NURSING DEPARTMENT, MEDICINE AND HEALTH COLLEGE
Lishui University, China
FACULTY OF HEALTH AND OCCUPATIONAL STUDIES
Department of Caring Sciences
Parents’ Experience of Having a Child with Cancer
A descriptive review
Xiao Siyu (Ruby)
Hu Sang (Honey)
2020
Student thesis, Bachelor degree, 15 credits Nursing
Abstract
Background: Childhood cancer incidence is rising. When a child is diagnosed with cancer,
it is a great challenge not only for the child but also for his or her parents. Paying attention to parents’ experience of having a child with cancer is of great significance to helping parents adapt to the disease and provide better care for their child.
Aim: To describe the parents’ experience of having a child with cancer. Design: A descriptive review of qualitative studies.
Method: All articles were searched in the databases PubMed and Cinahl. Suitable articles
were selected after careful reading, all results were compared, similarities and differences were categorized accordingly.
Results: A total of 10 articles were included in the review. Four themes were derived from
the findings: 1) Parents’ loss and the turmoil; 2) Benefit finding; 3) Adjustment and different ways of adaptation; 4) Social support. When a child was diagnosed with cancer, his or her parents would be in a mess. However, parents grew up during the treatment, adopted different ways of adaptation and received a great deal of support.
Conclusions: When a child was diagnosed with cancer, parents not only became chaotic in
their life, but also suffered greatly psychologically. Parents would adopt different ways to adjust themselves and adapt to this disease. During the process, parents received a lot of social support. Based on parents' experience, nurses should give more humanistic care to parents, take professional and targeted measures to help parents, and guide them to provide better care for their child.
Content 1. Introduction ... 1 1.1 Background ... 1 1.2 Definition ... 1 1.2.1 Definition of parents ... 1 1.2.2 Definition of cancer ... 1 1.2.3 Definition of child ... 2
1.3 The nurse’s role ... 2
1.4 Nursing theory ... 2
1.5 Early reviews ... 3
1.6 Problem statement ... 3
1.7 Aim and specific question ... 3
2. Method ... 4 2.1 Design ... 4 2.2 Search strategy ... 4 2.3. Selection criteria ... 5 2.4 Selection process ... 5 2.5. Data analysis ... 6 2.6. Ethical considerations ... 7 3 . Results ... 7
3.1 Parents' loss and the turmoil ... 7
3.1.1 Emotion distress ... 7
3.1.2 Lost the previous life ... 8
3.1.3 Family function imbalanced ... 8
3.2 Benefit finding ... 9
3.2.1 Love children more ... 9
3.2.2 Closer relationship in family ... 9
3.3 Adjustment and different ways of adaptation ... 10
3.3.1 Negative coping ... 10
3.3.2 Being hopeful ... 10
3.3.3 Taking control ... 10
3.4 Social support ... 11
3.4.2 Health workers ... 11
3.4.3 Social members ... 11
3.5 The chosen articles information ... 12
4. Discussion ... 13
4.1 Main results ... 13
4.2 Results discussion ... 13
4.2.1 Parents' loss and the turmoil ... 13
4.2.2 Benefit finding ... 14
4.2.3 Adjustment and different ways of adaptation ... 15
4.2.4 Social support ... 16
4.3 Methods discussion ... 17
4.4 Clinical implication for nursing ... 17
4.5 Suggestions for further research ... 18
5. Conclusions ... 18
6.Reference ... 19
1
1. Introduction
1.1 Background
In recent years, the incidence of childhood cancer is rising (Stiller, 2007). According to UICC (2012) report, more than 175,000 children are diagnosed with cancer worldwide each year (UICC, 2012). Childhood cancer becomes the second leading cause of child death (Kaatsch, 2010). In the United States, about 13,400 children and adolescents develop cancer each year (UICC, 2012). Eighty-four percent of childhood cancers occur in low- or middle-income countries (Zheng et al., 2015). In India, 1.6% to 4.8% children are diagnosed with cancer every year (Arora et al., 2009). From 2000 to 2010, the incidence of childhood cancer in China increased at an annual rate of 2.8% (Chen et al.,2013). It predicts that 6.7 million children will be diagnosed with cancer worldwide between 2015 and 2030 (Ward et al., 2019). Due to early diagnosis and effective treatment, childhood cancer has better survival rates than adult cancers (Zheng et al. 2015). The global 5-year survival rate for children with cancer was 37.4% in 2015, however, there are big regional differences (Ward et al., 2019). In high-income countries, the five-year survival rate for children with cancer is more than 80%, but in low and middle-income countries, the five-year survival rate is less than 30% (Lam et al., 2019).
The main types of cancer in children are different from adults. The most common cancers in children include acute leukemia, brain tumors, lymphoma, bone and soft tissue sarcoma, and germ cell tumors (Lam et al. 2019).
According to their diagnosis, treatment includes chemotherapy, radiotherapy, surgery, transplantation, or some combination of these (Angstrom-Brannstrom et al., 2015). Due to illness, treatment-related pain, and medication side effects, children who treat for cancer often experience pain, hair loss and blood test, which make them feel fearful and anxious (Hildenbrand et al., 2011).
1.2 Definition
1.2.1 Definition of parents
According to Oxford Dictionary, parents are a person’s father and mother (Oxford Living Dictionaries, 2019).
1.2.2 Definition of cancer
2
highly abnormal cells that can separate and spread to different parts of the body, and further inoculating them (Primrose et al. 2004).
1.2.3 Definition of child
A child refers to a young human who is below the age of puberty or below the legal age of majority (Oxford Living Dictionaries, 2019). The convention on the right of the child defines that children are anyone under 18 years old (U.N., 1989). However, according to Kaatsch (2010) article, “Childhood cancer” is usually used to refer to a child who has cancer under the age of 15, including 15 years old. Therefor, we choose the age of 15 and younger.
1.3 The nurse’s role
Nurses have four basic responsibilities: promoting health, preventing disease, relieving pain, and maintaining health (ICN, 2010).
It’s important for nurses to provide information to parents (Gibbins et al., 2012). Therefore, nurses should provide more medical information for parents and use medical skills to relieve their helplessness. Nurses should listen and pay attention to the emotional changes of parents and children actively and understand their feelings as much as possible (Mu et al., 2015). Children and their parents need to stay in hospital for a long time and their living environment will be change greatly. Nurses can create a good environment for children and their parents, help them adapt to unfamiliar hospital conditions and bring hope and courage to them (Mu et al., 2015). It is important to help parents and sick children build confidence. Nurses can encourage children and their parents to have a positive attitude and plan for the future after the disease stabilizes (Mu et al., 2015).
