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Family resources study: part 1: family resources, family function and caregiver strain in childhood cancer

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11 Pages
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Description

Severe illness can disrupt family life, cause family dysfunction, strain resources, and cause caregiver burden. The family's ability to cope with crises depends on their resources. This study sought to assess families of children with cancer in terms of family function-dysfunction, family caregiver strain and the adequacy of family resources using a new family resources assessment instrument. Methods This is a cross-sectional study involving 90 Filipino family caregivers of children undergoing cancer treatment. This used a self-administered questionnaire composed of a new 12-item family resources questionnaire (SCREEM-RES) based on the SCREEM method of analysis, Family APGAR to assess family function-dysfunction; and Modified Caregiver Strain Index to assess strain in caring for the patient. Results More than half of families were either moderately or severely dysfunctional. Close to half of caregivers were either predisposed to strain or experienced severe strain, majority disclosed that their families have inadequate economic resources; many also report inaccessibility to medical help in the community and insufficient educational resources to understand and care for their patients. Resources most often reported as adequate were: family's faith and religion; help from within the family and from health providers. SCREEM-RES showed to be reliable with Cronbach's alpha of 0.80. There is good inter-item correlation between items in each domain: 0.24-0.70. Internal consistency reliability for each domain was also good: 0.40-0.92. Using 2-point scoring system, Cronbach's alpha were slightly lower: full scale (0.70) and for each domain 0.26-.82. Results showed evidence of association between family resources and family function based on the family APGAR but none between family resources and caregiver strain and between family function and caregiver strain. Conclusion Many Filipino families of children with cancer have inadequate resources, especially economic; and are moderately or severely dysfunctional. Many caregivers are predisposed to caregiver strain or are already experiencing severe strain. To provide appropriate care for these families, physicians should regularly assess family function, resources and strain experienced by caregivers. The SCREEM-RES questionnaire used in this study is a helpful and reliable instrument to assess adequacy of family resources.

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Published 01 January 2011
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Panganiban-CoralesandMedina
AsiaPacificFamilyMedicine
2011,
10
:14
http://www.apfmj.com/content/10/1/14

RESEARCH

OpenAccess

Familyresourcesstudy:part1:familyresources,
familyfunctionandcaregiverstrainin
childhoodcancer
AvegeilleTPanganiban-Corales
*
andManuelFMedinaJr

Abstract
Background:
Severeillnesscandisruptfamilylife,causefamilydysfunction,strainresources,andcausecaregiver
burden.Thefamily

sabilitytocopewithcrisesdependsontheirresources.Thisstudysoughttoassessfamiliesof
childrenwithcancerintermsoffamilyfunction-dysfunction,familycaregiverstrainandtheadequacyoffamily
resourcesusinganewfamilyresourcesassessmentinstrument.
Methods:
Thisisacross-sectionalstudyinvolving90Filipinofamilycaregiversofchildrenundergoingcancer
treatment.Thisusedaself-administeredquestionnairecomposedofanew12-itemfamilyresourcesquestionnaire
(SCREEM-RES)basedontheSCREEMmethodofanalysis,FamilyAPGARtoassessfamilyfunction-dysfunction;and
ModifiedCaregiverStrainIndextoassessstrainincaringforthepatient.
Results:
Morethanhalfoffamilieswereeithermoderatelyorseverelydysfunctional.Closetohalfofcaregivers
wereeitherpredisposedtostrainorexperiencedseverestrain,majoritydisclosedthattheirfamilieshave
inadequateeconomicresources;manyalsoreportinaccessibilitytomedicalhelpinthecommunityandinsufficient
educationalresourcestounderstandandcarefortheirpatients.Resourcesmostoftenreportedasadequatewere:
family

sfaithandreligion;helpfromwithinthefamilyandfromhealthproviders.SCREEM-RESshowedtobe
reliablewithCronbach

salphaof0.80.Thereisgoodinter-itemcorrelationbetweenitemsineachdomain:0.24-
0.70.Internalconsistencyreliabilityforeachdomainwasalsogood:0.40-0.92.Using2-pointscoringsystem,
Cronbach

salphawereslightlylower:fullscale(0.70)andforeachdomain0.26-.82.Resultsshowedevidenceof
associationbetweenfamilyresourcesandfamilyfunctionbasedonthefamilyAPGARbutnonebetweenfamily
resourcesandcaregiverstrainandbetweenfamilyfunctionandcaregiverstrain.
Conclusion:
ManyFilipinofamiliesofchildrenwithcancerhaveinadequateresources,especiallyeconomic;and
aremoderatelyorseverelydysfunctional.Manycaregiversarepredisposedtocaregiverstrainorarealready
experiencingseverestrain.Toprovideappropriatecareforthesefamilies,physiciansshouldregularlyassessfamily
function,resourcesandstrainexperiencedbycaregivers.TheSCREEM-RESquestionnaireusedinthisstudyisa
helpfulandreliableinstrumenttoassessadequacyoffamilyresources.
Keywords:
familyresources,caregiverstrain,caregiverstress,caregiverburden,familyfunction,family

scoping
mechanism,familyresourcesassessment

*Correspondence:atpanganibanmd@yahoo.com
DepartmentofFamilyandCommunityMedicineUniversityofthe
Philippines-PhilippineGeneralHospitalTaftAvenue,Ermita,Manila
Philippines

©2011Panganiban-CoralesandMedina;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.

