BACKGROUND: Healthy behaviors, that is, engaging in regular physical activities, maintaining a healthy diet, limiting alcohol consumption, and avoiding tobacco and drug use, decrease the risk of developing late adverse health conditions in childhood cancer survivors. However, childhood cancer survivors may experience barriers to adopting and maintaining healthy behaviors. This study aimed to assess these barriers and facilitators to health behavior adoption and maintenance in childhood cancer survivors. METHODS: A focus group ( n = 12) and semi-structured telephone interviews ( n = 20) were conducted with a selected sample of European and Dutch childhood cancer survivors, respectively. The Theoretical Domains Framework (TDF) was used to inform the topic guide and analysis. Inductive thematic analysis was applied to identify categories relating to barriers and facilitators of health behavior adoption and maintenance, after which they were deductively mapped onto the TDF. RESULTS: Ten TDF domains were identified in the data of which "Knowledge," "Beliefs about consequences," "Environmental context and resources," and "Social influences" were most commonly reported. Childhood cancer survivors expressed a need for knowledge on the importance of healthy behaviors, possibly provided by healthcare professionals. They indicated physical and long-term benefits of healthy behaviors, available professional support, and a supporting and health-consciously minded work and social environment to be facilitators. Barriers were mostly related to a lack of available time and an unhealthy environment. Lastly, (social) media was perceived as both a barrier and a facilitator to healthy behaviors. CONCLUSION: This study has identified education and available professional support in health behaviors and the relevance of healthy behaviors for childhood cancer survivors as key opportunities for stimulating health behavior adoption in childhood cancer survivors. Incorporating health behavior support and interventions for this population should therefore be a high priority.

Center for Preventive Medicine and Digital Health Medical Faculty Mannheim Heidelberg University Röntgenstraße 7 D 68167 Mannheim Germany

Center of Expertise for Cancer Survivorship Department of Hematology Radboud University Medical Center Geert Grooteplein Zuid 10 6525 GA Nijmegen the Netherlands

Childhood Cancer International Europe Servitengasse 5 16 1090 Vienna Austria

Childhood Cancer Research Group Danish Cancer Society Research Center Strandboulevarden 49 2100 Copenhagen Denmark

Department of Clinical Medicine Faculty of Health Aarhus University and Aarhus University Hospital Palle Juul Jensens Boulevard 82 8200 Aarhus Denmark

Department of Oncology Pediatric Oncology KU Leuven Leuven Belgium

Department of Pediatric Hematology and Oncology University Hospitals Leuven Herestraat 49 3000 Leuven Belgium

Department of Pediatrics Emma Children's Hospital Amsterdam UMC Meibergdreef 9 1105 AZ Amsterdam the Netherlands

DOPO Clinic Division of Pediatric Hematology and Oncology IRCCS Istituto Giannina Gaslini Via G Gaslini 5 16147 Genoa Italy

Faculty of Medicine Utrecht University and Utrecht Medical Center Universiteitsweg 98 3584 CG Utrecht the Netherlands

Great North Children's Hospital Royal Victoria Infirmary Queen Victoria Road Newcastle upon Tyne NE1 4LP UK

International Clinical Research Center at St Anne's University Hospital Masaryk University Pekařská 53 Brno 656 91 Czech Republic

Oncology Department of Clinical Sciences Lund Lund University Skåne University Hospital Lasarettsgatan 40 221 85 Lund Sweden

PanCare Jacobus Bellamylaan 16 1401 AZ Bussum the Netherlands

Pediatrics Department of Clinical Sciences Lund Lund University Skåne University Hospital Lasarettsgatan 40 221 85 Lund Sweden

Population Health Sciences Institute Newcastle University Ridley Building 1 Queen Victoria Road Newcastle upon Tyne NE1 7RU UK

Princess Máxima Center for Pediatric Oncology Heidelberglaan 25 3584 CS Utrecht the Netherlands

Scientific Institute for Quality of Healthcare Radboud University Medical Center Geert Grooteplein 21 6525 EZ Nijmegen the Netherlands

Wolfson Childhood Cancer Research Center Newcastle University Center for Cancer Newcastle University NE1 7RU Newcastle upon Tyne Herschel Building Brewery Lane UK

Wolfson Childhood Cancer Research Center Translational and Clinical Research Institute Newcastle University Herschel Building Brewery Lane Newcastle upon Tyne NE1 7RU UK

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