Global Journal of Health Science; Vol. 14, No. 9; 2022
ISSN 1916-9736 E-ISSN 1916-9744
Published by Canadian Center of Science and Education

CLIMB® Program Evaluation of Quality of life, the Stress Response,
Self Esteem in Children Whose Parent Has Cancer: Pilot Study
Yuko Akagawa1, Hideaki Andoh1,2, Tomoko Ito1, Mai Narita2,3, Kaori Osawa4,
Sue P. Heiney5 & Sachiko Makabe1
1

Department of Nursing, Akita University Graduate School of Health Sciences, Akita, Japan

2

Center of Palliative Care, Akita University Hospital, Akita, Japan3

Akita Mental and Developmental Clinic for Children, Akita, Japan

4

Tokyo Kyosai Hospital, Cancer Consultation Support Center, Tokyo, Japan

5

College of Nursing, University of South Carolina, South Carolina, United State of America

Correspondence: Yuko Akagawa, Department of Nursing, Akita University Graduate School of Health Sciences,
Akita, Japan. Tel: 81-18-884-6551. E-mail: abe0204@hs.akita-u.ac.jp
Received: July 4, 2022

Accepted: August 18, 2022

doi:10.5539/gjhs.v14n9p15

Online Published: August 24, 2022

URL: https://doi.org/10.5539/gjhs.v14n9p15

Abstract
Children with a parent who has cancer express fears about cancer contagion, parental death and security of theirlife. CLIMB® (Children’s Lives Include Moments of Bravery) is a support program to improve children’s ability tocope with their parent’s cancer. This pilot study aims to describe the emotional impact of CLIMB® on children witha parent who has cancer. The elementary school version of QOL (Quality of life), the SRS-C (Stress Response
Scale for Children), Self Esteem, and satisfaction were evaluated.
Participants were seven children (three girls, four boys). All participants were satisfied with CLIMB®. The QOL
scores significantly increased from 79.9 (SD, 19.1; median, 86.7) points before the intervention to 85.1 (SD, 15.7;
median, 90.0) points after the intervention, indicating an improvement in the QOL (p=0.046). Subscale was no
significant difference according to sex. In the SRS-C scores no item showed significant differences in the pre- andpost-intervention scores. The total score had decreased, indicating a decrease in the stress response. The boys
showed a slight increase in the scores on the physical state subscale. The self-esteem scale scores were difference
between the pre- and post-intervention scores increased significantly for the total score (p=0.028) and thesubscales of “self in relationships” (p=0.042) and “self-assertion and self-determination” (p=0.038).
During CLIMB®, children received accurate cancer knowledge; and valued sharing their feelings among others
who are in the same situation. Children were highly satisfied with the program, although small changes were seen
in QOL and stress.
Keywords: Cancer, Children with a parent who has cancer, CLIMB® (Children’s Lives Include Moments ofBravery) program, QOL
1. Introduction
In recent years, the number of children with a parent who has cancer has increased, due to an increase in thenumber of young parents being diagnosed affected with cancer. Cancer statistics from the US Surveillance,
Epidemiology, and End Results (SEER) Program estimate that 10.4% of newly diagnosed cancer patients in the
United States are aged 18–55 years, and 22.4% of all cancer patients are aged 21–55 years (Howlader, et al., 2016).
This age corresponds to the childbearing and childrearing years, suggesting that the majority of these patients haveminor children. In addition, in the United States, an estimated 2.85 million minor children are living with a parent
diagnosed with cancer (Weaver, et al., 2010). This means that at least 18% of the parents with cancer have minor
children. In Japan, every year approximately 56,000 parents with minor children are diagnosed with cancer;
currently an estimated 87,000 minor children have a parent with cancer in Japan (Izumi, et al., 2015). This
represents roughly 4.3% of all children under the age of 18. Further, the average age of children whose parents
have cancer is reported to be 11.2 years (standard deviation, 5.2 years); as per a previous study, boys aged 7–12
years accounted for highest proportion of the minor population whose parents had cancer, at about 14,000 children,15

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Global Journal of Health ScienceVol. 14, No. 9; 2022