Panganiban-CoralesandMedina
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Background
Approximately144per1millionFilipinochildrenand
adolescentsarediagnosedwithcancereachyearin
Philippines[1].Thediagnosisofcancerinachildcan
sendafamilyintocrisis.Itnotonlydisruptsthechild

s
lifebutthefamily

slifeaswell-asfamilymemberstryto
adjusttheirroles,interactivepatternsandrelationships
insideandoutsideofthefamily.Thecrisisdrastically
changes

normal

routinesoffamilyinteractionsasthe
familyattemptstocope.Thefamily

sabilitytocopewith
amedicalcrisissuchascancerinachilddependson
theirresources.InthePhilippines,manyfamiliesmay
lackfinancialandotherresourcestodealwithchildhood
cancer.
AccordingtoBarakat,MarmerandSchwartz[2],family
functioniscentraltothequalityoflifeinchildrenwhile
undertreatmentforcancer;itmaypromotepositiveout-
comesforthem.Moreover;

...familiesofchildrenand
adolescentswithcancerratethemselvesaslesscohesive
andmoreconflictedthandofamiliesofhealthychildren

[3].Familyfunctionmeasurestheextenttowhicha
familyworksasaunit;itdenotesthefamily

sabilityto
copeandadjusttodifferentsituations.Screeningfor
familyfunctioningisimportanttoidentifystrengthsthat
canserveasbuffersincopingwithstressors[4].Thiscan
bedonewiththeuseoffamilyAPGARoriginally
designedbySmilkstein[5].AFilipinoversionofthetool
hasbeenusedandvalidatedinthePhilippinessince
1992;itsresultsreflectafamilymember

sperceptionof
andsatisfactionwiththefunctionalstateofhisfamily.It
isoneofthemostcommontoolsusedbyfamilyphysi-
ciansforassessingfamilyfunctionintheclinicalsetting.
Childhoodcancercausesseveredisruptionsinfamilylife
andresultsinmanystressorsofvaryingduration,certainty
andimpact[6-9].Theeffectsofchildhoodcancerare
oftenfeltbytheentirefamily,especiallythefamilycare-
giver.Moreover,becausechildrenarenotlegallycompe-
tent,mostdecisionsaboutcanceranditsmanagementare
madebytheadultfamilymembersandcaregivers.Child-
hoodcancercancausesignificantpsychosocialdistresson
adultfamilymembersandcaregivers.
Manneet.al.[10]foundthatmoderatetoseveredepres-
sivesymptomsinparentsdidnotimprove6monthsafter
diagnosis.Sloperet.al.[11]alsofoundthatpsychological
distressinparentsremainedhighat18monthsafter
diagnosis.
Caregiverstrainmeasuresstressorburdenduetothe
physical,personal,emotionalandfinancialstressincurred
byacaregiverasaresultof,orinrelationto,his/hercar-
egivingrole/s.InthestudydonebyBeckandLopes
amongcaregiversofchildrenwithcancerin2007,78%of
thecaregivershad

caregiverrolestrain

and100%pre-
sentedriskfor

caregiverrolestrain

[12].Itistherefore

Page2of11

importanttoidentifystrainamongcaregiverstoprevent
adversepsychosocialproblemsonthefamilycaregiver.
AccordingtoDr.GabrielSmilkstein[5,13]thefamily

s
abilitytoadapttoorcopewithcrisisdependsontheir
resources.InthePhilippines,apopularmethodusedby
familyphysicianstoassessfamilyresourcesisthe
SCREEMMethodofAnalysiswhichwasdevelopedby
Smilkstein[5]todeterminefamily

scapacitytoparticipate
intheprovisionofhealthcareortocopeintimesofcrisis.
Useofthistoolresultsinanarrativedescriptionofthe
social,cultural,religious,economic,educationalandmedi-
calresources,forwhichitsacronymstandsfor,asitrelates
topossiblesourceofhelporhindrancetotheprovisionof
careforpatients.
Atpresent,thereisaneedforreliableandvalidFilipino
instrumentstoassesstheadequacyoffamilyresources.
Thespecificobjectivesofthestudywere:1)todetermine
familyfunctionusingtheFilipinoFamilyAPGAR;2)to
measurethefamilycaregiverstrainutilizingtheModified
CaregiverStrainIndex;3)toevaluatefamilyresources
usinganewquestionnairebasedonthesixdomainsofthe
SCREEMmethodofanalysis-social,cultural,religious,
economic,educationandmedical;3)todeterminethe
relationshipbetweenfamilyresources,familyfunctionand
caregiverstrain;and4)todeterminethereliabilityofthe
newfamilyresourcesquestionnaireintermsofinternal
consistencyamongpediatriccancerpatients.
OperationalDefinitions

familyresources-meansthatcanbeusedbythe
familytocopewithdifficultsituations;includethe
followingresources:
socialresources-strongsocialsupportnetwork
whichmayincludespouse,children,parents,sib-
lings,neighbors,co-workersandothers
culturalresources-culturalvalueswhichcaninflu-
enceanindividualorfamily

sabilitytocareforthe
sickandcopewithstresse.g.optimism,familial-
ism,approachvsavoidancestyle,etc.
religiousresources-spiritualbeliefs,practices
andsupportservices
economicresources-family

sincomeand
savings
educationalresources-levelofformaleducation
attainedbyanindividualwhichallowshimto
understandthepatient

sconditionandgivehim
appropriatecare
medicalresources-acessibilitytomedicalfacil-
itiesandadequacyofhelpfromhealthcare
providers
Theseresourceswillbemeasuredbytheuseof
SCREEM-RES,anewlydevelopedfamilyresources
questionnairedevelopedbythestaffofthesectionof

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SupportivePalliativeHospiceMedicineoftheUni-
versityofthePhilippines-PhilippineGeneral
Hospital.

