Objective: To examine the interrelationships among resilience, self‐esteem, and depressive symptoms and determine whether resilience was a factor associated with quality of life for Hong Kong Chinese children with cancer. Methods: We used a cross‐sectional study design. Participants were 138 Hong Kong Chinese children (aged 7–14 years) who were admitted to the pediatric oncology units of an acute public hospital. The resilience, depressive symptoms, self‐esteem, and quality of life of participating children were assessed. The primary outcome was the association between resilience and quality of life in children with cancer. Results: In total, 72 boys and 66 girls were recruited for this study (mean age 10.6 years). The mean levels of resilience, depressive symptoms, self‐esteem, and quality of life were 23.4, 30.0, 23.0, and 63.6, respectively. There was a statistically significant strong positive correlation between resilience and quality of life (r = 0.60, p < 0.01), indicating that greater resilience was associated with better quality of life. Children with cancer from single‐parent families, those diagnosed with a brain tumor, and those who received multiple treatments reported significantly lower levels of resilience, self‐esteem, and quality of life, and greater depressive symptoms than other children (all p's < 0.001). Results of a multiple regression analysis revealed that resilience (p < 0.001) was a strong factor associated with quality of life among children with cancer. Conclusions: It is essential that healthcare professionals implement interventions to boost the resilience of children with cancer, thereby enhancing their quality of life.
Keywords: cancer; children; Chinese; depressive symptoms; psycho‐oncology; quality of life; resilience; self‐esteem
Despite the increased survival rate for childhood cancer following advances in medical treatment, cancer and its treatment are described as extremely stressful and threatening experiences in the life of a child.1 Moreover, it is well documented that chemotherapy, radiotherapy, and surgical treatments may have long‐term adverse effects on the psychological well‐being of children with cancer, such as decreased self‐esteem and increased risk for depression, that can adversely affect their quality of life.2–4
- Resilience is a strong factor associated with quality of life in children with cancer
- Children with cancer from single‐parent families, diagnosed with a brain tumor, and received multiple treatments had lower levels of resilience, self‐esteem, and quality of life, and greater depressive symptoms than other children
- It is essential that healthcare professionals implement interventions to boost the resilience of children with cancer, thereby enhancing their psychological well‐being and quality of life
There is some evidence that depression in childhood and adolescence may be caused by negative psychological traits, such as low self‐esteem.5 Self‐esteem is defined as an individual's subjective evaluation of their own worth and is derived from a person's perceptions or self‐evaluation about their self‐competence and efficacy.5 A previous study showed that low self‐esteem was an indicator of a high risk for depression among Chinese adolescents.6
An increasing number of studies have examined patients' resilience in adaptation to cancer.7 Resilience is defined as an individual's strength and ability to moderate the negative effects of stress, promote adaptation, and maintain mental well‐being in the face of adversity.8,9 The conceptual framework developed by Rosenberg10 suggests that resilience is built on a foundation of baseline characteristics, and is affected by social resources, perceived level of family cohesion, and other psychosocial outcomes (e.g., anxiety and depression). Although resilience was originally regarded as a psychological variable, it is increasingly recognized as an indicator of psychosocial outcomes including depression, anxiety, and quality of life.7,11–13 Assessing resilience in children with cancer is therefore crucial to build a comprehensive understanding of their responses to stress and adversity. This understanding is an essential prerequisite for designing appropriate psychological interventions to build children's resilience, and consequently enhance their quality of life.
Previous studies have examined the relationships between resilience and psychological well‐being among adult patients11,12,14 and children and adolescents15–17 with cancer. These studies revealed that resilience was an important psychological predictor of quality of life, and high resilience was associated with better psychological well‐being among patients with cancer. However, all of these studies were conducted in Western countries, meaning there is room for studies focused on these constructs to be conducted in Eastern countries. A review of the literature revealed that no similar study has been conducted in the Hong Kong Chinese context. Therefore, this study explored the relationships among resilience, self‐esteem, depressive symptoms, and quality of life in Hong Kong Chinese children with cancer. Specifically, we examined whether resilience was a factor associated with quality of life in children with cancer. We hypothesized that a higher level of resilience would be associated with better quality of life in children with cancer.
