{"paper_id":"bbe1ccb9-00f8-46fc-a4ad-b4c0625f1ca8","body_text":"Resilience and post-traumatic stress symptoms in grandparents following their grandchild’s cancer diagnosis from a multicenter cohort study in Switzerland (The GROkids Project) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Resilience and post-traumatic stress symptoms in grandparents following their grandchild’s cancer diagnosis from a multicenter cohort study in Switzerland (The GROkids Project) Peter Francis Raguindin, Anne Maas, Anica Ilic, Cristina Priboi, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7846728/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Background Resilience is the dynamic ability to adapt to adversity using personal and social resources. Childhood cancer represents a major family stressor, and grandparents often provide emotional, practical, and financial support. Yet, their psychosocial outcomes and resilience remain poorly understood. We aimed to: ( 1 ) identify resilience trajectories, ( 2 ) examine their association with post-traumatic stress symptoms, and ( 3 ) determine factors influencing resilience. Methods This multicenter cohort study included grandparents of children recently diagnosed with cancer and treated at one of eight participating pediatric oncology centers in Switzerland. Eligible grandparents were recruited and completed questionnaires at 3-, 6-, 12-, and 24- months post-diagnosis. Resilience (CD-RISC-10), post-traumatic stress symptoms (IES-R), information needs, health literacy (EU-HLS-Q12), partnership quality, and social support (MSPSS) were measured. We used group-based trajectory modeling to identify resilience trajectories (Aim 1), linear mixed models to examine associations of resilience trajectories with post-traumatic stress symptoms (Aim 2), and linear mixed-effects models to identify the internal and external resources for resilience (Aim 3). (Clinical trial no: Not applicable) Results We included data of 37 grandparents of 20 children with cancer. Mean age was 67.6 years; most were grandmothers (n = 25, 61%), unemployed or retired (n = 23, 59%), and partnered (n = 35, 90%). Two resilience trajectories emerged within two years after diagnosis: low-stable (n = 17, 43%) and high-declining (n = 23, 57%). Grandparents in the low-stable group reported significantly higher post-traumatic stress symptoms (β: -19.8, 90% CI -29.2, -10.4, p < 0.001). The following internal resources were positively associated with resilience: higher health literacy (β: 0.31, 90% CI 0.20, 0.42, p < 0.001), more information received (β: 1.53, 90% CI 1.27, 1.79, p < 0.001), and having income that meets needs (β: 7.56, 90% CI 1.86, 13.26, p = 0.029). No external resources showed significant associations. Conclusion Timely, clear, and tailored information may help strengthen grandparents’ resilience and reduce stress. resilience post-traumatic stress grandparents family cancer childhood cancer Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Resilience can be defined as “the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility and adjustment to external and internal demands.”( 1 ) It reflects an ongoing process of adaptation, shaped by both internal and external resources, that enables individuals to maintain or regain functioning in the face of adversity ( 2 , 3 ). Resilience is not a fixed trait but a dynamic process that varies across life stages and contexts ( 2 , 3 ). Studies have shown that resilience increases with age ( 4 ), possibly due to accumulated life experiences that are shaped through time. Older adults rely on both internal (personal) and external (social) psychological resources that help them maintain stability during stress ( 5 , 6 ). High resilience in this age group is hypothesized to be linked to lower post-traumatic stress symptoms, largely through the use of effective coping strategies that support adaptive functioning after adversity ( 7 , 8 ). The diagnosis of childhood cancer is a stressful event for the child and the family ( 9 ). Within the family system, grandparents are involved in the care of their grandchildren at the time of diagnosis and throughout treatment ( 10 , 11 ). They provide logistical support with childcare, emotional support to parents, and financial assistance when needed ( 10 ). Despite their involvement, few studies have investigated the psychosocial impact of childhood cancer on grandparents ( 12 ). Given the intensity of the psychosocial impact of childhood cancer diagnosis on the family, understanding how grandparents cope with these challenges is essential. A cancer diagnosis in a child can lead to a series of changes within the family, such as changes in childcare responsibilities, household chore responsibilities, employment and financial resources ( 13 – 15 ). This may require family members, including grandparents, to adapt in various ways. While several internal (personal) factors, such as economic status, general health, health literacy, and information provision ( 16 ), as well as external (social) resources, such as partnership status and quality, religious affiliation, and perceived social support ( 17 ), had been shown to contribute to resilience, their role in grandparents of children with cancer is yet unknown. To date, no studies have explored resilience in older adults whose grandchildren are diagnosed with a serious illness. In particular, no research has investigated resilience trajectories following a childhood cancer diagnosis, nor how these trajectories influence post-traumatic stress reactions in grandparents. Therefore, we aimed to: 1 ) identify trajectories of resilience in grandparents of children with cancer, 2 ) determine the association between resilience trajectories and