990806

research-article2021
HPQ0010.1177/1359105321990806Journal of Health PsychologyLuo et al.

Article

Journal of Health Psychology

Relationships between resilience

2022, Vol. 27(5) 1048­–1056
© The Author(s) 2021
Article reuse guidelines:
and quality of life in parents of sagepub.com/journals-permissions
DOI: 10.1177/1359105321990806
https://doi.org/10.1177/1359105321990806
children with cancer journals.sagepub.com/home/hpq

Y. H. Luo1 , W. H. C. Li1 , A. T. Cheung1 ,

L. L. K. Ho1, W. Xia1, X. L. He2, J. P. Zhang3
and J. O. K. Chung4

Abstract
A child suffering from cancer can be considerably stressful for parents, exerting a negative impact on their
psychological well-being and quality of life. This study explored the relationships between resilience and
quality of life in parents of children with cancer. We recruited 146 parents of children with cancer in two
tertiary hospitals in mainland China. The results revealed that greater parental resilience was associated
with better quality of life. It is essential to develop interventions that can enhance resilience for parents of
children with cancer, thereby improving their quality of life.

ClinicalTrials.gov ID: NCT03631485

Keywords
paediatric cancer, parents, quality of life, resilience

Introduction financial burdens and reorganisation of family

Cancer is a leading cause of death for children
(Steliarova-Foucher et al., 2017). An interna-
tional population-based registry study reported
that approximately 300,000 cases of cancer were
diagnosed among children aged 0–19 years each
year, and the worldwide incidence of childhood
cancer has increased (Steliarova-Foucher et al.,
2017). The diagnosis of cancer not only has dis-
tressing physical and psychological implications
for the children themselves but also causes con-
siderable stress for their parents (Li et al., 2010;
Shi et al., 2017). The period following a child’s
diagnosis of cancer is a critical time, during
which parents are confronted with a variety
of challenges, including the need to manage
intensive treatment regimes, uncertainty around
the disease, fear of cancer recurrence, possible
roles (Jenholt Nolbris et al., 2014; Tsimicalis
et al., 2013). During their children’s cancer expe-
rience, parents have reported that they felt drained
emotionally and physically, with up to 28% of
them suffering from depression (Van Warmerdam
et al., 2019), which compromises their ability to
cope with stressors and affects their health and
quality of life (Sultan et al., 2016).
1
University of Hong Kong, Hong Kong
2
People’s Hospital of Hunan Province, China
3
Central South University, China
4
Hong Kong Polytechnic University, Hong Kong
Corresponding author:
W. H. C. Li, School of Nursing, Li Ka Shing Faculty of
Medicine, University of Hong Kong, 21 Sassoon Road,
Pokfulam, Hong Kong SAR.
Email: william3@hku.hk
Luo et al. 1049
According to the World Health Organization,
quality of life is defined as an individual’s per-
ception of the status of their life, and is affected
by the individual’s physical and psychological
health, social relationships and relationships
with the surrounding environment (World
Health Organization, 2020). Previous studies
have compared the quality of life between par-
ents of children with and without cancer
(Modanloo et al., 2019; Quast et al., 2016). The
results showed that parents of children with
cancer reported lower quality of life than par-
ents of children without cancer (Modanloo
et al., 2019; Quast et al., 2016). It is therefore
important to determine the factors that can
affect the quality of life of adults whose chil-
dren are diagnosed with cancer.
Recent studies have revealed a strong rela-
tionship between quality of life and resilience
among both clinical and non-clinical popula-
tions (Lin et al., 2019; Temprado Albalat et al.,
2020). A previous study showed that resilience
could moderate the relationships between
symptom severity and quality of life among
patients with hypertension (Qiu et al., 2019).
Another study showed that patients with hidrad-
enitis suppurativa equipped with higher levels
of resilience reported fewer depressive symp-
toms and better quality of life than patients with
lower levels of resilience (Kirby et al., 2017).
Resilience has been defined as the ability to
move forward or stay unperturbed under stress
or adversity, and resilient qualities include per-
sonal virtues and strengths that can be culti-
vated and then be accessed under detrimental
conditions (Richardson, 2002). In the literature
on resilience, protective factors including active
coping, internal locus of control and strong
social support have been invoked to help
explain why some persons are more resilient
and adapt to stress or adversity better than oth-
ers; such factors of resilience may play a role in
improving a person’s quality of life (Lawford
and Eiser, 2001).
For parents of children with cancer, resil-
ience refers to the capacity to rebuild their life
and live normally after their children’s diagno-
sis. Measuring resilience may allow researchers
to develop a thorough understanding of how
parents respond to and cope with the stress of
their children’s cancer. Additionally, exploring
the correlation between resilience and quality of
life may guide the development of future inter-
ventions to improve parental well-being.
Nevertheless, there is a paucity of literature
examining the resilience of parents of children
with cancer (Rosenberg et al., 2013, 2014). Most
importantly, all of these studies were conducted
in Western countries, leaving room for studies
focused on these constructs to be conducted in
