This study was a descriptive cross-sectional survey that examined the illness perception, hope, social support and subjective well-being among parents of children with cancer.

The current sample included 108 (94% Jewish, 6% Muslim) parents of children with cancer recruited from two pediatric hematology-oncology wards in two different hospitals in central Israel with 60 beds altogether. The inclusion criteria were as follows: (a) parents of children aged 7–18; (b) parents of children diagnosed with cancer at least 6 months prior to the study and no more than one year after the termination of treatments; (c) ability to communicate in Hebrew; and (d) parental informed consent to participate in the study. In each hospital ward, data were collected from the child’s computerized records to assess the parents who met the criteria for inclusion in the study. Initial contact was made with the parents to explain the aims of the study. Parents who agreed to participate in the study defined themselves as primary caregivers. At the time of data collection, some patients were still in active treatment, some were in maintenance (e.g., with leukemia), and some were off treatment but for no more than one year. Characteristics of the parents and children are shown in Table 1.

All five research instruments administered to parents had previously undergone back-translation from English into Hebrew and into English again, demonstrating acceptable reliability. The Hebrew version of these instruments have been used across many studies with good reliability (e.g., Ronen et al., 2016; Orkibi et al., 2018; Bukchin-Peles and Ronen, 2022).

Approval to conduct the study was received from the ethics committee at each of the two hospitals with pediatric cancer units (# 0178-13-RMC, # 0611-14-TLV, respectively). Next, parents who met the study criteria were approached in writing to request their participation. Of the 125 families approached, 108 gave written consent and completed the questionnaires. Completion of the questionnaires by one parent per family took approximately 45 min.

We conducted descriptive statistics and Pearson correlations for all study variables using SAS software, 9.4 version. We performed structural equation modeling (SEM) to examine the study’s theoretical model using the Mplus Version 8.6 (Muthén and Muthén, 1998–2017). We specified hope, social support, illness impact perceptions, and well-being as latent constructs in the model. We measured each using the accepted parceling approach (Bandalos, 2002), with three indicators calculated as random thirds of the scale items.

We modeled parents’ positivity ratio and sociodemographic variables as observable variables. We used the Mplus MLR estimator, which enables a type of maximum likelihood estimation with robust standard errors and chi-square calculation in the presence of deviation of data from normality (Little and Rubin, 2003). We assessed the model’s fit to the data using chi-square, with a low value indicating a good fit. The data underlying the findings are available in this article.

Analysis of variance comparing age, sex, severity of illness, and stage of treatment did not show any significant differences between the groups, we, therefore, related to it as one group. As shown in Table 2, the mean scores of the questionnaires indicated the parents’ high levels of both hope (6.5 on a 1–8 scale) and social support (2.31 on a 0–3 scale). With regard to subjective well-being, the parents showed high means for both life satisfaction (2.95 on a 1–4 scale) and positivity ratio (1.82 for positive to negative emotions). With regard to illness-impact perceptions, the parents’ mean score of 5.62 (on a 0–10 scale) expressed a moderate level of concern about the impact of their child’s illness.

As seen in Table 3, moderately high significant correlations emerged among all the study variables. In line with the first hypothesis, a perception of lower illness impact attributed by parents to their child’s illness was correlated with parents’ higher life satisfaction (r = −0.39; p < 0.001) and higher positivity ratio (r = −0.55; p < 0.001). Thus, the first hypothesis was supported.

As shown in Table 4, significant correlations emerged between some of the parents’ demographic variables and study variables. Higher levels of social support (r = 0.23, p = 0.02), hope (r = 0.20, p = 0.04), positive emotions (r = 0.25, p < 0.001), and life satisfaction (r = 0.26, p = 0.001) were found among parents who worked before the child was diagnosed. Married parents reported higher levels of social support (r = 0.21, p = 0.02), positive emotions (r = 0.20, p = 0.04), and life satisfaction (r = 0.21, p = 0.03) compared to non-married parents. More highly educated parents showed lower illness impact perceptions (r = −0.22, p = 0.02) and higher levels of life satisfaction (r = 0.25, p < 0.01). The parents of children diagnosed with acute lymphoblastic leukemia (ALL) reported higher levels of social support (r = 0.28, p < 0.01) and positive emotions (r = 0.31, p = 0.001) and lower illness impact perceptions (r = 0.21, p = 0.03) compared to other diagnoses.