followed by boys and girls aged 0–6 years, at about 13,000 children each, and girls aged 7–12 years, at 12,000
children; children in elementary school accounted for more than half of this population (Izumi, et al., 2015).
Recent improvements in cancer survival rates have also contributed to an increase in the number of cancer patientswith minor children.
Children whose parents have cancer may incorrectly understand the disease and worry that cancer is transmittable
as well as be fearful of the parent’s death and life stability. These children report more physical complaints (Visser,
et al., 2004) and emotional problems and higher stress response symptoms (Grabiak, et al., 2007; Visser et al., 2007)
than children whose parents do not have cancer. Children whose parents have cancer have also been reported tohave higher anxiety and lower quality of life (QOL) than the general 8–16-year-old population (Hauken, 2018).
Children of patients with breast cancer have significantly more health problems than children of patients with othertypes of cancers (Altun, 2019). Children of cancer patients have also been found to be more socially isolated(Vannatta, et al., 2008) than their age-matched peers, particularly at school age. Conversely, some studies outlined
positive changes in children whose parents had cancer (Kissil, et al., 2010; Wong, et al., 2009). In these studies,
about half of the adults whose parents had cancer when they were children experienced posttraumatic growth; dueto their painful experiences that they gained an increased appreciation for life. In addition, these studies reported a
deep sense of trust in relationships, increased personal strength, and positive changes in health-related behaviors
among such adults. Adequate support reduces the stress levels in children and fosters communication between
parents and children. It is important to support children by building on their strengths, as this will have an impact
on the parents’ own struggles with cancer.
Children are effectively supported when they receive support promptly after a parent’s cancer diagnosis; when
they meet with peers of the same age who are in a similar situation and when they are enabled to carry on as usualwith their daily lives, their anxiety is reduced (Kennedy & Lloyd-Williams, 2009; Sears & Sheppard, 2004). In
addition to the child’s peers and school, parents and other adult family members are also important supporters(Davey, et al., 2011). However, without professional intervention, it may be difficult to provide effective support.
One type of support available for children is the CLIMB® program. This program was developed by The
Children’s Treehouse Foundation (childrenstreehousefdn.org, 2022) in the United States for children whoseparents have cancer. It is a program that mainly supports primary school children; the program aims to empowerchildren and build their capacity to cope with the stresses associated with their parent’s illness. In this program,children work in a group to create various objects and express their feelings. The effects of CLIMB® have been
documented by Kobayashi et al., (2017) who suggested that participation in the CLIMB® program in Japan
improved the quality of life (QOL) of children with posttraumatic stress symptoms as well as that of their parents,
and Neill et al. (2019) found that providing families the opportunities to talk about cancer can help minimize therisk of psychological and social problems. These studies focused on QOL and stress responses; however, the aimof the CLIMB® program is to harness the capabilities of children, and this aspect has not been adequately explored.
Therefore, in the present study, in addition to QOL and stress reactions, we examined self-esteem as a measure ofchildren’s own abilities. It has been reported that when self-esteem is enhanced, children recognize their own
self-worth, learn how to build relationships with those around them, and are likely to ask for help when they are introuble (Tokyo Metropolitan Staff Training Center, 2011).
The purpose of this study was to evaluate the QOL, stress reaction, and self-esteem of children who participated in
the CLIMB® program. The following research questions were addressed: 1) To what extent do the QOL, stress
reaction, and self-esteem change after the program, 2) do these changes differ by age and sex?, and 3) what is thelevel of satisfaction with the program and the acquired experiences?
2. Method
2.1 Study Setting and Participants
The study design was a pre-post test single group pilot study. The participants were elementary school children
aged 6–12 years whose parents were diagnosed with cancer in Japan and who were informed about their parent’s
cancer. Further, these children were participating in the CLIMB® program. Children with severe mental or
intellectual disabilities were excluded since CLIMB® is a group program, so if a child has difficulty understanding
the content of the program, that child would need individual attention.
The CLIMB® programs were held in August 2019 and March 2020. Before starting the program, the aims of thestudy were explained to the parents and children. After informed consent was obtained from the parents andchildren, the participants were asked to complete a questionnaire survey before and after the program.

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2.2 CLIMB® Program
CLIMB® stands for Children’s Lives Include Moments of Bravery. Participants are parents who have cancer andtheir children for elementary school students.
The purpose of CLIMB® is to help children unlock their own strengths and increase their ability to cope with thestresses associated with parental illness. CLIMB® sessions are structured programs that are conducted in closed
groups in the following manner: After confirming the attendance of the participating parents and children, they are
divided into separate rooms. The parents have an unstructured free discussion with health care providers, and thechildren are guided by the staff (Table 1). The program has three goals for children: (1) learning ways in which
they can express their emotions, (2) learning ways to communicate their emotions to those around them, and (3)learning ways to cope with their emotions. Specific emotions are dealt with in each session, and the childreninteract with each other through crafts and cancer-related education.
The program usually consists of six sessions, with one 2-hr session held every other week. However, for thepresent study, the program was consolidated to four sessions, with one 2.5-hr session held every other week,considering the poor transportation access in the region and to make sure the session dates coincide with children’slong vacation dates.
The CLIMB® program staff includes facilitators and assistants. The not-for-profit organization Hope Tree (2008)
conducts facilitator training courses for those wishing to become facilitators; their main duties include facilitating
the program, grasping the overall situation, and observing the situation empathetically. Doctors, nurses, clinicalpsychologists, and nursing students function as assistants; their main duties are to help the children understand thecontents of the sessions, supervise the working group, and promote interactions among the children.
Table 1. Content of the CLIMB® Program for the children’s group
Activity’s Goal

Feeling of the day

Activity“All about me”

1

Decrease isolation by sharing cancer
story with other children and learn about
feeling using happy as exemplar

Happy

2

Increase the children’s knowledge about
cancer and its treatment

Confused

To help the children self-disclose feelings about theparent’s illness and make sense of the event and tobuild cohesion and increase trust among the children.
“What is Cancer
Share your feelings of confusion. Learn about cancer.
“Feeling mask”

3Normalize feelings of sad

Sad

Making masks to express sad feelings. Sharing feelingsof sadness.
“Strong Box”
Create a strength box that expresses your strengths.
Decorate the box with a representation of what you likeand your strengths to overcome fear and anxiety. Sharewith everyone about your strengths.

4

Assist the children in identifying
strengths and normalizing anxiety

5

Assist the children in expressing andmanaging anger in healthy ways

Mad

Share feelings of anger and write anger and stressmanagement strategies on dice.