post-traumatic stress symptoms, and 3 ) identify internal (personal) and external (social) resources and contextual factors that influence resilience. METHODS This was a multicenter cohort study from a cohort of grandparents whose grandchildren were recently diagnosed with cancer in Switzerland (18). We followed the STROBE Statement Checklist for transparent reporting of study methods and results (19). (Clinical trial number: not applicable) Sample and procedures We included grandparents whose grandchild was recently diagnosed with cancer and was undergoing cancer treatment. Eligibility criteria included having a grandchild who: was under 18 years of age, had received a cancer diagnosis within the past three months, was treated at one of eight participating pediatric oncology centers in Switzerland, and the grandparent was fluent in German, French, or Italian. Recruitment was facilitated through hospital staff at the participating clinics, who either directly approached eligible grandparents or asked parents to provide contact information for the grandparents. Upon contact with the study team, grandparents received an information letter detailing the study’s objectives along with a consent form. We sent questionnaires to those who provided consent at four time points: 3 months (T1), 6 months (T2), 12 months (T3), and 24 months (T4) post-diagnosis. Summary of the tools and time point of measurement can be found in the Appendix ( Appendix Table S1 ). Follow-up reminders were sent after four weeks and phone calls were conducted if necessary. To support cohort retention, we sent greeting cards to the grandparents for major holidays and regular study updates . A clinical psychologist was available if needed. Enrollment was open from October 2020 to March 2023; follow-up was continued until December 2024. A designated research staff member entered all results, and 20% of responses were double-checked for accuracy. All datasets are stored on secure University servers with access restricted to authorized staff. Detailed study procedures can be found in a separate publication (18). Outcomes Resilience Resilience was assessed at T1-T4 using the Connor-Davidson Resilience Scale (CD-RISC 10), a 10-item self-report measure evaluating “positive adaptation in the face of stress or trauma” (20, 21). Items were rated on a 5-point Likert scale (0=not true at all, 4=true nearly all the time) and summed to create a resilience score. Missing responses were imputed using the mean of completed items when <25% of items were missing. Summary of items can be found in the Appendix ( Appendix Table S2 ). Post-traumatic stress symptoms Post-traumatic stress symptoms were measured at T3 and T4 using the Impact of Event Scale-Revised (IES-R), a 22-item self-report measure assessing subjective distress following traumatic events (22). For the current study, we revised the IES-R, such that the traumatic event focused on the grandchild’s recent diagnosis. The scale comprises three subscales: intrusion (8 items), avoidance (8 items), and hyperarousal (6 items). Items were rated on a 5-point Likert scale (0-4) Missing data (≤20% within a subscale) was imputed using the mean of completed subscale items. We only used the total score for this analysis ranging from 0-88, with higher scores indicating higher post-traumatic stress symptoms. Covariates Sociodemographic and contextual factors (at T1) We collected sociodemographic or contextual factors, namely, age, gender (male, female), language region (German, French/Italian), migration background (no migration background: those born in Switzerland and Swiss at birth, with migration background: all others), hospital proximity to the house of the grandparents (travel time measured in <0.5 hour, or ≥0.5 hours), and number of grandchildren (≤2, >2 grandchildren) all were collected at T1. Grandchild’s gender (male, female), grandchild’s age, cancer diagnosis (leukemia/lymphoma, other tumors), and therapy (chemotherapy, others) were all obtained from medical records. Internal (personal) resources We also collected internal resources, namely, household income satisfaction (“exceeds needs”;“meets needs”), education (compulsory school/vocational training, upper secondary/university), employment (unemployed/retired, employed), information received (medical information), general health, and health literacy. Information needs and preferences were assessed at T1-T4 using a validated scale adapted from the Grandparents Information Needs Questionnaire (23). The instrument evaluated information needs across multiple domains: 9 medical items (cancer type, treatment, treatment goals, side-effects, disease progression, relapse, survival chance, late effects, palliative care) and 5 psychosocial items (communication with family, support for parents, support for grandchildren, own support, peer support). Participants indicated if they had received information (yes/no) for each domain. We calculated a score by counting the number of domains in which the participant received information. General well-being was assessed using the first item of the Short Form-36 (SF-36) (24): \"In general, would you say your health is?