1.4 Nursing theory
3
Having a child with serious illness is a process of adaptation for parents. Parents will be confronted with lots of stimulation, such as anxiety, being unfamiliar with the disease, and changed living environment, Therefore, parents need to take positive measures to overcome those difficulties and adapt to changes. Roy’s adaptation theory can help parents accept the stimulation, improve their adaptation ability and reduce their stress.
1.5 Early reviews
In Gibbin et al (2012) review, it described the experience of parents whose child with cancer from different cultural backgrounds. The results showed that Chinese parents tended to take a fatalistic approach to that, Caucasian parents focused on keeping normal and talked with their children about their illness honestly, European and American mothers tended to compromise and negotiate with medical teams, while Latino mothers tended to follow medical advises and treatment plans. Jones et al. (2010) investigated the effects and stress of childhood cancer on fathers, which indicated that fathers experience unique stressors. They needed to take more financial responsibilities and take care of other family members. Clarke et al. (2009) review discussed gender differences in the psychosocial experiences of parents who had child with cancer, and the results showed that mothers often assumed the role of primary care provider and fathers provided more health care funding. Mothers had higher stress levels than fathers and sought social support more frequently.
1.6 Problem statement
Most previous studies focused on the experiences of cancer patients while few studies discussed the experiences of their parents. From early reviews, the articles they adopted were too early and were not able to provide the latest information for us. The literature in our study was from nearly the late ten years. At the same time, the authors found that some early reviews pay more attention to the differences in the gender of the parents, but the authors’ article didn’t care about it. The article focused on the experience of both parents. Childhood cancer was one of the most challenging diseases to their parents. With the increasing incidence of childhood cancer, the role of parents became more and more important. Emphasizing the parent's experience not only helps to relieve parent's stress and help parents adapt to their child’s illness, but also helps provide better care to child with cancer.
1.7 Aim and specific question
The aim of the literature review is to describe parents’ experience of having a child with cancer.
4
2. Method
2.1 Design
A descriptive literature review was used (Polit & Beck,2017) ．
2.2 Search strategy
Articles were found in two databases: PubMed and Cinahl.
The search terms used were “parents”, “child”, “neoplasms”, “cancer”, and “experience”. The Boolean term “AND” was used to combine these search terms (Polit &Beck, 2017). The search terms were used in different combinations, see table 1.
In PubMed, the following limits were set: Publication date 2009-2019, English. In Cinahl, the following limits were set: Publication date 2009-2019, English.
Table 1. Outcomes of database searches
Database and search Date
5 Medline Via Pubmed 2019.04.12 English 2009-2019 “parents”[MeSH]AND “child”[MeSH]AND”ne oplasms”[MeSH] AND experience 280 23 Cinahl 2019.04.12 English 2009-2019 “parents”[AB Abstract] AND “child” [AB Abstract]AND “cancer”[AB Abstract] AND “experience”[AB Abstract] 313 9 Total: 32
2.3. Selection criteria
The exclusion criteria:
①Scientific articles were quantitative articles or other literature reviews.
②The age of child older than 15 years old. The age of parent under 19 years old. ③Articles didn’t mention parents’ experience.
④The child was not diagnosed with cancer. The inclusion criteria:
①Articles related to the aim of review (that was, parents’ experience of having a child with cancer).
②Scientific articles were qualitative articles.
③The age of child under 15 years old (including 15 years old). The age of parents older than 19 years old.
④The child was diagnosed with cancer.
2.4 Selection process
6 Fig1. The selection process of articles.
2.5. Data analysis
According to the aim and research questions, the authors read the articles carefully and marked the selected articles with the letter code (A-J) (Lommi et al., 2015). Used matrices could help summarize the content of the articles (Polit & Beck, 2017). When read the results section of those articles, the results were listed in appendix2 and numbered. All results were compared, the similarities and differences were classified. The results were divided into 4 main topics and recorded in the Appendix3.
Record PubMed (n=280 )
Record Cinahl ( n=313)
Read title and after duplicates removed
( n=75)
Records excluded (n=518)
- Irrelevant to the present study’s aim (n=486) - Literature review(n=22) - Duplicates articles(n=10)
Read abstract ( n=32)
Full-text articles assessed for eligibility (n=10) Records excluded (n=43) - Quantitative articles（n=22） - No parents’ experience (n=21) Records excluded (n=22)
7
Appendix1 summarized the author, publication year, title, design and approach, sample, data collection method and method of data analysis. Appendix2 summarized the author, aim and results of the articles. Appendix3 summarized four categories and 11 sub-categories.
2.6. Ethical considerations
Every article was read objectively, independent of the author’s personal views and attitude. The results of the studies would not change according to author’s opinion. The degree program would not be copied.
3. Results
The articles were based on 10 qualitative articles. These 10 articles were all about parents’ experience of having a child with cancer. The themes and sub-themes of the results were presented in Table 2. Four themes were summarized as parents’ experience of having a child with cancer: 1) Parents’ loss and the turmoil; 2) Benefit finding; 3) Adjustment and different ways of adaptation; 4) Social support.
Table 2 The themes and sub-themes of the results
Themes Sub-themes
Parents’ loss and the turmoil Emotion distress Lost the previous life Family function imbalanced Benefit finding
Love children more
Closer relationship in family Adjustment and different ways of
adaptation Negative coping Being hopeful Taking control Social support Family members Health workers Social members
3.1 Parents’ loss and the turmoil
3.1.1 Emotion distress
8
they meet in the treatment, and didn’t sure whether their child would survive (Hill et al., 2009). The unpredictability of the future and uncertainty during the treatment made parents more anxious (Hamama-Raz et al., 2012; Nikfarid et al., 2017).
As for childhood cancer, many parents described that they felt guilty (Taleghani et al., 2012). On the one hand, they thought it was a revenge for their past evils (Taleghani et al., 2012). On the other hand, they couldn’t do anything to protect their child, which made them feel helpless (Hamama-Raz et al., 2012; Taleghani et al., 2012).