6

Facilitate communication
parent who has cancer

Feelings for
Parents“Get well card”

with

the

Scared“Anger cube”

Write a get well note to parent with cancer

2.3 Questionnaire Contents
We conducted an anonymous questionnaire survey before and after the CLIMB🄬 program. The attributes were
gender, age, grade, which parent had cancer, and the type of cancer.
The Kid-KINDL🄬 Elementary School Quality of Life Scale (Shibata, et al., 2003) was used to assess the children’s
own QOL. This scale asks questions about the child’s state over the past one week and consists of six subscales
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Global Journal of Health ScienceVol. 14, No. 9; 2022with a total of 24 questions. The Cronbach’s alpha coefficient was 0.84, confirming internal consistency. It consistsof the following subscales: physical health (α = 0.62), emotional wellbeing (α = 0.56), self-esteem (α = 0.71),
family (α = 0.64), friends (α = 0.57), and school life (α = 0.43). The items are scored using a 5-point scale, withresponses ranging from “very applicable” to “not applicable at all.” The scores range from 24 to 120 points(converted to 0–100 for this study), with higher scores indicating higher QOL. The reliability and validity of the
instrument in the elementary school population have been confirmed.
The Stress Response Scale for Children (SRS-C) was used to measure the stress response of children (Shimada, etal., 1994). This scale asks questions about current state and consists of four subscales with a total of 20 questions.
The Cronbach’s alpha coefficient was 0.92, confirming internal consistency. The subscales included physical state(Cronbach’s α=.82), depressive-anxious feeling (α =.79), irritated-angry feeling (α =. 81), and helplessness (α=.77). The scores ranged from 20 to 80 points, with higher scores indicating higher stress responses. The reliability
and validity of the instrument have been confirmed for the fourth-to-sixth-grade population.
Rosenberg’s Self-Esteem Scale (Japanese version) (2011) was used to measure self-esteem. It asks questions about
one’s current state and consists of three subscales with a total of 22 questions. To assess the internal validity of thescale, Pearson’s correlation was employed; Pearson’s r was 0.70, indicating a strong correlation (Ito & Wakamoto,2010). This scale included the following subscales: self-evaluation and self-acceptance, self in relationships, andself-assertion and self-determination. The items were scored using a 4-point scale, ranging from “agree” to“disagree,” with scores ranging from 22 to 88 points, and higher scores indicating higher self-esteem. The
reliability and validity of the scale have been confirmed for the fifth- and sixth-grade populations. Although theaforementioned three scales have limited use for first-to-third-grade students, our research team examined thecontent of the questions and the method of answering and believed that they could be answered with some support
from adults, so we decided to use them in this study.
To evaluate the level of satisfaction with the program, we used an evaluation developed by Hope Tree (2008). The
questionnaire consists of 10 questions, including “I am glad to be here,” “I was good talk to others about their
feelings,” “I think the group would help other children,” and “The staff was kind and friendly.” The items werescored used a 5-point response scale, with responses ranging from “very much” to “not at all.” In addition, we also
asked the participants to write freely about what they liked the most and about their own feelings and impressions.
2.4 Analyses
The individual attributes were simply tabulated, and the scores of the QOL, stress reaction, and self-esteem scales
were recorded at two time points, before and immediately after the program. The pre- and post-intervention scores
were compared using the Wilcoxon signed rank test. The scores of the post-intervention satisfaction evaluation
were recorded, and the free response items were summarized to examine the characteristics of the participants bysex and grade.
2.5 Ethical Considerations
This study was approved by the Ethics Committee of the author’s University (Approval No. 2262). And, as aclinical trial registration, we registered with the University Hospital Medical Information Network (UMIN) in
Japan (registration number: UMIN000043504). We explained the research to the children and their parents using
informed consent documents. The contents were 1) research background and purpose, method, 2) method ofprotecting personal information, and 3) questionnaire is anonymous, not disclosing any personally identifiable
information when disclosing the results. In addition, it also said that if physical and psychological hard areexperienced, the problem will be referred to the pediatrician or pediatric clinical psychologist. After the
explanation, consent was obtained from parents. If the child seemed to have difficulty understanding any part ofthe information, when answering the questionnaire, the CLIMB® staff gave a supplementary explanation verbally.
Participants in the study attended CLIMB® free of charge and received refreshments as part of the program. No
monetary incentives were given for participation in the study.
3. Results
One site (facility) participated in the study. Of the nine children who attended the sessions, seven participated in
the present study. The demographics of the seven children are shown in Table 2. The sample included four boys
and three girls. The mean age of the children was 9.1 (standard deviation [SD], 1.8; median, 9.0) years. In mostcases, the mothers had cancer. The common types of cancers were breast, pancreatic, and rectal cancer. All eligible
children lived with their parents, and their parents’ medical condition was stable during the CLIMB® sessions. The
treatment plan and hospital of treatment did not change during the study period.
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Global Journal of Health ScienceVol. 14, No. 9; 2022

Table 2. Participant characteristics and Comments about CLIMB®
Comments
ID Gender Age Grade Parental cancer

The best part of the
programFree Comments

1 boy

7

1st

Mother/pancreatic

drawing

It was all fun and joyful.

2 boy

7

2nd

Mother/ breast

Crafts were fun

It was fun. I learned for the first time that cancer is notcontagious.

3 boy

9

3rd

Mother/pancreatic

I enjoyed looking at the
Intravenous drip.

I learned a lot from what I could learn about my mom’s
anti-cancer infusion. I would like to do the craft again.
I learned about my mother’s illness. I am now able to ask
my mother about things I don’t understand or worry
about. My mother is now able to talk to me about her
illness.
I was able to tell my mother how I feel, which I normallycan’t say.

4 girl9

4th

Mother/breast

It was nice to see andtalk to a friend.

5 boy

10

4th

Mother /breast

Nice to talk to a friend.

6 girl10

4th

Mother/ breast

Good to hear from other It gave me courage to think that I am not alone.
friends.
I want to see my friends again.

7 girl12

6th

It was interesting to hear
Father/colorectal other people’s work andthoughts.

It was refreshing to talk a lot.