\" rated on a 5-point Likert scale (1=poor, 5=excellent). Health literacy was measured at T3 using the European Health Literacy Survey Questionnaire (HLS-Q12) (25) consisting of 12 items and assessing perceived difficulty in accessing, understanding, evaluating, and applying health information across healthcare, disease prevention, and health promotion domains. Items were rated on a 4-point Likert scale (1=very easy, 4=very difficult) and reverse-coded so higher scores indicated higher health literacy (sum score range: 12-48). Missing values were imputed using the median of the available responses when >80% of items were completed. External (social) resources We collected external resources, namely, partnership status (no partner, in partnership), partnership quality, and social support. Partnership quality was assessed using the Relationship-specific Attachment Scale for Adults (Beziehungsspezifische Bindungsskalen fur Erwachsene) (26), comprising 14 items rated on a 5-point Likert scale (1=completely disagree, 5=completely agree). Two subscales measured attachment security (6 items) and perceived available support (8 items). Negatively phrased items were reverse-coded. Subscale scores were summarized using means and standard deviations. Perceived social support was measured at T1 using the Multidimensional Scale of Perceived Social Support (MSPSS)(27), a 12-item self-report measure assessing support from three sources (three subscales), namely, family, friends, and significant others (4 items each). Items were rated on a 7-point Likert scale (1=very strongly disagree, 7=very strongly agree). Missing data (if ≤1 item per subscale missing) was imputed using the mean of the completed items within the respective subscale. We summarized the response through sum score of all the items. Mean scores were calculated by averaging responses within each subscale. Data analysis A framework for the analysis can also be found in the appendix ( Appendix Figure S1 ). Stata 19.5 (StataCorp, TX) was used for the analysis. For aim 1, we used group-based trajectory modeling (GBTM) to identify trajectories of resilience. GBTM uses finite mixture models with censored normal distributions, treating the resilience sum score as a continuous variable. Trajectories were modeled using linear, quadratic, and cubic polynomial functions of time. Parameters were estimated using maximum likelihood estimation. Model fit was evaluated using AIC, BIC, and entropy. For participants with at most one missing response on the resilience scale, last observation carried forward imputation was applied. Analyses were conducted using the traj package (28). For aim 2, we examined the associations between resilience trajectory group membership (identified in aim 1) and post-traumatic stress symptoms using Student’s t-test and linear mixed models (LMMs). For LMM, the IES-R sum score at T3 and T4 (continuous outcome) served as the dependent variable, and resilience trajectory group (categorical) as the independent variable. A random-intercept model was specified to account for repeated measures, with time included as a fixed effect. Models adjusted for age and sex were also fitted. For aim 3, we assessed associations of internal and external resources with resilience using linear mixed-effects models, with the resilience sum score as the continuous outcome. Univariable linear mixed-effects models were fitted for each predictor. Fixed effects included time points (categorical, T1-T4), sociodemographic and contextual factors, internal resources, and external resources. A random-intercept model was used to account for repeated measures nested within participants. Ethical considerations The study was approved by the Ethics Committee of Northwest and Central Switzerland (EKNZ 2020-01409, 26 August 2020). The study was done according to the Declaration of Helsinki and relevant national regulations. All participants provided written informed consent. RESULTS Of 85 grandparents invited to participate, 37 grandparents (25 grandmothers (61%); mean age: 67.6 years, range 55–80) of 20 grandchildren with cancer participated in the study (Table 1 , Fig. 1 ). Total follow-up time has a mean of 21.4 months (SD 1.6) ranging from 18.2–24.5 months. Most participants were unemployed or retired (n = 23; 59%), and nearly all were in a partnership (n = 35, 90%). The grandchildren were predominantly female (n = 12, 63%) with a mean age of 6.0 years at diagnosis. Leukemia was the most frequent diagnosis (n = 10, 53%). Table 1 Characteristics of participating grandparents (n = 37) and their grandchildren with cancer (n = 20). Sociodemographic characteristics and contextual factors, n = 37 Age, years mean (SD) range 67.6 (6.3) 55–80 Sex Male 16 39% Female 25 61% Language region German 31 76% French/Italian 10 24% Migration background 1 No 34 87% Yes 5 13% Hospital proximity <0.5 hour 10 27% ≥0.5 hour 27 73% Grandparent kinship Maternal grandmother 14 34% Maternal grandfather 12 29% Paternal grandmother 11 27% Paternal grandfather 4 10% Number of grandchildren ≤2 16 42% > 2 22 58% Child- and cancer-related characteristics, n = 20 Grandchild's sex Female 12 63% Male 7 37% Grandchild’s age at diagnosis, yrs mean (SD) range 6.0 (4.6) 0–15 Cancer diagnosis Leukemia/lymphoma 10 53% CNS/solid tumors/others 9 47% Therapy Chemotherapy 6 32% Combination/ surgery/ radiotherapy 13 68% Internal (personal) resources Household income satisfaction “Exceeds needs” 25 74% “Meets needs” 9 26% Education Compulsory school/Vocational training 23 60% Upper secondary education/University 15 40% Employment Unemployed/retired 23 59% Employed 16 41% General health 2 2.28 (0.72) Health literacy 3 57.2 (34.3) Information received 4 7.5 (4.9) Medical information 5.4 (3.3) Psychosocial information 2.1 (2.1) External (social) resources Partnership No 4 10% Yes 35 90% Partnership quality 5 Attachment security 2.7 (0.3) Perceived partner support 3.3 (0.4) Social support 6 Overall 5.9 (0.8) Family 5.9 (0.9) Significant others 6.0 (1.2) Friends 6.0 (1.0) 1 Migration background are classified into none or Swiss: born in Switzerland and not naturalized or Swiss at birth. Otherwise, respondent is classified as someone with migration background. 