Parental coping with childhood cancer and its relationship with self‐construal: A survey in southeast Iran

Abstract Background Childhood cancer is a major challenge for parapets. Parents are one of the main sources of emotional support for their child, but their ability to provide proper care during their child's illness and treatment depends entirely on the way they manage to cope with diagnosis and its outcomes. Parents' coping pattern seems to be affected by their perception of themselves or their surroundings. Aim To investigate parents' coping strategies with childhood cancer and its relation with self‐construal. Methods A total of 127 eligible parents participated in this descriptive correlational study. Results Medical, social support, and family strategies were respectively helpful for parents. The interdependent self‐construal score was higher than the independent self‐construal score. A significant relationship was found between interdependent self‐construal and social support (P = .01). Discussion It seems that individualists and collectivists' cultural context influence the usefulness of coping strategies. These differences should be considered in training of coping strategies.

Hofstede divides the cultures into individualism and collectivism. 9 It is assumed that individualists and collectivists have different selfconstrual. 10 In Western and individualistic cultures, the self-construal is independent of others in the form of knowledge about difference, unity, and stability of the inner personality. 6 Independent self-construal is active when a person feels a particular identity and distinguishes himself from others, 7 but the collectivistic concept of "self" includes others. Interdependent self-construal is the extent to which people construct fundamental connections to others, focus on their relationships, and are concerned with the ways in which they can benefit their social group. 11 Parents' inability to cope with stress can increase children's stress. 12 Therefore, it is important to examine the factors affecting the parental coping with the child's illness such as self-construal.
In a literature review, no study measured the relationship between self-construal and coping with one's or a child's health problems. However, studies have been conducted recently in India, 8 Turkey, 13 Philippines, 14 and the United States, 15 which have different cultural and self-construal conditions to determine the relationship between selfconstrual and coping in general populations. In sum, the results of these studies have shown that the individuals' self-construal, and whether they are individualistic or collectivistic, can influence the way an individual uses coping strategies in stressful conditions. 8,[13][14][15] Therefore, this study aimed to determine the parental coping in caring for a cancer child and its relationship with their self-construal in southeast Iran.

| Context
Hofstede et al 16 assessed the individualism index score for 76 countries, 0 was scored for the collectivistic countries and 100 for the individualistic countries. Iran, the 38th among 76 countries, was considered as a collectivistic country. 17 Iranian Islamic culture emphasizes altruism and strong family relationships, which make Iranians more committed to their relatives, especially when a family member experiences an illness. 18 Parents of cancer children face a variety of stressful sources, one of which is fear of death that is higher in men according to the terror management theory. 19 The term cancer is equivalent to death in the Iranian culture. 20,21 Parents do not usually gain their information from healthcare team, which can be stressful for them. 22 Unfortunately, there is currently no organized and principal structure for palliative and supportive care in Iran, with only five or six active centers.

| Study design and setting
The present study was descriptive correlational study. Parents of children with cancer referred to Afzalipour hospital and physicians' offices were studied in Kerman, the largest city in the southeast of Iran, from September 2017 to May 2018, Kerman provides oncology services to a large number of patients from other parts of the region.

| Sample size and sampling
Parents of under 15-year-old children with cancer who were aware of the illness diagnosis with no psychological illness were participated in the study using convenience sampling method. The sample size was 127 parents based on the results of the pilot study on 30 parents, with a confidence coefficient of 95% and a power of 80%. In addition, the pilot study measured the relationship between the mean scores of the coping pattern and self-construal (r = 0.24).

| Background information
A background information questionnaire consisted of parental characteristics such as age, occupation, level of education, living place, family relationship with the child, marital status, income, number of children, whether they had other child with cancer, whether they had lost any child, whether they had experienced the care for a cancer patient in their family, as well as the child's characteristics including age, gender, birth order, type of cancer, duration of illness, type of treatment, and frequency of referrals per month. "minimally helpful," "moderately helpful," and "extremely helpful"), and the final score is between 0 and 135, which is obtained from the scores of all items. The higher the scores, the more effective the parental coping. 23 The research team measured the validity and reliability of the questionnaire. The content validity index (CVI) was 90%. Reliability of the questionnaire was assessed by conducting a pilot study on 30 participants (also calculated in the final sample size), and Cronbach's alpha was .85. These results indicate the favorable validity and reliability of this questionnaire.