Table 3 shows the QOL scores, and Figure. 1 shows the pre-post-intervention changes in the total QOL scores. The
scores significantly increased from 79.9 (SD, 19.1; median, 86.7) points before the intervention to 85.1 (SD, 15.7;
median, 90.0) points after the intervention, indicating an improvement in the QOL (p=0.046). A significant
increase from 72.9(SD, 20.2; median, 75.0) points to 85.0 (SD, 19.4; median, 90.0) points was observed in themental health subscale (p=0.046). There was no significant difference according to sex, and there were no changes
in the QOL of girls in friends and school life subscales.

Figure 1. QOL Total score19gjhs.ccsenet.org

Global Journal of Health ScienceVol. 14, No. 9; 2022

Table 3. QOL comparison before and after CLIMB® (N = 7)
n

Pre

Post

data

data

P-value

Physical healthTotalmean ± sd

median [IQR]
Boy

mean ± sd

median [IQR]
Girl

mean ± sd

median [IQR]

7
4
3

86.4

±

16.5

92.1

±

10.4

95.0

[75.0, 100.0]

95.0[80.0, 100.0]

86.3

±

21.0

92.5

±

95.0

[65.0, 98.8]

97.5[80.0, 100.0]

86.7

±

12.6

91.7

±

85.0

[75.0, 100.0]

95.0[80.0, 100.0]

72.9

±

20.2

85.0

±

75.0

[65.0, 85.0]

90.0[60.0, 100.0]

67.5

±

22.5

86.3

±

75.0

[43.8, 83.8]

95.0[63.8, 100.0]

80.0

±

18.0

83.3

±

75.0

[65.0, 100.0]

90.0[60.0, 100.0]

82.9

±

25.8

87.9

±

100.0

[60.0, 100.0]

100.0[60.0, 100.0]

0.066

11.9
0.180

10.4
0.180

Emotional wellbeing
Totalmean ± sd

median [IQR]
Boy

mean ± sd

median [IQR]
Girl

mean ± sd

median [IQR]

7
4
3

19.4
0.046＊

21.4
0.068

20.8
0.655

Self-esteem
Totalmean ± sd

median [IQR]
Boy

mean ± sd

median [IQR]
Girl

mean ± sd

median [IQR]

7
4
3

19.1

83.8

±

32.5

90.0

±

100.0

[51.3, 100.0]

100.0[70.0, 100.0]

81.7

±

20.2

85.0

±

85.0

[60.0, 100.0]

95.0[60.0, 100.0]

75.7

±

21.9

79.3

±

85.0

[55.0, 95.0]

85.0[60.0, 95.0]

76.3

±

24.6

82.5

±

85.0

[51.3, 92.5]

87.5[66.3, 93.8]

75.0

±

22.9

75.0

±

70.0

[55.0, 100.0]

70.0[55.0, 100.0]

80.7

±

21.9

84.3

±

85.0

[60.0, 100.0]

85.0[60.0, 100.0]

82.5

±

26.0

86.3

±

92.5

[55.0, 100.0]

92.5[66.3, 100.0]

78.3

±

20.2

81.7

±

75.0

[60.0, 100.0]

85.0[60.0, 100.0]

80.7

±

19.2

82.1

±

80.0

[60.0, 100.0]

80.0[65.0, 100.0]

80.0

±

23.1

82.5

±

80.0

[60.0, 100.0]

85.0[62.5, 100.0]

81.7

±

17.6

81.7

±

80.0

[65.0, 100.0]

80.0[65.0, 100.0]

0.180

20.0
0.317

21.8
0.317

Friends
Total

mean ± sd

median [IQR]
Boy

mean ± sd

median [IQR]
Girl

mean ± sd

median [IQR]

7
4
3

17.7
0.180

15.5
0.180

22.9
－

FamilyTotalmean ± sd

median [IQR]
Boy

mean ± sd

median [IQR]
Girl

mean ± sd

median [IQR]

7
4
3

17.9
0.414

18.9
0.317

20.2
0.655

School life
Totalmean ± sd

median [IQR]
Boy

mean ± sd

median [IQR]
Girl

mean ± sd

median [IQR]

7
4
3

20

17.8
0.317

20.6
0.317

17.6
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Global Journal of Health ScienceVol. 14, No. 9; 2022

Total
Total

mean ± sd

median [IQR]
Boy

mean ± sd

median [IQR]
Girl

mean ± sd

median [IQR]

7
4
3

79.9

±

19.1

85.1

±

86.7

[68.3, 94.2]

90.0[65.8, 97.5]

79.4

±

86.7

±

23.1

15.7
0.046＊

17.0

89.2[55.4, 93.5]

93.8[68.8, 97.5]

80.6

±

17.0

83.1

±

73.3

[68.3, 100.0]

83.3[65.8, 100.0]

0.066

17.1
0.655

converted to 0–100, Wilcoxon signed-rank test. ＊p<0.05
The scores range from 24 to 120 points (converted to 0–100 for this study), with higher scores indicating higher QOL.

The SRS-C scores are shown in Table 4. Pre-post-intervention changes in the total scores are shown in Figure 2.
No item showed significant differences in the pre- and post-intervention scores. The total score had decreased,
indicating a decrease in the stress response. The boys showed a slight increase in the scores on the physical state
subscale. The girls showed a moderate decrease in the scores on the stress reaction subscale, but a pronounced
decrease in the scores on the anger subscale.

