Effect of Educational Intervention Based on Self-Efficacy Theory on the Caring Behaviour of Mothers Who Have Children With Cancer

Since children with cancer receive a lot of home treatment, parents feel more responsibility for issues including drug use control, poison control, drug side effects, and contact with the treatment team [1]. Parents, particularly mothers, as the most significant people in a child's support system, are often unaware of the causes of the disease and the ways in which they are treated, the economic consequences of the child's disease, and the frequent hospitalization of the child, which can lead to stress and psychological problems, as well as adverse effects on the child and the treatment process [2]. Thus, family members must reorganise their roles and interactive patterns regarding inside and outside relationships, and work to adapt to the new situation [3]. Thus, the performance of the whole family is influential [4]. Increased psychological pressure on caregivers can have consequences including family isolation, loss of hope for social support, disruption of family relationships, inadequate patient care, and, ultimately, abandonment of the patient [5]. Since the past two decades have witnessed a shift in healthcare from hospital to at-home care, more than 90% of outpatient and inpatient cancer treatments are now available at home. One of the factors that may facilitate this transition from hospital to home is proper education of the patient and his/her family members and other caregivers, as well as their active involvement in providing care. In addition, empowerment is one of the critical actions of nursing to attract participation and education of patients and their caregivers [6]. Empowerment, as a participatory educational approach, requires looking at the family and its needs as the core of care. One of the concepts of the empowerment model is self-efficacy [7]. The concept of self-efficacy was first introduced by Bandura in 1993 as a probable measure of one's trust in a particular behavioural competence or a chain of specific behaviours intended to control and manage perceived situations [8]. The ability to exert control over the intellectual/motivational processes present in one's behaviour is one of the distinctive features of human behaviour [9]. Self-efficacy has been defined as a mediating mechanism affecting the underlying motivational, emotional, and selective processes. Perceived self-efficacy is not related to the number of skills but to what one believes and can do under certain circumstances. Skills are easily influenced by one's doubts. Effective performance requires skill coupled with self-efficacy [10]. Research has indicated that self-efficacy can predict one's performance and change it as a result of learning [11], experience, and feedback. At the same time, many factors like personal knowledge, physical status, self-esteem, interpersonal environment, time available, complexity of tasks, and stress can affect self-efficacy and behavioural outcomes [12,13]. According to the results of various studies, the rate of depression in mothers with children with cancer is more than 80% [14,15]. In addition, the depression of parents, especially mothers, had an inverse effect on their self-efficacy, so that mothers with high degrees of depression had low self-efficacy. Eventually, this leads mothers’ performance as the main caregiver of children with various cancers to decrease [16,17]. In different studies, the results show that the status of self-efficacy in the mother remains average [18,19,20,21]. Interventions based on the Theory of Self-Efficacy (TSE) have demonstrated the effectiveness of this theory in improving or acquiring skills. TSE has been used in numerous studies like women's general health status [22], physical activity [23], adopting AIDS prevention behaviour [24], increasing women's awareness in preventing violence against women [25], maternal competence in women [26], and self-efficacy of mothers of children with autism [27,28]. Because of the nature of cancer and its psychological effects on mothers as caregivers, our study aimed to evaluate the effect of maternal education on how to care for a child with cancer, and their skill development, based on the TSE.

In this study, 86 mothers who had children with cancer were studied. 83.8% of the mothers were between 20 and 40 years old. 55.8% of children were 5 years old or younger. Other demographic data of the study population are provided in Table 1.

The results showed that the M±SD of mothers’ self-efficacy was 53.63±11.41. After intervention, the mean self-efficacy score was 63.83 in the first follow-up and 65.56 in the second follow-up. The mean score of caring behaviour before intervention was 100.73±18.91, which increased to 125.4 in the first follow-up and 126.63 in the second follow-up post-intervention. Distribution indices for self-efficacy and mothers’ caring behaviour before intervention and in the first and second follow-ups are displayed here as a boxplot (Figure 1).

Figure 1.

The repeated measure ANOVA test was used to investigate the effect of follow-up times on changes in mothers’ self-efficacy and caring behaviour. The results showed that the change in self-efficacy score and care behaviour in the different follow-up stages was statistically significant (P < 0.001). Therefore, it can be said that educational intervention changed the level of mothers’ self-efficacy and caring behaviour.

As shown in Table 2, the score of self-efficacy in the first and second follow-ups increased significantly (P < 0.001) in comparison with the pre-test. There was also no significant difference between the first and second follow-ups (P = 0.287). Furthermore, the score of caring behaviour in the first and second follow-ups increased significantly (P < 0.001) in comparison with the pre-test. However, there was no significant difference between the first and second follow-ups (P < 0.001).

The Linear Mixed Model was used to investigate the relationship between self-efficacy and caring behaviour and the effect of intervention on their changes over time by adjusting the effect of family size, mother's age, mother's occupation, mother's education, and number of chemotherapy sessions. The results showed that caring behaviour was not related to the mothers’ age, occupation, or education. Increase of household size was inversely related to caring behaviour. Self-efficacy and number of chemotherapy sessions were also directly related to caring behaviour (Table 3). Also, based on the results of the Linear Mixed Model, the effect of time was significant; therefore, it can be claimed that there was a significant change in caring behaviour score in the first and second follow-ups in comparison with the baseline before intervention.

This study aimed to determine the effect of mothers’ education and skill development according to TSE on their caring behaviour for a child with cancer and the continuation of care in Bandar Abbas Paediatric Hospital, which is the only paediatric cancer centre in the province. This study used innovations in the methodology and application of TSE to enhance the caregiving power of mothers’ caring behaviour for children with cancer in Iran.

