Introduction
Childhood cancer is an international public health challenge. Paediatric cancer accounts for approximately 1% of all cancers worldwide [1]. However, it is among the leading causes of death by childhood disease in many countries [2].
In Europe and the United States, the incidence of childhood cancers is higher, with around 150–200 cases per million children each year [3]. The most common cancer in these regions is leukaemia, particularly acute lymphoblastic leukaemia, brain tumours, and lymphomas. Thanks to early detection and advanced treatments, survival rates in these regions often exceed 80% [1].
In Africa, the incidence of paediatric cancer is estimated at 50–150 cases per million children per year, which is lower than in Western countries [4]. The most common cancers in Africa also include leukaemia and lymphoma, but sarcomas, such as HIV-associated Kaposi’s sarcoma, are more common in some regions. In Morocco, the incidence is estimated to be 1000 new cases per year and the incidence of leukaemia to be 100 new cases diagnosed per year [5]. Therefore, paediatric cancers in Morocco are dominated by leukaemia, particularly acute lymphoblastic leukaemia, followed by lymphomas such as Burkitt’s lymphoma and Hodgkin’s lymphoma. Skeletal tumours and soft tissue sarcomas are the primary solid tumours and represent 23% of all paediatric cancers, followed by sympathetic system cancers (12%), and then brain tumours (10% in females and 5% in males), and the 5-year survival rate for paediatric cancers in Morocco is estimated at 30–50%, depending on the type of cancer and access to care [5, 6].
Morocco has made significant progress in increasing the survival rate in paediatric oncology. However, despite the progress made, childhood cancer is often associated with notions of mortality, lack of cure, loss, and pain [7]. Confirming the diagnosis of cancer in a child can generate a huge level of stress for loved ones, leading to deep anxiety, panic, and depression throughout the family. The parents’ life situation involves an accumulation of stress factors, all of which differ in terms of duration, predictability, and impact [8]. The threat of death [9], the period of treatment after diagnosis [10–12], painful medical procedures [13, 14], intensive treatment regimens with possible health side effects [14], and family financial problems [10] are all factors that interfere with the demands and changes in the parents’ daily lives, resulting in heightened emotional distress [15–17]. Exceptional psychological resources are needed for these parents translated by adaptation strategies often referred to as “coping”, defined by Lazarus and Folkman 1984 as the set of constantly changing cognitive and behavioural efforts deployed to manage specific internal and/or external demands that are evaluated by the individual as consuming or exceeding his or her resources [18]. Although the term “coping” can be literally translated as “making do”, some researchers have suggested other translations such as “adjustment strategy” or “coping strategy” to describe how a person reacts to a stressful event threat.
Generally, individuals’ conceptions of adaptation represent a dynamic and contextual process that varies according to the situations and the requirements related to it [19]. For this, a variety of coping strategies can be used by parents of children with cancer (PCWC) to adequately cope with their children’s disease [20].
In fact, several conceptual models are proposed, including problem-focused or emotion-focused adaptation [21], active or passive strategies [22], approach or avoidance [23], behavioural or cognitive adaptation [24].
According to Hildenbrand et al. [16], the most frequently used strategies by PCWC are direct problem-solving strategies, positive cognitive restructuring, and acceptance, which are approach strategies aimed at dealing constructively with the challenges posed by the disease. It should also be noted that behavioural and cognitive avoidance strategies, such as distraction and avoidance of illness-related thoughts, are also observed [25] in coping strategies related to parents of children with cancer in the Malaysian population, and it was found that parents resorted more to self-distraction and religion. Sharma et al. [26] found that avoidance, distancing, and planned resolution were the most frequently used coping strategies in the Indian population.