Figure 2. The Stress Response Scale for Children (SRS-C) Total Score

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Table 4. SRS-C comparison before and after CLIMB® (N = 7)
n

Pre

Post

data

data

P-value

Physical stateTotalmean ± sd
median [IQR]

Boy

mean ± sd
median [IQR]

Girl

mean ± sd
median [IQR]

7
4
3

8.0

±

4.0

7.4

±

6.0

[5.0, 12.0]

5.0[5.0, 10.0]

7.5

±

7.3

±

3.3

3.3
0.357

2.6

6.5

[5.0, 11.0]

7.0[5.0, 9.8]

8.7

±

5.5

7.7

±

6.0

[5.0, 15.0]

5.0[5.0, 13.0]

6.9

±

2.9

7.1

±

5.0

[5.0, 11.0]

5.0[5.0, 11.0]

6.8

±

2.9

7.3

±

5.5

[5.0, 9.8]

5.0

[5.0, 11.8]

7.0

±

3.5

7.0

±

5.0

[5.0, 11.0]

5.0[5.0, 11.0]

7.4

±

3.4

6.4

±

5.0

[5.0, 11.0]

5.0[5.0, 6.0]

5.8

±

1.5

7.0

±

5.0

[5.0, 7.3]

5.0

[5.0, 11.0]

9.7

±

4.2

5.7

±

11.0

[5.0, 13.0]

6.0[5.0, 6.0]

7.1

±

2.4

8.1

±

6.0

[5.0, 10.0]

6.0[5.0, 9.0]

7.3

±

9.3

±

0.655

4.6
0.180

Depressive-anxious feelingTotalmean ± sd
median [IQR]

Boy

mean ± sd
median [IQR]

Girl

mean ± sd
median [IQR]

7
4
3

3.8
0.655

4.5
0.655

3.5
>0.999Irritated-angry feelingTotalmean ± sd
median [IQR]

Boy

mean ± sd
median [IQR]

Girl

mean ± sd
median [IQR]

7
4
3

2.9
0.414

4.0
0.317

0.6
0.180

Helplessness
Total

mean ± sd
median [IQR]

Boy

mean ± sd
median [IQR]

Girl

mean ± sd
median [IQR]

7
4
3

2.6

4.3
0.285

5.4

6.5

[5.3, 10.0]

7.5[5.3, 15.0]

0.180

7.0

±

2.6

6.7

±

2.1

0.423

6.0

[5.0, 10.0]

6.0[5.0, 9.0]

0.317

29.4

±

29.1

±

Total
Total

mean ± sd
median [IQR]

Boy

mean ± sd
median [IQR]

Girl

mean ± sd
median [IQR]

7
4
3

10.3

12.9

30.0

[20.0, 38.0]

22.0[20.0, 39.0]

27.3

±

8.5

30.8

±

25.5

[20.3, 36.0]

24.5[20.3, 47.5]

32.3

±

13.7

27.0

±

30.0

[20.0, 47.0]

22.0[20.0, 39.0]

0.713

15.9
0.655

10.4
0.157

Wilcoxon signed-rank test. ＊p<0.05
The scores ranged from 20 to 80 points, with higher scores indicating higher stress responses.

The self-esteem scale scores are shown in Table 5. Pre-post-intervention changes in the total scores are shown in
Figure 3. The difference between the pre- and post-intervention scores increased significantly for the total score(p=0.028) and the subscales of “self in relationships” (p=0.042) and “self-assertion and self-determination”(p=0.038).
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Figutr 3. Self-Esteem Scale (Japanese version) Total Score
Table 5. Self-Esteem comparison before and after CLIMB® (N=7)
n

Pre

Post

data

data

P-value

Self-acceptanceTotalmean ± sd
median [IQR]

Boy

mean ± sd
median [IQR]

Girl

mean ± sd
median [IQR]

7
4
3

27.7

±

4.0

29.6

±

29.0

[25.0, 32.0]

30.0[28.0, 32.0]

26.8

±

30.0

±

4.8

2.1
0.109

1.6

27.0

[22.0, 31.3]

30.0[28.5, 31.5]

29.0

±

3.0

29.0

±

29.0

[26.0, 32.0]

29.0[26.0, 32.0]

24.9

±

2.7

26.6

±

25.0

[23.0, 28.0]

27.0[25.0, 28.0]

24.5

±

26.3

±

0.109

3.0
>0.999Self in relationships
Totalmean ± sd
median [IQR]

Boy

mean ± sd
median [IQR]

Girl

mean ± sd
median [IQR]

7
4
3

3.1

1.5
0.042＊

1.5

24.5[21.5, 27.5]

26.0[25.0, 27.8]

25.3

±

2.5

27.0

±

25.0

[23.0, 28.0]

28.0[25.0, 28.0]

25.1

±

1.8

26.4

±

25.0

[24.0, 27.0]

27.0[25.0, 28.0]

24.0

±

0.8

25.3

±

24.0

[23.3, 24.8]

25.0[24.3, 26.5]

26.7

±

1.5

28.0

±

27.0

[25.0, 28.0]

28.0[28.0, 28.0]

0.109

1.7
0.180

Self-assertion and self-determination
Total

mean ± sd
median [IQR]

Boy

mean ± sd
median [IQR]

Girl

mean ± sd
median [IQR]

7
4
3

23

1.7
0.038＊

1.3
0.102

0.0
0.180

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Global Journal of Health ScienceVol. 14, No. 9; 2022

Total
Total

mean ± sd
median [IQR]

Boy

mean ± sd
median [IQR]

Girl

mean ± sd
median [IQR]

7
4
3

77.7

±

7.3

82.6

±

79.0

[70.0, 82.0]

82.0[82.0, 84.0]

3.3

75.3

±

7.9

81.5

±

76.0

[67.8, 82.0]

82.5[78.3, 83.8]

81.0

±

6.2

84.0

±

79.0

[76.0, 88.0]

82.0[82.0, 88.0]

0.028＊

3.1
0.068

3.5
0.180

Wilcoxon signed-rank test. ＊p<0.05
The scores ranging from 22 to 88 points, and higher scores indicating higher self-esteem.