caregiverstrain-physical,personal,emotionaland
financialstressincurredbyacaregiverasaresultof,or
inrelationto,his/hercaregivingrole/s.Thiswillbe
measuredbytheModifiedCaregiverstrainindex

familyfunction-measurestheextenttowhicha
familyworksasaunit;itdenotesthefamily

sabilityto
copeandadjusttodifferentsituationsbasedon5com-
ponents:adaptation,partnership,growth,affectionand
resolve;theFilipinoFamilyAPGARwillbeusedto
measurethis
Methods
SampleandDataCollection
Thisisacrosssectionalstudyinvolvinganon-randomized
conveniencesampleof90adultfamilycaregiversofchil-
drenwithcancerwhowerebeingseenatthepediatric
cancerclinicofatertiarygovernmenthospitalinthe
Philippines.Thestudyincludedfamilycaregiverswho
were18yearsoldandabove,andabletounderstand
proceduresandfollowinstructions,readandunderstand
Filipinolanguage.Aftertheconsentwasobtained,a
self-administeredquestionnairewasgiven.Thesocio-
demographicprofilewasalsoobtainedthroughthe
questionnaire.
Thestudyusedconveniencesampling,whichisuseful
fordescriptiveandcorrelationstudiesinrelativelynew
areasofinvestigation[14].Severalmotivationstousethis
methodarethefollowing:whenitisdifficulttocreatea
listformakingarandomselection,whentheobjectivesof
thestudydonotrequireexactresults,suchasinbiopsy-
chosocialsurveys;orwhentheresearcherisinterestedina
populationofwhichonlyafewcasesmaybeavailablefor
studyandthesethenmustserveasthesampleofthe
population,suchasfamiliesofchildrenwithcancer.
DataCollectionToolsandInstruments
FilipinoFamilyAPGAR
Familyfunctionmeasurestheextenttowhichafamily
worksasaunit;itdenotesthefamily

sabilitytocopeand
adjusttodifferentsituationsbasedon5components:
adaptation,partnership,growth,affectionandresolve.
TheFilipinofamilyAPGARisatranslatedFilipino
versionofSmilkstein

sfamilyAPGAR.Itsusehasbeen
analyzedinthePhilippinesby

Drs.LCabahugandA.
Pineda,Jrintheirstudy

FamilyAPGAR:ItsValidation
AmongFilipinoFamiliesEmergencyRoom,OutPatient
DepartmentSto.TomasUniversityHospital,Januaryto
April,1992.

Thisresearchshowedthatthetranslated
FilipinoAPGARhasagoodreliabilityindexasitscon-
tentsapproximatedtheSmilkstein

sEnglishversion.Like
theoriginalfamilyAPGAR,theFilipinofamilyAPGAR

Page3of11

consistsofstatementsonfive(5)parametersoffamily
functioning:Adaptability,Partnership,Growth,Affection
andResolve.Thefamilymember

sresponseisbasedon
thefrequencyoffeelingsatisfiedwitheachofthefive
parametersusinga3-pointscalerangingfrom0(hardly
ever)to2(almostalways).Thescaleisscoredbysum-
mingthevaluesforthefiveitemsforatotalscorethat
canrangefrom0-10.Ascoreof0-3denotesaseverely
dysfunctionalfamily,4-7moderatelydysfunctionalfamily
and8-10highlyfunctionalfamily[5,15].
ModifiedCaregiverStrainIndex(MCSI)
Caregiverstrainmeasuresstressorburdenduetothephy-
sical,personal,emotionalandfinancialstressincurredbya
caregiverasaresultof,orinrelationto,his/hercaregiving
role/s.TheModifiedCaregiverStrainIndex(MCSI)for
Filipinocaregiversisan11-itemquestionnairethatdeals
withfourmajorareasofburden-physical,personal,emo-
tionalandfinancial.Eachitemcanbeansweredbya
three-pointLikertscale.Summingthescoresinallofthe
itemswilldetermineifacaregiverhasstrain.Ascoreof

23isnormal,24-28showspropensityforstrainand

29
signifiesseverecaregiverstrain[16,17].
SCREEMFamilyResourcesSurvey(SCREEM-RES)
Familyresourcesarethemeansthatcanbeusedbythe
familytocopewithdifficultsituations;theseincludesocial,
cultural,religious,economicandmedicalresources.Anew
familyresourcesquestionnairedevelopedbyDr.Medina
andtheSectionofSupportivePalliativeandHospiceMed-
icine(SPHM),UniversityofthePhilippines-Philippine
GeneralHospitalwasusedtoassurehomogeneityinthe
datathatwillbecollectedregardingthesubject

spercep-
tionoftheadequacyofthefamily

sresources[Medina,
M.(2010).SCREEMBasedFamilyResourcesSurvey.
UnpublishedManuscript.].Thistoolwasformulatedby
theauthorstocreateavalidandreliablemeasureoffamily
resourcesthatwouldbeusefulinclinicalpracticeand
research.Itwasbasedonthe:1)SCREEMmethodofana-
lysisbySmilkstein[5,13]whichhasbeenusedinthelocal
settingtoassessfamily

scapacitytoparticipateinthepro-
visionofhealthcareortocopewithcrisis,aswellasfrom
2)reviewsofpublishedsurveys,andalso3)currentopi-
nionandexperienceofspecialistsoftheSectionofSPHM
intheuseoftheoriginalSCREEMMethodofAnalysis.
Thisinstrumentisabrief12itemquestionnairewhich
includesallthesixoriginalSCREEMdomains,andcon-
tains2itemsperdomain.Familycaregiversareaskedto
chooseoneofthefollowingresponses:stronglydisagree
(

lubosnahindisumasang-ayon

),disagree(

hindisuma-
sang-ayon

),agree(

sumasang-ayon

),andstronglyagree
(

lubosnasumasang-ayon

).
DataAnalysis
Descriptivestatisticswasdoneusingmeansforcontinuous
variables;frequenciesusingcategoricalvariables.For