The diverse coping strategies observed reflect the variety of emotional and behavioural responses of parents faced with their child’s illness, and culture plays a central role in how these responses manifest themselves in different populations [27]. In Western countries, culture tends to emphasise individualism and autonomy, which can lead parents to adopt strategies centred on information seeking, autonomous decision-making, and open expression of emotions. On the other hand, in more collectivist cultures, such as Morocco, family and community support is often favoured, and coping strategies frequently include elements of spirituality and connection to religious traditions. Religion, in particular, plays a significant role in the coping process [7], offering parents a framework for interpreting the illness, a means of finding hope and comfort, as well as moral support through practices such as prayer, reading the Koran, or consulting traditional healers. It is also essential to recognise that everyone reacts uniquely to such a situation, and that coping strategies may evolve over time according to individual circumstances and needs. Although most studies on this subject often come from Western countries, they nevertheless offer important insights into the coping mechanisms used by these parents. As for Morocco, although specific research on the cultural influence on stress management in oncology is scarce, some studies show that religious practices and family support play crucial roles in parents’ adaptation to the challenges posed by their child’s illness [10, 25]. These cultural dynamics modulate the effectiveness of mental health interventions and underline the importance of an approach adapted to local contexts.
However, so far no study in Morocco has investigated the relationship between psychological reactions and coping strategies of PCWC during active treatment. In summary, further studies on coping during cancer treatment are needed to guide the development of interventions and improve clinical practice, to meet the needs of patients and their families throughout their course of treatment. The present study aims to describe the prevalence of psychological distress in newly diagnosed PCWC at the Children’s Hospital of Rabat, and to study the likely correlations between certain coping strategies and psychological distress.
Material and methods
Participants
This study utilised a cross-sectional design involving PCWC undergoing cancer treatment at the Hospital. This hospital serves as one of the primary referral centres for childhood cancer treatment. Inclusion criteria included PCWC under 16 years of age with a confirmed diagnosis of cancer made at least 3 months previously during the data collection period. Parents of children with serious complications (severe infections, organ failure, side effects of cancer treatment like chemotherapy-induced toxicity) or those who refused to answer the questionnaire were excluded from the study. The ethical dimensions of confidentiality, anonymity, and free consent were respected for consecutive parents who met the inclusion criteria. The sample size was calculated using the formula developed by Schwartz [28] with a prevalence rate of 50% and an accuracy of 0.05 at 95% confidence interval. Data collection occurred from June to September 2023, employing a self-administered questionnaire comprising 2 parts: the first part covered socio-demographic factors, clinical history of participants, and the characteristics of the children diagnosed with cancer were also elicited, while the second part consisted of the 12-item general health questionnaire (GHQ12) and the brief coping orientation questionnaire.
Instruments
The general health questionnaire
Developed by Goldberg in 1970 [29] and used to measure psychological distress, this is a widely used tool in primary care for screening for psychological distress and psychiatric morbidity. Its use as a screening instrument has been well established and has been validated in Arabic [30]. The sensitivity and specificity of this scale are 0.88% and 0.84%, respectively. Each item is scored on a 4-point scale and gives a total score of 12 or 36 depending on the scoring method chosen. The notation style used for this study is the Likert scale. The cut-off point for the GHQ12 was set at 15 because the mean and median value obtained is statistically 15. Scores ≤ 15 are considered normal, while scores > 15 are considered evidence of psychological distress.
The Brief COPE
The Brief COPE is an abbreviated form of the COPE inventory coping orientation to problems experienced, by Carver et al., 1989, used in its Arabic version [31] as an effective assessment instrument in clinical care settings to evaluate the coping strategies of PCWC. The present study used the classification of Carver et al., who classify coping strategies into 2 broad strategies: problem-focused coping through religious spiritualities, acceptance of the problem, instrumental and/or emotional support, positive reframing, active adaptation, planning, and humour and emotion-focused coping: distraction, denial, evacuation, behavioural disengagement, blame, and substance abuse [25, 32]. The instrument consists of 28 items measuring 14 factors of 2 items each, which correspond to a Likert scale ranging from 1 to 4 as “I haven’t been doing this at all” marked as 1 to “I have been doing this a lot” marked as 4. Total scores on each scale range from 2 minimum to 8 maximum; higher scores indicate greater use of this specific coping strategy.
Statistical analysis and ethics
A description of the sociodemographic and clinical characteristics was carried out. Quantitative variables were analysed by dispersion measures while qualitative variables are presented by frequencies and percentages. The association between total GHQ12 score and socio-demographic factors was analysed using the Student’s t-tests and ANOVA. The comparison of the Brief COPE scales between the different groups was carried out by the t-test for independent samples. A Pearson correlation analysis was used between the Brief COPE scales and the total GHQ12 score, whose score (0–36) was the outcome variable studied.