The SEM analysis used to examine the remaining hypotheses showed a good fit between the research hypotheses and measurement model: χ² (48) = 65.10, p = 0.051. Since age, sex, severity of illness and stage of treatment did not contribute significantly to positivity ratio, we did not include them in the model. To control for the demographic variables that showed significant correlations with at least one independent or dependent study variable, we added the following to the model as control variables: parents’ religion, marital status, work before diagnosis, level of education and the child’s diagnosis (ALL vs. other). The research model showed a good fit, with no significant chi-square coefficient: χ² (104) = 117.15, p = 0.178. Next, we omitted the insignificant paths from the background variables to the study variables and re-ran the model, which again showed a good fit to the data: χ² (103) = 123.91, p = 0.079.

As shown in Figure 1, the SEM indicated significant direct effects between hope and life satisfaction (β = 0.37, p < 0.05), between social support and life satisfaction (β = 0.40, p < 0.05), and between social support and positivity ratio (β = 0.27, p < 0.05). Negative direct effects also emerged between the independent variables (hope and social support) and illness impact perceptions as well as between illness impact perceptions and positivity ratio (β = −0.46, p < 0.05). Regarding the second hypothesis, illness impact perceptions mediated only the effect between hope and positivity ratio (β = 14, p = 0.03). The indirect effect between hope and life satisfaction was not significant (β = 0.03, p = 0.47). This partially confirmed the second hypothesis.

The findings also lent partial support to the hypothesis regarding the mediating role of illness perceptions between social support and the two dimensions of well-being. The indirect effect between social support and positivity ratio was significant (β = 0.15, p = 0.016). However, no mediation emerged for the effect between social support and life satisfaction (β = 0.03, p = 0.460).

Well-being has become a research focus over recent years, emphasizing that life includes various crises and challenges. Attaining well-being points to the ability to become resilient and cope despite obstacles. This study’s main outcome was that parents of ill children experience emotional well-being, with more positive than negative emotions at a ratio of 1.82. Furthermore, they also express cognitive well-being, with a high degree of life satisfaction. These high levels of subjective well-being, even when facing an extremely stressful life event, like a child’s life-threatening illness, hold optimistic implications for these parents’ coping. This finding supports similar studies’ findings that Muslim and Jewish parents of children with cancer experience more positive than negative emotions (Abu-Raiya et al., 2015; Schwartz-Attias et al., 2023).

Based on Fredrickson’s (2013) theory, more positive emotions lead people to adjust better to challenging situations and even to flourish. A possible explanation for parents’ resilient well-being may be related to Headey and Wearing’s (1992) claim that human beings have a fixed emotional point to which they are drawn back after any change in circumstances. The resilient well-being rates of parents facing their child’s illness may offer important insights to health professionals, suggesting that these parents can be treated as people who may, over time, learn to make the most of their challenging situation, instead of people who deserve pity and sorrow. In the past, most studies have focused on the negative aspects of illness and the need to cope. However, the present study focused on the ability to achieve well-being. Such a focus can aid helping professionals in their daily work with parents of ill children to achieve higher levels of well-being, changing the focus from sickness to well-being.

The current study revealed the significant impact of parents’ illness-impact perceptions on their cognitive and emotional well-being. Bandura’s theory (1997), which emphasizes the role of expectancies and perceptions in shaping behavior, provides a possible explanation for these findings. Parents’ perceptions are influenced by hope and play a crucial role in their belief in their capacity to effect change and take positive actions. As a result, it is reasonable to expect that parents with more positive perceptions would experience better overall well-being.