2 General health was assessed using the first question of Short Form-36 (SF-36) with (1 = excellent to 5 = poor). Expressed in mean and SD 3 Health literacy measured using European Health Literacy Survey Questionnaire (HLS-Q12), expressed as percentage of ease of getting information for each domain (health care, disease prevention, and health promotion). Expressed in mean and SD 4 Information received measured using Grandparents Information Needs Questionnaire. It contains 14 items in total − 9 items medical information (cancer type, treatment, treatment goals, side-effects, disease progression, relapse, survival chance, late effects, palliative care) and 5 psychosocial information (communication with family, support for parents, support for grandchild, own support, peer support) items. Expressed in mean and SD 5 Partnership quality measured using Relationship-specific Attachment Scale for Adults (Beziehungsspezifische Bindungsskalen fur Erwachsene) with a scale of 1–5, including subscales. Expressed in mean and SD. 6 Multidimensional scale of perceived social support scale (MSPSS) assessed support from family, significant other, and friends (1 = strongly disagree to 7-strongly agree) Abbreviations: SD, standard deviation; CNS, central nervous system Trajectories of resilience (Aim 1) Detailed item responses of the participants on CD-RISC 10 can be found in the Appendix ( Appendix Table S2 ). We identified two distinct trajectories of resilience among grandparents. The first trajectory, observed in 17 grandparents (43%), was characterized by consistently low resilience over time (low-stable trajectory). The second trajectory, observed in 23 grandparents (57%), started with higher resilience levels that declined over time (high-declining trajectory) (Fig. 2 , Appendix Figure S2 ). Model fit indices and parameters for model selection can be found in the appendix ( Appendix Table S3 ). Association of resilience trajectories with post-traumatic stress symptoms (Aim 2) The low-stable trajectory group had higher IES-R scores compared to the high-declining trajectory group at 12 months (mean = 43.2 SD = 18.5 vs mean = 19.4 SD = 16.2, p < 0.001) and 24 months from the diagnosis (mean = 38.4 SD = 15.9 vs mean = 22.6 SD = 16.3, p 0.014) (Fig. 3 ). Linear mixed models confirmed that those with low-stable resilience trajectory had higher post-traumatic stress symptoms compared to high-declining trajectory (β: -19.8, 90% CI -29.2, -10.4, p < 0.001; age-sex-adjusted model; β: -19.2, 90% CI -29.3, -9.1, p < 0.001; Appendix Table S4 ). Determinants of resilience (Aim 3) Higher health literacy (β: 0.3, 90% CI 0.20, 0.42, p < 0.001), information received on more domains (β: 1.53, 90% CI 1.27, 1.79, p < 0.001), and household income that “meets needs” (β: 7.56, 9% CI 1.86, 13.26, p 0.029) were all associated with higher resilience (Table 2 ). The finding on information received was consistent regardless of whether the information was medical or psychosocial. In contrast, none of the external resources were significantly associated with resilience in grandparents. Table 2 Determinants of resilience (resilience sum score) among grandparents of grandchildren with cancer (n = 37; from univariable linear regression). Coefficient 90% CI P value Sociodemographic characteristics Age -0.10 (-0.54, 0.35) 0.725 Sex Male -ref Female -2.72 (-7.83, 2.40) 0.383 Language region German -ref Non-German 3.13 (-2.68, 8.94) 0.376 Migration background None-ref With 2.69 (-5.18,10.57) 0.574 Hospital proximity < 0.5 hour -ref >/= 0.5 hour -3.75 (-9.66, 2.16) 0.297 Kinship Maternal grandmother -ref Maternal grandfather Paternal grandmother Paternal grandfather 1.80 -0.41 4.70 (-5.66, 9.28) (-8.06, 7.23) (-6.06, 15.47) 0.635 0.916 0.391 Number of grandchildren </= 2 -ref > 2 grandchildren -0.98 (-6.45, 4.49) 0.767 Grandchild’s sex Male-ref Female -2.68 (-7.96, 2.60) 0.404 Grandchild’s age at diagnosis -0.29 (-0.88, 0.29) 0.410 Diagnosis Leukemia/lymphoma -ref Others 0.65 (-4.61, 5.91) 0.840 Therapy Chemotherapy – ref Others -0.07 (-5.29, 5.15) 0.983 Internal (personal) resources Income satisfaction “Exceeds needs” -ref “Meets needs” 7.56* (1.86,13.26) 0.029 Education Low -ref High 4.18 (-1.16, 9.52) 0.198 Employment Unemployed/retired - ref Employed 0.22 (-5.15, 5.60) 0.945 General health 1.55 (-2.13, 5.23) 0.488 Health literacy 0.31* (0.20, 0.42) < 0.001 Information received 1.53* (1.27, 1.79) < 0.001 Medical information 2.32* (1.97, 2.67) < 0.001 Psychosocial information 2.33* (1.56, 3.09) < 0.001 External (social) resources Partnership No -ref Yes -0.53 (-4.89, 3.82) 0.840 Partnership quality Attachment security 1.86 (-5.51, 9.23) 0.678 Perceived partner support 0.10 (-8.24, 8.43) 0.985 Social support Overall 0.14 (-2.70, 2.98) 0.936 Family -0.86 (-3.86, 2.14) 0.638 Significant other 0.78 (-1.48, 3.04) 0.568 Friends -0.04 (-2.73, 2.65) 0.980 1 Migration background are classified into none or Swiss: born in Switzerland and not naturalized or Swiss at birth. Otherwise, respondent is classified as someone with migration background. 2 General health was assessed using the first question of Short Form-36 (SF-36) with (1 = excellent to 5 = poor) 3 Health literacy measured using European Health Literacy Survey Questionnaire (HLS-Q12), expressed as percentage of ease of getting information for each domain (health care, disease prevention, and health promotion) 4 Information received measured using Grandparents Information Needs Questionnaire. It contains 14 items in total, 9 items medical information (cancer type, treatment, treatment goals, side-effects, disease progression, relapse, survival chance, late effects, palliative care) and 5 psychosocial information (communication with family, support for parents, support for grandchild, own support, peer support) items. 