Family-Related Factors Influencing Resilience of Korean Adolescents and Young Adults with Childhood Cancer: A cross-sectional study

doi:10.21203/rs.3.rs-4266688/v1

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Family-Related Factors Influencing Resilience of Korean Adolescents and Young Adults with Childhood Cancer: A cross-sectional study

https://doi.org/10.21203/rs.3.rs-4266688/v1

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Purpose

Resilience is considered an essential component of the successful recovery of adolescents and young adults (AYAs) from childhood cancer. Factors that affect resilience have been studied in various ways, but family-related factors in Korean AYAs with cancer have received insufficient attention. Families will likely play an important role in acquiring and maintaining resilience. This study aimed to identify family-related variables, such as parent-child communication, family strengths, and family support, that might influence the resilience of Korean AYAs with cancer.

Methods

This study recruited 141 Korean AYAs with cancer aged 11–26 years. Data were collected using online and offline questionnaires between June 2019 and January 2021. Family-related variables were examined as suggested by the Resilience in Illness Model. Data were analyzed using the t-test, analysis of variance, Pearson’s correlation analysis, and hierarchical regression.

Results

Resilience was positively correlated with all variables. According to the hierarchical regression analysis, higher levels of family strengths (β = .202, p = .039) and stronger family support (β = .456, p < .001) were associated with higher levels of resilience, with an explanatory power of 40.3% (F = 19.533, p < .001) after controlling for demographic and clinical characteristics.

Conclusion

The findings support the contribution of family strengths and support to the resilience of Korean AYAs. Future longitudinal studies are warranted to confirm family strengths and support as predictors while considering other relevant variables. Also, we suggest that family-centered programs include actively encourage family members’ participation in supporting AYAs by reflecting on family dynamics.

cancer

resilience

communication

family strength

social support

Owing to the high cure rate and advances in medical technology, childhood cancer is no longer considered an incurable disease but a chronic one [1-3]. More than 80% of children diagnosed with cancer are long-term survivors [4]. According to the annual report of cancer statistics in Korea in 2019, the crude rates were 14.2 per 100,000 (0–14 years) and 74.8 per 100,000 (15–34 years), and the five-year relative survival of patients with common childhood cancer from 2015 to 2019 was 85.2% [5].

Adolescents and young adults (AYAs) are in a critical transitional period and experience many changes in their physical, emotional, behavioral, cognitive, and sexual development [6]. During this period, a chaotic event such as being diagnosed with cancer can bring about dramatic changes in their lives and disrupt developmental accomplishments [7], causing diverse emotional, interpersonal, existential, and spiritual challenges [8]. Additionally, AYAs with cancer lack self-care skills and are not fully prepared to manage the long-term effects of the illness; they need to learn how to maintain a healthy and long life [9].

Previous studies have shown that the resilience of AYAs with childhood cancer plays a key role in overcoming cancer-related distress and in adjusting to the illness [10-14]. However, these studies were primarily conducted among North American AYAs. Resilience refers to an individual’s ability to maintain or restore relatively stable psychological and physical functioning when facing stressful life events and adversity [15]. The evidence suggests that resilience is among the most important factors in maintaining a long and healthy life by overcoming the adversity of being diagnosed with cancer and experiencing positive growth [16, 17]. Little research has been conducted on resilience and psychological adjustment among Korean pediatric cancer patients [12-14]. Hong and Park (2015) and Shin and Oh (2021) examined the predictors of resilience among Korean AYAs [12, 14]. Shin and Oh (2021) examined the relationship between resilience and diverse factors such as the level of cancer stigma, coping, spirituality, hope, family communication, and social support among Korean AYAs with cancer [14]. Hong and Park (2015) also examined types of coping and hope as factors that contribute to resilience among Korean AYAs with cancer [12]. They found that courageous coping and hope were common predictors of resilience in Korean AYAs. However, previous studies have been limited to exploring individual-level factors, such as disease-related characteristics and emotional factors that affect the resilience of AYAs with childhood cancer and have ignored family-related factors. Despite the importance of individual characteristics and personality as predictors of resilience among cancer patients [18], it is necessary to explore family-level factors that contribute to resilience.