Eastern countries. Although resilience has been
linked to quality of life in previous research con-
ducted in the West (Temprado Albalat et al.,
2020), it is uncertain whether this relationship
can be applied to different cultural groups, such
as people living in Eastern countries. There is
evidence showing that culture has a significant
impact on the relationship between resilience
and quality of life (Skevington et al., 2020). A
review of the literature revealed that no study
has been conducted in the Chinese context to
explore the relationships between resilience and
quality of life among parents of children with
cancer despite a thorough understanding of such
relationship is an essential prerequisite for
designing appropriate psychological interven-
tions to build parents’ resilience, consequently
enhance their quality of life. According to a
Chinese population-based study (Zheng et al.,
2015), the incidence of childhood cancer in
China was 87.1 per million and was increasing
at a rate of 2.8% per year. The increasing inci-
dence in Chinese children means that more
Chinese parents will need to face the fact of their
children’s diagnosis with cancer and the pres-
sure that comes with it. One study in South
China reported that up to 32.97% of parents with
children undergoing cancer treatment suffered
from severe posttraumatic stress symptoms (Shi
et al., 2017). It is essential to further understand
how Chinese parents respond to the stress of
their children’s cancer and how the stress influ-
ences parental psychological and physical well-
being. Accordingly, this study explored the
relationships between resilience and quality of
life for Chinese parents of children with cancer
1050 Journal of Health Psychology 27(5)
and examined whether resilience was a factor
associated with parental quality of life when
controlling for other possible effects of demo-
graphic and clinical characteristics.
Methods
Design and sample
A cross-sectional study was conducted in the
paediatric oncology wards of two tertiary hos-
pitals in mainland China. The study period,
including recruitment and data collection, was
from August to November 2018.
Parents of children (0–19 years old) with can-
cer were eligible for this study if they could
speak Mandarin and read Chinese. Either fathers
or mothers who were the primary caregivers of
children in hospital were invited to participate.
We excluded parents with physical disabilities,
mental illnesses, or cognitive and learning prob-
lems identified in their medical records. A trained
researcher explained the purpose and nature of
the study to eligible parents in the wards. Self-
report questionnaires were distributed to parents
after obtaining their informed consent.
The sample size was calculated using
G*Power 3.1 (Faul et al., 2007). According to a
recent study (Liu et al., 2019), resilience was sig-
nificantly correlated with the quality of life in
hierarchical regression, with an increase of R2 by
0.02 and an effect size of 0.06. To achieve a pre-
dictive power of 0.80 with an alpha of 0.05 in a
hierarchical regression model with no more than
11 predictors, the necessary sample size was cal-
culated to be at least 133 participants. A total of
168 parents of children with cancer were identi-
fied during the study period. Of these, 11 parents
refused to participate because of busy schedules
and four showed no interest in joining. We subse-
quently received seven largely incomplete ques-
tionnaires. Thus, 146 questionnaires were finally
used in data analysis.
Instruments
Connor-Davidson resilience scale (CD-RISC). The
CD-RISC is a self-rating scale designed by
Connor and Davidson (2003). The Chinese ver-
sion was translated and tested by Yu and Zhang
(2007), displaying good reliability and satisfac-
tory validity. It consists of 25 items and utilises
a 5-point Likert scale. The total score ranges
from 0 to 100, with higher scores reflecting
higher levels of resilience. It has been widely
used in clinical practice and treatment-outcome
research due to good validity and reliability
(Kim et al., 2019). The Cronbach’s α of the
scale in this study was .905.
Short form of the 6-dimension health survey (SF-
6D).  The SF-6D, first developed by Brazier
(2002), was derived from the SF-36 Health Sur-
vey. Hong Kong-based researchers subsequently
translated it into Chinese and produced a scoring
algorithm (McGhee et al., 2011). The six dimen-
sions of health in this scale assess physical func-
tioning, role limitations, social functioning,
pain, mental health and vitality. The total score
is calculated based on the scoring algorithm,
ranging from 0.32 for the worst possible health
state to one for full health. The SF-6D has been
proved reliable and valid in Chinese populations
(Lam et al., 2008). The Cronbach’s α of the
scale in this study was 0.705.
Data collection procedures
The characteristics of the parents and their chil-
dren were recorded in a demographic informa-
tion sheet. For the parents, sex, age, marital
status, educational attainment and family
monthly income were collected. For their chil-
dren, the parents reported sex, age, type of can-
cer, type of treatment and time since diagnosis.
All participants (parents) were then asked to
complete the Chinese versions of the CD-RISC
and SF-6D.
This study was approved by the Institutional
Review Board of the University of Hong Kong
and Hospital Authority of Hong Kong West
Cluster (UW 18-371). Written consent was
obtained from the parents after they were told the
purpose of the study. They were given the option
to participate in or withdraw from the study.
Luo et al. 1051

