Resilience of Parents who Have Children with Cancer

Cancer is one of the diseases that causes death in children in the world. The incidence of cancer globally every year is as many as 300 thousand children. Cancer that occurs in children causes major reactions in parents that are often associated with trauma and shock. Parents suffer from psychosocial problems, financial tensions, social isolation and conflicts of work and family roles and reduced time for other children and recreational activities. The main key in overcoming the problem of children with cancer is resilience. Research on the resilience of parents who have children with cancer is still limited. The absence of a literature study in the form of a scoping review of the resilience of parents who have children with cancer has made researchers interested in conducting literature studies. A systematic review is needed to disseminate the relevant literature on the resilience of parents who have children with cancer.


Search Methods
The first step is to search for scientific articles through 4 databases, namely Science Direct, Scopus, PubMed and Ebsco. The keywords used in English are "resilience OR resilience psychological" AND "parents OR father OR mother OR caregiver" AND "pediatric OR child OR children" AND "cancer OR malignancy OR oncology OR neoplasms". The research question is: What is the overview of resilience in parents who have children with cancer?

Inclusion and Exclusion Criteria
This literature review uses PRISM-ScR so that it can identify a wide variety of topics that discuss the resilience of parents who have children with cancer ( Figure 1). Reviewed articles are selected based on inclusion and exclusion criteria. The inclusion criteria in this study such as the year of publication of the article is not more than 5 years (2017)(2018)(2019)(2020)(2021)(2022), the research article is an original research article, full text, has an abstract, and is in English.

Figure 1. PRISMA Flowchart Data Extraction
After all the articles have been read by the researcher, the researcher compiles a summary and analysis of the results which will later be entered into the extraction table. The article is then extracted manually using a table that includes the author, year of research, research objectives, country, research design, sample, and research results.

Article Quality Assessment
Articles are analyzed for quality using the Joanna Briggs Institute (JBI) Critical Assessment method with article qualification standards well above 75% based on the relevance of research criteria and topics. This method is an important tool in assessing the quality, trustworthiness, and relevance of an article that has been published. The scoring criteria consist of "yes", "no", "unclear", and "not applicable" scores and each criterion with a score of "yes" is scored with 1 point, while the other answers are scored with 0 points. Each of those score points is then summed up to determine the notability value of the article. A good article notability standard is to have a score above 75% based on relevance to research criteria and topics. Articles collected after extraction of full text availability and original documents can be accessed (n = 388) Extraction of articles that do not fit the topic "Resilience of Parents Who Have Children with Cancer" (n = 370) Total articles reviewed (n = 18) Eligibility

Data Analysis
All full text articles that have been collected are then read in full by the researcher. Researchers use descriptive analysis methods. After reading all the articles in full text, the researcher conducted an in-depth analysis, and presented them into the form of a manual table. The researcher writes a description of the results of the scoping review study for later preparation of the discussion.

RESULTS
The results of the article search obtained 1679 articles consisting of several databases, namely Science Direct as many as 1229 articles, Scopus as many as 50 articles, PubMed as many as 191 articles and Ebsco as many as 209 articles. The articles obtained are then assessed so that they get 18 qualified articles. Articles were analyzed using the JBI Critical Appraisal Tool with standard values above 75% based on relevance criteria and topics ( Table 1). The results of the study are then analyzed by the researcher and manually extracted into a table form to make it easier to analyze the results for scoping review. The results of the analysis of the article are poured into the table as follows (Table 2).  There is a significant relationship between resilience and social support. Social support is one of the important factors influencing the level of resilience of parents with children with cancer. Self-efficacy is related to the level of parental resilience. The high level of parental resilience will be followed by high social support received, self-efficacy and a much better level of health. When comparing between parents who have children diagnosed with ALL and parents who have healthy children, it was found that parents whose children were diagnosed with ALL had a high level of life satisfaction, resilience and a fairly high level of parenting burden. There are 4 classes in the division of types of parental resilience including parents with good adaptation and optimism, parents who are strong but lack self-control, parents with moderate / moderate resilience, and parents who are maladaptive and less persistent. Parents, especially mothers who have more than one child, have a tendency to be able to enter the class of maladaptive and less persistent parents. Different levels of depressive symptoms were felt from the four resilience classes. Park