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continuousvariables,testsofdifferencesbetweenmeans
Results
andindependentgroupsweredonetodeterminediffer-
Demographics
ence.Reliabilityanalysiswasdonebymeasuringinter-itemAtotalof90FilipinofamilycaregiversofFilipinochil-
correlation,item-totalcorrelation,andCronbach

salpha.drenwithcancertookpartinthestudy.Table1shows
Forpreliminarytestforassociation,thestudyusedsim-thefamilycaregivers

demographics.Caregivers

agesran-
pledichotomouscategoriesfortheSCREEMQuestion-gedfrom18-65yearsoldwithameanageof36years.
naire.Eachitemwasscoredona0-3basisusingtheMostofthemwereabletoreachhighschool(62%)and
followingkey:StronglyDisagree=0,Disagree=1,Agreearethepatients

mothers(75%).
=2,andStronglyAgree=3.ThescoresforalloftheTable2showsthepatients

demographics.Meanage
items,domainsandentireSCREEM-RESweresummedwas7-8years(SD=5.37).Mostofthechildrenhave
resultingtoscoresof0-3foreachitem,0-6foreachhematologicmalignanciesandmosthavebeenunder-
domainand0-36fortheentireSCREEM-RES.Thescoresgoingtreatmentfor1yearorless.
werefurthergroupedtodetermineinadequacyorade-
quacyofresources.Inadequateresourcesforeachitem
FamilyFunctionandCaregiverStrain
havescoresof0to1,foreachdomain0to3andfortheBasedontheresultsoftheFamilyAPGAR,illustratedin
totalSCREEM-RES0-18.Ontheotherhand,adequateFigure1,44.4%offamilycaregiversreportedtheir
resourcesaresignifiedbythefollowingscores,2to3forfamiliesasbeinghighlyfunctional,44.4%moderatelydys-
eachitem,4to6foreachdomainand19to36forthefunctionaland11.1%areseverelydysfunctional.
wholeSCREEM-RES.ItisshowninFigure2that54.4%ofthecaregivers
Chi-squaretestwasusedtodetermineassociationwerewithoutcaregiverstrain,30.0%werewithpredispo-
betweenfamilyresources,familyfunctionandcaregiversitiontocaregiverstrainand15.6%werewithsevere
strain.Exacttestswereusedwhenindicated,suchascaregiverstrain.
whenexpectedfrequencieswerelowerthan5.Cramer

s
Vwasusedtodeterminethestrengthofassociation;and
FamilyResources
itincreasesfrom0to1asthestrengthofassociationTable3showsthecaregiversresponsesregardingthe
increases.availabilityoffamilyresourcesusingthefamily
Anexploratoryfactoranalysiswasalsodonetoexam-resourcesquestionnaire.Inadequatefamilyincomeand
inethestructureofrelationshipsbetweentheitemsoffamilysavingswerereportedby83.3%and80.9%of
thefamilyresourcesquestionnaire.Allstatisticalanalysisfamilycaregiversrespectively.Difficultaccesstomedical
inthestudywasdoneusingSPSS.Forthestudy,levelofhelpinthecommunitywasreportedby38.9%.23.3%
significancewassetat0.05.feltthattheireducationwasinadequatetounderstand

Table1FamilyCaregiverDemographics
AgeofFamilyCaregiver(inyears)
AgeGroupofCaregiver
Youngadult(18-35)
MiddleAdulthood(35-60)
Lateadulthood(60)
xeSaMleFemale
Educationalbackground
Elementary
Highschool
College
RelationshiptoPatient
Mother
Father
Grandmother
Sibling
Anut

NumberofCaregivers
Mean=35.67(SD=10.65)
444321575655276541332

Percent(%)
Median=35.00
49.4.3482.216.7383.7.61.86033.7.47.6113.4.3432.

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Table2PatientDemographics
MeanMedian
AgeofPatient(inyears)
7.9(SD=5.37)7.0
AgeofPatientatDiagnosis
5.6(SD=4.93)4.0
DurationofTreatment
1.6(SD=2.23)1.0
CancerTypeNumberofPatientsPercent(%)
Hematologic
6067.0
Nonhematologic
2831.0
missing
20.3

informationabouttheirpatients

disease.Adequatefaith
andreligionandadequatehelpfromreligiousgroups
werereportedby97.8%and84.4%offamilycaregivers
respectively.Sufficienthelpwithinthefamilyandcom-
munitywerereportedby94.5%and82.2%offamily
caregiversinthatorder.91.1%and88.9%reportedthat
theirculturestrengthenstheirfamilyandthecultureof
helpingandsharingisadequateintheircommunity
correspondingly.

Figure1
Caregivers

FamilyAPGAR
.

Page5of11

ReliabilityAnalysis
Cronbach

salpha(
a
)fortheentirescalewas0.80,
usingtheoriginalscoresfrom0to3foreachitem,
indicatinggoodinternalconsistencyreliability.There
isawiderangeofvaluesintheinter-itemcorrelation
matrix(-0.13to0.69)foralltheitemswhichisconsis-
tentwiththehighlymultidimensionalnatureofthe
scale.However,thereisgoodinter-itemcorrelation
betweenitemsineachdomain:social(0.27),cultural
(0.51),religious(0.35),economic(0.70),educational
(0.67),andmedical(0.24).Internalconsistencyreliabil-
ity,
a
,foreachdomainwere:social(0.61),cultural
(0.77),religious(0.60),economic(0.92),educational
(0.78),andmedical(0.40).
Inpreparationfortheplannedtestsforindependence
andassociation,furtheranalysiswasdoneusingasimpli-
fieddichotomousscoringsystem.Itemscoreswere
groupedintotwo(0-1=inadequate,2-3=adequate).
Usingthisscoringsystem,itemanalysisandreliability
resultswerelowercomparedtoanalysisusingthe

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Figure2
Caregivers

Strain
.