| Self-construal scale
Singelis designed the self-construal scale (SCS) in 1994 and revised it in 2000. The questionnaire consists of 30 items in the two areas of "independent self-construal" and "interdependent self-construal." Each item is evaluated based on a seven-point Likert scale, ranging from strongly disagree (1) to (7) strongly agree. Each participant will receive two points, one point for "independent self-construal" and one point for "interdependent self-construal." 24 This questionnaire has not been used in Iran, so the research team measured its validity and reliability. The CVI was calculated to be 90% for this questionnaire. Reliability of the questionnaire was assessed by conducting a pilot study on 30 participants (also calculated in the final sample size), and Cronbach's alpha was calculated .81. These results indicate the favorable validity and reliability of this questionnaire.

| Data collection and analysis
The researcher referred to the study setting during different work shifts (morning, evening, and night) and started sampling after obtaining the permissions from the authorities of the oncology centers of Kerman. The questionnaires were completed in a selfadministered form and in case the parents were illiterate, they would have been completed by interviewing.
To analyze the data, we used SPSS v 21. Descriptive statistics were used to describe the characteristics of the samples (frequency, percentage, mean, and SD). Pearson correlation coefficient was used to calculate the correlation between coping strategies and self-construal. Spearman correlation coefficient, independent t test, Mann-Whitney U, ANOVA, and Kruskal-Wallis tests were used to evaluate the mean scores of coping strategies and self-construal in terms of background characteristics. Furthermore, all variables with P < .2 were simultaneously inserted into a full model of multivariate linear regression to assess the effect of different variables on the coping strategies or self-construal. Significance level was set at .05.

| Ethical considerations
The ethics committee of Kerman University of Medical Sciences approved the protocol of the study (No. IR.KMU.REC.1396.1897).
The researchers explained research goals and protocol to the participants before their inclusion in the study, and if they had been willing to participate in the study, written informed consent would have been obtained from all eligible participants. Table 1 shows the characteristics of the participants. The parents' mean total score of the coping health inventory was 86.3 ± 19.75.

| RESULTS
The "mean per item" was used to compare the domains because the number of items in different subscales of the questionnaire was not equal. The lowest mean score was related to "allowing myself to get angry" (0.59 ± 0.95) and the highest mean score was related to the item "believing in God" (2.98 ± 0.12) ( Table 2). The interdependent self-construal score (1.55 ± 0.24) was higher than the independent self-construal score (1.29 ± 0.3). The total score of the SCS was obtained from the difference between the IND and INT scores (−0.26 ± 0.34). It should be noted that the higher the total score of the SCS, the higher the level of self-construal, and vice versa, the lower the total score, the higher the interdependent self-construal. Therefore, it can be concluded that the participants' interdependent self-construal was greater than their independent self-construal. A statistically significant relationship was found between self-construal and coping health inventory for parents (CHIP) support (P = .01). From the perspective of those with more interdependent self-construal, maintaining social support, self-esteem, and psychological stability were more helpful, but no significant relationship was found among other coping strategies and the dimensions of self-construal ( Table 3).
The results of the univariate analysis showed that fathers (com- A statistically significant relationship was observed between age and the mean score of self-construal. However, no significant relationship was found between other demographic variables and selfconstrual score. The variables in the bivariate analysis with a significant level of less than 0.2 were included in the multivariate linear regression model. Therefore, a significant relationship was found only between the number of children and self-construal score. In other words, people with three children had lower self-construal score than those who had one child (0.16), and they were more dependent (P = .33, F = 4.73, Adjusted R 2 = 0.03, R 2 = 0.2).

