Pub Med Use of Rituals/routines Family Nursing Apa Citation

J Pediatr Psychol. 2015 Aug; 40(seven): 664–671.

Family Rituals and Quality of Life in Children With Cancer and Their Parents: The Function of Family unit Cohesion and Hope

Susana Santos

¹Faculty of Psychology and Education Sciences, University of Coimbra,

Carla Crespo

²Faculdade de Psicologia, Universidade de Lisboa, and

M. Cristina Canavarro

¹Faculty of Psychology and Education Sciences, Academy of Coimbra,

Anne E. Kazak

³Nemours Children'southward Health Arrangement, Sidney Kimmel Medical College of Thomas Jefferson University

Received 2014 Sep 17; Revised 2014 Dec 23; Accepted 2015 February 2.

Abstract

Objective Family rituals are associated with adaptive functioning in pediatric illness, including quality of life (QoL). This commodity explores the function of family unit cohesion and hope as mediators of this clan in children with cancer and their parents.Methods Portuguese children with cancer (Northward = 389), on- and off-treatment, and ane of their parents completed self-report measures. Structural equation modeling was used to examine direct and indirect links betwixt family rituals and QoL.Results When children and parents reported college levels of family unit rituals, they as well reported more family cohesion and hope, which were linked to ameliorate QoL. At the dyadic level, children'due south QoL was related to parents' family rituals through the child's family cohesion. This model was valid across child'due south age-group, handling status, and socioeconomic status.Conclusions Family rituals are important in promoting QoL in pediatric cancer via family cohesion and hope individually and via family unit cohesion in terms of parent–child interactions.

Keywords: families, hope, parents, pediatric cancer, quality of life

Quality of life (QoL) is a widely accepted result in pediatric cancer that is helpful in agreement the impact of these illnesses and treatments on children and families. Decreased QoL is understandable and even expected, particularly during treatment, and may persist afterwards treatment ends (Klassen, Anthony, Khan, Sung, & Klaassen, 2011; Klassen et al., 2007). An agreement of QoL tin can be enhanced by examining kid adjustment in the context of social-ecological (Kazak, 1989) and transactional models (Fiese & Sameroff, 1989) of development, frameworks that highlight the contextual (eastward.g., family unit environment) and dynamic common effects betwixt children and parents that have identify beyond time.

Family rituals are special events, such as celebrations, traditions, and patterned family interactions, with a symbolic meaning shared by the whole family; these events are examples of family unit functioning that may exist associated with QoL (Fiese et al., 2002). Family rituals have been linked with positive outcomes, such as psychological functioning, adherence to treatment, and health-related behaviors (Crespo et al., 2013; Fiese, 2006; Fiese et al., 2002). Studies in community samples found that family ritual meaning was positively associated with adolescents' identity, feelings of security (Fiese, 2006), and predicted well-being over ane year (Crespo, Kielpikowski, Pryor, & Jose, 2011). In pediatric asthma, mothers' family ritual significant was associated with less feet in the child (Markson & Fiese, 2000). Although positive links between family rituals and children'southward health outcomes accept been consistently supported, the underlying pathways for these associations are non known.

One possible pathway is family cohesion, a characteristic of families known to be associated with positive kid outcomes. Fiese et al. (2002) concluded that when family rituals are interrupted, family cohesion is threatened. In addition, research suggested that children with cancer undergoing treatment with positive family performance (e.one thousand., high cohesion) were more than likely to study meliorate psychological adjustment and QoL (Barakat, Marmer, & Schwartz, 2010; Klassen et al., 2007). Family rituals can provide arrangement and increment cohesion by strengthening family ties (Crespo et al., 2013; Fiese, 2006; Fiese et al., 2002) that can exist important resources to manage the disease, encourage adherence to treatment, and promote adaptive parenting. Parents' family ritual meaning was connected to adolescents' well-beingness through both adolescents' and parents' perceptions of family unit cohesion in a community sample in New Zealand (Crespo et al., 2011). Additionally, Santos, Crespo, Silva, and Canavarro (2012) take demonstrated that family ritual meaning reported by children with asthma was linked to better QoL and to less emotional and behavioral problems, via less conflictual and more cohesive family environments. Together, these data suggest that family ritual meaning promotes better accommodation, and that family cohesion tin can exist a possible path via which this positive influence takes place.

