal of Lifestyle Medicine, 9. Available from
Glasgow, R.E., Vogt, T.M. & Boles, S.M. (1999). Evaluating the public health impact of health promotion interventions: The RE–AIM framework. American Journal of Public Health, 89, 13221327.
Gritz, E.R., Fingeret, M.C., Vidrine, D.J., et al. (2006). Successes and failures of the teachable moment: Smoking cessation in cancer patients. Cancer, 106(1), 1727.
Hettema, J., Steele, J. & Miller, W.R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91111.
Hollander, J.A. (2004). The social context of focus groups. Journal of Contemporary Ethnography, 33, 602636.
Hsieh, H.F. & Shannon, S.E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 12771288.
Institute of Medicine, National Research Council, Hewitt, M. & Ganz, P.A. (2006). From cancer patient to cancer survivor. Lost in transition: An American Society of Clinical Oncology and Institute of Medicine symposium. Washington, DC: National Academies Press.
Janz, N.K. & Becker, M.H. (1984). The health belief model: A decade later. Health Education & Behavior, 11(1), 147.
Kitzinger, J. (1994). The methodology of focus groups: The importance of interaction between research participants. Sociology of Health & Illness, 16(1), 103121.
Kitzinger, J. (1995). Introducing focus groups. BMJ, 311(7000), 299302.
Kolappa, K. & Henderson, D.C. (2013). No physical health without mental health: Lessons unlearned. Bulletin of the World Health Organization, 91, 33A.
Krueger, R.A. & Casey, M.A. (2000). Focus groups: A practical guide for applied research. Thousand Oaks, CA: Sage Publications.
Logan, J. & Graham, I. D. (1998). Toward a comprehensive interdisciplinary model of health care research use. Science Communication, 20, 227246.
Matthias, C., Harreus, U. & Strange, R. (2006). Influential factors on tumor recurrence in head and neck cancer patients. European Archives of Oto-Rhino-Laryngology, 263(1), 3742.
Mehnert, A., Brähler, E., Faller, H., et al. (2014). Four-week prevalence of mental disorders in patients with cancer across major tumor entities. Journal of Clinical Oncology, 32(31), 35403546.
Miller, W.R. & Rollnick, S. (2002). Motivational interviewing: Helping people change (3rd Edition). New York: The Guilford Press.
Morgan, D. (1997). Focus groups as qualitative research. Thousand Oaks, CA: Sage Publications.
Murphy, B.A., Ridner, S., Wells, N., et al. (2007). Quality of life research in head and neck cancer: A review of the current state of the science. Critical Reviews in Oncology/Hematology, 62(3), 251267.
National Cancer Institute (2015). Fatigue—for health professionals. Rockville, MD: National Cancer Institute. Available from
NVivo (2012). NVivo qualitative data analysis software, version 10. Melbourne: QSR International.
Ozakinci, G., Wells, M., Williams, B., et al. (2010). Cancer diagnosis: An opportune time to help patients and their families stop smoking? Public Health, 124(8), 479482.
Patton, M.Q. (1990). Qualitative evaluation and research methods, 2nd ed.Newbury Park, CA: Sage Publications.
Ranney, L., Melvin, C., Lux, L., et al. (2006). Systematic review: Smoking cessation intervention strategies for adults and adults in special populations. Annals of Internal Medicine, 145(11), 845856.
Rollnick, S., Miller, W.R. & Butler, C.C. (2008). Motivational interviewing in health care. New York: Guilford Press.
Rosenstock, I. (1974). Historical origins of the health belief model. Health Education & Behavior, 2(4), 328335.
Rubak, S., Sandbaek, A., Lauritzen, T., et al. (2005). Motivational interviewing: A systematic review and meta-analysis. The British Journal of General Practice, 55(513), 305312.
Sharp, L. & Tishelman, C. (2005). Smoking cessation for patients with head and neck cancer. Cancer Nursing, 28(3), 226235.
Sharp, L., Johansson, H., Fagerstrom, K., et al. (2008). Smoking cessation among patients with head and neck cancer: Cancer as a “teachable moment.” European Journal of Cancer Care, 17(2), 114119.
Shenton, A.K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22, 6375.
Simmons, V.N., Litvin, E.B., Unrod, M., et al. (2012). Oncology healthcare providers' implementation of the 5A's model of brief interventions for smoking cessation: Patients' perceptions. Patient Education and Counseling, 86(3), 414419.
Stewart, D.W. & Shamdasani, P.N. (2014). Focus group: Theory and practice, 3rd ed.Thousand Oaks, CA: Sage Publications.
Teunissen, S., Wesker, W., Kruitwagen, C., et al. (2007). Symptom prevalence in patients with incurable cancer: A systematic review. Journal of Pain and Symptom Management, 34(1), 94104.
van den Beuken–van Everdingen, M.H.J., de Rijke, J.M., Kessels, A.G., et al. (2007). Prevalence of pain in patients with cancer: A systematic review of the past 40 years. Annals of Oncology, 18(9), 14371449.
Warren, G.W., Marshall, J.R., Cummings, K.M., et al. (2013). Addressing tobacco use in patients with cancer: A survey of American Society of Clinical Oncology members. Journal of Oncology Practice, 9(5), 258262.
Whitlock, E.P., Polen, M.R., Green, C.A., et al. (2004). Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 40(7), 557568.
World Health Organization (2009). Global health risks: Mortality and burden of disease attributable to selected major risks. WHO Library Cataloguing-in-Publication Data. Available from



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed