|Ahead of print publication
Cancer resilience in parents of children with cancer; the role of general health and self-efficacy on resiliency
Narges Mohammadsalehi1, Azadeh Asgarian1, Marzieh Ghasemi2, Abolfazl Mohammadbeigi3
1 Research Center of Environmental Pollutants, Qom University of Medical Sciences, Qom, Iran
2 Research Student Committee, Faculty of Health, Qom University of Medical Sciences, Qom, Iran
3 Research Center of Environmental Pollutants, Faculty of Health, Qom University of Medical Sciences, Qom, Iran
|Date of Submission||29-Jun-2019|
|Date of Decision||14-Sep-2019|
|Date of Acceptance||01-Dec-2019|
|Date of Web Publication||03-Oct-2020|
Research Center of Environmental Pollutants, Qom University of Medical Sciences, Qom
Source of Support: None, Conflict of Interest: None
Introduction: Cancer in children affect their parents to some stress and worries during treatment process. This study aimed to assess the parental adjustment on the resiliency of parents of children with cancer and its relationship with social support, self-efficacy, and general health.
Materials and Methods: In a cross-sectional study, 107 parents of children with cancer were selected by convenience sampling method from the Oncology Departments of Qom Hospitals, Iran. Standard questionnaires including Phillips Social Support, Corner Davidson Resilience, Sheerer Self-Efficacy Inventory, and General Health Questionnaire (GHQ-28) were used for data collection. Pearson's correlation coefficient, Chi–square test, t-test, and multivariate linear regression were used for data analysis in SPSS software.
Results: A significant correlation was observed between cancer resilience and social support score (r = 0.285). Multivariate regression model Showed that social support was the most important predictor of cancer resilience (β =0.723, P = 0.045). In addition, self efficacy (β =0.356, P = 0.005) showed a direct relationship with cancer resilience. Nevertheless, an inverse association (β = -0.351, P = 0.025) was observed between GHQ score and cancer resilience in parents of children with cancer.
Conclusion: Cancer resilience in families of children with cancer is significantly associated with higher social support, more self-efficacy, and better general health. Interventional programs aimed at increasing family resilience and reducing stress by increasing the social support and self-efficacy in patients' families are helpful and necessary.
Keywords: Cancer, children, general health, resilience, self-efficacy, social support
|How to cite this URL:|
Mohammadsalehi N, Asgarian A, Ghasemi M, Mohammadbeigi A. Cancer resilience in parents of children with cancer; the role of general health and self-efficacy on resiliency. J Can Res Ther [Epub ahead of print] [cited 2020 Oct 20]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=297201
| > Introduction|| |
Cancer is a chronic life-threatening disease and the second leading cause of child death, after nonintentional injuries, in children under 14 years., The incidence of childhood cancer in Iran is different from 1.1% to 3.4% for all types of cancers.,
Having a child with cancer often has a negative physical and psychological effect on their parents and disrupts the child's coping with the disease due to symptoms and complications of disease., The parents' worries of the child with cancer starting form diagnosis, during treatment period, and hopefully to survivorship are the most severe stressors of parents and have been considered a traumatic event. Medical care and distresses about early childhood death cause feelings of despair, anger, confinement, and excessive tension in parents. Therefore, compatible and effective strategies in child and family members are necessary to maintain their own performance.,
The resilience is increased based on results of some studies in parents of children with cancer., Moreover, the coping strategies and psychological factors help these families in cancer resilience. Resilience has been conceptualized in different ways that can be viewed as a trait, a process, or an outcome., However, this term has a paradoxical definition and differ from only maintaining or returning to premorbid levels of adjustment following adversity, to bouncing back with improvement and measureable positive outcomes., Nevertheless, resilience is defined as a healthy or adaptive psychological outcome across and during exposure to adverse traumatic events that cause minimal distress and disruption in function over the passage of time.,
Social support, self-efficacy, and high level of general health are some factors that could improve the resilience of patients or their relatives after exposure to potentially traumatic events such as cancer in their children.,, The present study aimed to assess the parental adjustment on the resiliency of parents of children with cancer and its relationship with social support, self-efficacy, and general health.
| > Materials and Methods|| |
This analytic, cross-sectional study was carried out on 107 mothers of children with cancer who were admitted at the Oncology Departments of Qom Hospitals, Iran. Sample size calculation was conducted based on the correlation coefficient between cancer resilience and general health, with r = 0.26, study power of 1−β =0.80, and α =0.05. Based on these parameters, the minimum sample size was calculated as 98.
The study population in our study comprised parents of children with confirmed cancer diagnosis. All the eligible patients who were referred to Qom Hospitals at 2018 were included in the study by convenience sampling method. Inclusion criteria were confirmation of cancer diagnosis in child, mother' literacy skill for writing and reading, passing a minimum of 6 months and a maximum of 5 years from the onset of a child's illness, having only one child with cancer disease, and no exposure to other stressful events during the last 12 months (such as dying parents or first-rank relatives). Exclusion criteria were nonsatisfaction for participation in the study and caring with another member of family except his/her mother. The patients and their mothers were free to participate in the study, and informed consent was signed by the patients' mothers. Moreover, the protocol of this study was approved by the Ethical Committee of Qom University of Medical Sciences by IR.MUQ.REC. 1397.104 cod.
Five different questionnaires were used for data gathering including demographic information form, Phillips Social Support Questionnaire, Corner Davidson Resilience Questionnaire, General Health Questionnaire (GHQ-28), and Sheerer Self-Efficacy Inventory. Demographic information form included patient's age and gender; number of child in the family; cancer type; parents' age, education, and job; and income level of the family. Social support was measured by the Phillips Social Support Questionnaire which has 23 items and include social support in family (8 items), friends (7 items), and others (8 items). Scoring of this scale is based on 0 and 1, and the minimum and maximum scores of this scale are 0 and 23, respectively. The scoring in items 3, 10, 13, 21, and 22 was made inversely. The validity and reliability of this questionnaire had been evaluated in some studies in Iran., Connor–Davidson Resilience Scale was used in our study to distinguish the resilient and nonresilient individuals. This scale has 25 items evaluated on a 5-point Likert scale and scored from 0 = completely incorrect to 5 = always correct. The reliability coefficient of this scale was reported to be 0.89, and it has been estimated to be 0.87 and 0.89 in Iranian studies. The General Health Questionnaire containing 28 items (GHQ-28) was used to determine the psychological distress and social health of the participants. This questionnaire scores from 0 = “never” and 4 = “more than normal.” The validity and reliability of the GHQ questionnaire has been approved in some studies, which measures the general health in four scopes including physical health, anxiety, depression, and social support. The Sherer' self-efficacy scale  has 17 items and its scoring is based on a 5-point Likert scale from 1 to 5. The scoring of items 1, 3, 8, 9, 13, and 15 is made inversely. The minimum and maximum scores in this scale are 17 and 87, respectively. The validity and reliability of this scale has been approved by Navidian et al.'s study. The scores of Sherer' self-efficacy scale were categorized into three levels including 17–40 as weak, 40–65 as moderate, and above 65 as good based on Bagheri-Nesami et al.'s study.
Data analysis was conducted by descriptive statistics including mean, standard deviation, and percentage. In addition, Pearson's correlation coefficient, Chi–square test, t-test, and multivariate linear regression were used for analysis of data and interpretation. All analyses were conducted in using SPSS version 18 (SPSS Inc., Chicago, IL, USA).
| > Results|| |
The mean age of the children with cancer was 6.67 ± 3.94 years and ranged from 1 to 16 years. The mean age of the patients' mothers and fathers was 35.53 ± 4.83 years and 40.31 ± 6.64 years, respectively. The mean of diagnosis age of cancer in patients was 4.71 ± 3.63 years and varied from 0 to 14 years. [Table 1] shows the demographic characteristics of the study patients. The sex ratio of the patients was 1.28 (56.1% for males and 43.9% for females). The prevalence of malignant type of carcinoma in our patients was 72.9% (78/107) (95% confidence interval: 72.54%–73.26%). Parents' education showed that the highest proportion of them have educational level lower than college and the income level of the families was low.
The mean score of cancer resilience in the study patients was 88.03 ± 17.47 and ranged from 25 to 119. Moreover, the mean score of GHQ calculated was 41.40 ± 7.65 (ranged from 12 to 66). The self-efficacy and social support scores were 36.23 ± 7.98 and 19.10 ± 6.25, respectively. [Table 2] shows the detail scores of cancer resilience, GHQ, self-efficacy, and social support.
|Table 2: The mean, standard deviation, and minimum and maximum scores of cancer resilience, General Health Questionnaire, self-efficacy, and social support|
Click here to view
Based on the scores of self-efficacy questionnaire, 65.4% (70) of patients were categorized as having weak self-efficacy for treatment of their diseases, 66.6% (36) of patients were found to be moderate, and only 0.9% (1) of patients have good self-efficacy. Based on [Table 3], there was a significant difference in the mean score of cancer resilience among patients based on the self-efficacy level (P < 0.001), cancer type (P = 0.041), and father's education (P = 0.025). Nevertheless, there was no difference between the mean score of cancer resilience with mothers' education, parents' job, and income level (P > 0.05).
|Table 3: The relationship between the mean score of cancer resilience among patients, with demographic variables|
Click here to view
[Table 4] shows the Pearson's correlation coefficients between the mean score of cancer resilience among mothers of children with cancer by demographic variables. Statistically significant correlation was observed between cancer resilience and self-efficacy score (r = 0.370, P < 0.001), GHQ score (r = −0.325, P = 0.001), and social support score (r = 0.285, P = 0.003). According to the results of multivariate linear regression model [Table 5], social support was the most important predictor of cancer resilience that has a direct relationship with cancer resilience (β = 0.723, P = 0.045). In addition, self-efficacy was another predictor for good cancer resilience (β = 0.356, P = 0.005). Nevertheless, the GHQ score was another important predictor of cancer resilience with an inverse relationship. On the other hand, affecting to mental disorders was a risk factor for lower cancer resilience (β = −0.351, P = 0.025).
|Table 4: The correlations between the mean score of cancer resilience among patients with demographic variables|
Click here to view
|Table 5: The results of multivariate linear regression model of cancer resilience based on related factors|
Click here to view
| > Discussion|| |
Our study showed that parental cancer resiliency is associated with good general health, higher social support, and increased perceived self-efficacy. According to the results of the multivariate linear regression model, social support is the most significant predictor of cancer resilience. The effect of social support on high parental resilience was twofold of self-efficacy and good general health. Based on these findings, psychological status of parents of children with cancer is a significant factor that increased the resiliency. Evidences in 30 years show that social support plays a crucial part in successful coping., Moreover, social support improve the resiliency by buffering effect in dealing with stress and increase the positive mental health.,, Plumb's study  on families who have a child diagnosed with autism spectrum disorder indicates that most families experienced clinically high levels of stress and a direct correlation was observed between higher family resilience and lower level of stress. Nevertheless, based on his results, the higher levels of perceived social support correlated with increased parental stress. However, Plumb's study showed that families with high resilience are enforced to less parental stress. Another study on parents of children with cancer showed that lower resilience was related to higher distress, lower social support, and lower family function. Nevertheless, lower resilience was associated with higher percent of sleep disorders and lower health satisfaction.
Self-efficacy was a related factor for better cancer resilience in parents of children with cancer. In addition, good general health was a protective factor of high resilience, while affecting to mental disorders was risk factors for lower cancer resilience. It is shown that an inverse significant relationship exists between mothers' resilience and parental stress, anxiety, and depression. Other studies showed similar results and demonstrated the effect of emotional distress of parents of children with cancer on the resiliency status.,, A study by Bullough et al. in Afghanistan showed that perceived danger is negatively related to an individual's entrepreneurial intentions, but marginally less so among highly resilient individuals. Based on their results, during exposure to adversity or traumatic events such as war conditions or outbreaks of dangerous diseases, individuals could be able to grow their resilience by developing self-efficacy abilities. Moreover, Gayton and Lovell's study on medical students showed that resilience was significantly correlated with general health and well-being and suggested that increased resilience interventions for medical students could protect their well-being.
Based on our results, there was no relationship between the mean score of cancer resilience with mothers' education, parents' job, and income level. Therefore, it seems that asset index including parents' education, family income, and family job is not a predictor of good resilience in parents of children with cancer. A similar study showed that the psychological aspects is more important to demographic and individual characteristics in family residency in chronic diseases.,,, Therefore, besides enhancing the psychological aspects of self-efficacy and the high level of well-being in the parents and families, clinicians and care staffs should focus on interventions for patients' families to increase family resilience and reduce stress. Implementing spiritual health and coping strategies after exposure to adversity or potentially traumatic events also could be helpful for increasing the resilience level of patients and their families.
We assessed the psychological support including self-efficacy, social support, as well as general health on the resiliency level of parents of child with cancer for the first time in Iranian patients. However, due to low incidence rate of cancer in our setting, the sample size was restricted. Therefore, future studies with larger sample size are suggested for other researchers.
| > Conclusion|| |
Cancer resilience in families of children with cancer is significantly associated with social support. Enhancing self-efficacy and improving general health are the second and third important factors that are associated with better cancer resiliency of parents of children with cancer. Therefore, interventions for patients' families to increase family resilience and reduce stress by increasing social support and self-efficacy could be helpful programs. In addition, receiving education on spiritual health scope is a relief for those parents caring children with cancer at a long term.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Amir AH, Soheil Z, Mehran K, Esmaeil K, Abolfazl M. Survival rate of childhood leukemia in Shiraz, Southern Iran. Iran J Pediatr 2013;23:53-8.
Kaboudi M, Abbasi P, Heidarisharaf P, Dehghan F, Ziapour A. The effect of resilience training on the condition of style of coping and parental stress in mothers of children with Leukemia. Int J Pediatr 2018;6:7299-310.
Mousavi SM, Pourfeizi A, Dastgiri S. Childhood cancer in Iran. J Pediatr Hematol Oncol 2010;32:376-82.