This study’s intercorrelation findings revealed that when parents perceived their child’s illness as having a lesser impact on the family, they tended to experience enhanced emotional well-being, reflected in a higher ratio of positive to negative emotions. Moreover, these positive perceptions also correlated with greater cognitive satisfaction with their lives.

The study’s in-depth path analysis also demonstrated that illness perceptions act as a mediator between hope, social support, and parents’ emotions. This implies that when parents perceive their child’s illness as having a lesser impact on the family, they are more likely to experience heightened levels of positive emotions. In other words, hope and social support indirectly influence parents’ emotional well-being by shaping their perceptions of the illness’s impact.

The study’s outcomes for families of young children with illnesses align with previous research on parents of adolescents and young adults (aged 12–24) undergoing active cancer treatment (Juth et al., 2015). This consistency suggests that the role of perceptions in influencing emotions and well-being is applicable across different age groups and stages of illness. Therefore, this study underscores the vital role of perceptions in shaping parental well-being. It also highlights the importance of fostering positive perceptions through interventions that promote hope, social support, and a constructive outlook on the impact of a child’s illness on the family. By addressing and enhancing positive perceptions, such interventions can have meaningful implications for improving the emotional and cognitive well-being of parents facing the challenges of having a young child with an illness.

Hope was shown to be a crucial component in increasing both emotional and cognitive well-being experiences in the parents of ill children. The intercorrelations indicated that hope was correlated with life satisfaction (cognitive experience) and positivity ratio (emotional experience). The path analysis results indicated that hope showed a significant direct effect only on life satisfaction and not the positivity ratio. In line with the current model, an indirect effect emerged between hope and positivity ratio that went beyond the parents’ illness-impact perceptions, indicating that hope has the potential to increase parents’ positive emotions through their perceptions. Furthermore, hope can be increased by presenting parents with successful treatments and exposing them to the positive effects of the therapy.

According to Snyder (2000), people who score high on hope believe that they can adapt to potential difficulties and losses, entering into positive cognitive dialogues using self-statements such as “I can” and “I will not give up.” As a result, they tend to establish goals and focus on successes rather than failures. According to Seligman’s (2018) PERMA model, focusing on success and accomplishment leads to flourishing and better well-being. The current findings are compatible with prior research outcomes, showing that hope is a fundamental source of strength when coping, managing distress, and growing emotionally (Snyder, 2000; Groopman, 2006; Eche et al., 2020).

Social support has been found to be the main resource helping people cope. Diener and Oishi (2005) presented social support as the most important resource that may help people cope with stress, on the one hand, and increase well-being, on the other hand. Cohen et al. (2000) pointed to the importance of social support during circumstances of illness. Thus, it is logical to expect the link between one’s support and a more positive perception of the situation to result in positive emotions.

Like the hope variable, social support was also found to be a crucial component for parents dealing with their child’s life-threatening illness. The current findings showed that parents’ greater social support contributed to their higher levels of hope, positivity ratio, and life satisfaction, as well as less negative perceptions about the impact of their child’s illness on their lives. Most research on social support resources has revealed the positive contribution of this resource on well-being (Harper et al., 2019; Gise and Cohen, 2022). Research conducted among 330 parents of children with cancer in Mexico City demonstrated a positive correlation between parents’ social support and psychological well-being (r = 0.25, p < 0.01; Toledano-Toledano et al., 2021). This important role of social support appears to coincide with Hobfoll’s (2004) conservation of resources theory, suggesting that parents who have lost resources due to their child’s illness may consciously or unconsciously seek social support to maintain their subjective well-being. Social support may also be better achieved by helping parents attain social skills, participate in parental supervision and support groups, and help them determine who in their environment could help them cope. Future research should undertake a more sensitive examination of the kinds of social support that parents need when coping with an ill child in light of Cohen et al.’s (1985) differentiation between emotional support, informational support, material support, and so on.