| DISCUSSION
In the current study, a positive and significant correlation was found between social support, self-esteem, psychological stability, and interdependent self-construal, indicating that the higher the interdependent self-construal, the more helpful the strategies.
Searching in databases, we did not find a study with similar or opposite to this result. However, self-construal theory has a profound effect on the recognition, emotions, and motivations of individuals in all cultures. 25 Interdependent self-construal emphasizes close relationships and membership in the group. Individuals with an interdependent self-construal perceive "self" in connection with others. 26 These people tend to rely on others. 27 Dwivedi showed that individuals with more interdependent self-construal are more vulnerable to interpersonal conflicts, and need to be supported by family and friends to deal with problems. 8 The parents participated in the current study had a more interdependent self-construal. So far, no study has been conducted to investigate self-construal in Iran, but several studies have examined the difference of this variable in Asians, Europeans, and Americans, showing that Asians and, in general, the Orientals, have more interdependent self-construal than Europeans, the Americans and, in general, the Western societies. 28 Iran is a collectivistic country located in the southwestern part of Asia, so Iranians have more interdependent self-construal.
The parents' mean total score of the coping health inventory was 86.3 (score range: 40-135). The mean was higher than the results of previous studies in the United States. 29,30 In the present study, the highest mean score of coping strategies was related to the item "believing in God" (2.98 ± 0.12), which was consistent with the results of Nikfarid et al 31 and Aliakbari-Dehkordi et al. 32 Studies consider religion as a defensive shield against stress. 33 The majority of Iranians are Shiites. According to Qur'an, the Muslim holy book, believing in God has effects such as no sadness for difficulties and what one loses, which is achieved by trust in God and no dependency on material objects. 34,35 In the present study, the highest score of coping strategies was related to social support, self-esteem, and psychological stability, Since 71.7% of the study population who were females and unemployed had income below 1 million toman, which is below the poverty line, much of the stress on these parents came from economic pressures, so such stress could reduce the ability of parental coping. Therefore, the support of parents by close relatives can be financially and emotionally effective in improving the parental coping. It seems that parental access to social services and specialized support can reduce the stress associated with the diagnosis of a child's illness and enhance the parental coping. 37  The present study had some limitations. The concern, fatigue, and low mood of the parents might have an impact on their response and motivation to participate in the study. To overcome this limitation, the researcher tried to deliver the questionnaire to parents when they had a proper mood and were psychologically ready to complete the questionnaire without any stress, so that more information could have been obtained accurately. Furthermore, a large number of questions might reduce the accuracy, so sampling was done in the best possible time, which was determined by participants. Finally, the results should be generalized to other populations with caution because the sampling in this study was only from the oncology centers of Kerman, Iran.

| CONCLUSION
According to the results of this study, parental individualism or collectivism can be effective in using coping strategies, and "support" dimen- Abbreviations: CHIP, coping health inventory for parent; r, Pearson correlation coefficient.

ACKNOWLEDGMENT
We would like to thank all parents who cooperated in the research.

FUNDING
None to be declared.

ETHICS STATEMENT
The Kerman University of Medical Sciences Ethics Committee approved the study (IR.KMU.REC.1396.1897). The researcher gave explanations to the samples on their optional presence and that they can leave the study whenever they want. We also assured the participants that the collected information was confidential and would be used only for the research. Written informed consent was received from the parents. The study protocol was in accordance with ethical standards of Kerman University of Medical Sciences on human rights.

CONFLICT OF INTEREST
The authors declare no conflicts of interest. Mahlagha Dehghan had full access to all the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

TRANSPARENCY STATEMENT
The corresponding author, Mahlagha Dehghan, affirms that this manuscript is an honest, accurate, and transparent study, the important aspects of the study have not been omitted, and all discrepancies in the study have been explained.

DATA AVAILABILITY STATEMENT
The data that support the results of this study are available from the corresponding author upon reasonable request.