Page6of11

original(0to3)scores.Internalconsistencyremained
AnalysisforIndependenceandAssociation
good(
a
=0.70).Internalconsistencyreliability,
a
.forTestsforindependenceandassociationweredoneusing
eachdomainwere:social(0.38),cultural(0.67),religiousdichotomouscategoriesforfamilyresourcesandstan-
(0.39),economic(0.82),educational(0.80),andmedicaldardcategoriesrecommendedfortheFamilyAPGAR(3
(0.26).Inter-temcorrelationsforeachdomainandforcategories)andtheMCSI(3categories).Significant
theentireinstrumentremainedunchanged.associationswerefoundbetweenfamilyfunctionbased

Table3PercentageofFamilyCaregiversReportingontheAdequacyofFamilyResources
PercentageResponse(%)
ResourceDomainsDomainItemsAgreethatResourcesareAdequateDisagreethatResourcesareAdequate
SocialHelpwithinfamily94.55.5
Helpfromcommunity82.217.8
CulturalCulturestrengthensfamily91.18.9
Cultureofhelpingandcooperation88.911.1
ReligiousFaith&Religionhelpsfamily97.82.2
HelpfromReligiousgroups84.415.6
EconomicFamilySavings19.180.9
FamilyIncome16.783.3
EducationalAdequatetounderstandillness76.723.3
Adequatetocareforpatient83.316.7
MedicalAccesstomedicalcareincommunity61.138.9
Helpfromhealthcareproviders96.73.3

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ontheFamilyAPGARandtheadequacyofthefollow-
ingdomainsoffamilyresources:social(chisquare(2)=
18.440,exactp<0.001;p=0.001,Fisher

sExactTest,
FET),cultural(chisquare(2)=13.127,exactp=0.002;
p=0.003,FET),andmedical(chisquare(2)=8.291,
exactp=0.015;p=0.017,FET).Computedvaluesfor
Cramer

sVshowedmoderatetostrongassociationsof
thesedomainswithfamilyfunction:social(0.453),cul-
tural(0.382),andmedical(0.304).Resultsalsoshoweda
significantassociationbetweentheover-alladequacyof
familyresourcesbasedontheentireSCREEM-RESand
familyfunctionbasedontheFamilyAPGAR(chisquare
(2)=16.157,exactp=0.001;p=.002,FET).Cramer

sV
was0.426whichindicatesastrongassociation.Forthe
analysis,allcontingencytableshadatleast80%of
expectedfrequenciesthatwere5orlarger.Therewasno
significantassociationfoundbetweenfamilyresources
andcaregiverstrainbasedonMCSI,andbetweenfamily
functionandcaregiverstrain.
Thestudydidnotfindevidenceforsignificantassocia-
tionsbetweencaregiverstrainandotherdemographic
variablesinthesamplestudiedincluding:caregiver

sage
group(<20,20-35,36-50,>50),caregiver

seducational
attainment(elementary,highschool,orcollege),care-
giver

sgender(male,female),relationshiptothepatient
(mother,father,grandparent,aunt/uncle,others),the
patient

sagegroup(<6,6-12,13-19)andpatient

sgender
(male,female).Therewasalsonosignificantassociation
foundbetweenthefamilycaregiver

seducationalattain-
mentandthereportedadequacyofeducationalresources
basedonthesubscaleforeducationalresources.
ExploratoryFactorAnalysis
Exploratoryfactoranalysisofthe12itemfamilyresources
instrumentwasdoneusingthesimplified2-pointscoring
systemforeachitem.Thesamplesizeofthisstudywas
inadequate(Kaiser-Meyer-OlkinMeasureofSampling
Adequacyat0.640)foranactualfactoranalysis,butan
exploratoryfactoranalysiswasdonetoexaminethestruc-
tureofrelationshipsbetweentheitemsofthefamily
resourcesquestionnaire.VarimaxwithKaiserNormaliza-
tionwasused.Initialanalysisshowedthatthescaleis
composedof4domainswhichaccountedfor63.3%ofvar-
iance.Allitemsundertheoriginalsocial,culturalandreli-
giousdomainsformedthefirstfactor.Theremaining
itemsintheeconomic,educationalandmedicaldomains
formedtheotherthreefactorswhichdirectlycorre-
spondedtotheoriginaldomains.
Discussion
AccordingtoSmilkstein

scycleoffamilyfunction[13],
familiesfacedwithstressfullifeeventsmayexperiencedis-
equilibriumandtheirabilitytorecoverfromthisisdeter-
minedbytheavailabilityoffamilyresources;inadequate

Page7of11

resourceswouldleadtoterminaldisequilibriumand
adequateresourceswoulddirectthemintofunctional
equilibrium.ThisisalsotruewiththeABC×Modelof
FamilyStress[18,19]whichstatesthattheseverityand
durationoffamilydisorganizationduringacrisisisdeter-
minedbytheleveloffamilyfunctioning,theperceived
magnitudeofthecrisisandtheamountoffamily
resources.Familieswithinadequateresourcesareless
likelytoreturntotheirformerfunctionality.Thosewho
aremorepronetogointosevereandprolongedcrisis
tendtoexperiencemoreproblemsandstressors,lackcop-
ingresources,andbemoredysfunctional.
BasedontheresultsoftheFamilyAPGARandModified
CaregiverStrainIndex(MCSI)manyFilipinofamiliesand
familycaregiversexperiencesignificantpsychosocialdis-
tressfollowingthediagnosisofchildhoodcancer.These
familiesneedappropriatepsychosocialcareandsupportto
helpthemcopewiththeillness.
Thestudyusedanewlydevelopedinstrument,
SCREEM-REStoassessfamilyresourceswhichwasbased
onSmilkstein

sSCREEMmethodofanalysisoffamily
resources[5,13].Theresultsofwhichrevealedthateco-
nomicresourceswerethemostcommonlycitedasbeing
inadequate,thisisfollowedbyinadequateaccesstomedi-
calcareinthecommunity,inadequateeducational
resourcestounderstanddisease,inadequatehelpfromthe
community,andinadequateeducationalresourcestolearn
toprovidecare.Ontheotherhand,indecreasingorder,
theresourceswhichweremostcommonlycitedasbeing
adequatewerefaithandreligion,helpfromhealthcare
providers,helpwithinthefamily,andculturalresources.
ThePhilippinegovernmenthaslowbudgetforhealth;a
localtelevisionnewsprogramairedlastAugust12,2011
thattheadministrationonlyallocatesPhp300.00orUSD
7.14ofitsbudgetperannumforeveryFilipino