A 2d possible pathway involves promise. Promise is an overall perception that one's goals tin can be met (Snyder et al., 1997), a feature that is especially salient in the face up of obstacles or impediments. Family integration tin foster optimism (Blotcky, Raczynski, Gurwitch, & Smith, 1985) and hope (Shorey, Snyder, Yang, & Lewin, 2003). According to Snyder (2002), a family environment that lacks boundaries, support, and consistency jeopardizes the evolution of hopeful thinking. Family ritual meaning may be one way to provide family members the necessary structure and support to develop goal-directed actions. Family rituals permit recognizing past legacies, interpreting the nowadays, and looking to the future for promise (Fiese, 2006). Positive expectations and hope promote adaption to diagnosis and treatment in adolescents (Hinds et al., 1999). Some other written report of youth with cancer establish a positive relationship between hope and satisfaction with life (Hexdall & Huebner, 2007). Hope tin buffer the relationship between disability-related stress and adjustment in mothers of children with chronic physical condition (Horton & Wallander, 2001). A more hopeful family unit might perceive cancer, its treatment, and long-term consequences every bit challenges to overcome rather than a threat/fatality (Irving, Snyder, & Crowson, 1998). Hence, the family might generate more various or helpful coping strategies (Irving et al., 1998) that tin can translate into better accommodation.

The interdependence of the members of family dyads has been increasingly acknowledged in literature (Kenny, Kashy, & Cook, 2006). Nonetheless, enquiry by and large focuses on individuals (parents or children) and less frequently on common dyadic influences, or how perceptions of one (due east.g., parents) influence the other (due east.g., children), and vice versa. The purpose of this study was to clarify the associations between family ritual meaning and QoL, and specifically examine family cohesion and hope every bit avenues through which family ritual meaning was linked to QoL in children with cancer and their parents. It is also probable that these pathways may differ in parents and children. Children's QoL is hypothesized to be related to parents' family ritual meaning straight and through the child's perception of family cohesion and hope. Parents' QoL is hypothesized to be related to children's family unit ritual meaning direct and through parents' perception of cohesion and promise (run into Figure 1). Finally, as exploratory aims, differences of strengths of pregnant indirect effects linking each pair of independent and dependent variables through unlike mediators, and the invariance of the model across kid's age-group (child vs. adolescents), treatment condition (on- vs. off-handling), and socioeconomic condition (SES; low vs. medium/loftier).

Proposed mediation model (individual pathways are solid lines and dyadic pathways are dashed lines). The dashed lines backside the boxes represent direct dyadic effects of parents' family ritual meaning to children's quality of life and children's family ritual meaning to parents' quality of life.

Method

Participants and Procedures

This study was approved by the ethics committees of three Portuguese public hospitals: Portuguese Institute of Oncology and São João Infirmary, both in Porto, and Pediatric Section—Centro Hospitalar e Universitário de Coimbra in Coimbra. Betwixt June 2012 and February 2014, all participants who met inclusion criteria were invited to participate, using a consecutive sampling arroyo. Inclusion criteria consisted of a diagnosis of cancer at least 3 months ago, aged viii–20 years, receiving handling for primary diagnosed/relapsed cancer (on-treatment) or had finished antineoplastic treatments for principal diagnosed/relapsed cancer within the past 60 months (off-handling). Exclusion criteria were comorbidity with other chronic illness (eastward.g., diabetes), major developmental disorders (e.g., down's syndrome), or end-of-life care. Of the 391 parent–child dyads approached to participate, almost all (N = 389) provided data (99.49%). The 2 families that declined participation indicated that they were too busy or non interested.

A pediatric oncologist identified the eligible families according to the inclusion/exclusion criteria. The report aims were explained to all eligible participants, and informed consent was obtained from all parents and from children aged ≥xiii years; assent was obtained from the younger children. The children and parents were asked to individually consummate self-study measures in a paper-and-pencil version. The protocol was administered in a carve up room in either the inpatient or outpatient setting in the presence of a research assistant who assured that children and parents were unaware of each other'due south responses.

Participants were 389 Portuguese children with cancer and one of their parents¹ (85.thirty% female person). Children and parents ranged in age from 8 to 20 years (M = 13.25; SD = three.45) and 22 to 68 years, respectively. Sociodemographic and clinical characteristics of the sample are provided in Table I. The children were 3 months to 11 years afterwards primary diagnosis and roughly half of the sample was on-treatment (48.lxxx%).