Overview of Resilience of Parents Who Have Children with Cancer
Parents who have children diagnosed with solid tumors or who have received multiple cancer treatments significantly have a low level of resilience when compared to parents of children diagnosed with blood cancer (Oi Kwan Chung et al., 2022). Parents who run emotionally based coping strategies significantly have low levels of resilience and are followed by depression, anxiety, lack of social support, and a low quality of life when compared to parents who use problem-solving-based coping strategies (Oi Kwan Chung et al., 2022). Single parents of children with cancer have significantly low levels of resilience and are followed by the presence of depressive symptoms, lack of social support, and a worse quality of life than parents living with their partners (Oi Kwan Chung et al., 2022). Single parents who have children diagnosed with cancer will face much greater challenges, such as financial burden, social isolation, and lack of social support (Oi Kwan Chung et al., 2022).
The level of resilience of fathers and mothers has significant differences, where fathers have a higher level of resilience when compared to mothers (Habibpour et al., 2019). Mothers are more likely to suffer from post-traumatic stress disorder (PTSD) than fathers (Habibpour et al., 2019). This difference in the level of resilience between father and mother is due to the fact that mothers tend to be more sensitive to the effects of stressful difficult events and have the ability to feel much higher levels of stress when compared to fathers (Habibpour et al., 2019).
Mothers who have children diagnosed with cancer, especially acute leukemia, have lower levels of resilience, life satisfaction and a higher burden of care when compared to mothers who have healthy children undiagnosed with cancer (Baran et al., 2020). Children diagnosed with acute leukaemia will undergo a treatment process that requires hospitalization and lasts for a long period of time, this can reduce the level of maternal resilience (Baran et al., 2020). Another thing that can affect the low level of maternal resilience is that mothers must be willing to undergo the cancer treatment process outside the city far from where they live and some decide to move temporarily in the city where the cancer treatment process is carried out (Baran et al., 2020).

Resilience Model of Parents Who Have Children with Cancer
There are very few resilience models that provide a framework for understanding resilience in parents. The only model that specifically addresses the resilience of parents who have children with cancer is only RMP-CC (Stegenga et al., 2020;Ye et al., 2017). This model identifies there are two protective factors such as social support, coping fortitude mechanisms (Y. Stegenga et al., 2020;Ye et al., 2017) and three risk factors such as emotional distress, care/care burden (Stegenga et al., 2020;Toledano-Toledano et al., 2021;Ye et al., 2017), and uncertainty in disease (Stegenga et al., 2020;Ye et al., 2017).

Factors Affecting the Resilience of Parents Who Have Children with Cancer
Protective factors are aspects that can minimize the impact of risk factors. The role of protective factors is to modify negative effects into positive effects. The protective factor is: 1.
Communication Lack of effective communication between parents and children also negatively affects parental resilience (Y. . Communication is the main factor that affects the level of adaptation of parents to cancer suffered by children (Park et al., 2022). Parents who have difficulty communicating with children are due to the parents' lack of experience, information, and ability to cope with the child's emotions, while the child has limitations in understanding cancer, death at an early age, and the stigma that will be given related to cancer (Park et al., 2022). There is a positive relationship between receiving good health information from a team of health workers and the level of resilience of parents (Mezgebu et al., 2020). Receipt of information related to cancer treatment from health workers leads to an increase in resilience (Mezgebu et al., 2020). Providing information at the right time can help to avoid unnecessary stress, so that parents can have better resilience (Mezgebu et al., 2020). Lack of information related to the diagnosis and prognosis of cancer is a major barrier to parents' communication with children (Park et al., 2022). It is very important to provide accurate information regarding cancer treatment in children to parents, in order to strengthen the family and parents to overcome the child's emotions and be able to explain about cancer to the child during the developmental stage (Park et al., 2022). The level of social competence of parents such as easy to interact, make many friends, and being able to communicate well with other people who both have children diagnosed with cancer can be one of the causes of parents having a high level of resilience (Mustafa et al., 2019;Toledano-Toledano et al., 2021).
The stigma of the surrounding community is also a barrier to parents' communication with children (Park et al., 2022). This stigma can bring psychosocial pressure to parents and arises due to the incomprehension of people who do not have a background experience about cancer and the assumption that cancer is a very difficult disease to cure (Park et al., 2022).