smedical
services.Mostofthecountry

shospitalsareprivately-
owned;moreover,itssocialinsurancearm,thePhilippine
HealthInsuranceCorporation(PhilHealth)onlygives
healthbenefitstoregularpayingmembers.Thus,the
nation

shealthcaresystemcouldhardlyhelpitssickpeo-
pleandtheircaregiversandthisismuchfeltbycancer
victimswhoshouldermuchifnotalloftheirtreatments.
ManyFilipinofamilies,whoarelivinginthePhilippines,
havelimitedeconomicorfinancialresources.Basedon
datafromtheNationalStatisticsOffice(2000),70%ofFili-
pinofamiliescanonlyaffordtospendlessthanPhp2,200
(approximately45USD)forhealthcare-relatedexpenses
everyyear[20].Manylow-incomefamilieswhoarebeing
seenatthegovernmenthospitalwherethisstudywas
done,donotevenhaveadequatefinancialresourcesto
sustaintheirbasicneedsasmostofthemareminimum
wageearnersorunemployedthustheyhavelittleorno
savingsatall.Generally,theirlimitedeconomicresources
isrelatedtothereportedinadequacyandinaccessibilityto

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medicalcareinthecommunity.Asidefromthefamilies

inabilitytopayfortheirownmedicalcare,manyoftheir
communitieshavealsolimitedfinancialresourcesthat
couldprovidethemhealthcare.Thisconditionledthepri-
vatehealthcareinstitutionsandproviderstoavoidthe
poorcommunitiesandserveonlythemostprogressive
areasinthePhilippines.Thesefactorscontributetothe
seriousimbalanceinthedistributionofmedicalcare
resourcesinthecountrywhichfavorsthemostdeveloped
communities.
Withregardstothereportofinadequateeducational
resources,mostofourrespondentshavereachedhigh
schoolandthisshouldhaveallowedthemtounderstand
basicinformationabouttheillnessandinstructionson
caregiving.Thisinadequacymaybeduetootherfactors
suchasinadequatecommunicationandinformationshar-
ingbetweenfamilycaregiversandhealthcareproviders.
Thismayalsoreflectthefamilycaregiver

sneedformore
counselingandguidancefromhealthcareproviders.
Religiousresourceswerethemostcommonlycitedfamily
resourceswhichwereadequate.Filipinofamiliesareknown
forbeingreligious;religionandreligiouspracticesforma
significantpartoffamilylife.Theyareusuallyreadilyavail-
abletoFilipinofamiliesaschurches,variousreligiousinsti-
tutionsandreligiousgroupsarefoundinalmostallFilipino
communities.Theseresourcesarebelievedtobeimportant
intimesofcrisis;accordingtoMartini[21],religioncanbe
asourceofstrengthforthefamily.Healsostatedthat
accessiblereligioussupportservicesandreligiouspractices
candecreasethestressandburdenofcaregiving.
Alsoimportantintimesofcrisisissocialsupport.The
amountofdistressexperiencedbyfamiliesandparentsof
childrenwithcancerisrelatedtotheperceptionofand
satisfactionwithsocialsupport[22-26].Resultsofthecur-
rentstudyshowedthatsocialresources,particularlythe
helpwithinthefamily,werecitedasthenextmostade-
quatefamilyresources.Thisissupportedbythefactthat
ingeneral,Filipinosareknowntohavecloseknitfamilies,
neighborsandfriendsinthecommunityareusuallyready
tohelpthefamilyintimesofneed.
Althoughmanyfamilycaregivershadreportedinade-
quateaccesstomedicalcareintheircommunity,major-
ityofcaregiversalsoreportedthatthehelptheyreceive
fromhealthcareproviderswasadequate.Manyfamilies
inthisstudyhavetravelledlongdistancesfromtheir
communitiestoseekconsultandmedicalcarewhichwas
notavailableoraccessibleintheirowncommunities.The
highpercentageofcaregiverswhoreportedadequate
helpfromhealthprovidersmayhavereferredtothehelp
thattheywerereceivingfromprovidersinthehospital
wherethisstudywasdonewhichhasawellestablished
supportiveandpalliativecareprogramwhichhelps
patientsandfamilies,andnottothehelpfromhealthcare
providersintheirowncommunities.

Page8of11

Usingtheoriginal4-pointscoringsystemforeachitem,
calculatedvaluesofCronbach

salpha,inter-itemanditem
totalcorrelationindicatedthatthesetofquestionsfor
each2-itemdomainandtheentire12-itemquestionnaire
hadgoodreliability.Forapreliminaryassessmentofthe
SCREEM-RES,itemscoreswerecollapsedtoforma2-
pointscoringsystem.Usingthisscoringsystem,valuesof
Cronbach