The importance of the family environment in fostering pediatric cancer patients’ adjustment to diagnosis is widely accepted among researchers [11, 19, 20]. In particular, the importance of the family environment has increased in Korean culture, described by Kim et al. (2014) as a family-centered model [21]. In traditional Korean culture, the family is one of the main sources of financial, instrumental, and emotional support for family members and relatives [22]. Thus, families, specifically parents, play a critical role for their children, even during adolescence and emerging adulthood, by providing unconditional support [22]. In the context of a child’s cancer diagnosis, there seems to be an increased need for family support to manage symptoms and complete treatment plans. The need to investigate family-level factors has recently been demonstrated through funding opportunities to examine the risks and protective factors for family health and family-level interventions. According to the National Institutes of Health [23], existing research on patient populations has mainly focused on individual- or patient-level data (i.e., the type of cancer, type of treatment, or their risk and resilience) without fully considering the family dynamics and overall health of the family unit.

Unfortunately, relatively little attention has been paid to family-level predictors of resilience among Korean AYAs with cancer. This study aimed to identify family-related predictors of resilience in Korean AYAs with cancer and survivors. The results of this study will serve as basic data for preparing family-centered nursing interventions to enhance the resilience of AYAs with childhood cancer.

Theoretical Framework

The Resilience in Illness Model (RIM2) provided a guiding framework for this study [11]. According to the RIM, AYAs with cancer can produce resilience and self-transcendence as an outcome of the interactions between two risk factors (illness-related distress and defensive coping) and five protective factors. Among the protective factors, family environment was the focus of this study to answer the question: What are family-level predictors of resilience in AYAs in the context of childhood cancer? There were four family environment variables: family strengths, parent-adolescent communication, family support, and family cohesion and adaptability. Among these four family environment variables, we were interested in family strength, parent-adolescent communication, and family support as potential predictors.

Family strengths involve faith, trust, and respect for family members. They are useful tools for assessing a family’s ability to overcome and recover well when faced with problems [24]. Olson and Gorall (2003) describe family strengths as “characteristics and dynamics that enable one to demonstrate resilience and successfully handle family challenges.” [25]. Parent-adolescent communication is a type of family communication between adolescents and their parents. Family communication is defined as family members’ ability to communicate and express their thoughts and feelings in stressful situations [10]. According to Olson (2000), family communication is a mechanism that promotes the intersection of family cohesion and flexibility [26]. AYAs with cancer can stabilize their minds and bodies, relieve stress, and gain courage and strength to overcome the disease through communication with their parents [11, 27] and face cancer courageously [28]. Family support is one of the most robust components that can contribute to AYAs with cancer adjusting to their illness and developing resilience, even though they will become more independent in the developmental stage.

In Haase’s original study of AYAs who received hematopoietic stem cell transplantation (HSCT) [11], the influence of family environment on resilience was mitigated because of the influence of illness-related distress; therefore, there was no significant relationship between family environment and resilience. Thus, this study aimed to examine the family environment predictors of resilience among AYAs with cancer will contribute new knowledge.

The specific objectives are as follows:

1. To identify the level of parent-child communication, family strength, family support, and resilience among Korean AYAs with cancer.

2. To examine the correlation between parent-child communication, family strength, family support, and resilience.

3. To identify family-related factors that influence resilience in AYAs with childhood cancer.

Study Design

This was a cross-sectional, descriptive, correlational study of AYAs with childhood cancer to examine the correlations between resilience and family-related variables (family strengths, communication with parents, and family support) and identify family-related resilience predictors.

Setting & Participants

The participants in this study included all Korean AYAs with childhood cancer aged 11–26 years who were receiving or had not received treatment. The recruitment of AYAs and data collection were conducted online and offline between June 2019 and January 2021. Offline (in-person) recruitment was used for AYAs who visited the outpatient clinic of department of pediatric hematology and oncology, cancer center in Y University, Seoul, which is one of the largest pediatric cancer centers in South Korea. Online recruitment was performed through the Korea Childhood Leukemia Foundation website, which have managed AYA with childhood cancer during acute phase as well as chronic. The inclusion criteria were as follows: (1) 11–26 years of age, (b) diagnosed with childhood cancer at any stage but not in a hospice, (c) fully informed about their diagnosis, and (d) able to communicate in Korean to complete the required questionnaires. The required sample size for this study was estimated using G*Power 3.1.9. The required number of participants for the regression analysis was 118, with 10 predictors, an effect size of .15, a power of .80, and a significance level of .05. Considering the dropout rate, 156 people were asked to complete the questionnaire, and data from 141 people were used for the final analysis; 15 questionnaires with insufficient responses were excluded. The questionnaire was answered by 141 participants with no withdrawals.