Table I.

Sociodemographic and Clinical Characteristics of the Sample (N = 389 Dyads)

	M/n	SD/%
Parents
Age, M SD	42.31	half-dozen.60
Sex, n%
Male person	57	fourteen.70
Female	332	85.30
Marital status, northward%
Single/separated/divorced/widowed	60	fifteen.42
Married/partnered	329	84.58
SES, northward%
Low	213	54.eighty
Medium	139	35.70
High	37	9.50
Children
Age-group, northward%
Children (8–12 years)	165	42.twoscore
Adolescents (13–20 years)	224	57.lx
Sex, n%
Male	208	53.50
Female	181	46.50
Treatment status, n%
On-treatment	190	48.fourscore
Off-treatment	199	51.20
Fourth dimension since diagnosis in months, M SD	28.xv	27.02
Relapse status, n%
Nonrelapse	340	87.twoscore
Relapse	49	12.60
Malignancy, n%
Leukemias	141	36.25
Lymphomas	97	24.94
Langerhans cell histiocytosis	9	2.31
Solid tumor (extra central nervous system)	104	26.74
Key nervous system tumor	38	9.77
Intensity of handling, north%
To the lowest degree intensive	12	3.ten
Moderately intensive	141	36.20
Very intensive	173	44.50
Almost intensive	63	sixteen.20

Measures

Family unit Ritual Pregnant

Family ritual pregnant was assessed with the Portuguese version of the Family Ritual Questionnaire (FRQ; Fiese & Kline, 1993). Children and parents answered 15 forced-choice items covering family ritual meaning in three settings: dinnertime, weekend, and almanac celebrations (v items for each). Example items are "In some families dinnertime is just for getting food/In other families dinnertime is more than than only a meal it has special meaning"; "In some families there are potent feelings at birthdays and other celebrations/In other families annual celebrations are more casual; people aren't emotionally involved." Participants start chose the description that best represented their family, and and so decided whether that description was really true or sort of truthful. The four possible answers were scored using a 4-betoken Likert calibration. A full score was computed by taking the boilerplate of the item scores, and higher scores signal perceptions of stronger family unit ritual pregnant. Test–retest reliability of the FRQ over 4 weeks was r = .88 (Fiese & Kline, 1993). Internal consistency in this study was .81 for parents and .80 for children.

Family Cohesion

The children'due south and parents' perceptions of family cohesion were measured with the ix-detail Family unit cohesion subscale from the Portuguese version of the Family Surroundings Calibration (Moos & Moos, 1986). The scale assessed the degree of commitment, help, and support that family unit members provided to each other (e.g., "Family members aid and support one another"; "Family members spend a lot of fourth dimension together and pay attention to each other"). The participants responded using a 6-indicate Likert scale. Mean ratings were calculated with college scores indicating higher levels of family cohesion. Subscale'southward reliability was considered adequate with Cronbach's α .78 and exam–retest of r = .86 (Moos & Moos, 1986). Internal consistency on the electric current sample for parents was .86 and for the children was .77.

Hope

Parents' hope was measured by the Portuguese version of Adult Hope Scale (AHS; Snyder, Irving, & Anderson, 1991). Participants answered 12 items (e.chiliad., "I can recall of many ways to get out of a jam"; "I energetically pursue my goals") on an 8-indicate Likert scale; mean ratings were calculated. Children's hope was measured past the Portuguese version of Children Promise Scale (CHS; Snyder et al., 1997), comprising vi-items (east.m., "I call back I am doing pretty well"; "I can recall of many means to get the things in life that are most important to me"). The participants answered the items on a 6-point Likert scale and mean ratings were calculated. In both scales, higher scores denote college levels of hope. The test–retest reliability of AHS was r = .85 over 3 weeks and r = .71 for CHS over 4 weeks. Internal consistency in this sample was .84 for parents and .80 for children.

