Burden of care and childhood cancer: experiences of parents in an Asian context.

Burden of care and childhood cancer: experiences of parents in an Asian context. This article has two objectives. The first is to share findings onthe psychosocial psychosocial/psy��cho��so��cial/ (si?ko-so��shul) pertaining to or involving both psychic and social aspects. psy��cho��so��cialadj.Involving aspects of both social and psychological behavior. needs of Asian parents arising from a diagnosis ofcancer in their children. The second is to relate the findings to theconcept of burden of care in light of the propensity for Asian familiesto receive help from the informal network in a family crisis (Ow &Katz, 1999). Childhood cancer is a life-threatening and traumatic event A traumatic event is an event that is or may be a cause of trauma. The term may refer to one of the followiong: Traumatic event (physical), an event associated with a physical trauma Traumatic event (psychological), an event associated with a psychological trauma that affects the patient as well as the entire family. It interfereswith daily functioning and disrupts plans for the future. Family membersare confronted with a number of new challenges, including givingemotional support to the sick child, making arrangements for hospitalstays and appointments, and helping their other children cope with thedemands of an ill sibling. Demands are both internal to the family (forexample, new child care arrangements) and external (for example, meetingthe financial cost of treatment) (Sawyer, Streiner, Antoniou, Toogood,& Rice, 1997; Sloper, 1996; Wochna, 1997). Earlier empirical research Noun 1. empirical research - an empirical search for knowledgeinquiry, research, enquiry - a search for knowledge; "their pottery deserves more research than it has received" documented a wide range of effects onparents. Depending on the point of assessment, parents reporteddifferent degrees of psychological distress psychological distressThe end result of factors–eg, psychogenic pain, internal conflicts, and external stress that prevent a person from self-actualization and connecting with 'significant others'. See Humanistic psychology. and needs. Northam (1997)described the experience as a process similar to mourning when parentsgrieve over the likelihood of losing their children. Sawyer andcolleagues (1997) reported that during the period immediately after thediagnosis, parents tend to experience a high level of strain, anxiety,and sleep loss, but the distress declines and stabilizes over the firstyear. Other emotional experiences of parents include fearfulness,desperation, and guilt (Martinson et al., 1995). After diagnosis, families were also reported to have a strong needto receive and share information about their child's diagnosis, tohave questions answered honestly and comprehensibly com��pre��hen��si��ble?adj.Readily comprehended or understood; intelligible.[Latin compreh , and to understandwhy certain procedures were carried out for the patient (Northam, 1997;Shields et al., 1995; Sloper, 1996; Wochna, 1997). Caregiver difficulties are categorized as consisting of objectiveburden of care, which refers to practical problems such as disruptionsin family interaction, marital relations, financial needs, housekeeping,and work activities. Subjective burden of care refers to thepsychological reactions that family members experience, such as anxiety,depression, and a sense of loss (Fadden, Bebbington, & Kuipers,1987; Hoenig & Hamilton, 1966). Recent studies with relatives ofpatients with schizophrenia found that family burden and copingstrategies The German Freudian psychoanalyst Karen Horney defined four so-called coping strategies to define interpersonal relations, one describing psychologically healthy individuals, the others describing neurotic states. also differed across cultures. Factors such as social supportand personal resources may affect the burden of care (Magliano et al.,1998a, 1998b; Solomon & Draine, 1995). Social work is very muchinfluenced by the socioeconomic, political, and cultural needs of thepopulation (Ow, 1999). Because family responses and burden of care are likely to beinfluenced by social and cultural contexts, a study on the experiencesof parents in a multicultural Asian society was considered pertinent,both for service provision and contribution toward knowledge on workingwith an Asian population. This is particularly relevant whenpsychosocial interventions are highly recommended as an integral part ofcompetent and comprehensive medical care and not just as an independenttreatment modality treatment modalityMedtalk The method used to treat a Pt for a particular condition for cancer (Fawzy, Fawzy, & Canada, 1998). Singapore, a city-state of 647.5 square kilometers, had amulticultural population of just over 4 million in 2000 (SingaporeDepartment of Statistics, 2000), consisting of 79 percent with a Chineseethnic background, 6 percent with origins in India, 14 percent from theMalay archipelago Malay