This study used a cross‐sectional design. Hong Kong Chinese children admitted to the pediatric oncology units of an acute public hospital for cancer treatment were invited to participate. The study period, including participant recruitment and data collection, was from 1 February 2018 to 31 July 2019.
To be eligible for this study, children were as follows: (i) aged 7–14 years, (ii) diagnosed with cancer within the previous 6 months and currently undergoing active treatments, and (iii) able to speak Cantonese and read Chinese. Children younger than 7 years may have limited verbal and cognitive capacity to express themselves and be confused by questionnaires, and older children may have different life experiences and levels of cognitive development; therefore, only children aged 7–14 years were included in this study. We excluded children with cognitive and learning problems as identified from their medical records.
A statistical power analysis program (G*Power 3) was used to calculate the sample size.18 To detect a medium effect size of 0.06 in a multiple regression model with six independent variables, at least 133 participants were needed to achieve a statistical power of 80% at a 5% significance level. A convenience sample of 138 childhood cancer survivors was eventually recruited. Twelve participants chose not to join the study because of unavailability or disinterest, which gave a response rate of 92%.
We did not directly approach children with cancer and their parents. Instead, a promotional poster with details of the nature and purpose of this study was posted on notice boards in the pediatric oncology units to identify potential participants. Children with cancer and their parents could express their willingness to join the study to the nurses in charge at the oncology units. A briefing session to explain the purpose and nature of the study was then conducted for interested children with cancer and their parents. Written consent was obtained from parents after confirming their child's eligibility. Children were also invited to put their names on a consent form and were informed that their participation was voluntary. Both children and their parents were told that they had the right to withdraw from the study at any time and were assured of the confidentiality of their data. Participants received a set of self‐administered questionnaires in hard copy. These questionnaires assessed their levels of resilience, self‐esteem, depressive symptoms, and quality of life. The children were asked to complete the questionnaires by themselves during their stay in the pediatric oncology units.
The primary outcome of this study was the association between resilience and quality of life in children with cancer.
A demographic data sheet was constructed for this study and used to document participating children's demographic and clinical characteristics, including age, sex, diagnosis, treatment received, parental marital status, and parents' educational attainment.
The Resilience Scale for Children‐10 (RS10) was based on the Resilience Scale originally developed by Wagnild and Young.8 The RS10 measures a child's resilience in responding to life changes using five core elements as following: (
The Chinese version of the Center for Epidemiologic Studies Depression Scale for Children (CES‐DC) comprises 20 standardized items that assess depressive symptoms.20 All items are evaluated on a 4‐point Likert scale in relation to their incidence during the previous week, and are scored from 0 to 3 (0 = not at all, 1 = a little, 2 = some, and 3 = a lot). Total possible CES‐DC scores range from 0 to 60, with higher scores indicating greater number of symptoms. The CES‐DC had an alpha coefficient of 0.80 in this study, demonstrating good internal consistency.
The Rosenberg's Self‐Esteem Scale (RSES) was designed to measure self‐esteem as a global disposition and has been widely used with children.21 The Chinese version of the RSES comprises 10 items rated on a 4‐point Likert scale from 1 (strongly disagree) to 4 (strongly agree). Total possible scores range from 10 to 40, with higher scores indicating higher levels of self‐esteem. The RSES had an alpha coefficient of 0.78 in this study, demonstrating internal consistency.
The Chinese version of the Pediatric Quality‐of‐Life Inventory Cancer Module version 3.0 (PedsQL Cancer Module) comprises 27 items.22 Participants are asked how much of a problem each item has been over the last month. Each item is scored from 0 to 4 (0 = never, 1 = almost never, 2 = sometimes, 3 = often, and 4 = almost always). The items are then reverse scored and linearly transformed to a 0–100‐point scale, with higher scores indicating better health‐related qualify of life. The PedsQL Cancer Module had an alpha coefficient of 0.83 in this study, demonstrating good internal consistency.