Quality of Life

Parents' QoL was assessed by the Portuguese version of EUROHIS-QOL (Schmidt, Mühlan, & Power, 2006), a self-written report variation of the World Health Organization Quality of Life-100 and World Health Arrangement Quality of Life, abbreviated version. The EUROHIS provided an overall score of physical, psychological, social, and environmental QoL using eight items (east.g., "How satisfied are y'all with your health") scored on a five-point Likert calibration. A total score was computed by taking the average of the detail scores, with higher scores indicating better QoL. Children's QoL was measured with the Portuguese version of Pediatric Quality of Life Inventory™ (PedsQL™) 3.0 Cancer Module (Varni, Burwinkle, Katz, Meeske, & Dickinson, 2002), which includes 27 items on viii subscales (Pain and Hurt, Nausea, Procedural Anxiety, Handling Anxiety, Worry, Cognitive Bug, Perceived Physical Appearance, and Communication). Participants evaluate how frequently a specific trouble occurred in the by calendar month (east.g., "I go sick to my tum when I take medical treatments" or "I worry that my cancer will come back or relapse"), using a 5-point Likert calibration. The items were reverse-scored and linearly transformed to fit a 0–100 scale; the total QoL score, with higher scores indicating better QoL, was used. The Cronbach'southward α in a sample of x countries was .83 for EUROHIS-QOL (Schmidt et al., 2006). The test–retest of PedsQL™ for a role of the sample on-treatment (n = 52) was r = .79 inside 1 week. Internal consistency of total score in this written report was .83 for parents and .87 for children.

Intensity of Treatment

Intensity of treatment was measured past the Portuguese version of the Intensity of Treatment Rating Calibration 3.0 (Kazak et al., 2012). Using data from the medical record, 14 pediatric oncologists, bullheaded to patient identity, classified each child'southward treatment into one of four levels of intensity, from level 1 (to the lowest degree intensive treatment) to iv (most intensive treatment), based on diagnosis, phase of illness (chief diagnosis or relapse), phase/risk level for the patient, and treatment modalities. Interrater reliability for a subset of this sample on- and off-treatment (north = 59) was almost perfect (κ = .97; p < .001) (Santos, Crespo, Canavarro, & Pinto, 2014).

Clinical and Sociodemographic Characteristics

Other relevant clinical information (e.g., time since principal diagnosis) and sociodemographic data were collected from parents. Using data from both parents' job and educational level, the SES of each family was classified in 3 levels (low, medium, and high) according to an accustomed classification system for the Portuguese context. For analyses purposes, SES was dichotomized into ii levels: depression (n = 213; 54.fourscore%) and medium/high (n = 176; 45.20%).

Data Analysis

Preliminary descriptive statistics and correlations (Pearson and Spearman) were computed for all outcomes with the Statistical Parcel for the Social Sciences (SPSS, five. 21; IBM SPSS Inc., Chicago, IL). Structural equation modeling (SEM) was conducted with the Analysis of Moments Structures (AMOS, v. 21; Arbuckle, 2012) to examination the straight and indirect pathways. The method of estimation was the maximum likelihood. A model-generation application of SEM (Jöreskog, 1993, as cited in Kline, 2005) was adopted: After examining the results for the full proposed model, we trimmed the model by removing nonsignificant paths using p < .05 as criteria. The model'south goodness of fit was assessed using the reference value for the primary fit indexes: chi-foursquare statistic not-significant, comparative fit index (CFI) ≥ .95, and root mean square error of approximation (RMSEA) ≤ .06 (Hu & Bentler, 1999). The significance of indirect paths and differences of strength of meaning indirect paths linking each pair of contained and dependent variables through different mediators (Preacher & Hayes, 2008) was evaluated using bootstrap resampling procedures with 5,000 samples (95% bias-corrected bootstrap confidence interval [CI]) (Amos Development Corporation, 2010).

Multigroup analyses were conducted to determine whether the model was valid across the child's age-group (8–12 vs. thirteen–20 years), handling status (on- vs. off-treatment), and SES (low vs. medium/high) with structural weights (Byrne, 2010), constrained to be equal across groups, and assessed the difference in model fit using the chi-square deviation method (Byrne, 2004).

Results

Preliminary Analyses

Tabular array Two presents the means, standard deviations, and correlations for all outcomes.

Table II.