Archipelago,great island group of SE Asia, formerly called the East Indies. Lying between the Asian mainland and Australia, and separating the Pacific Ocean from the Indian Ocean, it includes Brunei, Indonesia, the Philippines, Papua New Guinea, East Timor, , and about I percent Eurasian (Singapore Department ofStatistics, 1995). With increasing dual-income families and a population policy thathad previously discouraged more than two children per household,demographic data showed the beginning of an inverted pyramid For the structure in the Louvre in Paris, France, see .The inverted pyramid is a metaphor used to illustrate how information should be arranged or presented within a text, in particular within a news story.The "pyramid" can also be drawn as a triangle. with anincreasingly higher proportion of elderly residents ages 60 and above(Singapore Department of Statistics, 1995). Recent official figuresreported a total fertility rate The total fertility rate (TFR, sometimes also called the fertility rate, period total fertility rate (PTFR) or total period fertility rate (TPFR)) of a population is the average number of children that would be born to a woman over her lifetime if she of 1.475 children born per 1,000 femalesages 15 to 44 (Singapore Department of Statistics, 2001). The concernfor the below replacement birth rate had prompted the government to forma high-level panel of experts to explore means to reverse the trend. Given the importance of children to Singapore society andindividual families, the diagnosis of a life-threatening illness to achild produces tremendous emotional strain with implications for boththe parents and the extended family. In Singapore, almost 80 childrenunder age 12 are diagnosed with cancer every year. Childhood cancer isthe second most common cause of death in children between the ages offive and 19 (Singapore Immigration immigration,entrance of a person (an alien) into a new country for the purpose of establishing permanent residence. Motives for immigration, like those for migration generally, are often economic, although religious or political factors may be very important. and Registration, 1998). Otherfactors pertinent to understanding the effect of childhood cancer onparents in Singapore are the value of children for personal and socialsatisfaction in a generally collectivist col��lec��tiv��ism?n.The principles or system of ownership and control of the means of production and distribution by the people collectively, usually under the supervision of a government. environment (Chung, Chen, Kuo,& Purushotam, 1981; Quah, 1994) and the significance of the extendedfamily as part of the informal support network in coping with a familycrisis (Ow & Katz, 1999). In Singapore, the choice of using alternative or traditionalmedicine may also be a source of stress for parents. Although using adual system of medical care is common, much of traditional medicine doesnot have an established scientific foundation. However, studies ondisease representations and related behavioral intentions amongSingaporeans showed that when a disease was rated either as "lifethreatening" (for example, cancer, diabetes, or heartdisease),"due to blocked qi" (a Chinese illness concept), or"caused by a virus" (for example, venereal venereal/ve��ne��re��al/ (ve-ner��e-al) due to or propagated by sexual intercourse. ve��ne��re��aladj.1. Transmitted by sexual intercourse.2. diseases ortuberculosis), the dimension showing the strongest relationship tobehavioral intentions was life-threatening. When a disease was perceived as life-threatening, people indicatedmore likelihood of visiting a Western doctor and less likelihood ofvisiting a sinseh (practitioner of Chinese medicine), using homeremedies, or taking traditional Chinese medicine Traditional Chinese MedicineDefinitionTraditional Chinese medicine (TCM) is an ancient and still very vital holistic system of health and healing, based on the notion of harmony and balance, and employing the ideas of moderation and prevention. . It has been found that Indian medicine tends to be used, preferred,and perceived to be most effective for diseases low in severity, whereasChinese medicine was preferred for diseases viewed as low inspiritual-psychological causation (for example, spirit possession orsleep loss) or not virally caused. Malay medicine was used, preferred,or perceived as most effective for nonserious and nonviral conditions.In contrast, Western medicine was more likely used, preferred, orperceived as effective for diseases believed to be serious or virallycaused (Bishop, 1998; Tan & Bishop, 1996). When the prognosis or the progress of treatment under Westerndoctors is poor, parents may be confronted with the dilemma of decidingwhether it is safe to include alternative medicine as a means ofboosting the chances of recovery and with questions on how to weave thevarious elements of traditional cures with Western medication shouldthey decide to do so. STUDY HYPOTHESES The main study sought to examine the