Measurements

The questionnaire was based on Haase’s RIM study and was the same tool as the family-related variable-specific tool used in Haase’s study [11]. If there was a Korean version whose reliability and validity were verified, the existing tool was used with the original author’s permission.

Demographic and Disease-related Characteristics

The questionnaire used to identify the participants’ general and disease-related characteristics included questions about their age, sex, education status, diagnosis, period after diagnosis, current treatment status (on or off treatment), and recurrence (yes/no).

Resilience

Resilience was measured using Haase’s resilience measurement tool [11, 29] after translating it into Korean [12]. This tool was developed to measure the resilience of adolescents with childhood cancer by assessing elements of superiority, competence, achievement, and growth. This measurement consists of a 15-item 6-point scale, with 1 representing “strongly agree” and 6 representing “strongly agree.” The total score ranges from 15 to 90. A higher score indicates a stronger will to recover. Regarding internal reliability, Cronbach’s α was .87 in the previous study with a pediatric cancer population [10] and .089 in this one.

Parent-Adolescent Communication

The Parent-Adolescent Communication Scale (PACS) measured communication between parents and adolescents and young adults. Barnes and Olson developed this instrument to measure the openness and awareness of problems in parent-adolescent communication from adolescents’ perspectives [30]. The 20-item PACS is rated on a 4-point Likert-type scale, with 1 representing “strongly disagree” and 4 representing “strongly agree.” The total scores range from 20 to 80, with higher scores indicating more open and less problematic communication. There are two sets of norms for adolescents: one for communication with the father and another for communication with the mother. The measure reported excellent reliability, with Cronbach’s alpha ranging from 0.82 to 0.92 in the previous study [31]. In terms of the internal reliability of communication with the father and mother in this study, Cronbach’s α was 0.92 and 0.91, respectively.

Family Strengths

Family strengths were measured using two subclasses of the Family Strength Scale [32]: family pride (seven items) and family strengths (five items). The scale uses a 5-point Likert-type scale, with 1 representing “strongly disagree” and 5 representing “strongly agree.” The total scores range from 12 to 60, with higher scores indicating greater perceived family strengths [33]. The family pride subclass measures loyalty, respect, and trust within the family, while Accord measures a family’s sense of competence. The measure reported excellent reliability, with Cronbach’s alpha ranging from 0.72 to 0.83 in a previous study [34]. In terms of internal reliability, Cronbach’s α for family strength was .86 in this study.

The Perceived Social Support-Family (PSS-Family)

The PSS-Family consists of 20 items that measure the extent to which individuals perceive that their families support them through the necessary information and feedback [35]. Each item was scored on a 5-point Likert-type scale, with 1 representing “totally disagree” and 5 representing “totally agree.” The total scores range from 20 to 100, with higher scores indicating greater levels of perceived social support from family. The measure reported excellent reliability; Cronbach’s alpha was .91 in a previous study [35] and 0.91 in this study.

Data Collection and Ethical Consideration

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the institutional review boards of Y University and Y Hospital in S city in Korea (2019-0263-003) and participating institution (D university) in United States (Pro00105744). We recruited 141 AYAs with cancer. The survey was administered either online or in person. In the case of offline collection, the researchers explained the study’s purpose and content in a way that was easy for the participants to understand. In the case of online collection, participants who saw the recruitment poster on the Leukemia Foundation’s website and carefully read the study’s purpose and contents could decide whether to join the study. If they agreed to participate, they signed an electronic consent form before they could start the online survey. The researchers followed them up to ensure they met the inclusion criteria and confirmed their voluntary participation. Additionally, the participants were informed that this was an anonymous survey with no possible leakage of personal information or threat to their safety and that participation was voluntary without any negative effects. Participants were also informed that they could withdraw from the study at any time without any disadvantages. We explained that all information would be coded and safely processed only for this study, and those who voluntarily agreed to participate were selected. Approximately 15–20 min were required to complete the questionnaire, and a gift card worth $20 was given after questionnaire completion as a token of gratitude for the respondents’ participation.