During the treatment, when parents saw the pain of their child, they mentioned that they felt angry and upset (Mariyana et al., 2018). They were overwhelmed and had little hope that their child would survive (Angstrom-Brannstrom et al., 2010). Especially in cancer wards, parents witnessed other child who died after years of treatment, began to lose hope and thought that their child would die at any time. Parents felt trapped in cancer and expected to be liberated from it (Taleghani et al., 2012).
3.1.2 Lost the previous life
After a child was diagnosed with cancer, parents described that they had lost the normal life, and that the quality of their life declined significantly (Khoury et al., 2013; Taleghani et al., 2012). Before the child got illness, parents could do what they wanted to do, like traveling and visiting relatives and friends. However, after their child got illness, they didn't have the chance because their time must be adapted to the child's treatment and they needed stay at home and hospital for a long time (Angstrom-Brannstrom et al., 2010; Kim et al., 2017). Social isolation was another consequence of parents taking care of a child with cancer. Parents needed to spend more time to accompany and take care of their child, so most parents couldn't go out to meet their friends (Taleghani et al., 2012). As children's immune system was too weak, some people even couldn't invite friends to their homes and didn't have time to interact with others (Kim et al., 2017).
Many parents reported that repeated hospitalizations and the need for parents to stay with their children for long periods of time not only affected the way they carry out their family responsibilities, but also had a negative impact on their work (Nikfarid et al., 2017; Kim et al., 2017). Some mothers even quitted their jobs in order to concentrate on caring for their hospitalized child while fathers changed their jobs to face enormous financial pressure (Khoury et al., 2013; Kim et al., 2017).
3.1.3 Family function imbalanced
9
Illness exacerbated their stress, the communication between parents was reduced, as if two strangers were living together. Sometimes they argued and shouted at each other. It made couple relationship become more tense and anxious (Doumit et al., 2017).
Parents described that they didn't have time to accompany other family members, which made them feel sad and guilty (Kim et al., 2017). It’s specially about sibling competition (Doumit et al., 2017). Parents needed to accompany sick child in the hospital, so other children had to stay at home alone and received less attention, which made them feel uneasy and were jealous of sick child (Khoury et al., 2013; Shortman et al., 2013).
3.2 Benefit finding
3.2.1 Love children more
During the treatment, parents tried harder to take care of their children. They described that they could answer their child's questions frankly and explained them in a way that their child could understand (Angstrom-Brannstrom et al., 2010). Parents tried to make fresh and healthy food for their child every day, which could bring benefits to their body (Kim et al., 2017). During the treatment, the child couldn’t go to school. Parents tried to entertain them with activities, such as crafts, role-playing and sports, and they became child's playmates (Kim et al., 2017). Pain was the most common symptom in children with cancer. In order to control pain, mother made much effort, such as taking medicines prescribed by doctors, using Eucalyptus oil, or massaging to alleviate pain (Mariyana et al., 2018). Parents also tried to divert their child's attention. Child could do something they like. For example, they could watch TV and read stories to encourage children to talk and tell jokes (Mariyana et al., 2018). Parents encouraged their children to fight against pain and supported them when they felt pain (Mariyana et al., 2018). Parents pleased their child, did whatever they want to do and satisfied child's needs, hoping that the pain could be alleviated and their children would be happy during the rest of the time (Mariyana et al., 2018).
3.2.2 Closer relationship in family
10
parents, gave them emotional support and a chance to rest (Angstrom-Brannstrom et al., 2010).
3.3 Adjustment and different ways of adaptation
3.3.1 Negative coping
Parents described that they sometimes became negative and depressed during the treatment. When they saw their child suffered from pain, they felt angry and often cried. They really wanted to have a place to share their inner anxiety, but they didn't have (Hamama-Raz et al., 2012). Some parents compared their lives with healthy children, and thought that their child experienced worse things, which would lead to feelings of inner imbalance and make them become more angry and despaired (Nikfarid et al., 2017). Parents often felt tired. They wanted to escape from the child care responsibilities and to find a place to have a rest, rather than taking care of the sick child all day (Hamama-Raz et al., 2012).
3.3.2 Being hopeful
Parents described that they should remain hopeful about their child's cancer. Some parents regarded their child's disease as god's will. Some parents regarded the disease as a punishment. If they denied to cure the disease of their child, they would receive further punishment (Nikfarid et al., 2017). But most parents saw faith in god as a positive response (Doumit et al., 2017). They thought that religion could bring them hope, so they often prayed for that (Taleghani et al., 2012). Parents adopted positive coping strategies to deal with their child's illnesses, encouraged the child to keep optimistic and avoid negative thoughts (Nikfarid et al., 2017).
3.3.3 Taking control
11
3.4 Social support
3.4.1 Family members
Parents thought family support was a weapon in the fight against cancer (Doumit et al., 2017). During difficult periods, parents received a great deal of support from the family (Kim et al., 2017). The grandparents brought food and helped take care of the healthy children (Kim et al., 2017). Siblings tried to take care of the sick child and made him laugh (Kim et al., 2017). Sometimes, other children would throw their arms around parents’ shoulders and comfort them (Shortman et al., 2013). After a child was diagnosed with cancer, the mother often sought support from her husband (Nikfarid et al., 2017). However, fathers would mask their fears and emotions to reduce their partners' worries (Hill et al., 2009). They played an active role in trying to encourage mothers to take time off from the experience and to become stronger (Hill et al., 2009). Parents said that they were not alone in this battle, and the strong support boosted their morale and helped them do better (Doumit et al., 2017).
3.4.2 Health workers
Parents described that health workers could provide a great sense of security to them. Medical centers were places where parents could feel safe (Hamama-Raz et al., 2012). There were different leaflets and booklets, parents could ask professionals many helpful questions (Shortman et al., 2013). They got hope and direction (Hamama-Raz et al., 2012). In the long process of treatment, health workers would sometimes accompany the child to play, so that parents could get a short relax. Health workers also concerned about the parents (Angstrom-Brannstrom et al., 2010). They communicated with parents in a friendly way, tried to reduced parents' fear and provided psychological support to parents (Doumit et al., 2017).
3.4.3 Social members
Social members brought comfort to the parents. For parents, they described that shared difficult situations with friends and got their support could make their life easier (Angstrom-Brannstrom et al., 2010). Other parents with similar diagnoses in child could also offer support. They could talk to each other anything about their child's illness, share bad or good experience, and get emotional support from each other (Angstrom-Brannstrom et al., 2010; Doumit et al., 2017).
12
teachers kept in touch with parents and children. They often visited the sick child at home or hospital, encouraged the child and his or her parents (Angstrom-Brannstrom et al., 2010).