parents' perceptions ofpsychosocial needs, social support, and coping strategies. This articleis focused only on data exploring two hypotheses related to the conceptof burden of care based on parents' perceptions of psychosocialneeds arising from the illness. (Articles reporting data on other issuessuch as coping strategies are being written separately.) First, I hypothesized that given the value of children and thepractical support available in a collectivist context, the subjectiveburden of care would be more pronounced at the stage of diagnosis andinitial treatment compared with the objective burden of care. Second, Ihypothesized that after discharge from the hospital, when the childwould be cared for at home, the objective burden of care arising frompractical demands would be greater than the subjective burden of care,as practical support from the informal social network might decreasewhen the crisis appeared to be over. METHOD Questionnaire A pilot study was conducted with face-to-face interviews of threeparents before the main study to test the usefulness of a semistructuredquestionnaire I designed for obtaining information about psychosocialneeds guided by literature cited earlier. At time 1 (T1, first phase ofdata collection), questions on parents' personal emotions included"What was your first reaction to the diagnosis of your child?""Do you feel there is an explanation for your child'sillness?" "If yes, what do you think it is? Pleasedescribe." These questions helped to explore thoughts, behavior,feelings, and beliefs that might contribute to the subjective burden ofcare. At time 2 (T2, second phase of data collection three to six monthslater), questions were "Since the first interview, are there anychanges to your feelings to the diagnosis of the illness?""What do you now feel is the explanation for your child'sillness?" "Are there any changes to what you firstthought?" "If yes, how did these changes come about?" Questions related to other areas of needs followed a similarformat. For example, questions on child care at T1 included "Areboth you and your spouse working? If yes, how did you manage with work,looking after the home and the ill child at the same time?""Are you satisfied with the current arrangements? If yes, why? Ifnot, what were the problems encountered?" "If there are otherchildren, who looks after them when the ill child is in hospital?" At T2, I reviewed the responses from T1 with the parents and askedwhether there were any changes and what caused them. I also sought toknow who they talked to and what information they needed at both phasesof data collection and included questions such as "Do you tend toseek more information about your child's illness? If yes, what kindof information?" "Was it easy to communicate with doctors,nurses, and social workers about what you need to know? If yes, whathelped? If not, why?" "Besides professionals in the hospital,did you talk to other people to help you understand your child'sillness? If yes, what questions did you ask them?" Both the questionnaire and the face-to-face interviews were foundto be an adequate mode of data collection and were adopted for the finalstudy. The final semistructured questionnaire included questions on theparents' perception of the illness, hospitalization hospitalization/hos��pi��tal��iza��tion/ (hos?pi-t'l-i-za��shun)1. the placing of a patient in a hospital for treatment.2. the term of confinement in a hospital. experience,psychosocial needs, social support, coping strategies, and perceivedoutcome of the experience. A formal presentation of the final studydesign was made to the medical staff for feedback before parents werecontacted through the social workers. Participants All parents with children diagnosed in the first six months of 1998from the two hospitals with a pediatric pediatric/pe��di��at��ric/ (pe?de-at��rik) pertaining to the health of children. pe��di��at��ricadj.Of or relating to pediatrics. oncology ward were invitedverbally by their social worker to participate in the final study.Participation was voluntary and confidentiality was emphasized. Whenconsent was received, the parents were introduced to the researcherconducting the interviews. Other than this, the social workers were notinvolved in the research process. Delinking the research process fromservice delivery was done purposely to facilitate a more objectivedecision regarding participation. Interviews were conducted separatelyif both parents participated and ranged from one hour to one hour and ahalf and were tape-recorded with signed consent. Of the 47 cases registered during the first phase of datacollection, 32 respondents from 28 families consented to interviewswithin three months after the diagnosis (T1). Reasons fornonparticipation were default from treatment after diagnosis orreceiving treatment overseas, and understandably, parents also cited alack of time for and interest in the interviews during the crisis. Because of attrition arising from relapse or death, only 22 parentsfrom 20 