5 Partnership quality measured using Relationship-specific Attachment Scale for Adults (Beziehungsspezifische Bindungsskalen fur Erwachsene)with a scale of 1–5, including subscales 6 Multidimensional scale of perceived social support scale (MSPSS) assessed support from family, significant other, and friends (1 = strongly disagree to 7-strongly agree) Abbreviations: CI, confidence interval; SD, standard deviation; CNS, central nervous system; ref, reference group *p values < 0.05 DISCUSSION Resilience plays an important role in shaping an individual’s response to traumatic stress, such as a grandchild’s cancer diagnosis. In our study, we identified two distinct resilience trajectories among grandparents of children with cancer: one with consistently low levels (low-stable) and another with initially high resilience that declined over time (high-declining). Grandparents in the low-stable group had higher levels of post-traumatic stress symptoms, suggesting that this subgroup may be particularly vulnerable to long-term psychological distress. Income satisfaction, health literacy, and information received are internal resources that were associated with higher resilience in grandparents. Our findings provide novel insights into the psychological adaptation processes of grandparents during their grandchild's cancer trajectory and highlight potential targets for intervention. The high-declining resilience trajectory may reflect two distinct mechanisms. First, the initially elevated resilience may represent an adaptive stress response characterized by rapid mobilization of psychological resources during the acute crisis period compatible with the “shift-and-persist” model ( 29 , 30 ). This model shows that adaptation to stress through techniques like managing one’s emotions (shifting) and endure challenges by staying optimistic and finding purpose (persisting) could be a protective coping mechanism. This could be reflected as high resilience in our study ( 29 , 30 ). This initial surge in resilience may enable grandparents to maintain emotional stability, provide instrumental support to the family, and contribute to family cohesion during the most uncertain phases of diagnosis and treatment initiation. As treatment progresses and uncertainty possibly diminishes, resilience levels may naturally decline and return to pre-crisis baseline levels eventually, reflecting successful adaptation rather than psychological deterioration. This interpretation is supported by the concurrent decline in post-traumatic stress symptoms observed at T4, suggesting resolution of acute stress responses. Second, the resilience decline may reflect the cumulative burden of prolonged stress and emerging challenges during later treatment phases. Continuous or long-term exposure to stress may result in a decline in resilience, consistent with the stress-resilience theory ( 31 – 33 ). Treatment completion, while symbolizing medical success, paradoxically removes the structured medical environment that provided clear objectives and frequent professional medical and institutional support. Our previous studies indicate that families continue to worry about recurrence, late effects, and the long-term psychosocial impact ( 34 , 35 ). Grandparents may also face new challenges in the post-treatment phase, such as navigating complex family readjustment processes related to the recovering child’s behavioral and developmental changes, difficulties in sibling adjustment, and intergenerational financial strain accumulated during treatment - all of which may contribute to decreasing resilience. The low stable resilience trajectory represents a particularly vulnerable subpopulation. Grandparents exhibiting this resilience trajectory had elevated levels of post-traumatic stress throughout the study period, potentially indicating inadequate stress processing and difficulty adapting to the cancer experience ( 3 ). This pattern aligns with the view that resilience resembles a personality trait and represents a relatively stable construct ( 36 ). Grandparents in this trajectory may have fewer coping strategies or pre-existing psychological vulnerabilities ( 36 , 37 ). Previous studies also found low resilience to be associated with poorer mental health outcomes, including depression, anxiety, adjustment disorders, and post-traumatic stress disorder ( 36 ). Interventions improving resilience may help preventing physical and mental health disorders ( 38 ). We found several factors and resources to be associated with resilience. Grandparents who had received more information about both psychosocial and medical topics showed higher resilience. This is in line with previous studies that demonstrated the importance of information delivery to grandparents of children with cancer ( 23 , 39 ). The mechanism underlying this association may involve enhanced cognitive control and reduced uncertainty through improved understanding of disease processes, treatment protocols, and expected outcomes. Access to comprehensible, relevant information enables grandparents to construct coherent mental models of the experience, facilitating predictive coping and proactive problem-solving strategies ( 40 , 41 ). This cognitive clarity enhances self-efficacy beliefs, promoting confidence in their ability to navigate complex medical environments and providing meaningful family support ( 40 , 41 ). Furthermore, knowledge acquisition regarding available psychosocial resources, communication strategies, and other families' experiences contributes to an expanded coping repertoire and reduced feelings of isolation ( 12 , 23 , 42 ). The information-resilience association may be bidirectional, as higher resilience may also motivate active information-seeking behavior, creating positive feedback loops that sustain adaptive