In addition, and to determine the predictive factors of psychological distress, a multivariate linear regression analysis was performed, with p < 0.05 as significant. Statistical Package for the Social Sciences version 25 was used for data processing.
The Ethics Committee for Biomedical Research at Mohammed V University, Rabat 01/23 approved the study protocol. All participants gave written informed consent. Data collected from participants were treated confidentially.
Results
Participant characteristics
A total of 232 PCWC participated in the study with an acceptance rate of 98 %. The average age was 36.25 ±8.98 years and 7.43 ±4.45 years for the children. Participants were predominantly female 88.8%, married 88.6%, and with irregular occupation 86.1%. On admission, haematological tumours (67.2%) were the most common cancers in children. Children were cared for under Health Insurance Coverage for the Economically Indigent in 67.2% of cases. Distress was reported by (83.2%) of participants, having given a score of 15 or more (Table 1). No significant correlation was detected between psychological distress and the socio-demographic characteristics of the participants, such as the age and sex of the parents or the child, the parents’ level of education and occupation, and their socio-economic status.
Table 1
Participants’ characteristics (n = 232)
Description of the means for the Brief COPE scales and study of the gender effect
Table 2 shows that participants more often reported problem-focused strategies: religion 96.6%, acceptance 92.7%, or instrumental support 87.1%. In addition, emotion-focused strategies – denial 74.6% and distraction 75.4% – were also reported in preference. The table also shows significant gender differences: active coping strategies p = 0.043, instrumental support p < 0.001, and acceptance p = 0.041 were used preferentially by men, and the humour strategy p = 0.01 was reported by women.
Table 2
Means and standard deviations of the Brief COPE scales and comparison of means of Student’s t-test of the different scales by gender
Coping style and psychological distress
The results show that problem-focused coping strategies, such as active coping, acceptance, and positive reframing, are associated with a reduction in psychological distress. Of these, acceptance has the strongest and most significant correlation [(r = –0.5), p < 0.001] with reduced distress scores, suggesting that people who realistically accept their situation are less likely to experience severe psychological distress.
In contrast, strategies such as blaming and denial were significantly positive with r = 0.25, p < 0.001 and r = 0.24, p < 0.001, respectively, with an increase in psychological distress, meaning that these coping approaches are potentially damaging and may exacerbate symptoms of stress or anxiety (Table 3).
Table 3
Correlations between general health questionnaire score and Brief COPE scales
And to identify the predictors of distress, the linear regression model allows analysis of the statistically significant elements (Table 4). The results showed that the predictive factors of psychological distress in parent of children with cancer focus on acceptance (β = –1.9; CI = –2.58; –1.23; p < 0.001) and denial (β = 0.46; CI = 0.07; 0.84; p = 0.02).
Table 4
Univariate and multivariate linear regression analysis of all Brief COPE scales and general health questionnaire score
Discussion
Caring for a child with cancer is an extremely difficult experience for PCWC, regardless of cultural background. This study showed that psychological distress was reported in 83.2% of participants. This finding is consistent with other studies using the same tool, which showed ranges of 70 to 90% of psychological morbidity among PCWC [10, 33, 34]. Similarly, studies conducted such as the one by Pai et al. have also reported that parents of children with cancer more often reported emotional distress than parents of healthy children [15]. The prevalence of psychological distress is increased by the multiple challenges parents face when accompanying their child through the rigorous and painful procedures of cancer treatment.
Although the levels of distress reported in our study are alarming. None of the socio-demographic characteristics of the participants were associated with distress. This result is also similar to other studies on predictors of psychological distress in PCWC [33, 35]. This may be attributed to the fact that medical care, meals, and accommodation are provided free of charge for the duration of treatment, which reduces the socio-economic burden and therefore makes parents less likely to suffer psychological distress. However, previous studies have shown the association of psychological distress – gender [36], age [37], level of education [17], number of children [38], financial problems, and duration of illness [10].