Data Analysis

We analyzed the data using SPSS 26.0 for Windows (IBM, Seoul, South Korea), and all p-values were two-sided with significance level set at 5%. The participants’ demographic traits were represented by whole numbers and percentages; demographic details, resilience, communication with father and mother, family strengths, and family support were represented by means and standard deviations. For resilience, communication between father and mother, family strengths, and family support according to demographic details, we performed a t-test, analysis of variance (ANOVA), Scheffe’s test, and the Duncan test as post-hoc tests. For intervariable correlations, we performed Pearson’s correlation analysis and used hierarchical regression analysis to examine the factors that influence the resilience of AYAs with cancer.

Demographic and Disease-Related Characteristics and Differences

Table 1 shows the participants’ general and disease-related characteristics. The 141 participants were between 11 and 26 years old (M = 16.83, SD = 3.9), and 78 (55.3%) were boys. In terms of education, most participants were in middle school (42/141, 29.8%), followed by high school (39/141, 27.7%), elementary school (35/141, 24.8%), and college (25/141, 17.7%). Hematological malignancy was the most common diagnosis (65/141, 46.1%), followed by solid tumors (29/141, 20.6%), brain tumors (25/141, 17.7%), and unspecified tumors (22/141, 15.6%). A post-diagnosis period of between three and six years was the most frequent (40/141, 28.4%), followed by within one year (33/141, 23.4%). Fifty-five (39.0%) respondents were currently undergoing treatment, and the rest (86/141, 61.0%) received follow-up care after completing treatment. Twenty-two participants (15.6%) had experienced cancer recurrence.

The differences in variables according to participants’ general and disease-related characteristics are shown in Table 1. Resilience differed according to sex and treatment status and was significantly higher for girls than for boys (p = .017) and for participants who were under treatment than for those who were not (p = .011). There were no significant differences in resilience based on other general or disease-related characteristics. Differences were observed in variables other than resilience according to the childhood cancer type. Participants diagnosed with solid tumors reported a higher level of communication with their parents (father: p = .015; mother: p = .023), family strengths (p = .002), and family support (p = .024) than those with other childhood cancer types. Participants between three and six years showed significantly more positive aspects of communication with the father (Duncan test) (p = .047) than those with a post-diagnosis period of between one and three years. The variables had no significant differences according to other general and disease-related characteristics.

Levels of Resilience and Family-Related Variables

The mean total score of resilience was 69.11 (SD = 11.54) out of 90. The mean total scores of communication with fathers and mothers were 59.93 (SD = 10.25) and 64.43 (SD = 9.20) out of 80, respectively. The mean total score was 43.34 (SD = 7.90) out of 60 for family strengths and 77.60 (SD = 11.68) out of 100 for family support, all of which were above the median (Table 2).

Correlations across Resilience and Family-Related Variables

The results of the correlation analyses are presented in Table 3. Resilience was positively correlated with all variables. The more positive the communication with the father (r = .389, p <. 001) and mother (r = .449, p < .001), the stronger the family strengths (r = .485, p < .001), and the more appropriate the family support ( r= .583, p < .001), the higher the level of participants’ resilience.

Family-Related Factors Influencing Resilience

Hierarchical multiple regression was used to assess whether family-related factors, including the level of parent-child communication, family strength, and family support, predicted resilience after controlling for the influence of participants’ sex and treatment status (see Table 4). Preliminary analyses were conducted to ensure that the assumptions of normality, linearity, multicollinearity, and homoscedasticity were not violated. To determine the autocorrelation of the dependent variable, we used the Durbin-Watson index; the Durbin-Watson index was 1.929, which is independent. In addition, the tolerance in checking the multicollinearity of errors for the model in this study was below 1.0, the range was between .387 and .985, and the variance inflation factor (VIF) ranged between 1.015 and 2.586, below the limit of 10, which confirmed that all basic assumptions were satisfied.

In Step 1, participants’ sex and treatment status were entered while converting these variables into dummy variables. Both sex and treatment stage affected resilience. Regarding sex, women showed higher resilience than men (β = .176, p = .039). In terms of treatment stage, participants off treatment (β = .200, p = .019) showed higher resilience than participants under treatment, and the explanatory power was 6.6% regarding resilience, with the model being statistically significant (F = 5.665, p = .004).

In Step 2, family strengths, family support, and parent-child communication were entered. Only family strengths and support were found to affect resilience after controlling the demographic variables of sex and treatment status. The more positive the family strengths (β = .202, p = .039) and the stronger the family support (β = .456, p < .001), the higher the resilience, and the explanatory power was 40.3% (F = 19.533, p < .001).