This study was approved by the Institutional Review Board of the University of Hong Kong and Hospital Authority of Hong Kong West Cluster (reference, UW 16‐023).
All statistical analyses were conducted using SPSS version 23.0 for Windows (IBM Corp). The internal consistency of the instruments used in the study was determined by calculating their Cronbach's α values. Descriptive statistics were used to calculate the mean, standard deviation, and range of the scores for each scale. Relationships among the RS10, CES‐DC, RSES, PedsQL Cancer Module, and participants' demographic data were investigated with Pearson's product‐moment correlation coefficients. With reference to Cohen,23 correlation coefficients of 0.10–0.29, 0.30–0.49, and 0.50–1.0 were typically interpreted as small, medium, and large effect sizes, respectively. A one‐way between‐groups analysis of variance (ANOVA) was used to assess the mean RS10, CES‐DC, RSES, and PedsQL Cancer Module scores by parental marital status, brain tumor diagnosis, and multiple treatments received. A multiple regression analysis was used to explore whether resilience, depressive symptoms, and self‐esteem were factors associated with children's quality of life, while controlling for the possible effects of parental marital status, brain tumor diagnosis, and multiple treatments received.
Table 1 presents participants' demographic and clinical characteristics. In total, 72 boys and 66 girls were recruited for this study, with a mean age of 10.6 ± 2.4 years. Twelve participants (8.7%) were from single parent families. Most participants had a diagnosis of leukemia (39.9%) or brain tumor (30.4%). More than half (68.1%) of the participants received a single treatment and about 32% received more than one cancer treatment. The mean depressive symptom scores for children with cancer in this study (30.0) were relatively higher than those previously reported for children without cancer (20.9),24 whereas the mean self‐esteem (23.0) and quality of life (63.6) scores for children with cancer in this study were lower than those previously reported for healthy children (28.1 and 70.7, respectively).25
1 TABLEDemographic and clinical characteristics of the participants (N = 138)
Frequency % Sex Male 72 52.2 Female 66 47.8 Diagnosis Leukemia 55 39.9 Lymphoma 25 18.1 Brain tumor 42 30.4 Osteosarcomas 12 8.7 Kidney tumor 4 2.9 Treatment received Surgery 5 3.6 Radiotherapy 4 2.9 Chemotherapy 85 61.6 Multiple treatments 44 31.9 Parental marital status Live with both parents 126 91.3 Single‐parent family 12 8.7 Parents' educational attainment Primary school or below 3 2.2 Lower secondary school 38 27.5 Upper secondary school 60 43.5 Tertiary education 37 26. 8 Religion Yes 44 31.9 No 94 68.1
1 TABLEDemographic and clinical characteristics of the participants (N = 138)
Mean Standard deviation Range of ages (7–14 years) 10.6 2.4 Resilience 23.4 6.6 Depressive symptoms 30.0 6.6 Self‐esteem 23.0 3.9 Quality of life 63.6 9.8
Table 2 presents interrelationships among the RS10, CES‐DC, RSES, and PedsQL Cancer Module scores, children's age and sex, parental marital status, parents' education attainment, religion, children's diagnosis, and the treatment received. There was a statistically significant strong positive correlation between RS10 and PedsQL Cancer Module scores (r = 0.60, p < 0.01), indicating that greater resilience was associated with better quality of life. A strong positive correlation was also found between brain tumor diagnosis and multiple treatments (r = 0.73, p < 0.01). There was a statistically significant strong negative correlation between CES‐DC and PedsQL Cancer Module scores (r = −0.59, p < 0.01), indicating that greater depressive symptoms were associated with lower quality of life. A strong negative correlation was also observed between brain tumor diagnosis and PedsQL Cancer Module scores (r = −0.52, p < 0.01), indicating that a brain tumor diagnosis was associated with lower quality of life. Furthermore, there were statistically significant medium correlations between: RS10 and CES‐DC scores (r = −0.46, p < 0.01); CES‐DC and RSES scores (r = −0.31, p < 0.01); RSES and PedsQL Cancer Module scores (r = 0.41, p < 0.01); multiple treatments and CES‐DC scores (r = 0.41, p < 0.01); multiple treatments and PedsQL Cancer Module scores (r = −0.38, p < 0.01); brain tumor diagn and CES‐DC scores (r = 0.47, p < 0.01); parental marital status and RS10 scores (r = −0.42, p < 0.01); parental marital status and CES‐DC scores (r = 0.34, p < 0.01); parental marital status and RSES scores (r = −0.41, p < 0.01); and parental marital status and PedsQL Cancer Module scores (r = −0.30, p < 0.01).