families were interviewed again three to six months later (T2).The final sample of 22 respondents closely represented the populationmix of Singapore, consisting of Chinese (72.7 percent), Malay (18.2percent), Indian (4.5 percent), and 4.5 percent of other nationalities.More than three-quarters (77 percent) of the 22 respondents weremothers; 41 percent of the parents were employed and working, 9 percentwere employed but on unpaid leave, and the rest were unemployed. The children had a variety of conditions, including Wilm'stumor tumor:see neoplasm. , neuroblastoma NeuroblastomaDefinitionNeuroblastoma is a type of cancer that usually originates either in the tissues of the adrenal gland or in the ganglia of the abdomen or in the ganglia of the nervous system. , germ cell tumor Germ cell tumor (GCT) is a tumor (neoplasm) derived from germ cells. (Germ cells themselves are not pathogenic; i.e., they are not the viral and bacterial "germs" that cause illness.) Germ cell tumors can occur both inside and outside of the gonads (ovary and testis). , brain tumor Brain TumorDefinitionA brain tumor is an abnormal growth of tissue in the brain. Unlike other tumors, brain tumors spread by local extension and rarely metastasize (spread) outside the brain. , leukemia leukemia(lkē`mēə), cancerous disorder of the blood-forming tissues (bone marrow, lymphatics, liver, spleen) characterized by excessive production of immature or mature , andlymphoma. Analysis Content analysis was performed on the transcripts of the 22interviews from T1 and T2 to categorize cat��e��go��rize?tr.v. cat��e��go��rized, cat��e��go��riz��ing, cat��e��go��riz��esTo put into a category or categories; classify.cat responses into various domainsof psychosocial needs. Based on the pilot study and literature citedearlier, psychosocial needs were categorized into six domains.Subjective burden of care was identified as parents' personalemotions such as distress, anxiety, and sense of loss. Objective burdenof care included disruption to family interaction, marital relations,child care, and housekeeping, as well as need for information.Parents' psychosocial needs were categorized into high, average, orlow levels. A high level of need was indicated by parents'perceived difficulty in managing that particular category of need; anaverage ranking was indicated by a report of no difficulty in managingthat particular need; and a low level of need was reflected by apositive change or improvement in management of that area of need. A second researcher was involved in the content analysis. Responseto every question was transferred to a grid that included a"yes" or "no" box and the reasons for the responses.These responses were then further analyzed as indicators of needs in thevarious domains using a rating scale as illustrated in the following: * Housekeeping: Score of low need--extra social support available, no difficulties Score of average need--usual amount of social support available, some difficulties but managed by immediate family Score of high need very little or no social support available, social services required * Personal emotions: Score of low need adapting and coping well with the changes in family life, restored sense of control, feels better and gives appropriate meaning to the illness Score of average need--adapting and coping with some of the changes in family life, restored some sense of control, feels the same and attempting to give some meaning to the illness Score of high need--unable to adapt and cope with the changes in family life, no sense of control, feels worse and unable to find an appropriate meaning to the illness. Comparison with an independent rater on five randomly selectedcases for both T1 and T2 showed 91 percent agreement. Uncertainties such as whether "feeling worried" at T1shifting to "feelings of sadness" at T2 indicated the samehigh or decreased level of need related to personal emotions wereexamined and discussed with the first researcher as arbitrator, toensure consistency in the content analysis. In this case, worry andsadness were both categorized as reflecting a high level of need relatedto personal emotions and that there was, therefore, no change in realterms in the subjective burden of care between the two time periods. Limitations Limitations to the study included attrition from 32 parents at T1to 22 parents at T2 (about 31 percent reduction) because of relapse ordeaths when parents were too distressed to be interviewed, resulting ina loss of valuable information for the comparison between T1 and T2.Another limitation was that only parents were invited to participate.There were a number of families with other children older than 12 whocould have provided important insights on psychosocial needs and copingfrom the siblings' perspectives. From a methodological point ofview, although there were yes and no options to most of the questions,transcribing qualitative data into descriptive categories also proved tobe a challenge. In spite of these limitations, the findings