Descriptive Statistics and Matrix of Intercorrelations Among Report Variables for Parents and Children

Variable	Parents						Children						M	Range	SD
	1	two	3	4	five	six	7	viii	9	10	11	12
Parents
1. Family unit ritual meaning (P)													three.34	1–four	0.fifty
ii. Family cohesion (P)	.47**												4.93	1–6	0.77
iii. Hope (P)	.13**	.31**											five.83	1–8	one.13
iv. QoL (P)	.20**	.35**	.36**										3.53	i–5	0.53
five. Age (P)	−.07	.01	.08	−.04									42.31	–	6.60
6. Sex (P; male/female)	−.04	−.09	−.08	−.12*	−.06								–	–	–
Children
vii. Family ritual meaning (C)	.35**	.23**	.04	.12*	−.15**	−.00							3.28	i–4	0.fifty
8. Family unit cohesion (C)	.27**	.38**	.09	.18**	−.12*	−.08	.49**						5.10	1–half-dozen	0.61
9. Promise (C)	.thirteen**	.xv**	.17**	.08	.xi*	.03	.13**	.31**					4.53	1–6	0.82
10. QoL (C)	−.02	.04	.thirteen**	.11*	.06	−.01	.09	.19**	.28**				75.18	0–100	13.58
eleven. Age (C)	−.07	.01	.09	−.05	.43**	−.01	−.22**	−.05	.12*	−.08			xiii.25	–	3.45
12. Sexual practice (C; male/female person)	−.05	−.03	−.02	−.03	.04	−.08	−.02	.08	−.01	−.13*	.09		–	–	–
13. SES (low/medium-high)	.xiii*	.15**	.12*	.twenty**	.07	−.12*	.08	.09	.09	.02	−.09	.04	–	–	–

SEM Examination of the Mediation

A path model was constructed to examine the direct and indirect links between family ritual meaning and QoL for parents and children. First, we tested a total model, present in Effigy 1, that showed a good fit χ²(iv, North = 389) = 5.13, p = .28; CFI = one; RMSEA = .03. Next, nosotros trimmed this model, by removing the nonsignificant paths. Effigy ii and Table Three depict the final trimmed model that presented a good fit χ²(11, N = 389) = fifteen.87, p = .fifteen; CFI = .99; RMSEA = .03.

Trimmed model (nonsignificant paths are not represented). The path model shows the indirect furnishings of family ritual meaning on parents' and children's QoL via family cohesion and hope.

Notation. Fit indices for the model were as follows: χ^two(11, N = 389) = xv.87, p = .fifteen; CFI = .99; RMSEA = .03. Bold figures represent standardized coefficients. For simplicity, covariances (found in Tabular array 3) are not depicted; ***p < .001; **p < .01; *p < .05.

Table 3.

The Unstandardized Coefficients and Standard Errors for all Parameters, and the Bias-Corrected Bootstrap Conviction Intervals for the Indirect Effects

Estimated parameters	Unstandardized coefficients	SE	p	BC bootstrap, 95% CIs for indirect effects
Direct furnishings (individual level)
Rituals P → Cohesion P	0.72	0.07	<.001
Rituals P → Promise P	0.27	0.11	.016
Cohesion P → QoL P	0.18	0.03	<.001
Hope P → QoL P	0.13	0.02	<.001
Rituals C → Cohesion C	0.54	0.06	<.001
Rituals C → Promise C	0.22	0.08	.009
Cohesion C → QoL C	2.38	1.14	.036
Hope C → QoL C	iv.xi	0.84	<.001
Directly effects (dyadic level)
Rituals P → Cohesion C	0.12	0.06	.033
Covariances
Rituals P ↔ Rituals C	0.09	0.01	<.001
e (Cohesion P) ↔ east (Hope P)	0.21	0.04	<.001
due east (Cohesion C) ↔ eastward (Hope C)	0.12	0.02	<.001
e (Cohesion P) ↔ e (Cohesion C)	0.11	0.02	<.001
e (Hope P) ↔ e (Promise C)	0.15	0.05	.002
east (Cohesion P) ↔ e (Promise C)	0.05	0.03	.084
eastward (Hope P) ↔ e (Cohesion C)	0.04	0.03	.190
e (QoL P) ↔ e (QoL C)	0.41	0.32	.190
Indirect effects (individual level
Rituals P → QoL P (via Cohesion P)	0.13	0.03	<.001	[0.08, 0.xix]
Rituals P → QoL P (via Promise P)	0.03	0.02	.011	[0.01, 0.07]
Rituals C → QoL C (via Cohesion C)	0.30	0.62	.028	[0.15, 2.61]
Rituals C → QoL C (via Hope C)	0.89	0.twoscore	.006	[0.25, 1.81]
Indirect furnishings (dyadic level)
Rituals P → QoL C (via Cohesion C)	0.28	0.19	.031	[0.02, 0.81]
Differences of strength of indirect furnishings (private level)
Rituals P → QoL P (via Cohesion P) ≠	0.10	0.03	.004	[0.04, 0.sixteen]
Rituals P → QoL P (via Promise P)
Rituals C → HRQoL C (via Cohesion C) ≠	0.twoscore	0.77	.632	[−i.22, 1.83]
Rituals C → HRQoL C (via Hope C)