2 TABLEIntercorrelation coefficients among the scores of the RS10, CES‐DC, RSES, PedsQL, and demographic and clinical characteristics (N = 138)
A B C D E F‐1 F‐2 F‐3 F‐4 F‐5 G‐1 G‐2 G‐3 G‐4 H I J K Age (A) 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Sex (B) −0.05 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Parental marital status (C) 0.05 0.17 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Parents' educational attainment (D) −0.20 0.07 −0.02 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Religion (E) −0.03 0.15 −0.20 0.13 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Diagnosis (F) Leukemia (F‐1) −0.19 −0.16 −0.04 0.17 −0.02 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Lymphoma (F‐2) 0.18 0.19 −0.01 −0.13 0.00 −0.18 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Brain tumor (F‐3) 0.02 0.03 0.13 0.05 −0.01 −0.14 −0.19 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Osteosarcomas (F‐4) 0.03 −0.14 −0.10 −0.09 0.06 −0.19 −0.15 −0.20 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Kidney tumor (F‐5) 0.08 0.16 −0.05 −0.12 0.00 −0.12 −0.07 −0.10 −0.05 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Treatment received (G) Surgery (G‐1) 0.14 −0.11 −0.06 −0.09 −0.05 0.01 0.11 −0.13 −0.06 0.24* 1 ‐ ‐ ‐ ‐ ‐ ‐ ‐ Radiotherapy (G‐2) −0.09 0.01 −0.05 −0.05 0.07 −0.14 −0.08 −0.11 0.25* 0.17 −0.03 1 ‐ ‐ ‐ ‐ ‐ ‐ Chemotherapy (G‐3) 0.03 0.01 −0.02 −0.02 −0.07 0.46* 0.26* −0.41* −0.07 −0.19 −0.25* −0.22* 1 ‐ ‐ ‐ ‐ ‐ Multiple treatments (G‐4) −0.05 0.03 0.06 0.07 0.07 −0.33* −0.28* 0.73* 0.01 −0.10 −0.13 −0.12 −0.37* 1 ‐ ‐ ‐ ‐ RS10 (H) 0.11 −0.16 −0.42* −0.04 −0.07 0.19 −0.09 −0.31* 0.12 0.05 0.07 0.11 0.20 −0.29* 1 ‐ ‐ ‐ CES‐DC (I) 0.00 −0.08 0.34* −0.05 −0.12 −0.20 −0.08 0.47* −0.05 −0.09 −0.04 −0.13 −0.31 0.41* −0.46* 1 ‐ ‐ RSES (J) 0.10 −0.16 −0.41* −0.13 0.02 0.08 0.12 −0.22* 0.10 −0.02 0.01 0.13 0.13 −0.19 0.28* −0.31* 1 ‐ PedsQL (K) −0.03 −0.04 −0.30* 0.02 0.10 0.11 0.04 −0.52* 0.05 0.06 0.07 0.15 0.20 −0.38* 0.60* −0.59* 0.41* 1
1 Abbreviations: CES‐DC, Center for Epidemiologic Studies Depression Scale for Children; PedsQL, Pediatric Quality‐of‐Life Inventory Cancer Module version 3.0; RS10, Resilience Scale for Children‐10; RSES, Rosenberg's Self‐Esteem Scale.