Several limitations of the study should be mentioned. The current sample size, non-randomized recruitment method, and lack of a control group may limit the generalizability of the research findings to similar populations. A convenience sample was utilized due to the rarity of pediatric cancer in the 7-18-year-old age cohort. Furthermore, although we encountered impressively high return rates from two major medical centers (86%), some families declined to participate due to the discomfort of self-disclosing their experiences. Due to the large variety of diagnoses and the small size of each specific sickness, the study included parents of children who had been in various phases of treatment, starting from six months from the diagnosis to one year from the end of treatments. Despite the differences in the treatment phases, the research findings showed no differences between the phase groups, so we treated them as one group.

We recommend future longitudinal research to follow up on changes in subjective well-being, hope, and social support among parents of children with cancer over time, until several years after the conclusion of treatments. Follow-up research could also examine how positive personal and environmental resources may help these families adjust more effectively in transitioning back to normative life.

In addition, further empirical investigations should be conducted regarding possible intergenerational relations between parents’ and children’s well-being in the pediatric cancer context. Previous research has shown that parents’ emotional responses to stressful situations correlate with their children’s emotional responses. For example, Arabiat et al. (2018) found that a mother’s emotional strain was clearly associated with a higher risk for depression and anxiety in her child. In addition, prior research has revealed that the higher emotional and cognitive well-being of parents may impact not only their own lives but also their ability to help their children during their distressing illness (Hildenbrand et al., 2011). Research in a similar field, conducted in Germany among parents with cancer who have children under the age of 18, examined the main factors that help families develop resilience during a crisis. The findings revealed that family resilience in crisis is influenced, among other things, by social resources and open communication between family members (Heuser et al., 2024). Thus, maintaining parental well-being may have a positive effect on a child’s emotions and life satisfaction despite the pain, fears, and disruption to routine that the illness elicits (Harper et al., 2019). These possible dyadic intergenerational mechanisms should be examined in further research.

This study highlights the crucial role of hope and social support as valuable resources for individuals and how perceptions are interconnected with these resources, ultimately influencing one’s overall well-being. Recognizing the significance of perception on emotional experiences, the care team should explore innovative ways to positively impact how individuals perceive their circumstances. While the diagnosis itself cannot be altered, changing the way it is perceived can significantly enhance coping strategies and adaptation to the situation, leading to improved coping and well-being.

To implement a proactive intervention, engaging with parents right from the time of diagnosis is recommended. This early engagement allows parents to express their perceptions, discuss their strengths, and identify available and lacking resources. Based on this understanding, a tailored coping intervention plan can be devised, guiding them toward accessing the necessary resources and support systems. For instance, facilitating opportunities for knowledge enhancement or connecting them with other families who have successfully coped with similar situations can be beneficial. Currently, in Israel, individualized support is provided to parents from the moment of diagnosis, continuing throughout treatment, and is administered by a multidisciplinary team specializing in crisis and trauma. Additionally, a social worker serves as the case manager, leading emotional care for both the parent and child.

In addition to the above measures, various proven tools can be employed to enhance resilience and shift perceptions. Conducting mindfulness workshops, guiding imagery exercises, introducing yoga, and incorporating other evidence-based practices are effective methods to promote positive change in perception and bolster emotional resilience. By focusing on hope, social support, and perception, and by implementing these proactive strategies, the care team can make a meaningful impact on individuals’ lives, facilitating better adaptation and improved well-being despite the challenges posed by their conditions. For example, based on the current study’s findings and with the aim of providing additional support to parents, the authors developed a family card game designed to facilitate conversations and emotional expression and support resources for both parents and children. This game aims to help families during the treatment period and beyond. It has been distributed across all oncology departments in Israel and has received positive feedback from psychologists, parents and children, indicating that it provides emotional relief on both a personal and family level.