Data analyses Table 1.  Characteristics of parents and children.

Statistical analyses were conducted with IBM Characteristics Frequency %

SPSS Statistics 25.0 (IBM Corporation 2017, Gender
Armonk, NY, USA). Descriptive statistics were  Female 89 61.0
used to calculate the frequency and percentage  Male 57 39.0
for the categorical variables and the mean and Marital status
standard deviation (SD) for the continuous vari-  Married 137 93.8
ables. The internal consistency of each scale  Divorced 9 6.2
used in this study was determined by calculat- Educational attainment
ing the Cronbach’s α. The Pearson correlation   Primary school 24 16.4
coefficient was used to detect the relationships   High school 100 68.5
between resilience, quality of life, parental  College 22 15.1
demographic characteristics and children’s Income (¥, CNY)
clinical characteristics. Based on the results of   <3000 89 61.0
the correlational analyses, hierarchical regres-  3000–5000 33 22.6
sion analysis was used to explore whether resil-   >5000 12 8.2
ience, parental demographic characteristics and  Missing 12 8.2
children’s clinical characteristics were associ- Children’s gender
ated with quality of life.  Female 68 46.6
 Male 78 53.4
Type of cancer
Data sharing statements   Hematology tumor 104 71.2
  Solid tumor 42 28.8
The data that support the findings of this study
Type of treatment
are openly available in Figshare.   Single therapy 128 87.7
  Multiple therapies 18 12.3
Time since diagnosis (month)
Results
 0–6 88 60.3
The parental demographic characteristics and  7–12 36 24.7
children’s clinical characteristics are shown in   >12 22 15.1
Table 1. Approximately 60% of the parents
  Mean SD
were mothers, and the majority of the parents
were married. The mean (SD) age of the parents Parents’ age in years 33.77 5.59
was 33.77 (5.59) years. The majority of chil- Children’s age in years 6.20 3.76
dren had been diagnosed with haematological
CNY = China Yuan, US$ 1.00 = ¥ 7.02.
tumours and were receiving single therapy. The
mean (SD) age of the children was 6.20 (3.76)
years. The mean (SD) scores of resilience and of this study suggested a medium positive correla-
quality of life for the parents of children with tion between resilience and quality of life (r = 0.41,
cancer were 61.82 (13.99) and 0.75 (0.14), p < 0.01)). We also found relatively weak positive
respectively. correlations of quality of life with educational
Table 2 presents the relationships between attainment and with family monthly income.
resilience, quality of life, demographic character- The results of hierarchical regression analysis
istics of parents and children’s clinical characteris- are shown in Table 3. The results showed that the
tics. Referring to Cohen (1992), correlation overall model explained 22% of the variance.
coefficients in the ranges of 0.10 to 0.29, 0.30 to When controlling for the possible effects of edu-
0.49 and 0.50 to 1.0 were interpreted as small, cational attainment and family income, we found
medium and large effects, respectively. The results that the change in the R2 value was 0.15; that is,
1052 Journal of Health Psychology 27(5)

Table 2.  Correlations among quality of life, resilience, demographic and clinical characteristics.