We conducted this study to identify family environment factors that contribute to the resilience of AYAs with childhood cancer. Our study highlights the importance of family strength and support as predictors of resilience in Korean AYAs with cancer.

First, the AYAs in this study reported that family strengths influenced resilience. AYAs with cancer are confident about overcoming cancer well when they perceive that family members trust and respect each other and try to solve problems with one mind. A previous study reported that families with better psychosocial outcomes were flexible and cohesive, found new meaning in life, communicated, and effectively solved problems [36]. In addition, because family strengths play a protective role in resilience, it is necessary to identify and maximize the positive aspects of families, even in difficult situations, to improve resilience [10, 11].

In the present study, family support positively affected resilience. Family support for AYAs with childhood cancer is important [37]. AYAs diagnosed with cancer and undergoing treatment may have unmet physical and psychological demands and may be forced to rely excessively on their parents. AYAs want to be independent but must consider parental involvement in caring, friends, and advocacy during all processes. Adolescents typically extend their sources of social support from family to friends or non-family members; however, family members still receive the most important support from other family members [38]. Adolescents may share concerns with their peers during non-serious stressful situations but depend primarily on their parents and family members when facing extreme stress [37]. Parents must allow AYAs to participate independently, accept what they want, and protect the overall treatment process [39].

Despite recent changes in family structures and increased individualism in Korean society, traditional Korean culture is characterized by familism, which prioritizes the family as a whole and emphasizes family harmony. Thus, traditional Korean culture places great importance on family adaptability, cohesion, and parent-child relationships [40]. In this cultural context, the role of parents in the positive adaptation and coping strategies of AYAs with cancer has been greatly emphasized. A previous study showed that Korean AYAs with cancer who experienced low self-esteem felt satisfied and supported when they were able to share their symptoms and thoughts with their parents, leading to better coping strategies [41]. Additionally, parents were found to play a pivotal role in promoting adaptation to a cancer diagnosis by enabling AYAs to communicate their emotional needs and concerns to their parents throughout cancer management [42].

In this context of the increased importance of the family environment, healthcare providers should consider the need for family-centered interventions to maximize AYA’s resilience. For example, Salem et al. (2017) developed and applied the FAMily-Oriented Support (FAMOS) intervention to help families cope with psychological problems related to cancer and reported high satisfaction among study participants [43]. Family-centered interventions for managing cancer-related problems may help AYAs and their family members reduce conflict [44] and ultimately reduce psychological distress. In the future, in planning and organizing a family-centered program for families caring for AYAs with cancer, it will be necessary to consider individualized content that reflects family characteristics such as family type and communication style.

Contrary to our expectations, communication with parents did not predict the level of participants’ resilience in the regression model after controlling for other variables such as sex and treatment status. These results are not consistent with those of Shin and Oh (2021), who found that parent-child communication predicted the level of resilience among Korean childhood cancer survivors [14]. The critical role of parent-child communication in better adjustment and resilience has been widely acknowledged among researchers [45, 46]. In the context of childhood cancer, if AYAs receive information that is truthful, transparent, and customized in line with their preferences and developmental stage, they feel respected and have the confidence to overcome cancer [47]. Most importantly, parent-child communication is a modifiable factor that can be targeted in clinical interventions to improve psychological outcomes in pediatric cancer patients [48].

This inconsistency may reflect the communication challenges experienced by AYAs with cancer and their families. AYAs aged 11–26 may choose not to share their problems with their parents to reduce their chances of emotional disturbance. Indeed, it has been reported that AYAs with cancer experience difficulties discussing their prognosis or death with their parents during treatment [49, 50]. Alternatively, the inconsistency may reflect AYAs’ preference to communicate with a healthcare provider about their disease, treatment process, and prognosis and to prefer peer groups for emotional connection despite their psychological dependence on their parents, or it could reflect communication avoidance, which is prevalent in patients with cancer. Communication among family members is one of the most challenging issues for individuals diagnosed with cancer [51].

Korean AYAs may experience additional challenges in communicating with their parents in a culture of Confucianism and familyism with a strong hierarchy [21]. However, patriarchal or parent-centered communication, prevalent in Korean families, may increase feelings of helplessness and anxiety [52, 53]. In one study, the mother’s withdrawal and harsh communication style interrupted proper help in the diagnosis and treatment process and led to negative effects on AYAs with cancer [54]. Additionally, evidence supports the possible relationship between parent-child communication and maladaptive coping [50]. Despite the insignificant findings of parent-child communication on resilience, more studies are required on the relationship between parent and adolescent communication and AYAs’ resilience in the childhood cancer context.