The results indicated that there was a significant difference in the mean score of self-efficacy after the intervention, because parents need to be more sensitive to their children's needs and emotions and pay more attention to their children. These abilities of parents — to provide adequate nutrition for their children, provide preventive and corrective health care, diagnose the signs and symptoms of illness in children, develop habits to maintain cleanliness, and encourage children to get proper rest time and outdoor activities for their children — are all things that should be considered in children with cancer because of their special needs. This finding is in line with the results of other studies [31,32,33]. Studies aimed at investigating the effect of family-centred education on increasing parental awareness and self-efficacy in weight control and physical activity, and caring for a child with asthma and epilepsy, also showed that education can increase self-efficacy and improve home care effectively [34,35,36,37]. Self-efficacy is a principle that links knowledge and behaviour. For this reason, a sense of self-efficacy enables individuals to do extraordinary work using skills to overcome obstacles. Performance requires both skill and belief in the ability to perform that skill. Self-efficacy is a pre-requisite to a behaviour; so special attention should be paid to increasing self-efficacy [36]. In the present study, considering that the follow-up was done in two stages with intervals of 3 and 6 months, the mean scores of self-efficacy in the first and second stage follow-up had no significant differences, which indicates the stability of self-efficacy [38]. Consistent with the results of a clinical trial conducted on the continuation of mothers’ breastfeeding self-efficacy, our findings revealed that the mean scores of self-efficacy after educational intervention increased at two follow-up intervals [39]. In contrast, another study aiming to examine the impact of parental education on the self-efficacy of mothers of children with autism showed that mothers’ education did not significantly increase their self-efficacy in the first and second follow-ups. The results further indicated that parental education and nurturing skills were not effective in enhancing parental self-efficacy [40]. This difference can be due to lack of attention to emotional or marital problems of parents, the lack of social support during the implementation of the program, and the compactness of the treatment and content sessions, as well as the questions that examine the general feeling of parental self-efficacy rather than measuring parental self-efficacy in managing their children's problems.

The difference between the mean scores of caring behaviour before and after the intervention in the two stages shows the effect of educational intervention to improve mothers’ caring behaviour, which is consistent with the results of other studies [41,42,43]. Another study on the effect of education of mothers of children with cancer undergoing chemotherapy on prevention of the gastrointestinal side effects showed that educational intervention had a significant impact on reducing these effects [6,44]. An investigation on the effect of educational intervention on the home care behaviour of parents who had children with cancer undergoing chemotherapy indicated that the intervention was effective in reducing the effects of chemotherapy [45]. In our study, the parents received education about caring behaviours including how to reduce the side effects of chemotherapy at home. The results showed that the educational intervention had an effect on parental caring behaviours, which included reducing the effects of chemotherapy. The second stage findings revealed that parental caring behaviour, in addition to being persistent, also increased over time, probably due to the experiences they gained and used during this period. In a study performed on parents of children with diarrhoea, vomiting and pneumonia, the effect of training on parents’ performance and satisfaction showed that the training program had a significant effect on parental care compared to the control group [46]. Furthermore, in a study designed to empower parents in caring for a child with leukaemia, the results indicated that the intervention could be effective in parental satisfaction, especially in the mother, regarding how to care for a child with leukaemia and decrease the side effects of chemotherapy [47]. The result of a study on caregivers of people undergoing bypass surgery also showed that the intervention led to increased self-efficacy and improved care behaviour, and thus, increased care for patients undergoing surgery [48].

Our results showed that with increasing the duration of the study, and even after the intervention at the time of follow-up, the mothers’ caring behaviour was still significantly related to self-efficacy. In other words, mothers are aware of their role in caring for their children and do consider this ability as intermittent. They are able to maintain the continuity of behaviour by maintaining and promoting self-efficacy in their caring behaviour. Bandura argued that people with high self-efficacy are more likely to face challenges that need to be controlled and threats that need to be avoided. Given this confidence, the ability to increase their ability to cope with a variety of challenges will be relatively easier. Thus, as a hypothesis, this sense of confidence for success in solving the challenge is associated with lower levels of negative emotional reactions both before and after intervention [49,50,51]. The Linear Mixed Model results showed that an increase in family size was inversely related with mothers’ caring behaviour. In fact, in families of smaller sizes, the mother's caring behaviour was better, and the relationship became more meaningful. In other words, in larger families, the mother could not be more focused on caring for her child and providing services. This would reduce the mother's caring behaviour. In addition, she would not be able to benefit from various trainings to perform caring behaviour and overcome obstacles [52,53]. The number of chemotherapy sessions was also effective in predicting performance of caring behaviour. There is also the fact that caring behaviour is very important in treatment, and chemotherapy is done to reduce the invasion of cancer cells to other tissues. This can be achieved by completing the course of chemotherapy. The data analysis results also confirmed such a relationship. On the other hand, a higher number of chemotherapy sessions leading to higher caring scores can be attributed to an increased severity of the disease, and the fact that the mother would be able to accompany the child to perform chemotherapy with more ability due to understanding the severity of the disease [54,55].

This study had some limitations, including a small sample size that may influence the attendance of all children with a single treatment centre, as well as the death of patients or discontinuation of treatment, and the difficulty of working with parents with special psychological conditions (including caring for a child with cancer, problems with parenting, and attending classes), as well as having too many questions and distributing questionnaires, and not having a control group to better evaluate intervention.

The results of this study indicated that the theory-based educational program for mothers improves their caring behaviour and self-efficacy. As education is one of the main pillars of health care, it seems that authorities and practitioners should pay more attention to designing.