A B C D E F G H I J K L
Gender (A) 1  
Age (B) –0.09 1  
Marital status (C) –0.15 –0.03 1  
Educational attainment (D) 0.03 –0.17a 0.01 1  
Income (E) –0.06 –0.03 –0.08 0.30b 1  
Children’s gender (F) 0.02 0.10 0.05 0.07 0.00 1  
Children’s age (G) –0.00 0.55b 0.09 –0.21a –0.24b 0.09 1  
Type of cancer (H) 0.11 –0.29b –0.10 0.15 0.23b –0.02 –0.36b 1  
Type of treatment (I) 0.09 0.02 –0.01 0.16 0.10 0.07 –0.03 0.41b 1  
Time since diagnosis (J) –0.02 0.11 0.04 0.08 0.07 –0.02 0.12 –0.06 0.00 1  
Resilience (K) –0.15 0.06 0.09 0.11 0.16 –0.16 0.05 0.04 –0.06 0.02 1  
Quality of life (L) 0.05 –0.00 –0.04 0.24b 0.20b –0.03 –0.03 0.16 0.01 0.01 0.41b 1
a
Correlation is significant at the 0.05 level (2-tailed).
b
Correlation is significant at the 0.01 level (2-tailed).

Table 3.  Hierarchical regression analysis for in the literature. Understanding the factors asso-
quality of life. ciated with quality of life is essential to develop
Variable B SE B β p appropriate psychosocial interventions to
improve the psychological well-being and qual-
Step 1 ity of life among parents of children with cancer.
  Educational attainment 0.04 0.02 0.15 0.09 As the effects on parents and children are closely
 Income 0.03 0.02 0.16 0.08 related and interacting, addressing parental psy-
Step 2 chological well-being and quality of life is ben-
  Educational attainment 0.03 0.02 0.13 0.12 eficial for the children with cancer themselves
 Income 0.02 0.02 0.10 0.23
and the whole family (Mullins et al., 2016). A
 Resilience 0.00 0.00 0.40 0.00
previous study showed that Chinese parents of
R2 = 0.22 Adjusted R2 = 0.20
children with cancer had a lower quality of life
R2 change = 0.15
than the Chinese population as a whole (Tian
F = 11.90 p < 0.001
et al., 2012). Therefore, it is vital to conduct
appropriate interventions to enhance the quality
of life in this group.
resilience explained an additional 15% of the Similar to previous studies (Klassen et al.,
variance in quality of life. With all of the varia- 2008; Quast et al., 2016), we found that parents
bles entered into the model, only resilience made with higher family income and educational
a statistically significant contribution (p < 0.05). attainment reported better quality of life than
Additionally, the β coefficient for resilience was those with lower family income and educational
0.40, indicating that resilience was associated attainment. In a previous study of the determi-
with quality of life. nants of health-related quality of life in parents
of children with cancer, higher educational
attainment was shown to be associated with a
Discussion lower perceived burden of parental caregiving
We examined the relationships between quality and improved self-regard, resulting in higher
of life and resilience in Chinese parents of chil- quality of life (Klassen et al., 2011). More atten-
dren with cancer, an area that is underrepresented tion should therefore be devoted to those parents
Luo et al. 1053
with lower educational attainment and family
income, in particular to assess whether they
encounter any financial burden or difficulties in
taking care of their sick children. This could also
be incorporated into standard cancer care in pae-
diatric oncology (Pelletier and Bona, 2015).
A hierarchical regression analysis was con-
ducted to identify which factors were associ-
ated with quality of life in parents of children
with cancer. Regardless of cultural differences,
the findings are consistent with the studies con-
ducted in the West (Kirby et al., 2017; Temprado
Albalat et al., 2020) showing that parents’ resil-
ience was associated with their quality of life.
The results suggest that parents with a higher
level of resilience might have a greater ability
to cope with the stress and adversity, which
probably allowed them to adopt successful to
the situation of their children being diagnosed
with cancer (Wu et al., 2015). It is recom-
mended that further studies obtain qualitative
information, perhaps by conducting qualitative
interviews to explore the challenges experi-
enced by parents and investigate how they with
different levels of resilience adjust and adapt to
their child’s illness.
The findings of this study suggest that more
interventions could be developed and imple-
mented to enhance parental resilience to promote
quality of life. According to a recent meta-analy-
sis, the distress felt by paediatric cancer patients
is associated with parental distress (Bakula et al.,
2019). Parental factors were also found to be an
important driver of children’s ability to adjust,
especially to a medical condition (Fedele et al.,
2013). Indeed, one study suggested that parent-