A limitation of this study is that it relied on AYAs’ self-reports without sufficiently considering complex family dynamics through a questionnaire. The study participants were recruited from a university-affiliated hospital in Korea. Therefore, the results cannot be generalized to other Korean AYAs. In addition, our study examined only family-related factors without considering other relevant variables in the guiding model (RIM), such as individual physical and psychological factors. This may have limited our ability to determine whether family-related factors are the strongest predictors of resilience. Thus, it is necessary to include other relevant factors, as suggested in the RIM, to gain a comprehensive understanding of the predictors of resilience. Finally, as various family-related factors affect the resilience of AYAs with cancer, future research should conduct in-depth interviews to identify additional factors and understand the relationship and dynamics of related factors.

In caring for AYAs with cancer, the influence of the family, including parents, cannot be ruled out. In Eastern cultures, especially in Korean society, which is still more family-oriented than in the West, the family will be the main driving force for AYAs with cancer to maximize resilience and potential power. This study supports the idea that family-related factors predict AYAs’ resilience. The AYAs in this study reported that the greater the recognition of family strengths and social support from their families, the higher the level of resilience they reported. The next step following this study is to conduct a longitudinal study with all relevant variables to understand the predictors of resilience. Based on the results of the proposed study, it will be possible to propose a multifaceted intervention, such as a family-centered program, which can actively encourage the participation of family members by considering family characteristics.

Conflict of Interest

No existing or potential conflict of interest relevant to this article was reported.

Funding statement

This study was supported by the American Cancer Society Doctoral Scholarship in Cancer Nursing (Grant Number: 134558-DSCNR-20-079-03-SCN).

Ethical approval

This study was approved by the Ethics Committee of Duke University (Pro00105744) and Severance Hospital, Seoul Korea (2019-0263-003).

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Table 1 General Characteristics and Resilience, Parent-Adolescent Communication, Family Strengths, and Family Support (N = 141)

Variables	Categories	N(%)	Resilience		Communication with father		Communication with mother		Family strengths		Family support
Variables	Categories	N(%)	M(SD)	t(p) or F(p)	M(SD)	t(p) or F(p)	M(SD)	t(p) or F(p)	M(SD)	t(p) or F(p)	M(SD)	t(p) or F(p)
Sex	Boys	78(55.3)	67.04(12.09)	-2.413 (.017)	59.95(9.75)	0.019 (.985)	63.60(9.29)	-1.197 (.233)	42.78(8.14)	-0.934 (.352)	76.49(11.98)	-1.265 (.208)
Sex	Girls	63(44.7)	71.67(10.30)	-2.413 (.017)	59.91(10.96)	0.019 (.985)	65.47(9.05)	-1.197 (.233)	44.03(7.58)	-0.934 (.352)	78.98(11.24)	-1.265 (.208)
Education level	Elementary	35(24.8)	66.46(9.69)	1.489 (.220)	59.69(8.20)	1.149 (.332)	61.86(8.57)	1.835 (.144)	41.89(6.51)	0.643 (.589)	75.03(9.70)	1.538 (.208)
	Middle	42(29.8)	70.43(12.85)		61.63(10.58)		66.74(9.83)		44.00(8.42)		80.57(10.87)
	High	39(27.7)	71.26(11.98)		57.54(12.54)		64.21(9.48)		44.15(8.53)		77.18(14.06)
	College/university	25(17.7)	67.24(10.35)		61.00(7.89)		64.50(7.90)		43.00(7.89)		76.88(11.03)
Diagnosis	Hematologic malignant^a	65(46.1)	67.95(9.87)	1.596 (.193)	58.87(10.76)	3.634 (.015) ^* b>d	64.53(8.99)	3.291 (.023) ^* b>d	42.25(7.66)	5.343 (.002) ^* b>a,c,d	78.03(11.14)	3.247 (.024) ^* b>c
	Solid tumor^b	29(20.6)	73.14(10.33)		65.33(8.27)		68.31(6.99)		48.24(6.04)		82.34(9.17)
	Brain tumor^c	25(17.7)	67.44(12.98)		59.46(9.11)		62.92(9.17)		42.60(8.15)		73.44(12.68)
	Not specified^d	22(15.6)	69.09(14.93)		56.71(10.32)		60.73(10.87)		40.95(8.26)		74.82(13.24)
Post-diagnosis period	< 1yr^a	33(23.4)	66.52(9.66)	1.365 (.249)	59.67(8.22)	2.484 (.047) ^† 3-6>1-2,2-3	62.97(8.76)	1.206 (.396)	42.12(5.84)	2.262 (.066)	75.79(10.94)	1.684 (.157)
	1–2yr^b	19(13.5)	66.58(12.38)		57.25(11.50)		65.26(6.50)		42.47(6.48)		74.26(10.01)
	2–3yr^c	22(15.6)	69.45(10.14)		55.64(13.50)		61.81(10.32)		40.09(10.52)		76.36(13.55)
	3–6yr^d	40(28.4)	72.15(12.58)		63.45(8.48)		65.97(8.92)		45.43(7.46)		81.30(9.94)
	> 6yr^e	27(19.1)	69.26(12.06)		60.42(9.88)		65.37(10.67)		45.00(8.40)		77.70(13.67)
Recurrence	Yes	22(15.6)	68.14(8.58)	-.429 (.669)	61.62(10.05)	0.833 (.412)	63.68(9.21)	-0.414 (.680)	42.91(6.85)	-0.278 (.781)	77.77(11.18)	0.074 (.941)
Recurrence	no	119(84.4)	69.29(12.00)	-.429 (.669)	59.62(10.30)	0.833 (.412)	64.57(9.23)	-0.414 (.680)	43.42(8.09)	-0.278 (.781)	77.57(11.82)	0.074 (.941)
On treatment	Yes	55(39.0)	66.14(12.65)	-2.582 (.011)	59.09(10.17)	-0.777 (.438)	63.13(9.50)	-1.350 (.179)	42.60(6.93)	-0.890 (.375)	75.84(12.14)	-1.442 (.152)
On treatment	no	86(61.0)	71.07(10.34)	-2.582 (.011)	60.49(10.32)	-0.777 (.438)	65.27(8.95)	-1.350 (.179)	43.81(8.46)	-0.890 (.375)	78.73(11.30)	-1.442 (.152)