salpha,inter-itemanditemtotalcorrelation
wereslightlylower.However,reliabilitymeasures
remainedadequateforgroupanalysisexceptforthemedi-
caldomainscale.Exploratoryfactoranalysiswasalsodone
ontheitemsofthefamilyresourcesquestionnaire.Four
factorswereextracted:socio-cultural-religiousfactor
(includesallitemsintheoriginalsocial,culturalandreli-
giousdomains),educationalfactor(itemsintheeduca-
tionaldomain),economicfactor(itemsintheeconomic
domain),andmedical(itemsinthemedicaldomain).This
factorstructureisconceptuallyconsistentwithandsup-
portstheoriginalSCREEMbasedsixdomainstructure.
Itemsintheoriginalsocial,culturalandreligiousdomains,
whichallloadedintothefirstfactor,areallcloselyrelated
tothesocio-culturalaspectsoffamilylife.Whilethethree
otheroriginaldomainsdirectlycorrespondedtothethree
otherfactorsextracted.
Forthisstudy,scoresforeachdomainandtheentire
familyresourcesinstrumentweregroupedintodichoto-
mouscategories(adequateresourcesandinadequate
resources).Standardrecommendedcategoriesforthe
familyAPGARandtheMCSIwereusedforfamilyfunc-
tionandfamilycaregiverstrainrespectively.Results
showedthatthereisevidenceofsignificantassociation
betweenadequacyoffamilyresourcesandfamilyfunction.
However,thestudydidnotfindanysignificantassociation
betweenfamilyresourcesandcaregiverstrain,and
betweenfamilyfunctionandcaregiverstrain.Thismaybe
partlyexplainedbythefactthatboththefamilyresources
questionnaireandtheFamilyAPGARarefamilyfocused
instruments,whiletheMCSIisfocusedonindividualcare-
givers.Otherfactorsmayaffectcaregiverstrainsuchasthe
caregiver

spersonalorinternalresourcesandthepatients

severityoftheillness,degreeofincapacitationandcaregiv-
ingneeds.Amoreintensivepsychometricevaluationand
evaluationoftheSCREEM-RESweredone,andwillbe
presentedinasucceedingpaper[MedinaM,Panganiban-
CoralesA,NicodemusLandAngA.2010.Family
ResourcesStudyPart2:DevelopmentandPsychometric
AssessmentoftheSCREEMFamilyResourcesSurvey
(SCREEM-RES).Unpublished].
Themajorityofthefamilycaregiversinthestudywere
youngmotherswhoaremorepronetoexperiencesignifi-
cantstressandcaregiverstrain[27-29].However,thecur-
rentstudywasnotabletoshowanysignificantassociation
betweencaregiverstrainandthecaregiver

sage,gender
andrelationtothechild.Therewasalsonoevidenceof

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significantassociationbetweencaregiverstrainandother
demographicvariablesincludingthecaregiver

seduca-
tionalattainment,andthepatient

sageandgender.
Furtherstudiesareneededtodeterminetherelationships
betweenthesedemographicvariables.
Thisstudyfocusedonfamilyresources,familyfunction
andfamilycaregiverstrain;andtherelationshipsbetween
thesefactors.Abetterunderstandingofthesefactorsand
theirrelationshipsisimportantinthedevelopmentof
waystodeterminethefamily

sriskofgoingintosevere
crisis.Itisalsoimportantinthedevelopmentofappro-
priateandeffectivefamilyinterventionstohelpfamilies
whoareatriskandfamilieswhoarealreadyinseverecri-
sis.Moreover,thisstudyprovidedinitialevidencesthat
thefamilyresourcesinstrumentusedinthisstudyisa
helpful,reliableandvalidtoolintheassessmentofthe
adequacyoffamilyresources,especiallyintimesofsevere
stressandcrisis.
StudyLimitationsandFutureResearch
Recommendations
Therelativecostandtimethathasrequiredtheresearch-
erstocarryoutthisinvestigationwassmallusingconveni-
encesampling;italsoenabledthemtogatheruseful
informationthatwouldhavenotbeenpossibleusingprob-
abilitysamplingtechniques.However,thesubjectsthey
usedinthisstudymaynothavewhollyrepresentedthe
populationofpediatriccancercaregivers;hence,itlimited
theabilityofthispapertomakegeneralizationsaboutthe
entirepopulation.Itisthereforerecommendedthataran-
domizedpopulationbegeneratedinafollow-upstudyso
astoavoidunderoroverrepresentationofthisparticular
groupofcaregivers.
Thecross-sectionalstudydesignusedinthisstudy
foundsignificantassociationsbetweenfamilyresources
andfamilyfunction,butthestudydesignalsolimitedthe
abilitytoestablishcausality.Futurelongitudinalstudies
maybetterdescribetherolesoffamilyresources,family
functioningandcaregiverstrainduringtheillnesstrajec-
tory.Also,thissurveyisbasedonself-report,andmaybe
pronetosocialdesirabilitybias.Socialdesirabilitybiasisa
tendencyoftherespondentstoreplyinamannerthatwill
beviewedfavorablybyotherswhichleadstooverreport-
ingofgoodcaregiverandfamilycharacteristicsandunder
reportingofbadcharacteristics.Thoughmostofthe
familycaregiversweremothers,otherrelativeswerealso
includedinthestudy.Relianceondifferentfamilymem-
bersmaybealimitationconsideringthattheymayhave
differentinteractionswiththechildandpossiblydifferent
emotionalreactionstothechild

sillness.
Thestudywasalsolimitedbytheavailabilityofappro-
priateFilipinodatacollectiontoolsandinstruments.The
lackofreadilyavailableFilipinopsychosocialtoolsto

Page9of11

assessthefamilywasasignificantlimitationofthestudy.
FuturestudiesarewarrantedoncemoreFilipinofamily
assessmentinstrumentsbecomeavailable.Thefamily
resourcesquestionnaireusedinthisresearch,liketheori-
ginalSCREEMMethodofAnalysisbySmilksteinfrom
whichitisbased,isonlymeanttodoageneralassess-
mentoffamilyresources.Itisplannedtobeageneric
instrumentthatcanbeusedindifferentpopulationsand
settings.Assessmenttoolswhicharemorecaregiver
focused,ormorediseasespecificarealsoneeded.For
example,amorecaregiver-specifictoolcanbedeveloped
byincludingvariablesthataremoredirectlyrelatedto
caregiverstrainsuchaspersonalorinternalresources,
severityofpatient