2
Based on the results of these correlation analyses, we performed between‐groups ANOVA to compare the means of RS10, CES‐DC, RSES, and PedsQL Cancer Module scores by participants' demographic and clinical characteristics. The results (Table 3) showed that participants from single‐parent families reported statistically significantly lower levels of resilience (p < 0.001), self‐esteem (p < 0.001), and quality of life (p < 0.001), but greater depressive symptoms (p < 0.001) than participants that lived with both parents. Moreover, participants diagnosed with a brain tumor reported statistically significantly greater depressive symptoms (p < 0.001) and lower levels of resilience (p < 0.001), self‐esteem (p < 0.001), and quality of life (p < 0.001) than participants with other cancer diagnoses. Additionally, participants that received multiple treatments reported greater depressive symptoms (p < 0.001) and lower levels of resilience (p < 0.001), self‐esteem (p = 0.001), and quality of life (p < 0.001) than those that received only one treatment.
3 TABLEBetween‐groups ANOVA to compare the means scores of RS10, CES‐DC, RSES, and PedsQL of participants with different parental marital status, brain tumor diagnosis and multiple treatments (N = 138)
( RS10 CES‐DC RSES PedsQL Mean (SD) Mean (SD) Mean (SD) Mean (SD) Parental marital status <0.001 <0.001 <0.001 <0.001 Live with both parents 126 23.93 (6.19) 29.18 (7.24) 23.60 (3.42) 64.78 (11.86) Single‐parent family 12 17.42 (8.13) 38.58 (5.73) 16.58 (3.23) 50.67 (14.16) Brain tumor diagnosis <0.001 <0.001 <0.001 <0.001 Yes 42 20.02 (6.85) 34.83 (4.90) 21.52 (4.23) 55.02 (7.58) No 96 24.82 (5.97) 27.89 (7.60) 23.63 (3.63) 67.28 (11.48) Multiple treatments <0.001 <0.001 <0.001 <0.001 Yes 44 20.45 (6.67) 33.86 (6.50) 21.75 (4.03) 57.55 (10.30) No 94 24.72 (6.07) 28.19 (7.41) 23.56 (3.76) 66.36 (11.54)
3 Abbreviations: CES‐DC, Center for Epidemiologic Studies Depression Scale for Children; PedsQL, Pediatric Quality‐of‐Life Inventory Cancer Module version 3.0; RS10, Resilience Scale for Children‐10; RSES, Rosenberg's Self‐Esteem Scale; SD, Standard deviation.
Table 4 shows the summary results of a multiple regression analysis. The results showed that the overall model explained 58% of the variance. After controlling for the possible effects of parent marital status, brain tumor diagnosis, and multiple treatments, we found that the R
4 TABLESummary of multiple regression for variables predicting quality of life (N = 138)
Variable predicting quality of life Step 1 Parent marital status −11.71 3.05 −0.28 <0.001 Brain tumor diagnosis −11.00 2.73 −0.43 <0.001 Multiple treatments −0.43 2.68 −0.02 0.87 Step 2 Parent marital status −2.45 2.85 −0.06 0.39 Brain tumor diagnosis −6.82 2.23 −0.27 0.003 Multiple treatments 2.04 2.13 0.08 0.34 Resilience 0.87 0.12 0.48 <0.001 Depressive symptoms −0.28 0.11 −0.18 0.009 Self‐esteem 0.30 0.21 0.10 0.16 R2 = 0.58 ‐ ‐ ‐ ‐ Adjust R2 = 0.56 ‐ ‐ ‐ ‐ R2 change = 0.30 ‐ ‐ ‐ ‐
4 Abbreviations: B = unstandardized coefficient; SE B = standard error of unstandardized coefficient; β = standardized coefficient.