2.
Adaptation & Optimism Resilient parents will have good adaptability and optimistic attitude (Y. Luo, Wang, et al., 2022). Usually characterized by the presence of self-confidence and persistence, being able to effectively overcome problems in times of difficulty and adapt well to the diagnosis of cancer in children (Y. Luo, Wang, et al., 2022;Toledano-Toledano et al., 2021). An optimistic attitude is the most prominent among these characteristics (Y. Luo, Wang, et al., 2022). Interventions based on the processing of self-optimism can be carried out to increase resilience in parents (Y. Luo, Wang, et al., 2022). In contrast, parents whose resilience level is low are characterized by the presence of a poor level of self-adaptation (maladaptation) and persistence (Y. Luo, Wang, et al., 2022). In this category, parents usually have difficulty controlling the negative impacts that arise due to the diagnosis of cancer on children (Y. Luo, Wang, et al., 2022).
The most prominent factor in influencing the level of resilience of parents who have children with cancer is due to a positive and optimistic attitude towards the cure of cancer suffered by children (Y. . Interventions given with the aim of cultivating cognitive aspects and optimism can also improve resilience in the elderly (Y. . Parents who have low resilience will usually experience self-distrust in the face of cancer suffered by the child, and this is the biggest obstacle in increasing resilience (Y. . The care team and all health workers directly influence the psychological factors of parents in reducing the pressure / stress of child care so that parents can better adapt to the difficult situation faced (Mezgebu et al., 2020). On the other hand, the lack of information from the team of health workers related to cancer and how the treatment process can cause parents' distrust of the health worker team which will later cause parents to feel worried and frustrated, so that in the end it will worsen the level of resilience of parents (Mezgebu et al., 2020).
Following recreation is also one of the positive predictors of resilience. This is because this activity can help parents in developing better positive adaptations (Mezgebu et al., 2020). In this activity, parents will have more fun time and can produce a bond of happiness, learning, antics, and exchanging experiences between them (Mezgebu et al., 2020).

3.
Spirituality, Religiosity, Faith, and Self-Transcendence Spirituality relates to well-being, understanding the human soul, and the best plan to be carried out (Silva et al., 2021). Religiosity, spirituality, and faith can help the process of developing resilience (Silva et al., 2021). These three things are the main mechanisms and STRADA : Jurnal Ilmiah Kesehatan DOI: https://doi.org/10.30994/sjik.v12i1.987 ISSN: 2252-3847 (print); 2614-350X (online) Vol.12 No.1 May 2023 Page. 12-27 sources of support that can be used by parents who have children diagnosed with cancer in the face of the difficult reality of life due to cancer (Silva et al., 2021). Resilience is important for parents who have children with cancer, because resilience can train parents to emphasize more humanity, can help in maintaining health, and train parents to find new meanings of the difficult conditions that are being experienced caused by cancer experienced by children (Silva et al., 2021). Resilience is shown by how parents can keep moving forward, living better after a cancer diagnosis in a child by being optimistic and effective (Silva et al., 2021). Religious teachings, prayer and faith in God play an important role in increasing parental resilience (Mustafa et al., 2019).
The high level of resilience and transcendence of parents who have children with cancer has a significant relationship with high levels of well-being and low levels of depression and anxiety felt by parents due to cancer treatment in children (Bajjani-Gebara et al., 2019). Selftranscendence can be a link in building a positive relationship between resilience and wellbeing in parents who have children with cancer (Bajjani-Gebara et al., 2019).