M(SD): Mean (Standard Deviation); post-hoc: ^*Scheffe, ^†Duncan

Table 2. Level of Variables

	N	M(SD)	Min	Max	Range
Resilience	141	69.11(11.52)	34	90	15–90
Communication with father	135	59.93(10.25)	25	80	20–80
Communication with mother	140	64.43(9.20)	35	80	20–80
Family strengths	141	43.34(7.90)	19	59	12–60
Family support	141	77.60(11.68)	39	99	20–100

Table 3 Correlation between Research Variables (N = 141)

Resilience

r (p)

Communication with father

r (p)

Communication with mother

r (p)

Family strengths

r (p)

Family support

r (p)

Resilience

.389

(< .001)

.449

(< .001)

.485

(< .001)

.583

(< .001)

Communication with father

.389

(< .001)

.601

(< .001)

.648

(< .001)

.632

(< .001)

Communication with mother

.449

(< .001)

.601

(< .001)

.582

(< .001)

.728

(< .001)

Family strengths

.485

(< .001)

.648

(< .001)

.582

(< .001)

.641

(< .001)

Family support

.583

(< .001)

.632

(< .001)

.728

(< .001)

.641

(< .001)

Table 4 Hierarchical Regression Analysis of Variables Influencing Resilience (N = 141)

Variables	Step 1					Step 2
	B	SE	β	t	p	B	SE	β	t	p
(constant)	64.579	1.666		38.773	< .001	18.625	5.873		3.171	.002
Sex(Female)	4.093	1.916	.176	2.087	.039	2.383	1.593	.103	1.496	.137
Treatment (No)	4.677	1.977	.200	2.366	.019	2.921	1.594	.125	1.833	.069
Communication with father						-0.080	0.110	-.728	0.168	.469
Communication with mother						0.075	0.128	.060	0.585	.559
Family strengths						0.291	0.139	.202	2.088	.039
Family support						0.150	0.106	.456	4.237	< .001
Adj.R2	.066					.403
F(p)	5.665(.004)					19.533(<. 001)

No competing interests reported.

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Family-Related Factors Influencing Resilience of Korean Adolescents and Young Adults with Childhood Cancer: A cross-sectional study

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