The overall results showed there were no interrelationships among demographic characteristics, psychological well‐being, and quality of life in children with cancer, with the exception of parental marital status. Similar to previous studies conducted in Hong Kong,6,24,26 our results revealed that children with cancer from single‐parent families had lower levels of resilience, self‐esteem, and quality of life, but greater depressive symptoms than children that lived with both parents. One possible reason is that family is an important orientation in Chinese culture that emphasizes integrity and collective interests, and single‐parent families are therefore often stigmatized in Chinese society.27 Previous studies have shown that stigmatization is a salient factor that negatively affects children's psychological well‐being.27,28 In addition, having a child with a chronic illness such as cancer means that single parents may encounter challenges such as financial burdens, social isolation, and diminished social support.29 There is a paucity of studies investigating the association between single parenting and psychosocial functioning among children with chronic illness. To examine such a relationship, a longitudinal study that collects data throughout the whole treatment process is recommended. It is also recommended that further studies obtain qualitative information, perhaps by conducting qualitative interviews to explore the challenges experienced by single parents and investigate their adjustment and adaptation to their child's illness.
Our findings were consistent with previous studies that showed children with brain tumors had more negative psychological sequelae compared with children with other cancer diagnoses.30,31 This study also showed that children who received multiple treatments reported more depressive symptoms and lower quality of life than those that received one treatment, which may be attributable to experiencing greater occurrence and severity of treatment‐related symptoms.2 However, the results of a multiple regression analysis showed that when brain tumor diagnosis was accounted for, multiple treatments was no longer a significant predictor. This might be due to the strong correlation between brain tumor diagnosis and multiple treatments. When two variables are highly correlated, it is possible that one can be significant and the other is not in a regression.32
The overall results added further support to the existing literature that in the face of adversity (diagnosed with cancer), high resilience in children was associated with better psychological outcomes and quality of life. The results of a multiple regression analysis supported our hypothesis that resilience was a factor associated with quality of life in children with cancer.
Because of the cross‐sectional nature of the study design, we could not make inferences about causal relationships. Another limitation was that we recruited only children aged 7–14 years. Future study may consider recruiting survivors with a wider age range, such as 7–18 years. Furthermore, this study did not assess parents' resilience, self‐esteem, or depressive symptoms; these factors may impact their children's psychological well‐being. Additionally, children were asked to self‐report their psychological well‐being and quality of life. However, information from parents on the psychosocial well‐being and quality of life of their children may further enhance our understanding of the impact of cancer and its treatments on the children.
Healthcare professionals should pay more attention and expend more effort to promote psychological well‐being and enhance quality of life of children with cancer from single‐parent families, those diagnosed with a brain tumor, and those receiving multiple treatments. As resilience is a strong factor associated with quality of life in children with cancer, assessing resilience, particularly at the time of cancer diagnosis, could be a useful tool to screen whether children are at high risk for depression and reporting poor quality of life throughout the cancer treatment process. Most importantly, the findings indicated the necessity of interventions to enhance the resilience in children with cancer. A systematic review and meta‐analysis of resilience training programmes showed that interventions using cognitive behavioral therapy (CBT), mindfulness, and a combination of CBT and mindfulness techniques were found to be effective in improve individual resilience.33 Another previous study showed that adventure‐based training was effective in enhancing levels of resilience among university students.34 However, more rigorous empirical scrutiny is required to determine the feasibility, suitability, and effectiveness of these interventions before it can be used to enhance resilience among children with cancer.
This study highlighted the importance of assessing the resilience of children with cancer and implementing appropriate interventions to boost their resilience, with the aim of promoting their psychological well‐being and enhancing their quality of life.
We would like to thank the children and parents for participating in the study. This study was funded by Health and Medical Research Fund, Food and Health Bureau, Hong Kong SAR Government (grant reference: 15163011).
The authors have no conflicts of interest to disclose.
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
By Joyce Oi Kwan Chung; William Ho Cheung Li; Ankie Tan Cheung; Laurie Long Kwan Ho; Wei Xia; Godfrey Chi Fung Chan and Violeta Lopez
Reported by Author; Author; Author; Author; Author; Author; Author