functioning throughout the treatment trajectory. We also found that grandparents reporting income that “meets needs” showed higher resilience than those reporting income that “exceeds needs.” This finding is counterintuitive, as most research suggests that greater financial resources support resilience ( 43 ). Our measure was based on self-reported income satisfaction (“how well do you get along with your household income”). Higher resilience among those who reported “meets needs” may reflect positivity and self-efficacy, which are part of the resilience construct ( 44 ). However, it should be noted that those who report “meets needs” should be interpreted with caution due to limited statistical power. The literature remains inconclusive regarding other determinants of resilience in older adults ( 40 , 41 , 45 ). In our study, we observed no associations between social support, partnership quality, and resilience. Given the limited sample size, this null finding may reflect insufficient statistical power, precluding definitive interpretation. However, if true, it could indicate that resilience in grandparents is less influenced by external resources than previously assumed. Older adults typically exhibit higher baseline resilience due to accumulated life experience, repeated adversity, and long-term shaped coping strategies ( 46 ). Resilience in later life is largely shaped by stable traits and coping patterns, consistent with the developmental timing hypothesis ( 47 , 48 ). Generational differences in help-seeking and social networks may further reduce the impact of current external resources, suggesting other unmeasured factors are more relevant in resilience building for this population. Strengths and Limitations To our knowledge, this study represents the first longitudinal examination of resilience among grandparents of children with cancer. The trajectory analysis approach, a perspective not previously explored in the literature, provides crucial insights into resilience evolution during their grandchild’s cancer journey. Identifying trajectories helped identifying groups vulnerable for higher levels of post-traumatic stress symptoms. The multicenter design enhances representativeness and generalizability within the national context, while the sample size remains substantial given the rare events and recruitment challenges inherent in this population. Several methodological limitations need to be highlighted to provide context in our findings. Selection bias represents a significant concern, as enrollment occurred through parental recruitment, potentially creating systematic exclusion of grandparents with strained family relationships, geographic barriers, or limited involvement in the child's care. This recruitment strategy may have favored grandparents with stronger emotional investment, better family communication patterns, and greater social support networks, resulting in systematically higher resilience than would be observed in the broader grandparent population. The self-selection nature of participation further reinforces this bias, as grandparents willing to engage in our cohort study may possess inherently different psychological characteristics, including higher baseline resilience, better health status, or greater comfort with emotional disclosure. Thus, resilience estimates for our study may be higher than their true value. Measurement bias is an additional concern. CD-RISC 10 lacks established validation in the elderly Swiss population, raising questions about construct validity, cultural appropriateness, and normative interpretation of scores in the aging population ( 20 ). Age-related cognitive changes, differential item interpretation, and cohort-specific understanding of resilience concepts ( 46 ) may influence response patterns in ways not captured by existing psychometric evaluations. Finally, limited statistical power precluded some analytical approaches. We were unable to conduct complex multivariable regression analyses that could account for interactions among sociodemographic and contextual factors and resources. Trajectory analysis with only two identified groups may oversimplify the heterogeneity of resilience patterns, potentially masking additional meaningful subgroups or transition points. Implications and future research Our findings reveal the impact of a diagnosis of childhood cancer on grandparents’ resilience. This underscores the importance of holistic care that includes not only the immediate family, but also grandparents and extended family members who might provide support. To help reduce grandparents’ anxiety and stress related to the cancer experience, a tailored information dissemination program is needed addressing grandparent-specific preferences and needs. Healthcare teams should encourage parents to be open to the inclusion of grandparents in family discussions, to ensure a comprehensive and family-centered care. Future research should adopt family-centered approaches examining psychosocial outcomes across parents, siblings, and grandparents as integrated units. Additionally, investigation of intrafamilial dynamics and family resilience processes, currently focused on nuclear families, should expand to include grandparent contributions. Larger cohort studies are needed to explore complex associations and interactions and to identify additional factors influencing resilience in this understudied population. CONCLUSION We identified two distinct resilience trajectories among grandparents following their grandchild’s cancer diagnosis: one characterized by initially high resilience that gradually declined, and another marked by persistently low resilience. The latter group experienced significantly elevated post-traumatic