3.5 The chosen articles information
These ten articles were from seven countries: Sweden (Angstrom-Brannstrom et al., 2010), Lebanon (Doumit et al., 2017; Khoury et al.,2013), Israel (Hamama-Raz et al.,2012), England (Hill et al., 2009; Shortman et al., 2013), Korean (Kim et al., 2017), Indonesia (Mariyana et al., 2018), Iran (Nikfarid et al., 2017; Taleghani et al., 2012).
In six of the articles, the participants were fathers and mothers (Angstrom-Brannstrom et al., 2010; Doumit et al., 2017; Hamama-Raz et al., 2012; Khoury et al.,2013; Mariyana et al., 2018; Taleghani et al., 2012). In three of the articles, the participants were mothers (Kim et al., 2017; Shortman et al., 2013; Nikfarid et al., 2017). In the remaining article, the participants were fathers (Hill et al., 2009).
In five of the articles, in-depth interviews with the parents were adopted (Hill et al., 2009; Khoury et al.,2013; Mariyana et al., 2018; Nikfarid et al., 2017; Taleghani et al., 2012).In two of the articles, an interview guide with questions for semi-structured interviews was adopted (Hamama-Raz et al., 2012; Shortman et al., 2013). One article adopted Group sessions (Kim et al., 2017). This was done in the form of sharing and discussing photos with group members. And the two other articles didn’t mention which type of interviews they have adopted (Angstrom-Brannstrom et al., 2010; Doumit et al., 2017).
In all of the chosen articles, the interviews were recorded and transcribed word to word (Angstrom-Brannstrom et al., 2010; Doumit et al., 2017; Hamama-Raz et al., 2012; Hill et al., 2009; Khoury et al.,2013; Kim et al., 2017; Mariyana et al., 2018; Nikfarid et al., 2017; Shortman et al., 2013; Taleghani et al., 2012).
13
4. Discussion
4.1 Main results
This review focused on the parents’ experience of having a child with cancer. Four themes were derived from the findings: 1) Parents’ loss and the turmoil; 2) Benefit finding; 3) Adjustment and different ways of adaptation; 4) Social support. When a child was diagnosed with cancer, parents’ life became chaotic. They experienced emotion distress, lost their previous life and their family function became imbalanced. However, during the treatment, they also found that they love their child more and their family relationship became closer. Parents had to adjust themselves to deal with the cancer, so they adopted different ways. At the same time, parents received a great deal of support, such as support from family members, from health workers and from other social members.
4.2 Results discussion
4.2.1 Parents' loss and the turmoil
After their child was diagnosed with cancer, parents would experience the emotion distress. Their life and family function would also change. In this review, the findings showed that when parents heard that their child was diagnosed with cancer, shock, uncertainty, guilty and fear would always haunt them (Khoury et al., 2013; Doumit et al., 2017; Nikfarid et al., 2017). This finding was similar with the Gibbin et al. (2012) study. In Gibbin et al. (2012) article, it reported that parents were shocked by the diagnosis, anxious about the uncertainty, feared of the future and guilty of not having discovered the illness early enough. Therefore, nurses should pay attention to parents’ emotion and try to listen and accept parents’ feelings like surprise, anger (Mu et al., 2015). In Stewart et al. (2012) study, it reported that many parents were disoriented by the lack of knowledge. So providing medical information and expertise skills to increase the parents’ trust were very important (Mu et al., 2015).
14
would help them take care of sick child and family members better (Kars et al., 2008; Gibbin et al., 2012).
This review found that the family function would become imbalanced during treatment (Khoury et al., 2013; Doumit et al., 2017). This finding was similar with the study of Mu et al. (2015). During the treatment, the function of the family was changed. The mother mainly focused on caring for the child with cancer, while the father had to pay for the treatment cost (Mu et al., 2015). As siblings believed that their parents payed more attention to the sick child, their relationship with their parents became worse. Therefore, parents should try their best to maintain family function stable and should not ignore other family members.
In Roy’s adaptation model, stimulus was any factor that causes the response (Roy & Andrews, 1999). When parents knew their child was diagnosed with caner, their emotion distress was a stimulus. Parents became anxious. In order to take care of the sick child, they lost their normal life and their family and marriage relationship even became unstable. So, nurses could pay attention to parents’ psychological and help them to adjust themselves to cope with the situation.
4.2.2 Benefit finding
However, when a child was diagnosed with cancer, there were not only negative aspects, but also positive changes. In this review, the findings showed that parents tried every means to take care of their sick child (Angstrom-Brannstrom et al., 2010). This finding was similar with the study of Mu et al. (2015), which reported that parents would expend energy in physical and emotional during their child's treatment, though, they still tried their best to accompany and support their child. Nurses could play an important role in taking care of sick children better. In terms of diet, nurses could guide parents to choose the food which was suitable and beneficial to the sick child, so as to enhance the child's immunity (Kim et al., 2017). On the other hand, nurses could instruct parents on how to take the medicine correctly. It could help the child feel better especially when the child was in pain or other physical discomfort (Mu et al., 2015).
In addition, this review found that family members became closer. This finding was similar with the Benedetti et al. (2014) study. Having a supportive family team made parents feel safer and more protected, which had a positive impact on the process (Benedetti et al., 2014). It not only reduced the pressure of parents, but also helped them to take care of their child more efficiently.
15
looked up information to know about childhood cancer through consulted medical personnel. They tried their best to take good care of their child. Therefore, during the treatment, nurses could provide more professional advice to parents and guided them on how to take care of the child correctly.
4.2.3 Adjustment and different ways of adaptation
After a child was diagnosed with cancer, parents adopted different methods to adjust themselves to deal with the situation. This review showed that many parents would become upset (Nikfarid et al., 2017; Taleghani et al., 2012). This finding was similar with the Gibbin et al. (2012) study. It reported that parents often cried, especially mothers. They expressed their worries and sadness by crying (Hamama-Raz et al., 2012). In this review, it found that when parents saw the side effects of their child's treatment, they became angry and irritable (Taleghani et al., 2012). This finding was similar with the study of Gårdling et al. (2017). On the one hand, nurses should pay attention to parents' emotional changes, encourage parents and tell them successful cases to enhance their confidence. On the other hand, nurses could provide personalized medical information to increase parents' sense of security (Mu et al., 2015).