Obviously, to cope with a disease like childhood cancer is often a burden for family members. In the context of adaptation strategies, the results of this study revealed that parents use both problem-focused and emotion-focused coping strategies with a greater emphasis on the former. This corroborates the findings of Sutan et al. in the Malaysian population [25], but the findings of Sharma et al. indicate that Indian parents use emotion-focused coping strategies more than problem-focused coping strategies [26].
Among the coping strategies focused on the problem, the one most frequently used by these parents was religious practice. This tendency could be explained by the fact that all the participants are Muslims, for whom stressful events are interpreted as divine trials. As a result, they tend to intensify their religious activities compared with normal.
The protective role of religion in the psychosocial adjustment of parents of children with cancer has been described in numerous studies [7, 10, 17, 25, 37]. Prayer and religious faith are often seen as sources of emotional support and comfort in difficult times. Denial as well as emotional adaptation strategy was the most used among PCWC, while the least used strategy was substance use. This may demonstrate, at some point, a tendency on the part of the PCWC to deny the reality of the presence of their children’s illness.
In the Moroccan context, it is mainly women who take care of sick children. However, remarkable findings for Active Coping, Acceptance, and Instrumental Research strategies that show significant differences, respectively, (p < 0.041), (p < 0.001), and (p < 0.043) between parent groups. These 3 coping strategies were more prevalent among fathers, which also aligns with the study of Friðriksdóttir et al. for the exploration of dyadic relationships within the parental couple. The findings relate specifically to maternal anxiety in the first year following the diagnosis, which was favourably supported by instrumental support from fathers [39].
The results obtained on the links between coping responses and psychological distress show that participants with lower psychological distress scores make greater use of active coping and acceptance as coping methods to mobilise positive coping strategies, such as seeking social support, actively engaging in child care, and adopting constructive perspectives. This finding is similar to that of other studies in which problem-focused coping is frequently associated with lower levels of anxiety and depression in PCWC [40, 41]. In contrast, Greening and Stoppelbein found that frequent use of problem-solving strategies was associated with increased psychological symptoms in parents. This may be explained by the fact that adopting these strategies requires coping with the stressor, which can subsequently provoke anxiety. On the other hand, the findings of significantly positive correlations between emotion-based coping strategies (denial and self-blame) and GHQ12 scores are also consistent with the findings of other studies [42, 43] which emphasise that, in the face of emotional distress, PCWCs use various forms of avoidance and denial that could delay crucial decisions regarding the child’s treatment or fail to mobilise the necessary support resources. This behaviour can lead to an exacerbation of stress, a decrease in psychological well-being, and a worsening of overall distress. However, according to Zarina et al., the emotion-focused coping mechanism is bidirectional. In the short term, it may be beneficial, as it enables the individual to adapt to the situation, but in the long term, this strategy may be inappropriate, as it may increase stress [44, 45]. Therefore, to improve the mental state of parents, it is recommended to offer regular psychological support and promote positive coping strategies such as acceptance, while reducing the use of negative mechanisms such as denial. Encouraging social support and providing clear information about the disease and treatments are also essential.
Limitations
The over-representation of parents and guardians in our sample may introduce a potential bias in the results, given that the role of primary career is generally attributed to mothers [46]. This may influence parents’ perceptions and coping strategies. Moreover, the type of study that is based on description and correlation does not allow us to conclude cause and effect relationships between variables. For this, complementary longitudinal studies are favourable to understand the multiple dimensions of parental adaptation, considering the complex interactions between individual, contextual, and situational factors. This could lead to the development of more targeted and effective interventions to support parents faced with their child’s illness.
Conclusions
The study highlights the significant psychological distress experienced by parents of children undergoing cancer therapy in Morocco, with an average GHQ12 score indicating high levels of distress. Coping strategies such as acceptance and denial were found to be key predictors of psychological distress, with acceptance serving as a protective factor and denial contributing to higher levels of distress. The frequent use of religious coping strategies underscores the importance of cultural context in shaping how parents manage the emotional challenges of caring for a child with cancer. These findings suggest the need for tailored psychological interventions that address the specific coping mechanisms employed by parents in this context, with a focus on promoting adaptive strategies like acceptance while mitigating the negative impact of denial.