sillness,andthepatient

scaregiving
needs.Futurestudiesshouldassesstherelationsbetween
thesevariablestofamilyresourcesandfamilyfunction-
dysfunctioninordertocomprehensivelyevaluateallpos-
siblefamilyresourcesthatcouldhelpfamiliescopewith
crisis.AmoreintensiveevaluationoftheSCREEM-RES
wasdone,andwillbepresentedinasucceedingstudy
(Medina,Panganiban-Corales,NicodemusandAng,
2010).
Afollowupstudyusingabiggerandmoreheteroge-
neouspopulationisalsorecommended.Thesestudies
canfurtherevaluatethereliabilityandvalidityofthe
SCREEM-RES.Furthermore,studiesareneededtobetter
determinecutoffvaluesforadequacyoffamilyresources.
Resultsofthisstudydescribedthepsychosocialneedsof
familiesandcaregivers.Theseresultssupporttheuseof
familyinterventionstoimprovefamilyresources,support
familyfunction,andeasecaregiverstrain.
Conclusion
ManyFilipinofamiliesofchildrenwithcancerhaveinade-
quatefamilyresources,especiallyeconomicresources,to
dealwithmedicalcrises;andmanyfamiliesaremoderately
orseverelydysfunctional.
Manyadultfamilycaregiversarepredisposedtocaregiver
strainorarealreadyexperiencingseverestrain.Majorityof
Filipinofamilycaregiversofchildrenwithcancerdisclosed
thattheyhaveinadequateeconomicresources.Many
familiesalsoreportinaccessibilitytomedicalhelpinthe
communityandinsufficienteducationtounderstandand
carefortheirpatients.Mostfamiliesacknowledgedthat
theirfamily

sfaithandreligionishelpful;theyalsofeltthat
helpfromwithinthefamilyandhealthproviderswereade-
quate.Inordertobeabletoprovideappropriatecarefor
familiesofpatientswithsevereillnessessuchaschildhood
cancer,physiciansshouldregularlyassessfamilyfunction,
familyresourcesandthestrainexperiencedbyfamilycare-
givers.TheSCREEM-RESquestionnaire,whichwasused
inthisstudy,isahelpfulandreliableinstrumenttoassess
theadequacyoffamilyresources.

Panganiban-CoralesandMedina
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2011,
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PermissionandUseoftheFamilyResources
Questionnaire
Permissionontheuseoffamilyresourcesquestionnaire
utilizedinthisstudymustbeobtainedfromManuelF.
Medina,Jr.M.D.andtheSectionofSupportivePalliative
andHospiceMedicine,DepartmentofFamilyandCom-
munityMedicine,UniversityofthePhilippines-Philippine
GeneralHospital,Manila.Thecontentandformatofthis
familyresourcesquestionnairemustnotbemodifiedor
alteredwithoutthepermissionofthetooldeveloper.
ListofAbbreviations
APGAR:isanacronymforAdaptability,Partnership,Growth,Affection,Resolve
while;MCSI:standsforModifiedCaregiverStrainIndex;SCREEM-RES:standsfor
Social,Cultural,Religious,Economic,Educational,MedicalResources;SPHM:is
anabbreviationforSupportivePalliativeandHospiceMedicine.
Acknowledgements
TheauthorsarethankfulfortheinsightfulcommentsreceivedfromDr.Roberto
Ruiz,Dr.IreneYu-MaglonzoandDr.LeilanieApostol-Nicodemusofthe
DepartmentofFamilyandCommunityMedicine,UniversityofthePhilippines-
PhilippineGeneralHospital,whoprovidedcriticalreviewofearlierdraftsofthis
manuscript.Theauthorsalsoacknowledgethesupportfromtheresearch
assistantsoftheSectionofSupportivePalliativeandHospiceMedicinewho
collectedthedatafortheFamilyResourcesStudy,AlmiraCruzandElaineMiral.
Authors

contributions
Thisdocumentisbasedonapreviousreportforaresearchentitled

Testing
theassociationoffamilyresourceswithcaregiverstrainandfamilyfunction
amongpediatriccancerpatientsusinganovelSCREEMquestionnaire

which
waspresentedattheAnnualResident

sResearchForumoftheDepartment
ofFamilyandCommunityMedicine,UniversityofthePhilippines-Philippine
GeneralHospital,October,2010.
ACwiththesupervisionofMM,wasresponsiblefortheoverallpreparation
oftheoriginalresearchmanuscript,includingtheanalysisandwrite-upof
thefindingsanddiscussion.Thefamilyresourcesquestionnairewas
developedbyMMwhoalsoprovidedcriticalreviewoftheoriginal
manuscript.Theoriginalmanuscriptwasfurtheredited,dataanalysiswas
checkedandadditionalanalysiswasdonebyMM,resultinginthecurrent
manuscript.BothACandMMreadandapprovedthefinalmanuscript.
Authors

information
MMisafamilymedicineconsultantatUniversityofthePhilippines-
PhilippineGeneralHospitalandisthecurrentheadoftheSectionof
SupportiveHospiceandPalliativeMedicinewhichprovidespalliativecareto
bothadultandpediatriccancerpatientsinthisinstitution.Hehaswritten
variousmanuscriptsonpalliativecareandhasbeenactiveinteachinghis
residentsandfellowsinaddressingpsychosocialissuesofpatients.
ACisanewlycertifiedfamilyandcommunitymedicinespecialisttrainedat
theUniversityofthePhilippines-PhilippineGeneralHospital.Atthetimeof
theconceptualizationofherresearchasarequirementforgraduationin
residencytraining,shewasinspiredbytheworksofDr.MMforchildren
withcancerasshewasrotatingatthesectionofSupportivePalliativeand
HospiceMedicinewherethelatterisheadthusbothcollaboratedforthe
fulfillmentofthisstudy.
Competinginterests
Theauthorsdeclarethattheyhavenocompetinginterests.
Received:6June2011Accepted:31October2011
Published:31October2011
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