Although parents experienced sadness and helpless during the treatment, this review showed that most parents still maintained a positive attitude (Doumit et al., 2017; Taleghani et al., 2012; Nikfarid et al., 2017). This finding was similar to the study of Johns et al. (2009). According to Johns et al. (2009) study, it described that Latina mother think positive thinking and optimism were parts of the study intervention. It was of great significance to take advantage of existing resources to help parents and children cope with the disease together, take a positive attitude towards the treatment effect, and plan for the future life (Mu et al., 2015).
Parents often felt panic in that they did not know about their child’s illness. Therefore, they tried to gain more control to accept the reality (Hill et al., 2009; Taleghani et al., 2012). This finding was similar with the Gibbin et al. (2012). According to Gibbin et al. (2012), parents wanted to learn more knowledge about the disease through talking with medical professionals and the Internet. It was important to provide clear information for parents. So, in order to increase parents understanding, nurses could enhance parents’ sense of control by repeating medical information, providing written information, and answering questions patiently (Gibbin et al., 2012; Mu et al., 2015).
16
levels to adapt to the stimuli. In order to make an adaptive response, parents maintained a positive attitude and increased their sense of control by acquiring information to deal with the child cancer. As for ineffective response, parents often felt irritable and helpless. They expressed their feelings by crying and tried to escape the reality.
4.2.4 Social support
In this review, the findings showed that parents received a lot of support (Kim et al., 2017; Nikfarid et al., 2017). This finding was similar to the study of Gibbin et al. (2012). Parents received support from family members, health workers and other social members, which were very beneficial.
The findings showed that parents could receive support from family members (Kim et al., 2017). Mu et al. (2015) reported that family support enhanced family members’ resilience. Besides, family members could also help parents take care of siblings, reduce their stress and provide emotion support (Kim et al., 2017).
This review found that health workers provided a great sense of security to parents (Hamama-Raz et al., 2012). In the study of Gibbin et al. (2012), it reported that professionals provide more medical information to reduce parents’ anxious, pay attention to the psychological. It was important for nurses to pay attention to every parent and adapt care, according to parents’ need to provide support to them (Brody & Simmons, 2007).
In this review, the findings showed that parents of other sick children also provided some support (Doumit et al., 2017). This finding was similar to the study of Johns et al. (2009). Johns et al. (2009) reported that they often talked to other mothers with similar experiences and offered advice to each other. Providing a space for parents to talk about their experiences and helping parents normalize their experience were very helpful (Gibbin et al., 2012). Since child needed to stay at hospital for a long time, parents needed financial support, they had to continue working. But due to the long-term treatment time, parents' work was often limited and conflicted (Angstrom-Brannstrom et al., 2010; Gibbin et al., 2012). So workplace and health care policies could light parents’ burden by providing adequate assistance, leave and flexible working hours (Nicholas et al., 2009).
17
4.3 Methods discussion
This review had some strengths. Firstly, the authors selected all articles from PubMed and CINAHL, so the source of the articles were reliable. Secondly, when searching these articles, the authors used MeSH terms and AB Abstract. According to Polit &Beck (2017), it could narrow the search for articles and the articles which we searched would be more relevant to the aim and increase the credibility of the results. Thirdly, the authors chose articles published from 2009 to 2019, which were recent articles. Excluding articles that were produced over ten years, it ensured that the authors could get updated results. Fourthly, these selected articles were from seven countries, so the results had high credibility and could be used universally. Fifth, this was a descriptive review of the qualitative literature on parents’ experience of having a child with cancer. According to Polit & Beck (2017), the qualitative articles aimed to describe a person’s experience of something. So, it was very advantageous for all articles the authors selected were qualitative articles. Finally, when selecting these articles, the authors had clear and specific inclusion and exclusion criteria, which strengthened the plasticity of the study (Polit & Beck, 2017).
However, there were still several limitations. Firstly, the authors selected all articles from PubMed and CINAHL, which meant that the number of articles were limited. Secondly, the articles searched by authors were all from 2009 to 2019, which was relatively short. The authors couldn’t compare them with previous articles. Thirdly, the selected articles were all English and articles of other language were excluded, which meant that the results are limited.
4.4 Clinical implication for nursing
18
4.5 Suggestions for further research
The authors found that most of the selected articles involve only one interview. So, the authors suggest that a phased follow-up interview could be adopted. The authors also suggested that parents could document their experience of caring for their child by taking photos, recording and keeping diaries and blogs.
5. Conclusions
19
6. Reference
Alligood M.R. (2014). Nursing theorists and their work (8th ed.). St. Louis, Missouri: Elsevier Mosby.
Ångström-Brännström C., Engvall G., Mullaney T., Nilsson K., Wickart-Johansson G., Svärd A-M., Nyholm T., Lindh J. & Lindh V. (2015). Children Undergoing Radiotherapy: Swedish Parents’ Experiences and Suggestions for Improvement. PLoS ONE, 10(10): e0141086. DOI: 10.1371/journal.pone.0141086.
Ångström-Brännström C., Norberg A., Strandberg G., Soderberg A. & Dahlqvis V. (2010). Parents’ Experiences of What Comforts Them When Their Child is Suffering From Cancer.
Journal of Pediatric Oncology Nursing, 27(5): 266–275.
DOI：10.1177/1043454210364623.
Arora R.S., Eden T.O., Kapoor G. (2009). Epidemiology of childhood cancer in india. Indian
Journal of Cancer, 46(4): 264–273. DOI:10.4103/0019-509X.55546.
Benedetti G.M., Garanhani M.L. & Sales C.A. (2014). The treatment of childhood cancer: unveiling the experience of parents. Rev Lat Am Enfermagem, 22(3): 425-431. DOI: 10.1590/0104-1169.3264.2433.
Brody A.C., & Simmons L.A. (2007). Family resiliency during childhood cancer: The father’s perspective. Journal of Pediatric Oncology Nursing, 24: 152-165.
DOI: 10.1177/1043454206298844.
Clarke N.E. , Mccarthy M.C. , Downie P., Ashley D.M. & Anderson V.A. (2009). Gender differences in the psychosocial experience of parents of children with cancer: a review of the literature. Psychooncology, 18(9): 907-915. DOI: 10.1002/pon.1515.
20
Doumit M.A.A. & Khoury M.N. (2017). Facilitating and hindering factors for coping with the experience of having a child with cancer: a lebanese perspective. Journal of Psychosocial
Oncology, 35(3):346–361. DOI: 10.1080/07347332.2017.1283654.