Table 3 showed that at the individual level, family ritual meaning was associated with QoL, via family cohesion (95% CIs, [0.08, 0.19] and [0.15, ii.61]) and promise (95% CIs, [0.01, 0.07] and [0.25, 1.81]) for both parents and children, respectively. At the dyadic level, children's QoL was linked to parents' family unit ritual meaning through the child's perception of family cohesion (95% CI, [0.02, 0.81]).

A comparison of the strength of pregnant indirect effects was calculated. For parents, only non for children, the indirect path from family ritual meaning to QoL via family cohesion was stronger than the ane via promise (95% CI, [0.04, 0.16]). Multigroup analyses confirmed that the model was valid across kid's age-group Δχ²(ix) = 12.96, p = .xvi, treatment condition Δχⁱⁱ(9) = 14.03, p = .12, and SES Δχ²(nine) = xv.78, p = .07.

Discussion

The findings of the current study are congruent with prominent goals of improving the QoL of children with cancer and their parents, providing family back up, and developing empirically supported interventions. Family rituals are of import components of family operation but accept been underexplored in the pediatric cancer literature.

In line with the social-ecological and transactional models' assumptions almost the mutual influences between parents and children (Fiese & Sameroff, 1989; Kazak, 1989), family unit ritual pregnant was positively associated with better QoL through family cohesion and hope in a large Portuguese sample of patients and parents. In add-on, parents' family ritual meaning was positively associated with children's family cohesion, which, in plow, was linked to meliorate children's QoL.

Consistent with prior research showing associations between meaningful family unit rituals and adaptive family operation (Fiese, 2006; Imber-Black, 2014), and between positive family operation and psychological adaptation (Barakat et al., 2010; Litzelman et al., 2013), parents and children who endorsed more family unit ritual meaning perceived their families every bit more cohesive and experienced improve QoL. It is possible that a family that has frequent and meaningful interactions, perceives their family as closer and interdependent (Crespo et al., 2011). A more cohesive family unit might be more inclined to share responsibilities (eastward.g., medication tasks, monitoring of symptoms), decision-making, and offer support—"being there"—which might contribute to ameliorate QoL.

The clan of family ritual pregnant and hope is some other new finding in pediatric cancer. When parents and children endorse more family ritual pregnant, they have more hope. The data underscore the rationale that family rituals act equally an anchor, providing security in times of change (Fiese, 2006; Imber-Black & Roberts, 1998). Families that accept a more secure base may feel more than hopeful to deal more flexibly with their disease- and handling-related challenges. They might, for instance, engage in more than adaptive coping behaviors (east.g., treatment adherence, prevention behaviors). When the families have more than hope, they perceive better QoL (Hexdall & Huebner, 2007; Horton & Wallander, 2001). Families who are more than hopeful may besides be less hypervigilant and/or worry or ruminate less about symptoms, leading to amend QoL. Notwithstanding, in the absence of previous empirical evidence and given that the association between family ritual pregnant and hope was small, this result must be interpreted with caution.

Similar to the findings of Crespo and colleagues (2011), when parents ascribed more meaning to family rituals, children reported a stronger sense of family cohesion, which, in turn, was linked to ameliorate QoL. Although children and adolescents are active participants in daily living routines and cocreators of meaningful rituals, adults play the part of "kinkeepers" and have a stronger say in how family rituals are organized (Fiese, 2006). This may explain why family ritual meaning perceived by parents was associated with children'south QoL, via children's cohesion, but non the contrary.

The comparing of the strength of pathways of children and adults is novel. For children, both family cohesion and hope are of import mediators betwixt family ritual meaning and QoL. However, for parents, family ritual meaning promoted QoL mainly via family cohesion. This suggests that family ritual pregnant has a more of import function in fostering family integration and closeness, than on promoting an optimistic outlook. Fostering family cohesion through family rituals (due east.k., eating meals together imbued with a special significant shared by family unit members) may exist easier and more tangible than irresolute attitudes (due east.g., hopefulness) and can provide a structure to enhance family well-beingness. In addition, a cohesive family can lighten the brunt of the caregiver by the sharing of responsibilities (Klassen et al., 2007). This may explicate why family unit ritual meaning promotes QoL mainly via family cohesion for the parents, but not for the children.