Moradi A, Semnani S, Roshandel G, Mirbehbehani N, Keshtkar A, Aarabi M, et al
. Incidence of childhood cancers in Golestan province of Iran. Iran J Pediatr 2010;20:335-42.
O'Conner-Von S. Coping with cancer: A web-based educational program for early and middle adolescents. J Pediatr Oncol Nurs 2009;26:230-41.
Phipps S, Long A, Willard VW, Okado Y, Hudson M, Huang Q, et al
. Parents of children with cancer: At-risk or resilient? J Pediatr Psychol 2015;40:914-25.
Southwick SM, Bonanno GA, Masten AS, Panter-Brick C, Yehuda R. Resilience definitions, theory, and challenges: interdisciplinary perspectives. Eur J Psychotraumatol 2014;5:10. doi: 10.3402/ejpt.v5.25338.
Davoudi S, Shaw K, Haider LJ, Quinlan AE, Peterson GD, Wilkinson C, et al
. Resilience: A bridging concept or a dead end? Reframing resilience: challenges for planning theory and practice interacting traps: Resilience assessment of a pasture management system in Northern Afghanistan urban resilience: What does it mean in planning practice? Resilience as a useful concept for climate change adaptation? The politics of resilience for planning: A cautionary note: Edited by Simin Davoudi and Libby Porter. Plan Theory Pract 2012;13:299-333.
Sippel L, Pietrzak R, Charney D, Mayes L, Southwick S. How does social support enhance resilience in the trauma-exposed individual? Ecol Soc 2015;20:10. DOI: doi.org/10.5751/ES-07832-200410.
Bullough A, Renko M, Myatt T. Danger zone entrepreneurs: The importance of resilience and self-efficacy for entrepreneurial intentions. Entrep Theory Pract 2014;38:473-99.
Gayton SD, Lovell GP. Resilience in ambulance service paramedics and its relationships with well-being and general health. Traumatology 2012;18:58-64.
Ghasemipoor M, Ganje JS. The relationship between the social support and mental health in Lorestan university students in 2009. Sci Magazine Yafte 2010;12:57-64.
Beygzadeh KZ, Rezaei A, Khalouei Y. The relationship between social support and life satisfaction with happiness among home-dwelling older adults in Shiraz the relationship between social support and life satisfaction with happiness among home-dwelling older adults in Shiraz. Iran J Ageing 2015;10:172-9.
Connor KM, Davidson JR. Development of a new resilience scale: The Connor-Davidson resilience scale (CD-RISC). Depress Anxiety 2003;18:76-82.
Tajikzade F, Sadeghi R, Karimian RF. The comparison of resilience coping style and pain catastrophizing in cancer patients and normal people. Anesthesiol Pain 2016;7:38-48.
Bayati A, Beigi M, Salehi M. Depression prevalence and related factors in Iranian students. Pak J Biol Sci 2009;12:1371-5.
Sherer M, Maddux JE, Mercandante B, Prentice-Dunn S, Jacobs B, Rogers RW. The self-efficacy scale: Construction and validation. Psychol Rep 1982;51:663-71.
Navidian A, Abedi MR, Baghban I, Fatehizade MS, Poursharifi H. Reliability and validity of the weight efficacy lifestyle questionnaire in overweight and obese individuals. J Behav Sci 2009;3:217-22.
Bagheri-Nesami M, Sohrabi M, Ebrahimi MJ, Heidari-Fard J, Yanj J, Golchinmehr S. The relationship between life satisfaction with social support and self-efficacy in community-dwelling elderly in Sari, Iran, 2012. J Mazandaran Univ Med Sci 2013;23:38-47.
Pinkerton J, Dolan P. Family support social capital resilience and adolescent coping. Child Fam Soc Work 2007;12:219-28.
Sanjari M, Jafarppour M, Safarabadi T, Hosseini F. Coping with cancer in teenagers and their parents. Iran J Nur 2005;18:111-22.
Rosenberg AR, Wolfe J, Bradford MC, Shaffer ML, Yi-Frazier JP, Curtis JR, et al
. Resilience and psychosocial outcomes in parents of children with cancer. Pediatr Blood Cancer 2014;61:552-7.
Asghari Nekah S, Jansooz F, Kamali F, Taherinia S. The resiliency status and emotional distress in mothers of children with cancer. J Clin Psychol 2015;7:15-26.
Hosseini Ghomi T, Salimi Bajestani H. Effectiveness of resilience training on stress of mothers whose children, suffer from cancer in Imam Khomeini hospital of Tehran. Health Psychol 2013;1:97-109.
Ercan H. The Relationship between resilience and the big five personality traits in emerging adulthood. Eurasian J Educ Res 2017;70:83-103.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]