Most children selected response 5 of “very satisfied with the program” for all 10 questions on the evaluation.
However, one first-grade boy and one second-grade boy selected response 2 of, “I don’t really think so” for theitems of “I was glad to talk to others about my feelings” and “Listening to others talk about cancer reduced myfeelings of being alone in the pain.” Table 2 shows the children’s impressions. The first–third graders mostlycommented on the craft activities. The students in fourth grade and above described the joy of meeting friends inthe same situation and being able to share their feelings.
4. Discussion
The purpose of this study was to assess whether the QOL, stress responses, and self-esteem changed after the
CLIMB® program, and whether there the differences were modified by age and sex. The results showed anincrease in the children’s mental health, as reflected by the increase in the total and subscale scores of QOL and in
the self-assertiveness and self-determination subscales. Further, stress reactions showed a decrease. The children’ssatisfaction was also high, indicating that the CLIMB® program in this study had a positive impact on children.
4.1 Changes after the CLIMB® Intervention
CLIMB® was effective in improving the children’s QOL. The pre-intervention QOL of the subjects was similar tothat of children of healthy parents (Shibata, et al., 2007), indicating that parental cancer did not affect the QOL inthe subjects of this study. The fact that the QOL improved may have been due to the sense of loneliness arisingfrom the emotional burdens (Altun, 2019) of the children whose parents had cancer. In particular, children do not
actively talk to their friends about their parent’s cancer, so the fact that the children in a similar situation gathered at
CLIMB® and were able to share their feelings may be the reason for the improvement in their mental QOL. In
terms of sex, there was no change in the QOL of girls in terms of friends and school life. It can be assumed thatgirls aged 9–12 years old and in the upper grades of elementary school already had enough friends in school andthe neighborhood even if they were unable to talk about their parent’s cancer. Another reason may be that 9–
12-year-olds are developmentally capable of acquiring multiple perspectives, and they understand how to act andbehave in public places such as schools.
CLIMB® was effective in reducing the total SRS-C scores. Because pre-intervention total scores were lower thanthose in a previous study (Shimada, et al., 1994), it can be assumed that the original stress response was not strong,even though the parent had cancer. The lack of significant changes in the subscales of helplessness and depression
may be related to the fact that the children participating in CLIMB® were originally informed about their parent’s
cancer by the parents themselves. When children are not told the truth, they are more likely to hold misconceptions
and feelings of remorse, such as thinking that it was their own fault that their parent had become ill, and this may
negatively affect their growth and development (Siegel, et al., 1996). Because parents and children who
participated in CLIMB® discuss cancer in the home and share their feelings with each other, perhaps a trusting
relationship was already formed.
The boys showed a slight increase in the physical state scores. In terms of satisfaction, the boys found it difficult toshare their feelings, listen to others, and relate their experiences to their peers. There are sex differences indevelopment, and it is thought that boys face difficulties expressing their feelings in words at their age, so theyexpress them physically. Girls showed a decrease in the scores on all subscales of the SRS-C, with a particularly
pronounced decrease in anger. In upper elementary school children, exchange of positive or negative emotions
have been shown to increase coping efficacy in stressful situations and reduce helplessness (Maki, 2019).
Therefore, we believe that being able to share feelings with other children in the same situation provided a certain
degree of support. We believe that the same reason holds true for the significant reduction in anger. In the24

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Global Journal of Health ScienceVol. 14, No. 9; 2022