The associations tested did non differ by child's age-group, handling status, or SES. Although the nature of family rituals will naturally differ in families of younger versus older children, the commitment to initiate and maintain rituals may be consistent. Similarly, although beingness off-handling differs in major means from existence on-treatment, family unit rituals, cohesion, and hope seemed to exist equally important in both conditions. Moreover, although lower SES may entail increased challenges, this does not seem to compromise the influence of family rituals. It is worth noting that more half of this sample was composed of low SES families. SES is associated with lower QoL in pediatric cancer in general (Litzelman et al., 2013). This is particularly timely because Portugal is experiencing an economic crisis with increased rates of unemployment and fewer fiscal supports for families in the health-care organization (e.g., less reimbursement of transportation and medicine and increased user fees associated with care, fifty-fifty in a system with National Wellness System). Although SES obviously is not easy to change, these data propose that enhancing family ritual significant can be of import even in the presence of financial distress.

Of course, the findings must be considered within the scope of some limitations. First, this is a Portuguese sample and may not exist fully generalizable to other cultures. While research in other cultural contexts will help clarify this point, family cohesion and hope are rather universal concepts equally are family rituals (e.1000., family celebrations, meals). Second, given the cantankerous-sectional research pattern, information technology is not possible to institute causality among the variables. Although nigh literature endorses the function of rituals as promoters of family unit belonging and cohesion (e.yard., Crespo et al., 2011; Fiese et al., 2002; Santos et al., 2012), more than longitudinal studies are needed to test the direction of these furnishings and how family unit rituals, family cohesion may influence each other over time. An alternative model where hope was the independent variable and family unit cohesion and ritual meaning were the mediators had a poor fit. Third, although QoL is a widely accepted relevant outcome that covers multiple domains, testing these associations with respect to other outcomes (e.m., feet, depression, well-being) will be important. 4th, because most parents were mothers, caution must exist taken when generalizing results; fathers' perceptions of family ritual meaning and whether fathers' family unit ritual meaning holds a similar relation with QoL are not known. 5th, it is possible in that location are other clinical of import variables not addressed in this study (e.g., treatment adherence, diagnosis, fourth dimension since diagnosis, intensity of treatment) that might explain more of the variance of the children's QoL. Sixth, in addition to family rituals, it would be valuable to examine whether family unit cohesion is also linked to hope. Finally, cancer-specific family rituals may likewise exist meaningful (eastward.chiliad., marker the end of a chemo bike) and should be investigated as strategies to promote well-being.

The results provided empirical prove for the relevance of incorporating an adaptive focus on family rituals in interventions in pediatric cancer, comparable with the family interventions adult for other health problems (Fiese, 2006). In the face of serious illness, meaningful family rituals may contract, disappear, or be put aside (Imber-Blackness, 2014). Moreover, some families, under specific circumstances, may find it difficult to acquit out flexible and meaningful rituals; when family rituals are bereft or too rigid (Roberts, 2003), the benefits of these family events may be weakened or disappear altogether. The data in this report advise that, to the extent possible, helping families recognize, preserve, arrange, and develop new salubrious family rituals beyond the course of treatment may help foster QoL by improving family cohesion and hope.

In decision, understanding the factors and the mechanisms that link family rituals and performance tin inform the development of interventions. The current written report showed that family ritual pregnant predicted QoL via family cohesion and hope, at the individual level, and that children's QoL was influenced by parent' family ritual meaning, but only via children's family cohesion, and that these associations are similar across child's age-group, treatment status, and SES. Our findings contribute to the literature that suggests the relevance of interventions that tin create, activate, or adapt family rituals, as naturally existing family resource, to address the psychosocial needs of children with cancer and their parents during this adverse period of the family's life.

Funding

This research was supported by a PhD fellowship from the Portuguese Foundation for Science and Engineering science (SFRH/BD/80777/2011;) to Susana Santos. Additional support for the grooming of this manuscript was provided from K05CA128805 (Kazak) and the Nemours Center for Healthcare Delivery Science.

Conflicts of interest: None declared.

Footnotes

1 The term "parent" is used to denote the master caregiver; even so 2.10% of those were grandparents, with whom the children lived.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542831/

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