stress symptoms, underscoring the need for healthcare providers to identify and support this vulnerable population. Tailored, cancer-specific information delivery tailored to grandparents’ needs may enhance resilience and help prevent adverse psychological outcomes. Declarations Ethics approval and consent to participate The study was approved by the Ethic Committee of Northwest and Central Switzerland (EKNZ 2020-01409; 26 August 2020). The research was conducted in accordance with the principles of the Declaration of Helsinki. The study is compliant with the Swiss Human Research Act (810.30 Federal Act of 30 September 2011 on Research involving Human Beings) and Federal Regulations on Data Protection (235.1 Federal Act on Data Protection of 25 September 2020). Informed consent was obtained from all study participants before any data collection Consent for publication Not applicable Availability of data and materials Data used in the study is available to interested parties upon reasonable request from the corresponding author. Competing interest Authors declare no conflicts of interest. Funding The study was funded by the Swiss National Science Foundation (Grant No. 10001C_182129/1). Author contributions PFR conceptualized the study. AI & CP collected the data. PFR cleaned the dataset, performed the analysis, and plotted the graphs. PFR, AM, KR & GM wrote the first draft. AI, CP, AF, FS, UT, TD & KS provided expert feedback on the drafts. KS & GM secured funding. KS & GM supervised the study. All authors approved the submission of the manuscript. Acknowledgments We would like to thank the following people for the support offered in recruiting participants for the GROkids project: Basel: Prof. Dr. med. Nicolas von der Weid; Dr. med. Bettina Blank Bellinzona: Dr. med. Pierluigi Brazzola; Pamela Balestra Bern: Prof. Dr. med. Jochen Rössler; Dr. med. Eva Maria Tinner Oehler; Rebecca Bächtold Geneva: Prof. Marc Ansari; Maryline Bovero; Rodolfo Lo Piccolo Lausanne: Prof. Dr. med. Maja Beck Popovic; Dr. Manuel Diezi; Eléna Lemmel Lucerne: Katja Bannenberg; Barbara Gantner; Dr. Daniela Dyntar; Nadja Muelebach; Lea Imbach; Dr. Pauline Holmer St. Gallen: Dr. med. Jeanette Greiner References APA Dictionary of Psychology. VandenBos GR, editor. Washington, DC, US: American Psychological Association; 2007. xvi, 1024-xvi, p. Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18(2):76-82, doi:10.1002/da.10113. Bonanno GA, Westphal M, Mancini AD. Resilience to loss and potential trauma. Annu Rev Clin Psychol. 2011;7:511-35, doi:10.1146/annurev-clinpsy-032210-104526. MacLeod S, Musich S, Hawkins K, Alsgaard K, Wicker ER. The impact of resilience among older adults. Geriatr Nurs. 2016;37(4):266-72, doi:10.1016/j.gerinurse.2016.02.014. Fino E, Mema D, Russo PM. War trauma exposed refugees and posttraumatic stress disorder: The moderating role of trait resilience. J Psychosom Res. 2020;129:109905, doi:10.1016/j.jpsychores.2019.109905. Ying L, Wu X, Lin C, Jiang L. Traumatic severity and trait resilience as predictors of posttraumatic stress disorder and depressive symptoms among adolescent survivors of the Wenchuan earthquake. PLoS One. 2014;9(2):e89401, doi:10.1371/journal.pone.0089401. Pavlacic JM, Buchanan EM, McCaslin SE, Schulenberg SE, Young JN. A systematic review of posttraumatic stress and resilience trajectories: Identifying predictors for future treatment of veterans and service members. Professional Psychology: Research and Practice. 2022;53(3):266-75, doi:10.1037/pro0000451. Agaibi CE, Wilson JP. Trauma, PTSD, and resilience: a review of the literature. Trauma Violence Abuse. 2005;6(3):195-216, doi:10.1177/1524838005277438. Vogt AJ, Bartels L, Grotzer M, Bodenmann G, Leibundgut K, Rössler J, et al. Posttraumatic stress symptoms in parents of children with newly diagnosed cancer: 1-year trajectories and relationship variables as predictors. Journal of Pediatric Psychology. 2024;49(11):818-26, doi:10.1093/jpepsy/jsae077. Gantner B, Priboi C, Schilling FH, Michel G, Roser K. Systematic review: Care provided by grandparents of children with a chronic disease or a disability. EJC Paediatric Oncology. 2023;2, doi:10.1016/j.ejcped.2023.100126. Wilson JL. An Integrative Review of Grandparents' Experiences in Childhood Cancer. J Pediatr Hematol Oncol Nurs. 2024;41(1):67-77, doi:10.1177/27527530231194569. Priboi C, Gantner B, Holmer P, Neves da Silva L, Tinner EM, Roser K, et al. Psychological outcomes and support in grandparents whose grandchildren suffer from a severe physical illness: A systematic review. Heliyon. 2022;8(5):e09365, doi:10.1016/j.heliyon.2022.e09365. Rorbech JT, Tofting-Olesen K, Enskar K, Haslund-Thomsen H, Jensen CS, Dreyer P. Siblings' lived experiences of transitions between hospital and home in paediatric oncology: A qualitative study. Eur J Oncol Nurs. 2025;76:102853, doi:10.1016/j.ejon.2025.102853. McLoone JK, Wakefield CE, Glasson N, Wiener L, Ortiz R, Ilbawi A, et al. The Lived Experience of Childhood Cancer Survivors and Their Parents: A Multi-National Study of Access to Survivorship Care and Information and Support Needs. Pediatr Blood Cancer. 2025;72(5):e31593, doi:10.1002/pbc.31593. Erker C, Yan K, Zhang L, Bingen K, Flynn KE, Panepinto J. Impact of pediatric cancer on family relationships. Cancer Med. 2018;7(5):1680-8, doi:10.1002/cam4.1393. Bonanno GA, Galea S, Bucciarelli A, Vlahov D. What predicts psychological resilience after disaster? The role of demographics, resources, and life stress. Journal of consulting and clinical psychology. 2007;75(5):671. Hobfoll SE. Social and psychological resources and adaptation. Review of general psychology. 