Gårdling J., Törnqvist E., Edwinson M.M. & Hallström I. (2017). Parents' lived experiences during their children's radiotherapy. Journal of Pediatric Oncology Nursing, 34(2):140–147. DOI: 1043454216646540.
Gibbins J., Steinhardt K. & Beinart H. (2012). A Systematic Review of Qualitative Studies Exploring the Experience of Parents Whose Child Is Diagnosed and Treated for Cancer.
Journal of Pediatric Oncology Nursing, 29(5):253–271. DOI: 10.1177/ 1043454212452791.
Hamama-Raz Y., Rot I. & Buchbinder E. (2012). The coping experience of parents of a child with retinoblastoma-malignant eye cancer. Journal of Psychosocial Oncology, 30(1): 21-40. DOI：10.1080/07347332.2011.633977.
Hildenbrand A.K., Clawson K.J., Alderfer M.A. & Marsac M.L. (2011). Coping with pediatric cancer: strategies employed by children and their parents to manage cancer-related stressors during treatment. Journal of Pediatric Oncology Nursing, 28(6):344–54. DOI: 10.1177/1043454211430823.
Hill K., Higgins A., Dempster M. & Mccarthy A. (2009). Fathers' views and understanding of their roles in families with a child with acute lymphoblastic leukaemia: an interpretative phenomenological analysis. Journal of Health Psychosocial, 14(8):1268-1280. DOI ： 10.1177/1359105309342291.
International council of nurses (ICN). (2012). The ICN Code of Ethics for Nurses. (Retrieved from http://www.icn.ch/images/stories/documents/about/icncode_english.pdf, accessed 07.05.20).
21
American mothers of children with cancer. Journal of Pediatric Oncology Nursing, 26: 167– 175. DOI:10.1177/1043454209334416.
Jones B.L., Pelletier W., Decker C., Barczyk A. & Dungan S.S. (2010). Fathers of Children With Cancer: A Descriptive Synthesis of the Literature. Social Work in Health Care, 49(5): 458–493. DOI: 10.1080/00981380903539723.
Kaatsch P. (2010). Epidemiology of childhood cancer. Cancer Treatment Reviews, 36(4): 277-285. DOI:10.1016/j.ctrv.2010.02.003.
Kars M.C., Duijnstee M.S.H., Pool A., Van Delden J.J.M. & Grypdonck M.H.F. (2008). Being there: Parenting the child with acute lymphoblastic leukaemia. Journal of Clinical
Nursing, 17: 1553-1562. DOI:10.1111/j.1365 2702.2007.02235.x.
Khoury M.N., Huijer H.A. & Doumit M.A. (2013). Lebanese parents' experiences with a child with cancer. European Journal of Oncology Nursing,17(1):16-21. DOI: 10.1016/j.ejon.2012.02.005.
Kim M. A., Yi J., Sang J., Kim S. H., & Heo I.Y. (2017). Experiences of korean mothers of children with cancer: A Photovoice study. Journal of Psychosocial Oncology, 35(2):128– 147. DOI: 10.1080/07347332.2016.1263265.
Lam C.G., Howard S.C., Bouffet E. & Pritchard-Jones K. (2019). Science and health for all children with cancer. Science, 363(6432):1182–1186. DOI:10.1126/science.aaw4892.
Lommi M., Matarese M., Alvaro R., Piredda M. & De Marinis M.G. (2015). The experiences of self-care in community-dwelling older people: a meta-synthesis. International Journal of
Nursing Studies, 52(12):1854-1867. DOI:10.1016/j.ijnurstu.2015.06.012
22
Mu P.F., Lee M.Y., Sheng C.C., Tung P.C., Huang L.Y. & Chen Y.W. (2015). The experiences of family members in the year following the diagnosis of a child or adolescent with cancer: a qualitative systematic review. JBI Database of Systematic Reviews &
Implementation Reports, 13(5): 293-329. DOI: 10.11124/jbisrir-2015-1698.
Nicholas D.B., Gearing R.E., McNeill T., Fung K., Lucchetta S. & Selkirk E.K. (2009). Experiences and resistance strategies utilized by fathers of children with cancer. Social Work
in Health Care, 48: 260–275. DOI: 10.1080/00981380802591734.
Nikfarid L., Rassouli M., Borimnejad L., & Alavimajd H. (2017). Experience of chronic sorrow in mothers of children with cancer: a phenomenological study. European Journal of
Oncology Nursing, 28: 98–106. DOI：10.1016/j.ejon.2017.02.003.
Oxford Living Dictionaries. (2019). Parents. ( Retrieved from :
https://en.oxforddictionaries.com/definition/child/ accessed 15.08.19).
Oxford Living Dictionaries. (2019). Child. ( Retrieved from :
https://en.oxforddictionaries.com/definition/parents/ accessed 15.08.19).
Polit, D.F. & Beck, C.T. (2017). Nursing research. Generation and Assessing Evidence for
Nursing Practice (10th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
Primrose S. B. & Twyman R. (2004). Genomics: applications in human biology. Elsevier
SAS, 47(04): 207–208. DOI:10.1016/S0003-3995(04)00039-5.
Roy C. (1970). Adaptation: A conceptual framework for nursing. Nursing Outlook, 18: 42-45.
23
Roy C., & Andrews H. A. (1999). The Roy adaptation model (2nd ed.). Stamford, (CT): Appleton & Lange.
Shortman R.I., Beringer A., Penn A., Malson H., Lowis S.P. & Sharples P.M. (2013). The experience of mothers caring for a child with a brain tumour. Child Care Health &
Development, 39(5): 743-749. DOI：10.1111/cch.12005.
Sridharan G. (2014). The Concept of Cancer Stem Cell in Oral Squamous Cell Carcinoma.
Journal of Tumor, 2(10): 257–260. DOI:10.6051/j.issn.1819-6187.2014.02.58.
Stewart J.L., Pyke-Grimm K.A & Kelly K.P. (2012). Making the right decision for my child with cancer: the parental imperative. Cancer Nursing, 35(6):419-428. DOI:10.1097/NCC.0b013e3182431071.
Stiller C. (2007). Childhood cancer in Britain. Archives of Disease in Childhood, 92(7): 657. DOI:10.1007/BF00373278.
Taleghani F., Fathizadeh N. & Naseri N. (2012). The lived experiences of parents of children diagnosed with cancer in iran. European Journal of Cancer Care, 21(3): 340-348. DOI： 10.1111/j.1365-2354.2011.01307.x.