4.
Competency Regarding personal competence in resilience, some parents have low personal competence (Mustafa et al., 2019). This may be due to different factors, parents are not able to deal with treatment complications; They have a lack of information about treatment methods (Mustafa et al., 2019). In addition, parents do not have the skills to handle urgent circumstances in care (Mustafa et al., 2019). Without knowledge, skills and training, parents feel that they cannot provide adequate and proper upbringing to their child (Mustafa et al., 2019). Parents with a high level of resilience tend to have a high level of competence in caring for and caring for children diagnosed with cancer (Y. . There is a positive relationship between psychological well-being and the resilience of parents who have children diagnosed with cancer related to the self-competence of parents (Mustafa et al., 2019). Self-competence can improve parents' ability to take care of their children properly, efficiently, and carry out treatment to a higher level (Mustafa et al., 2019). Self-competence also increases the knowledge of parents so that it can be easier to carry out care functions properly and can handle stressful situations that arise more effectively (Mustafa et al., 2019). Therefore, personal competence leads to an increase in the level of psychological well-being of parents (Mustafa et al., 2019).

5.
Coping Coping or an approach that focuses on the process of solving problems in dealing with cancer suffered by children will have a good effect on increasing resilience in parents (Y. Stegenga et al., 2020;Ye et al., 2017). This approach or coping will directly lead to the pressure that arises and will later produce a solution to the problem related to cancer suffered by the child (Y. .

6.
Social support Social support (Y. Mezgebu et al., 2020;Mohammadsalehi et al., 2020;Stegenga et al., 2020;Ye et al., 2017) and the finances received and perceived by parents have a great influence on increasing resilience in parents (Y. . Social support from local friends, vacation/recreation, and getting good health information from a team of health workers have a positive relationship with the level of resilience (Mezgebu et al., 2020). The way parents view social support differs depending on the culture embraced by the surrounding community (Mezgebu et al., 2020). In countries in the Middle East and Asia, parents are mostly afraid to receive social support because they tend to accept the ugly stigma of cancer suffered by children (Mezgebu et al., 2020).
Good social support in parents with a high level of resilience has a positive impact on self-efficacy and health levels (Mohammadsalehi et al., 2020). The psychological status of parents who have children diagnosed with cancer is a significant factor in the increase in STRADA : Jurnal Ilmiah Kesehatan DOI: https://doi.org/10.30994/sjik.v12i1.987 ISSN: 2252-3847 (print); 2614-350X (online) Vol.12 No.1 May 2023 Page. 12-27 resilience itself (Mohammadsalehi et al., 2020). Social support also plays a good role in increasing resilience and serves as a buffer in managing the stress / pressure that is being faced, and will improve the mental health of parents (Mohammadsalehi et al., 2020). Risk factors are factors that can increase negative developmental outcomes in individuals in the future. Risk factors are: 1.
Depression Resilience negatively relates to depressive symptoms, stress, and anxiety levels that parents feel (Mezgebu et al., 2020;Mohammadsalehi et al., 2020;Oi Kwan Chung et al., 2022;Toledano-Toledano et al., 2021). Parenting depression as a risk factor for parental resilience will also affect the adaptation process (Park et al., 2022). The high rate of depression in parental care is due to the characteristics of cancer that is rapidly spreading and unexpected (Park et al., 2022). Cancer usually affects children during the child's developmental stage in the absence of a history of certain diseases (Park et al., 2022). Unexpected diagnoses in cancer usually require repeated inpatient treatment and require follow-up care at home (Park et al., 2022). Parents who have children with cancer will tend to have problems both physical and mental and can be categorized as dangerous circumstances because they will have difficulties in the process of recovering from the traumatic situation experienced (Mezgebu et al., 2020). This is because psychological disorders experienced by parents contribute greatly to reducing the level of parental resilience (Mezgebu et al., 2020). Parents who do not experience depression in the process of treating a child with cancer will tend to have a better level of resilience (Mezgebu et al., 2020).