areinteresting and instructive. I hope the article will stimulate furtherinterest in examining the needs of parents of children with cancer fromdifferent cultural backgrounds. RESULTS In terms of the relative importance of needs at T1, personalemotional need was considered as most imperative, followed by childcare, housekeeping, and information. At T2, in relative order ofimportance, personal emotional need remained the most obvious, followedby informational need (Table 1). Subjective Burden of Care At T1, distress among all the parents was reported as high andincluded various combinations of the following emotions: fear (n = 5),worry (n = 7), sadness (n = 7), shock, disbelief, and lack of acceptance(n = 13), sense of hopelessness (n = 3) and guilt (n = 6). Trauma expressed as shock, disbelief, and an inability to acceptthe diagnosis was the most frequently reported at T1. Parent 4 wascategorized as experiencing a high level of need in the domain ofpersonal emotions at both phases. At T1, he reported that he "never thought it could be cancer, was unprepared for it. When the doctor came out from the operation and confirmed it was cancer, my heart sank. I felt like crying ... just couldn't believe that what the doctor said was true." At T2, he said, "I am getting more disillusioned dis��il��lu��sion?tr.v. dis��il��lu��sioned, dis��il��lu��sion��ing, dis��il��lu��sionsTo free or deprive of illusion.n.1. The act of disenchanting.2. The condition or fact of being disenchanted. , losing hope,there is no progress, only regression. During the interview, the doctorhad promised that the condition would improve. But now, it doesn'tseem to be so." At the beginning parent 11, for example, said, "I hoped thatthe test result was not true, that there was something wrong with thetest result." Parent 15 reported that she "wanted to run away from theproblem, if there was a hole, I would climb into it." Most parentswho expressed disbelief reported that the diagnosis was unexpectedbecause there was no family history of the illness and no obvioussymptoms before diagnosis. In fact, parent 17 described it as"quite unreal, even though we knew about the illness, itdidn't hit us straight away." Guilt associated with parents' perception of their part inillness causation, ranging from failure in moral responsibility toneglect in physical care such as diet, was also common. For example,parent 22 felt guilty because she thought the illness might be relatedto "letting the child eat the wrong food since the child was veryparticular about food and only liked fried and fatty food and notvegetables" Parent 1 reported feeling guilty and believed that"God is waking him up" through the child's illnessregarding his moral responsibility as a parent. With both parentsworking, his son was fostered with his sister and brother-in-law and wasseldom brought home by the parents, even over the weekend. Parent 19 reported feeling guilty because the child fell down threetimes and she did not seek treatment earlier. These parents continued tofeel guilty and sad at T2, especially when the children's medicalcondition did not improve. Changes in Personal Emotions over Time Parents who reported ability to cope with the distress of diagnosisand treatment at T2 were categorized as having a low level of need.First, positive changes in the subjective burden of care appeared to bedirectly associated with the medical condition of the child. Forexample, parent 13, who reported experiencing a sense of hopelessness atT1, was continually asking "why should it happen to me, to myfamily, why to him (ill child) especially?" but at T2, she reportedfeeling happier and more accepting of the diagnosis because the childwas "much better. Hope everything will be fine forever." Parent 16 expressed a high level of need in personal emotions at T1but a low level at T2. At T1, she said, "I felt my heart break. Icouldn't believe that any of my children could get this cancer. Ialways stayed at home to look after them. The first time I was informedof the illness, I felt it was hopeless. I lost hope." However, atT2, she reported positive changes in her emotions, saying that "Ifeel ok. She (ill child) is healthy now. When she can play around, Ialso feel happy." Second, a positive problem-focused rather than emotion-focusedapproach to coping (Folkman et al., 1986) helped parents such as parent24 who reported at T1 being "very shocked, kept asking why, thisrare kind of cancer, neuroblastoma; but at T2, stated that "more orless, I have already accepted the diagnosis. Don't think about why.I just think about what treatment is best for her." Similarly,parent 28 reported guilt at T1 because "I asked myself if I did nottake care of myself when I was pregnant." At T2, she reported:"I don't think about it (illness) now, whatever it is, it isthere. My main concern now is about what can be done for him (ill child)in the future. I am not the kind to ponder about the past. I am moreconcerned about finding a solution." Third, all responses to the question