The results of this study partially support the FMSF, in which not all contextual variables (family income, family structure, geographic location, social support, child age, and disease severity) significantly influenced family management. In this study, social support positively affected EFM and negatively influenced DFM. Social support indicated that for each increase of one point in social support, easy family management rose by 33%; on the one hand, the DFM decreased by 13%. This finding confirmed the importance of social support in the family management framework. It was consistent with the previous findings, in which parents in the US who had children with food allergic and had more social support were significantly associated with less parental monitoring, as well as a study in China reported that parents who had children with chronic conditions and had a relationship with friends, relatives, and neighbors increased parental mutuality, one component of EFM [31, 48]. Better social support caused low levels of stress and burden, so it interfered with the management efforts and perceived fewer difficulties, and predicted resilience [23, 49–51]. This result followed the previous research that stated that social support significantly predicted the resilience of Iranian parents with childhood cancer [51]. Specifically, this finding accordance with a study in China, found that social support affected the EFM of families with childhood leukemia through family functioning [52].
Based on the basic theory of FMSF, this study supported that the contextual influences of "family's social network" or social support from extended family and friends positively contributed to easy family management [23]. During taking care the children with cancer, parents receive more support, particularly emotional support, from their family, significant others, and healthcare providers than before, which helped them to overcome their difficulties [53, 54]. In this study, most parents (88.5%) received adequate support from their family, friend, and healthcare team. As a result, the EFM level was high, while the DFM level was low. This was not surprising, considering that most of the parents were Javanese and lived in rural areas with a culture of "going royong" (solid cooperation) and "tulung tingling" (mutual help) are extreme traditionally [55].
Another finding of this study found that the severity of the disease negatively influenced EFM and positively affected the DFM of Indonesian parents whose children with leukemia. Children with cancer and leukemia are generally treated by chemotherapy, which it took a long and routine time, potentially causing difficulty for parents, such as they spend a lot of time and energy, disruptions in family dynamics, and negative feelings of the patient [56, 57]. Moreover, the adverse effects of treatment were common in childhood leukemia, as mentioned in Mexican children with ALL, with 81.2% experiencing adverse events, with more than half having severe effects (52.6%) [58]. The more severe the disease, the more complex the problems and burdens faced by parents; as a consequence, changes in their perspective of illness and family management occurred, such as increasing management efforts, family life difficulty, and view of the condition's impact [29, 59–61]. This finding also aligns with a previous study on children with chronic conditions in China. The frequency of hospitalization and the number of medicines significantly predicted a child's daily life and easy family management [26, 31]. This study involved more children in the maintenance phase, in which the parents experienced a long period of caring for their child, causing the normalization process, as well as parents in the US who had children with stage IV cancer got accustomed to their life and conditions [62].
Another important finding in this study was that EFM negatively affected DFM. Although limited studies evaluated this correlation, this finding supported a previous study of Chinese caregivers whose children with chronic conditions found that EFM significantly negatively affected DFM (effect size − .90) [32]. Positive parents’ view on the child's daily condition, good management skills, and close relationships with partners will make the family situation conducive and lower stress of parents, so that the difficulties encountered and easier in caring for children, and also parents have more optimistic expectations for their children, with the result a lowering of DFM. In this study, the parents have cared for their children for at least three months, so even though they perceived to adapt to their condition, a report stated that mothers whose children with ALL after three months passed their difficulties with worrying about some potential risks for their children and develop new skills to treat their children [54, 63]. Moreover, better EFM is influenced by the characteristics of the Indonesian population, as a report in 2020 stated that Indonesia was the most religious country in the Asia Pacific, in which positive religious coping was significantly related to psychological distress [64, 65].
The subsequent findings of this study were that the child's age, the severity of the disease, and family management ( both EFM and DFM) directly affected the HRQOL of children. Age of the child positively affected the HRQOL of children (b = .813, β = .181, p = .000). This finding was normal in case the higher age, the more prolonged therapy received by children, and they were in the last phase of therapy where the anti-cancer drugs less in doses and side effects [3]. This result was related to the general situation in childhood ALL, as reported from the US, children who reached the remission phase of chemotherapy between 90–100% and 5-year survival rate of around 92% [66]. This finding was inconsistent with a previous study in Saudi Arabia of children with cancer (70% of them was leukemia) aged 8–15 years which found that the total mean of children's quality of life (QOL) was 73.48 (± 15.78). There was no association between the age of the child and their QOL; interestingly, children under seven slightly predicted one subscale of QOL "pain and hurts" [67].
Furthermore, a qualitative study in Yogyakarta, Indonesia, stated that school-age children with cancer experienced the trauma of procedural pain as a component of HRQoL [68]. Secondly, the severity of the disease negatively affected the child’s HRQoL (b = -2.081, β = − .248, p = .000). The severity of the disease experienced by children is closely related to the severity of the adverse effects during active treatment. This finding was consistent with previous studies that reported more adverse effects and fatigue of children with cancer predicted poorer children’s QOL and HRQoL [18, 69, 70]. Family management was the last variable that influenced a child's HRQoL; higher EFM increased HRQoL, while greater DFM reduced HRQoL. This study partially confirmed that a previous study of Korean parents with an epileptic child stated that easy family management had a significantly direct effect on the child's QOL; on the other hand, difficulty in family management was not significantly correlated to QOL [25]. Furthermore, a study in Brazil found that one component of EFM, "parental mutuality," is positively associated with all aspects of HRQoL and the general health state [71]. This finding was consistent with a study of Chinese caregivers of childhood chronic conditions found that EFM significantly affected the children functioning, and DFM did not significantly affect DFM [32].
Another interesting finding was that EFM and DFM partially mediated the relationship between the severity of disease and HRQOL, in which DFM was a slightly more potent mediator than EFM. This finding partially confirmed the theory of family management style; in this situation, the effect severity of the disease can be raised or lowered through the parents' condition in easy family management or difficulty in family management [27]. This result also supports two previous studies that stated family management was mediating between contextual influences and child functioning and child’s quality of life of children with chronic diseases [25, 32]. One component of EFM was parental mutuality; this can be explained that even though the child experienced the worse conditions, if the parental mutuality were superior would cause the repair of children's HRQOL. A survey of 111 parents of children with cancer treatment in South Korea reported that family communication skills (ß = 0.403, p < 0.001) were a protective factor for family resilience as much as 29% [72, 73]. Moreover, the better easy family management indicated families had various skills and knowledge in caring for their children in any conditions and could handle it well in case their child got severe disease. In line with a literature review, this result mentioned that the disease-specific knowledge of parents directly impacted child health outcomes [74].
Furthermore, the mediating effect of DFM on the severity of disease and HRQoL can be explained that the coping of parents different individually, such as perception of their child's future and perceived difficulty while taking care of their child potentially worse the child's HRQoL, as mentioned of a study of caregivers of childhood cancer during active treatment in Spain experienced less psychological adjustment than parents whose children had completed treatment [73]. Additionally, this finding was in line with a newest previous study that parents who had negative parenting styles had mediated the relationship between parental stress and behavioral problems of children [75]