developmental stage, older children may not talk about their feelings as much. Iwata et al. (2020) used the Japaneseversion of the Strength and Difficulties Questionnaire (SDQ) with fifth- and sixth-grade students and their parents
to assess their children’s behavioral and emotional issues. Parents rated their children’s behavioral problems(hyperactivity, inattention, etc.) similar to the ratings of their children. However, parents rated their children’s
emotional issues lower than their children did, indicating that the parents did not have an accurate understanding of
their children’s emotional issues. Therefore, an environment like CLIMB® where parents can discuss and shareemotional problems with other parents is very important.
Self-acceptance an increasing trend. The total score had increased significantly after the intervention, and thescores on the “self in relationships” and “self-assertion and self-determination” subscales had also showed anincrease. The reason for this may be related to the fact that the children felt accepted in the environment.
Furthermore, the children’s temperament and daily interactions with their parents and surroundings may also be
related, but this could not be clarified in this study. Children with high self-acceptance have lower social anxiety
and better relationships with others than those with low self-acceptance (Zahals, 2001). We infer that afterparticipating in CLIMB®, the children continued to live positively with their own strengths and with the help of
those around them. Regarding the changes observed in self-acceptance, it can be assumed that the children wereable to learn about role models by participating in CLIMB® and were able to view themselves positively with thehelp of external factors. In addition, being connected with children of the same age’s generation who have the sameproblems is also important for being able to depict one’s future self-image.
4.2 CLIMB® for Children
The participants had high satisfaction scores for CLIMB®, and they enjoyed the program. CLIMB® programs
gather groups of children whose parents have cancer; some children may have been reluctant to participate because
they may have thought it focused on grief and fear related to their parent’s cancer. However, we believe that wewere able to promote continued participation by making the program enjoyable. The target participant this time
included lower-to-upper elementary school students, and they were able to learn and understand the characteristics,
treatments, and side-effects of cancer.
The younger boys were not very satisfied with talking about their feelings to others and listening to other people’s
experiences and feelings; however, they enjoyed the drawing and crafts programs. In addition, they learned for the
first time that cancer is not contagious. This indicates that these children were previously living with the idea thatthey might get cancer from their parents. A previous study showed that compared with having no knowledge,
having correct information about their parent’s cancer can help reduce the stress levels in children (Siegel, et al.,1996). We believe that CLIMB® was able to relieve the anxieties that children have when they imagine that cancer
can be transmitted to them. CLIMB® also provided enjoyable hands-on activities such as crafts. From theviewpoint of language development, younger children may have difficulty expressing and sharing their feelings.
Boys are less likely to express their feelings than girls, and younger children are less likely to express their feelings
than older ones (Watanabe & Fujino, 2016). Therefore, it is advisable to engage with younger children in a waythat allows them to express their feelings through activities that require less language and tap into unconscious
feelings. They can also be told what older children have said, using expressions that are easy to understand, while
asking them questions to determine their understanding. In addition, opportunities for children to express their
feelings non-verbally are also important.
4.3 Implications
CLIMB® targets elementary school students, and the purposes and procedures are the same for both younger andolder students. However, younger children have immature linguistic skills and may have difficulty communicating
their feelings and fully understanding what others say. Therefore, it is necessary to devise ways to help thesechildren understand the content of CLIMB®. For example, when asking children to express their feelings, wesuggest preparing pictures of various facial expressions and asking them to choose the one that matches their
feelings. In addition, it is also a good idea to encourage children to express their feelings not only in words but also
by means of arts and crafts and other activities.
Further, parents’ wishes and desires must also be taken into account. Mothers diagnosed with breast cancer whileparenting a young child (3–12 years old) valued communication with their child and wanted useful, practical, andeasily accessible resources (Sinclair, et al., 2019). Therefore, it is important to promote communication between
mothers and children through CLIMB®. However, some regions do not have easy access to CLIMB® owing totransportation difficulties. Another problem is the aforementioned coronavirus pandemic, making it necessary to
conduct CLIMB® in a hybrid format that utilizes online meetings and resources. The effectiveness of the hybrid
format also needs to be examined in the future.
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5. Limitations
Although the number of subjects in this study was small, the data were valuable for pilot validation. The physicaland psychological states of the parents in this study were stable, so there were no drastic changes in the children’s
lives. In addition, because the number of subjects was small, we were not able to analyze the impact of different
types of cancers; this aspect must be studied in the future.
At the start of this study, the novel coronavirus (COVID-19) pandemic had started in Japan. At many sites, the
CLIMB® sessions were cancelled or postponed. Since then, it has been difficult to have face-to-face CLIMB®
sessions. In a previous study, adolescents and young adults with cancer found social media and online communities
to be useful sources of information (Cheung & Zebrack, 2017) and community (Kaal et al., 2018), respectively.
However, elementary school students may find it difficult to utilize social media until they are in their higher
grades, but it is necessary to consider creating age-appropriate resources to help younger children interact withothers.
6. Conclusion
During CLIMB®, children received accurate knowledge about cancer and valued sharing their feelings among
others in the same situation. Children were highly satisfied with the program, although only small changes wereseen in QOL and stress.
The coronavirus pandemic is an issue that necessitates CLIMB® to be conducted in a hybrid format that utilizes
online meetings and resources. The effectiveness of the hybrid format also needs to be examined in the future.
Acknowledgements
I would like to thank all the participants. Funding from the Grant-in-Aid for Young Scientists (20K19164) is
gratefully acknowledged. We would like to thank Editage (www.editage.com) for English language editing.
Competing Interests Statement
The authors declare that there are no competing or potential conflicts of interest.
References
Altun, H. (2019). Evaluation of emotional and behavioral problems in school-age children of patients with breast
cancer. Turkish Journal of Oncology, 34, 12-20. https://doi.org/10.5505/tjo.2018.1824
Cheung, C. K., & Zebrack, B. (2017). What do adolescents and young adults want from cancer resources? Insights
fromaDelphipanelof
AYA patients.
Support
Care
Cancer,25,
119-126.
https://doi.org/10.1007/s00520-016-3396-7
Children’s Treehouse Foundation. (2022). Retrieved from https://childrenstreehousefdn.org/who-we-are/Davey, M. P., Tubbs, C. Y., Kissil, K., & Nino, A. (2011). ‘We are survivors too’: African-American youths’
experiencesof
copingwithparentalbreastcancer.
Psycho-oncology,
20,
77-87.
https://doi.org/10.1002/pon.1712
Grabiak, B. R., Bender, C. M., & Puskar, K. R. (2007). The impact of parental cancer on the adolescent: an analysisof the literature. Psycho-oncology, 16, 127-137. https://doi.org/10.1002/pon.1083
Hauken, M. A., Senneseth, M., Dyregrov, A., & Dyregrov, K. (2018). Anxiety and the quality of life of children
living with parental cancer. Cancer Nursing, 41, E19-E27. https://doi.org/10.1097/NCC.0000000000000467
Howlader, N., Noone, A. M., Krapcho, M., Miller, D., Bishop, K., Altekruse, S. F., ... Cronin, K. A. (Eds). (2016)
SEER Cancer Statistics Review, 1975-2013, National Cancer Institute. Retrieved fromhttp://seer.cancer.gov/csr/1975_2013/ (based on November 2015 SEER data submission).
HopeTree. (2008). https://hope-tree.jp/ (In Japanese)
Inoue, I., Higashi, T., Iwamoto, M., Heiney, S. P., Tamaki, T., Osawa, K., … & Matoba, M. (2015). A national
profile of the impact of parental cancer on their children in Japan. Cancer Epidemiology, 39, 838-841.
https://doi.org/10.1016/j.canep.2015.10.005
Ito, M., & Wakamoto, J. (2010). An attempt to create a scale to measure self-esteem required at school, 52nd
Annual Convention of the Japanese Association of Educational Psychology, Collected Papers. (In Japanese)
Iwata, N., Kumagai, R., & Saeki, I. (2020). Do mothers and fathers assess their children’s behavioral problems inthe same way as do their children? An IRT investigation on the strengths and difficulties questionnaire.
Japanese Psychological Research, 62, 87-100. https://doi.org/10.1111/jpr.12268 (In Japanese)26