about whom they talked toabout the child's illness other than hospital professionals, withthe exception of two parents, indicated strong emotional and practicalsupport from immediate family and relatives and occasionally, friendsand fellow church members. Two parents without a family support networklocally cited church friends as their main sources of support. Objective Burden of Care For psychosocial needs subsumed under objective burden of care,child care and housekeeping were reported as the more pressing when theill child was in the hospital at T1 and information needs afterdischarge from hospital at T2 (Table 1). At T1, informal family support during the crisis was available fromthe extended family such as the child's grandparents (ninefamilies) and aunts (three families). For example, parent 22 describedchild care arrangements at T1: My mother and sister help to look after the ill child and my other child. My mother helps with taking care of the home. We take turns to go to the hospital to look after the ill child. My sister would also go to the hospital to look after the ill child when necessary. At T2, parent 22 reported that the child care and housekeepingarrangement remained satisfactory with family support. Some parents had more complicated alternative child care and livingarrangements. For example, parent 1 reported at T1 that with bothparents working, the healthy children went to live with their paternal PATERNAL. That which belongs to the father or comes from him: as, paternal power, paternal relation, paternal estate, paternal line. Vide Line. grandparents and the parents would join them for dinner there everyday.At T2, because both parents were still working, the ill child also wentto live with the paternal grandparents after discharge. However, therewere plans to buy a home nearer the paternal grandparents as soon aspossible to facilitate the use of extended family support and to reducecommuting time. Other families with no help from the extended familymanaged with live-in maids (two families) or lived on one income becauseone spouse temporarily stopped working (three families). Family interaction was examined as the nature of the marital andparent-child relationship after diagnosis. At T1, most parents perceivedmarital relationship Noun 1. marital relationship - the relationship between wife and husbandmarital bedfamily relationship, kinship, relationship - (anthropology) relatedness or connection by blood or marriage or adoption as "normal," primarily a stoiccontinuation of their parental roles, described by parent 4: "Interms of responsibility, we are doing what we can, so no changes,"or parent 20 who said, "No, we have been married for 22 years, wemake adjustments accordingly," and parent 13 who said,"Relationship is still the same. The diagnosis is fated. Should notchange the marriage. Both should face the problems together." Four parents reported marital difficulties, but these resulted fromproblems that existed before the diagnosis. Two of these parents setaside the problems to concentrate on caring for the ill child. Parent-child difficulties were primarily the result of the lack oftime for well siblings, especially during the hospitalization period.Parent 2 at T1, for example, said that they "didn't spendenough time with the elder daughter, in fact neglected her because allthe attention was focused on the ill child." At T2, she reportedthat she "tried to talk more to and explain to the elder child hersibling's medical condition and that she was 'more careful andconcerned' over her (elder) child's healthy Information need was comparatively higher at T2 compared with othertypes of psychosocial needs under those associated with the objectiveburden of care (Table 1). Further examination of the qualitative datarevealed that at T1, the parents' contact with social workers andmedical professionals was helpful in finding out more about the illnessand the treatment protocol and coping with the side effects Side effectsEffects of a proposed project on other parts of the firm. oftreatment. However, at T2, most of the parents had questions reflectinganxiety about maintaining the child's health but had less contactwith medical professionals and social workers. At T2 they reportedturning to friends, parents of other ill children, or literature forinformation. Responses to the question of what they talked about withothers included the kind of diet (for example, macrobiotic or organic)that could help develop resistance, permissible or useful form ofexercises, prospects of full recovery, preventing relapse, whetheravoiding certain foods or eating places and using traditional herbswould boost immunity. DISCUSSION AND IMPLICATIONS FOR SOCIAL WORK Taken together, the results confirmed the first hypothesis that thesubjective burden of care was higher than the objective burden of careat the initial stage after diagnosis. At T2, with continued informalsocial support, parents were generally adjusting well to the routine ofmanaging additional household