2.
Stress and care burden Treatment burden negatively related to resilience (Mohammadsalehi et al., 2020;Stegenga et al., 2020;Toledano-Toledano et al., 2021;Ye et al., 2017). The low level of parental resilience is more due to parents experiencing treatment stress and are less able to use all the resources they have effectively in the treatment of children diagnosed with cancer (Habibpour et al., 2019). Low resilience in parents who have children with cancer is usually associated with high levels of pressure, low social support and family functioning, and is followed by high levels of sleep disorders experienced by parents and low levels of health (Mohammadsalehi et al., 2020). The ability of parents and families to manage time, plan activities, and have standard rules that must be carried out in times of difficulty can cause parents to have a high level of resilience (Toledano-Toledano et al., 2021).

The Impact of Resilience on Satisfaction/Quality of Life and Psychological Well-Being of Parents with Children with Cancer
Parents who have children with cancer have a much lower level of quality of life compared to parents who have children undiagnosed with cancer (Y. H. . Parents who have a high level of income and education have a better quality of life when compared to parents who have a low income and have a low level of education (Y. H. . This will usually be followed by a lower level of care burden experienced by parents and a much better level of self-esteem, while parents with low levels of education and income will tend to face the burden of financial problems and difficulties related to the care of their child affected by cancer (Y. H. . Resilience is the only factor attributed to quality of life in parents of children with cancer (Oi Kwan Chung et al., 2022). There is a very significant positive relationship between resilience and psychological well-being in parents with children with cancer (Mustafa et al., 2019). This is because parents have received a cancer diagnosis in their child and all its complications using certain coping strategies, have faced many urgent conditions during cancer treatment, increasing the sense of tolerance and responsibility in parents, and strong faith in God as the main helper for parents, so that finally parents can feel satisfied with what has happened to their child (Mustafa et al., 2019 greater strength and ability to cope with stress and difficulties during the child's cancer diagnosis period, which will later better empower and maintain the psychological well-being and quality of life of the parents (Oi Kwan Chung et al., 2022). Resilience has a very positive impact on parents, including parents will feel satisfied with life and improve their psychological well-being (Y. H. Mohammadsalehi et al., 2020;Mustafa et al., 2019).

Interventions to Improve the Resilience of Parents with Children with Cancer
Resilience-based group therapy interventions are an effective strategy for parents with children with cancer in overcoming cancer suffered by children (Hoseinzadeh et al., 2019). The implementation of resilience-based group therapy interventions will improve the mental health of parents, increase resilience and ability to overcome problems posed by cancer (Hoseinzadeh et al., 2019).
PRISM-P interventions show a positive effect on the level of parental resilience and provide much better benefits when administered individually to parents who have children with cancer (Rosenberg et al., 2019). This PRISM-P can help parents feel more resilient, which can later facilitate their ability to care for their child (Rosenberg et al., 2019).
The smartphone-based application-based resilience training program, developed according to the Kumpfer resilience framework, contains 8 tasks that parents must follow to practice skills that can later encourage the resilience factor of parents who have children with cancer (Y. Luo et al., 2021). Parents who participate in the program have higher levels of resilience and fewer depressive symptoms than parents who do not participate in the program (Y. Luo et al., 2021).
Resilience is the only factor attributed to quality of life in parents of children with cancer (Oi Kwan Chung et al., 2022). There is a very significant positive relationship between resilience and psychological well-being in parents with children with cancer (Mustafa et al., 2019). Parents with a higher level of resilience have greater strength and ability to cope with stress and difficulties during the child's cancer diagnosis period, which will later better empower and maintain the psychological well-being and quality of life of the parents (Oi Kwan Chung et al., 2022). Resilience has a very positive impact on parents, including parents will feel satisfied with life and improve their psychological well-being (Y. H. Mohammadsalehi et al., 2020;Mustafa et al., 2019).
Some interventions that can be done to improve the resilience of parents who have children with cancer such as resilience-based group therapy interventions (Hoseinzadeh et al., 2019), PRISM-P intervention (Rosenberg et al., 2019), and an application-based training program on smartphones developed according to Kumpfer's resilience framework (Y. Luo et al., 2021).

American
Psychological Association.