gjhs.ccsenet.org

Global Journal of Health ScienceVol. 14, No. 9; 2022

Kaal, S. E., Husson, O., van Dartel, F., Hermans, K., Jansen, R., Manten-Horst, E., … & van der Graaf, W. T.
(2018). Online support community for adolescents and young adults (AYAs) with cancer: user statistics,
evaluation,
andcontent
analysis.
Patient
PreferAdherence,
12,2615-2622.
https://doi.org/10.2147/PPA.S171892 (In Japanese)
Kennedy, V. L., & Lloyd-Williams, M. (2009). How children cope when a parent has advanced cancer.
Psycho-oncology, 18, 886-892. https://doi.org/ 10.1002/pon.1455
Kissil, K., Nino, A., Jacobs, S., Davey, M., & Tubbs, C. Y. (2010). “It has been a good growing experience for me”:
Growth experiences among African American youth coping with parental cancer. Families, Systems and
Health, 28, 274-289. https://doi.org/10.1037/a0020001
Kobayashi, M., Heiney, S. P., Osawa, K., Ozawa, M., & Matsushima, E. (2017). Effect of a group intervention forchildren and their parents who have cancer. Palliative Support Care, 15, 575-586.
https://doi.org/10.1017/S1478951516001115
Maki, I. (2019). Influences of emotional exchanges with guardians on elementary school students’ helplessness:
analysis by structural equation modeling. Japanese Journal of Educational Psychology, 67, 223-235.
https://doi.org/10.5926/jjep.67.223 (In Japanese)
O’Neill, C., O’Neill, C. S., & Semple, C. (2020). Children navigating parental cancer: outcomes of a psychosocial
intervention. Comprehensive Child and Adolescent Nursing, 43, 111-127. https://doi.org/10.
1080/24694193.2019.1582727
Sears, H. A., & Sheppard, H. M. (2004). “I just wanted to be the kid”: adolescent girls’ experiences of having aparent with cancer. Canadian Oncology Nursing Journal, 14, 18-25.
Shibata, R., Nemoto, Y., Matsuzaki, K., et al. (2003). A study of the Kid-KINDL Questionnaire for measuring
quality of life in elementary school children in Japan. Journal of the Japan Pediatric Society, 107, 1514-1520.
(In Japanese)
Shimada, N., Togasaki, Y., & Sakano, Y. (1994). Development of Stress Response Scale for Children. The
Japanese Journal of Health Psychology, 7, 46-58. https://doi.org/10.11560/jahp.7.2_46 (In Japanese)
Siegel, K., Karus, D., & Raveis, V. H. (1996). Adjustment of children facing the death of a parent due to cancer.
Journal of the American Academy of Child and Adolescent Psychiatry, 35, 442-450.
https://doi.org/10.1097/00004583-199604000-00010
Sinclair, M., Schofield, P., Turner, J., Rauch, P., Wakefield, C., Mann, G. B., … Stafford, L. (2019). Maternalbreast cancer and communicating with children: a qualitative exploration of what resources mothers want andwhat health professionals provide. European Journal of Cancer Care, 28, e13153.
https://doi.org/10.1111/ecc.13153
Tokyo Metropolitan Staff Training Center. (2011). Research on self-esteem and self-affirmation. Retrieved fromhttps://www.kyoiku-kensyu.metro.tokyo.lg.jp/09seika/reports/bulletin/h23.html (In Japanese)
Vannatta, K., Grollman, J. A., Noll, R. B., & Gerhardt, C. A. (2008). Impact of maternal breast cancer on the peerinteractions of children at school. Psycho-oncology, 17, 252-259. https://doi.org/10.1002/pon.1232
Visser, A., Huizinga, G. A, van der Graaf, W. T. A., Hoekstra, H. J., & Hoekstra-Weebers, J. (2004). The impact ofparental cancer on children and the family: a review of the literature. Cancer Treatment Reviews, 30, 683-694.
https://doi.org/10.1016/j.ctrv.2004.06.001
Visser, A., Huizinga, G.A., Hoekstra, H. J., van der Graaf, W. T., Gazendam-Donofrio, S. M., & Hoekstra-Weebers,
J. (2007). Emotional and behavioral problems in children of parents recently diagnosed with cancer: alongitudinal study. Acta Oncologica, 46, 67-76. https://doi.org/10.1080/02841860600949560
Watanabe, Y., & Fujino, S. (2016). The development of emotional literacy on children; focusing on emotional
expressions 2016. Hose University Bulletin 73, 83-97. (In Japanese)
Weaver, K. E., Rowland, J. H., Alfano, C. M., & McNeel, T. S. (2010). Parental cancer and the family: apopulation-based estimate of the number of US cancer survivors residing with their minor children. Cancer,
116, 4395-4401. https://doi.org/10.1002/cncr.25368
Wong, M. L., Cavanaugh, C. E., Macleamy, J. B., Sojourner-Nelson, A., & Koopman, C. (2009). Posttraumatic
growth and adverse long-term effects of parental cancer in children. Families, Systems and Health, 27, 53-63.
https://doi.org/10.1037/a0014771
27

gjhs.ccsenet.org

Global Journal of Health ScienceVol. 14, No. 9; 2022

Zahals, E. (2001). The child’s worries about the mother’s breast cancer sources of distress in school age children.
Oncology Nursing Forum, 28, 1019-1025.
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