demands, and the results did not supportthe second hypothesis that with the ill child discharged from hospitalobjective burden of care would be greater than the subjective burden ofcare. Parents' anxiety associated with poor recovery and concernabout relapse continued to render the subjective burden of care moreimperative than the objective burden of care at T2. Overall, subjectiveburden of care seemed to be more important than other categories ofpsychosocial needs over the period of study, whereas objective burden ofcare appeared to decrease over the same period. There are two possiblereasons for the present findings. First, recent findings support that the fact that among modernChinese, cooperative yet self-reliant orientation may coexist as"an exemplary synthesis of individualist in��di��vid��u��al��ist?n.1. One that asserts individuality by independence of thought and action.2. An advocate of individualism.in and collectivistvalues" (Ho & Chiu, 1994, p. 154). This dual orientation,together with the tendency for Chinese and Hindu-Indian individuals touse a limited sphere for disclosure in managing distressful information(Mehta, 1990; Ow & Katz, 1999), could explain why parents reportedbetter coping with psychosocial needs of a practical nature such aschild care but not with personal emotions. Seeking practical help may reflect collectivism collectivismAny of several types of social organization that ascribe central importance to the groups to which individuals belong (e.g., state, nation, ethnic group, or social class). It may be contrasted with individualism. specific to rolerelationship dependent on the self--other relationship involved (Ho& Chiu, 1994), whereas coping with personal emotions belong more tothe realm of self-reliance (Ow & Katz, 1999), in which the tendencyto resort to self-directed coping strategies may be understood in termsof the Confucian and Hindu tradition of self-discipline (Cheung, 1986;Mehta, 1990). Continued feelings of distress may therefore reflect atypical self-reliant strategy in coping with personal emotions thatrequires professional social work intervention to help surface andalleviate. Second, Singaporeans tend to be dual users of both Westernallopathic medicine Some medical dictionaries define the term Allopathy or Allopathic medicine as the treatment of disease using conventional medical therapies, as opposed to the use of alternative medical or non-conventional therapies. and traditional medicine (Bishop, 1994; Quah, 1989).Chinese, Malay, and Indian traditional medicine all typically focus onthe interconnectedness of the physical, emotional, spiritual, andenvironmental dimensions of life as essential for well-being (Lim &Bishop, 2000). Good health is the result of a harmonious balance betweenand among the various systems both internal and external to theindividual (Fielding & Chan, 2000). Illness is therefore adisharmony dis��har��mo��ny?n.1. Lack of harmony; discord.2. Something not in accord; a conflict: "the disharmonies that assail the most fortunate of mortals"Peter Gay. or overall disequilibria that can be treated by food tobalance the yin and yang Yin and YangNountwo complementary principles of Chinese philosophy: Yin is negative, dark, and feminine, Yang is positive, bright, and masculine [Chinese yin dark + yang bright] elements of heat and cold, wet and dry (Koo,1984), or acupuncture acupuncture(ăk`ypŭng'chər), technique of traditional Chinese medicine, in which a number of very fine metal needles are inserted into the skin at specially designated points. and exercise such as Tai Chi Tai ChiDefinitionT'ai chi is a Chinese exercise system that uses slow, smooth body movements to achieve a state of relaxation of both body and mind. to ensure an adequateand smooth flow of energy or qi (Beinfield & Korngold, 1991), forexample. Given the multifaceted medical system the respondents areconfronted with, it is not surprising that information need emerged assignificant at T2. Therefore, social work intervention should include addressingaspects of the holistic body, mind, and spirit interconnection intraditional medicine to enhance the parents' sense of control overmaintaining health and preventing relapse. Lack of such information mayincrease parental stress because discharge from the hospital means thatthe locus of control locus of controln.A theoretical construct designed to assess a person's perceived control over his or her own behavior. The classification internal locus indicates that the person feels in control of events; external locus for the child's well-being, to a large extent,has shifted from the hospital to the parents. Social work interventionshould provide avenues for the management of personal emotions after thechild's discharge from the hospital and structured opportunities todiscuss alternative or supplementary methods of helping the childthrough diet and exercise parallel to Western outpatient medicaltreatment. Parents who use problem-focused strategies in coping would benefitfrom social