focused intervention improved not only parental
well-being but also children’s adjustment to their
diagnosis of cancer (Fedele et al., 2013). Hence,
enhancing parental quality of life may affect
children’s cancer experience, improving chil-
dren’s adjustment and well-being.
Implications for future practice
The study showed that parents reported low
quality of life during the period of their chil-
dren receiving cancer treatment in hospital.
Therefore, providing psychosocial care for
parents of children with cancer is of paramount
importance. In particular, it is imperative for
healthcare professionals to identify parents
with low levels of resilience during their
child’s cancer experience and provide prompt
psychosocial support to enhance their resil-
ience, thereby improving their quality of life.
The findings of this study suggest that health-
care professionals should provide more coping
resources, such as educational and psychoso-
cial support, to parents with low income or
education. Moreover, this study revealed that
resilience is a factor associated with parental
quality of life and may be a useful indicator to
screen parents who are at risk of low quality of
life during their children’s cancer trajectory.
Therefore, it is crucial for healthcare profes-
sionals to understand parental resilience and
its effects on parental quality of life. Most
importantly, early identification of the level of
resilience in parents of children with cancer is
important for health professionals to plan,
develop and implement appropriate interven-
tions to improve parental quality of life.
Over the last decade, resilience training pro-
grammes have increased in importance since
the flourishing of the positive psychology
movement (Bolier et al., 2013). The results of
earlier studies have revealed that resilience
training can enhance the psychological well-
being of adolescents and help to ameliorate the
depressive symptoms of breast cancer patients
(Bolier et al., 2013). By cultivating positive
emotions, changing cognitive habits and foster-
ing the ability to recognise positive events, par-
ticipants in resilience training programmes
strengthen their ability to overcome adversity
and manage stress (Chmitorz et al., 2018), con-
sequently improve their quality of life.
In Western countries, resilience training
programmes have been implemented and have
proved to be effective in improving psycho-
logical outcomes for parents of children with
cancer (Rosenberg et al., 2019). Through one-
on-one delivery, these programmes target the
four skills of cognitive reframing, meaning
making, stress management and goal setting.
1054 Journal of Health Psychology 27(5)
However, although low levels of resilience
were previously found in Chinese parents of
children with cancer (Ye et al., 2015), there is
a lack of culturally adjusted resilience training
programmes to improve the situation. More
rigorous empirical scrutiny is required to
determine the effectiveness of resilience train-
ing before it can be used as an intervention to
enhance resilience among Chinese parents of
children with cancer and promote their quality
of life.
Limitations
The limitations of this study included the use of
convenience sampling and the fact that the par-
ents were recruited from only two hospitals in
Central China, which may limit the generalisa-
bility of the findings. In addition, the cross-sec-
tional design left us unable to explore the causal
relationships between parental resilience and
quality of life. It is recommended that future
research should involve a longitudinal study to
further confirm whether resilience could serve
as a predictor for quality of life among parents
of children with cancer.
Conclusion
This study addressed an important literature
gap by establishing that resilience is associated
with quality of life for Chinese parents of chil-
dren with cancer. Measuring resilience is a pre-
requisite to better understanding how parents
respond to the stress of their children’s cancer.
Future studies may consider developing and
evaluating interventions that can help enhance
the resilience of parents of children with cancer
to promote their quality of life.
Declaration of conflicting interests
The author(s) declared no potential conflicts of inter-
est with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
ORCID iDs
Y. H. Luo https://orcid.org/0000-0002-5510-4697
W. H. C. Li https://orcid.org/0000-0002-2562
-769X
A. T. Cheung https://orcid.org/0000-0002-6498
-0314
Supplemental material
Supplemental material for this article is available
online.
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