UICC. (2012). Annual report 2012 [EB/OL]. (Retrieved from: http:// www.vicc.org/annual-report-2012/. accessed 15.08.19).
UN General Assembly. (1989). Convention on the right of child. (Retrieved from :
https://www.refworld.org/docid/3ae6b38f0.html/ accessed 15.08.19).
Ward Z.J., Yeh J.M., Bhakta N., Frazier AL. & Atun R. (2019). Estimating the total incidence of global childhood cancer: a simulation-based analysis. The Lancet Oncology, 20(4):483– 493. DOI:https://doi.org/10.1016/S1470-2045(18)30909-4.
Ward Z.J., Yeh J.M., Bhakta N., Frazier A.L., Girardi F. & Atun R. (2019). Global childhood cancer survival estimates and priority-setting: a simulation-based analysis. The Lancet
24
Zheng R.S., Peng X.X., Zeng H.M., Zhang S.W., Chen T.H., Wang H.M. & Chen W.Q. (2015). Incidence, mortality and survival of childhood cancer in china during 2000–2010 period: a population-based study. Cancer Letters, 363(2), 176-180.
APPENDIX 1
Overview of selected articles
Authors + Year of publication + Country
Title Design (possible
approach)
Participants Data collection method(s) Data analysis method(s) Angstrom-Brannstrom C., Norberg A., Strandberg G., Soderberg A., Dahlqvist V. + 2010 + Sweden. Parents’ experiences of what comforts them when their child is suffering from cancer. A descriptive design/ A qualitative approach. Number: 9 Age: Don’t mentioned. Gender: female (n = 8) and male (n = 1) Interviews. Length of interview: 60-90 minutes. The interview was recorded and verbatim recorded by the secretary. Qualitative content analysis (Graneheim & Lundman, 2004). A
Doumit M.A. A., Khoury M. N. + 2017+ Lebanon.
Facilitating and hindering factors for coping with the experience of having a child with cancer: a lebanese perspective. A descriptive design/ A qualitative approach. Number: 12
Age:Parents age from
24-48 years old(mean age of 36). Gender:female (n = 10) and male (n = 2) Interviews. Length of interview: 50-55 minutes. Use Arabic to collect data, all interviews were tape recorded and then transcribed verbatim.
Thematic analysis.
B
Hamama-Raz Y., Rot I., Buchbinder E. + 2012+ Israel. The Coping Experience of Parents of a Child with Retinoblastoma-Malignant Eye Cancer. A descriptive design/ A qualitative approach. Number: 24 Age: Parents age
ranged from 33-52 years old. (mean age of 40.82) Gender: female (n = 12) and male (n = 12) Semi-structured interview. Length of interview: 1-2.5 hours.
The interviews were conducted at the parents' home at a
Content analysis.
predetermined time and were recorded word for word. Hill K., Higgins A., Dempster M., Mccarthy A. + 2009+ England. Fathers’ views and understanding of their roles in families with a child with acute lymphoblastic leukaemia An explorative design/ A qualitative approach. Number: 5
Age: The participants
were aged between 31 to 42 years Old. Gender: female (n = 0) and male (n = 5). In-depth semi-structured Interviews. Length of interview: Between 1-2 hours. The interview took place at the hospital where the children were being treated. All the interviews were tape recorded and then verbatim recorded. Interpretative phenomenologi cal analysis (IPA). D Khoury M.N., Huijer A.S., Doumit M.A. A. + 2013 + Lebanon Lebanese parents’ experiences with a child with cancer. An explorative design/ A qualitative approach. Number: 12
Age:Parents age from
24-48 years old (mean age of 36). Gender: female (n = 10) and male (n = 2) In-depth semi-structured interviews. Length of interview: 50-55 minutes. Tapes recorded in Arabic and later translated into English. PI also recorded field observations. In each interview, PI invited the participants to share his/her views.
Hermeneutic analysis
(Diekelmann & Ironside,1998)
Kim M.A., Yi J., Sang J., Kim S.H., Heo I. + 2017 + Korean. Experiences of Korean mothers of children with cancer: A Photovoice study A descriptive design/ A qualitative approach. Number: 5 Age: Mothers age
ranged from 32-42 years old (mean age of 39). Gender: female (n = 5) and male (n = 0) Group sessions. Every week, participants take about 10 photos which related to the theme they
agreed,and choose two key photos to share with the group. During the weekly 1.5 hours group meeting, shared key photos and discuss the stories behind the photo.
Constant comparative method (Strauss & Corbin, 1990). F Mariyana R., Allenidekania A., Nurhaeni N. + 2018 + Indonesia Parents' Voice in Managing the Pain of Children with Cancer during Palliative Care. An explorative design/ A qualitative approach. Number: 8
Age: Parents age from
32-50 years old (mean age of 42). Gender: female (n = 7) and male (n = 1) In-depth semi-structured interview. Length of interview: 45-60 minutes. Using Sony voice recorder, transcribed verbatim. Colaizzi method. G Nikfarid L., Rassouli M., Borimnejad L., Alavimajd H. + 2017 + Iran. Experience of chronic sorrow in mothers of children with cancer: a phenomenologica l study. An explorative design/ A qualitative approach. Number: 8 Age:Parents age ranged from 24-48 years old. Gender: female (n = 8) and male (n = 0) In-depth semi-structured interviews. Length of interview: lasted between 35-60 minutes.
Each interview was listened to several times the same day and a few days later and transcribed. Shortman R.,
Beringer A., Penn A., Malson H., Lowis S., Sharples P. + 2013+ England. The experience of mothers caring for a child with a brain tumour. An descriptive design/ A qualitative approach. Number: 6 Age:Don’t mentioned. Gender: female (n = 6) and male (n = 0). Semi-structured interviews. Length of interview: lasted between 60-120 minutes. All the interviews were tape recorded and then verbatim recorded.
Using the iterative process, the whole data were grouped into themes, then divided into subcategories. I Taleghani F., Fathizadeh N., Naseri N. + 2012 + Iran. The lived experiences of parents of children diagnosed with cancer in Iran. An explorative design/ A qualitative approach. Number:15
Age:Parents age from
25-45 years old. Gender: female (n = 11) and male (n = 4) In-depth interviews. Length of interview: average 90 minutes. Listen to all interviews several times and record, then transcribed verbatim.