workers able to direct, and perhaps even teach, patients andparents about food rules and simple exercises in maintaining health fromthe Asian perspective (Chan, 2001). Given that parents also often shareinformation when they meet in the hospital, social workers couldformalize such contacts into parents' support groups with an activeinvolvement in the parents' search for information that wouldsatisfy the Asian holistic orientation toward promoting health andwell-being complementary to allopathic medicine. However, alternative approaches have implications for training andresearch in social work in health. Increasingly, university courses andliterature with accompanying videotapes are available to enable thesocial worker to keep abreast Verb 1. keep abreast - keep informed; "He kept up on his country's foreign policies"keep up, followtrace, follow - follow, discover, or ascertain the course of development of something; "We must follow closely the economic development is Cuba" ; "trace the of alternative approaches to well-beingbeyond the conventional methods in counseling, especially for parentsseeking to fight an illness that sometimes seems outside the control ofmedical science (Chan, 2001; Hiew, 1999). Future research on such aholistic approach holistic approachA term used in alternative health for a philosophical approach to health care, in which the entire Pt is evaluated and treated. See Alternative medicine, Holistic medicine. would be useful in providing new avenues for socialwork intervention in developing resilience and wellness (Hiew, 2000). The small sample has made generalization difficult. Asians are aheterogeneous group. Although there are many similarities, there arealso differences peculiar to specific belief systems and traditions. Ifa larger sample were available, it would be useful to make finercomparisons and generalizations of Asians from a cross-culturalperspective such as whether Malay-Muslim parents with an Islamicworldview world��view?n. In both senses also called Weltanschauung.1. The overall perspective from which one sees and interprets the world.2. A collection of beliefs about life and the universe held by an individual or a group. fare better in managing personal emotions than Chinese parentswho are atheists or whose belief systems come from a largely pantheistic pan��the��ism?n.1. A doctrine identifying the Deity with the universe and its phenomena.2. Belief in and worship of all gods.pan pool consisting of Christian, Buddhist, Taoist, or animistic an��i��mism?n.1. The belief in the existence of individual spirits that inhabit natural objects and phenomena.2. The belief in the existence of spiritual beings that are separable or separate from bodies.3. religions.It might also enable other comparisons related to socioeducationalfactors such as whether English-educated parents who have better accessto information via Internet resources and other written material on theillness, treatment protocols, and side-effects cope better thanChinese-educated or vernacular-educated parents without similar access. CONCLUSION The subjective burden of care experienced by parents may be theconsequence of a combined tendency to seek a traditionally holisticapproach to prevention and treatment of illness beyond that provided byallopathic AllopathicPertaining to conventional medical treatment of disease symptoms that uses substances or techniques to oppose or suppress the symptoms.Mentioned in: Traditional Chinese Medicine (or 'Western') medicine at the hospital and theselective disclosure of distress among Asians in general. Psychosocialneeds might differ in intensity and variety at different times, and theavailability of information relevant to achieving a sense of control mayhave an effect on subjective burden of care. Within the collectivistapproach to family crisis, objective burden of care, on the other hand,appeared to be successfully mediated by practical support from theinformal social network. 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An earlier version of this articlewas presented at the First SIOP-Asian Congress Post-Congress Workshop onPsychosocial Support psychosocial supportA nontherapeutic intervention that helps a person cope with stressors at home or at work. See Companionship, Most significant other. , April 29, 2000, Singapore. The author thanks theSingapore Children's Foundation (CCF CCFabbr.Cooperative Commonwealth Federation of Canada ) for funding the study; socialworkers and research officers of CCF, and medical personnel of the KKWomen's and Children's Hospital A children's hospital is a hospital which offers its services exclusively to children. The number of children's hospitals proliferated in the 20th century, as pediatric medical and surgical specialties separated from internal medicine and adult surgical specialties. and the National UniversityHospital, Singapore, for their support and assistance. Original manuscript received February 21,200I Final revisionreceived November 12, 2001 Accepted January 10, 2002