Interpretive phenomenolog y approach.
APPENDIX 2
Author(s) Aim Results
Angstrom-Brannstrom C., Norberg A., Strandberg G., Soderberg A., Dahlqvist V.
To describe parents’ narratives concerning what they find comforting when they have a child suffering from cancer.
A1: Physically and emotionally close between parents and sick child.
A2: Care children actively. A3: Hope.
A4: Nurses help parents felt secure. A5: Talk with other sick children parents. A6: Family members closer together. A7: Something they can’t do as they used to before.
A8: Diagnosis: small hope.
A9: School teachers try to support and help in various ways.
A10: Work mates and employers support.
A11: The kindness and thoughtfulness of friends. Doumit M.A. A., Khoury M. N. To gain an in-depth understanding of factors
facilitating and hindering coping methods of Lebanese parents with a child with cancer.
Hindering factors to coping: B1: Fear, hard.
B2: Couple’s relationship become nervous and anxious.
B3: Sibling rivalry.
Facilitating factors for coping: B4: Family support.
B5: Strong religious beliefs. B6: Talking with other parents.
Hamama-Raz Y., Rot I., Buchbinder E. This study investigates coping of parents whose children developed unilateral RB and were treated with enucleation.
C1: Before discovery, heavy suspicion, uncertainty.
C2: Anxious.
C3: Withdraw the responsibility of take care of the child.
C4: In medical center feel security. C5: Helpless.
Hill K., Higgins A., Dempster M., Mccarthy A.
The aim is interview fathers and review their roles in the family at different stages of their children's treatment.
D1: Uncertainty and lack of control.
D2: Taking control and deal with situation. D3: Help other family members accept the reality. D4: Useful supports from other fathers.
D5: Keep everything as normal as possible. D6: Father mask emotions to help mother become stronger.
Khoury M.N., Huijer A.S., Doumit M.A. To explore the experiences of Lebanese families living with a child with cancer.
E1: Shock of the diagnosis.
E2: Deterioration of quality of life. E3: Living with added burdens.
E4: Disease influence family and sibling dynamics.
E5: Living with uncertainty. Kim M.A., Yi J., Sang J., Kim S.H., Heo I. To provide a description of Korean mothers’
lives post diagnosis of their children with cancer.
F1: Don’t have time to relieve stress.
F2: Don’t have time to socialize with friends. F3: Can’t spend time with other family members F4: Can’t develop career.
F5: Prepare healthy food for children. F6: Being a playmate with children. F7: Family support.
Mariyana R., Allenidekania A., Nurhaeni N.
To know how the experiences of mothers managing their children's pain during palliative care following cancer diagnosis.
G1: Couldn’t know pain the child was feeling. G2: Mothers try to hide feelings when child is in pain.
G3: Fighting, anger, nagging, annoyance, and upset.
G4: Could not manage their child's pain at home. G5: Interventions to reduce their child's pain. G6: Distract their child attention from the pain. G7: Giving encouragement.
G8: Please their child. Nikfarid L., Rassouli M., Borimnejad L.,
Alavimajd H
To explore the lived experiences of chronic sorrow experienced in a group of Iranian mothers of children with cancer.
H1: Inability to perform other roles. H2: Returned to a somewhat normal life. H3: Being optimistic.
H4: Cried most of the time. H5: Uncertainty.
H6: Compare life with others. H7: Seeking support from husband. H8: Religious fear and hope. Shortman R., Beringer A., Penn A.,
Malson H., Lowis S., Sharples P.
To explore the impact of having a child with a brain tumour on the main
caregiver in the family; (2) to describe mothers’ experiences of coping with their child’s
illness, including personal barriers and strengths; (3) to identify causes of stress and sources of support to inform improvements in care delivery.
I1: Fear.
I2: Maintaining a positive outlook. I3: Familial support.
I4: Information from health care.
I5: Familial interactions were not always positive. I6: Siblings feeling jealous.
Taleghani F., Fathizadeh N., Naseri N. To describe the lived experiences of parents of children diagnosed with cancer in Iran.
J1: Guilty, lose hope.
J4: Loss of normalcy and routines of day-to-day life.
APPENDIX 3
Categories Sub-categories Study findings
Parents’ loss and the turmoil Emotion distress A8: Small hope.
C2: Anxious. C5: Helpless.
D1: Uncertainty (E5, H5) and lack of control. E1: Shock.
I1: Fear(B1).
G3: Fighting, anger, nagging, annoyance, and upset.
J1: Guilty, lose hope.
J6: Feeling trapped in the cancer.
Lost the previous life A7: Something they can’t do as they used to before.
J4: Loss of normalcy and routines of day-to-day life.
H1: Inability to perform other roles. E2: Deterioration of quality of life. J3: Social isolation.
E3: Living with added burdens. F1: Don’t have time to relieve stress.
F2: Don’t have time to socialize with friends. F3: Can’t spend time with other family members.
F4: Can’t develop career.
Family function imbalanced B2: Couple’s relationship become nervous and anxious.
E4: Disease influence family and sibling dynamics.
I5: Familial interactions were not always positive.
I6: Siblings feeling jealous.
Benefit finding Love children more A2: Care children actively.
G5: Interventions to reduce their child's pain. G6: Distract their child attention from the pain.
G7: Giving encouragement. G8: Please their child.
F5: Prepare healthy food for children. F6: Being a playmate with children.
Close relationship in family A1: Physically and emotionally close between parents and sick child.
A6: Family members closer together.
Adjustment and different ways of adaptation Negative coping C3: Withdraw the responsibility of take care of the child.
H4: Cried most of the time.
H6: Compare life with healthy children. J7: Don’t believe the effectiveness,
Being hopeful B5: Strong religious beliefs.
H8: Religious fear and hope. J2: Faith and religious belief A3: Hope.
I2: Maintaining a positive outlook.
Taking control D5: Keep everything as normal as possible.
H2: Returned to a somewhat normal life. J5: Accept the reality of the disease. (D3) D2: Taking control and deal with situation.
Social support Family members H7: Seeking support from husband.
B4: Family support. (F7) (I3)
D6: Father mask emotions to help mother become stronger.
Health workers A4: Nurses help parents felt secure.
B7: Communication style of health workers. C4: In medical center feel security.
I4: Information from health care.
Social members A5: Talk with other sick children parents. (B6)
D4: Useful supports from other fathers. A9: School teachers try to support and help in various ways.