2002;6(4):307-24. Michel G, Raguindin PF, Priboi C, Ilic A, Holmer P, Scheinemann K, et al. Acute and long-term psychosocial consequences in grandparents when a grandchild is diagnosed with cancer - the GROKids Project: a population-based mixed-methods study protocol. BMC Psychol. 2023;11(1):280, doi:10.1186/s40359-023-01309-w. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-9, doi:10.1016/j.jclinepi.2007.11.008. Davidson JR. Connor-Davidson Resilience Scale (CDRISC) Manual. Unpublished 2018 [Available from: www.cdrisc.com. Campbell-Sills L, Stein MB. Psychometric analysis and refinement of the connor–davidson resilience scale (CD-RISC): Validation of a 10-item measure of resilience. Journal of Traumatic Stress. 2007;20(6):1019-28, doi:https://doi.org/10.1002/jts.20271. Weiss DS. The impact of event scale: revised. Cross-cultural assessment of psychological trauma and PTSD: Springer; 2007. p. 219-38. Wakefield CE, Drew D, Ellis SJ, Doolan EL, McLoone JK, Cohn RJ. 'What they're not telling you': a new scale to measure grandparents' information needs when their grandchild has cancer. Patient Educ Couns. 2014;94(3):351-5, doi:10.1016/j.pec.2013.10.030. Maruish M. User’s Manual for the SF-36v2 Health Survey. Quality Metric Incorporated. 2011;198. Sørensen K, Van den Broucke S, Pelikan JM, Fullam J, Doyle G, Slonska Z, et al. Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q). BMC Public Health. 2013;13(1):948, doi:10.1186/1471-2458-13-948. Asendorpf J, Banse R, Wilpers S, Neyer F. Beziehungsspezifische Bindungsskalen fur Erwachsene (Relationship-specific attachment scales for adults). Diagnostica. 1997;43:289-313. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. Journal of personality assessment. 1988;52(1):30-41. Jones BL, Nagin DS. A Stata Plugin for Estimating Group-Based Trajectory Models. . Pittsburgh, PA: Carnegie Mellon University 2012, https://ssrc.indiana.edu/doc/wimdocs/2013-03-29_nagin_trajectory_stata-plugin-info.pdf Chen E, Miller GE. “Shift-and-persist” strategies: Why low socioeconomic status isn’t always bad for health. Perspectives on psychological science. 2012;7(2):135-58. Chen E, Jiang T, Chen MA, Miller GE. Reflections on resilience. Development and Psychopathology. 2024;36(5):2551-8, doi:10.1017/s0954579424000403. Southwick SM, Charney DS. The science of resilience: implications for the prevention and treatment of depression. Science. 2012;338(6103):79-82, doi:10.1126/science.1222942. Russo SJ, Murrough JW, Han M-H, Charney DS, Nestler EJ. Neurobiology of resilience. Nature Neuroscience. 2012;15(11):1475-84, doi:10.1038/nn.3234. Lazarus RS, Folkman S. Stress, appraisal, and coping: Springer publishing company; 1984. Mader L, Roser K, Baenziger J, Tinner EM, Scheinemann K, Kuehni CE, et al. Household income and risk-of-poverty of parents of long-term childhood cancer survivors. Pediatr Blood Cancer. 2017;64(8), doi:10.1002/pbc.26456. Christen S, Mader L, Baenziger J, Roser K, Schindera C, Tinner EM, et al. \"I wish someone had once asked me how I'm doing\": Disadvantages and support needs faced by parents of long-term childhood cancer survivors. Pediatr Blood Cancer. 2019;66(8):e27767, doi:10.1002/pbc.27767. Angevaare MJ, Roberts J, van Hout HPJ, Joling KJ, Smalbrugge M, Schoonmade LJ, et al. Resilience in older persons: A systematic review of the conceptual literature. Ageing Res Rev. 2020;63:101144, doi:10.1016/j.arr.2020.101144. Gorska S, Singh Roy A, Whitehall L, Irvine Fitzpatrick L, Duffy N, Forsyth K. A Systematic Review and Correlational Meta-Analysis of Factors Associated With Resilience of Normally Aging, Community-Living Older Adults. Gerontologist. 2022;62(9):e520-e33, doi:10.1093/geront/gnab110. Chmitorz A, Kunzler A, Helmreich I, Tuscher O, Kalisch R, Kubiak T, et al. Intervention studies to foster resilience - A systematic review and proposal for a resilience framework in future intervention studies. Clin Psychol Rev. 2018;59:78-100, doi:10.1016/j.cpr.2017.11.002. Silveira JM, Winstead-Fry P. The needs of patients with cancer and their caregivers in rural areas. Oncol Nurs Forum. 1997;24(1):71-6. Trică A, Golu F, Sava NI, Licu M, Zanfirescu ȘA, Adam R, et al. Resilience and successful aging: A systematic review and meta-analysis. Acta Psychologica. 2024;248, doi:10.1016/j.actpsy.2024.104357. Sterina E, Hermida AP, Gerberi DJ, Lapid MI. Emotional Resilience of Older Adults during COVID-19: A Systematic Review of Studies of Stress and Well-Being. Clin Gerontol. 2022;45(1):4-19, doi:10.1080/07317115.2021.1928355. Holmer P, Muehlebach N, Ilic A, Priboi C, Roser K, Raguindin PF, et al. Exploring grandparents' psychosocial responses to childhood cancer: A qualitative study. Psycho-Oncology. 2024;33(2), doi:10.1002/pon.6304. Schafer SK, Supke M, Kausmann C, Schaubruch LM, Lieb K, Cohrdes C. A systematic review of individual, social, and societal resilience factors in response to societal challenges and crises. Commun Psychol. 2024;2(1):92, doi:10.1038/s44271-024-00138-w. Minnett K, Stephenson Z. Exploring the Psychometric Properties of the Connor-Davidson Resilience Scale (CD-RISC). Adversity and Resilience Science. 2024, doi:10.1007/s42844-024-00159-8. Timalsina R, Songwathana P. Factors enhancing resilience among older adults experiencing disaster: A systematic review. Australasian Emergency Care. 2020;23(1):11-22, doi:10.1016/j.auec.2019.12.007. Li Y-T, Ow YSY. Development of resilience scale for older adults. Aging & Mental Health. 2021;26(1):159-68, doi:10.1080/13607863.2020.1861212. Masten AS. Resilience Theory and Research on Children and Families: Past, Present, and Promise. Journal of Family Theory & Review. 2018;10(1):12-31, doi:10.1111/jftr.12255. Masten AS. Resilience in Developmental Systems: Principles, Pathways, and Protective Processes in Research and Practice. In: Ungar M, editor. Multisystemic Resilience: Adaptation and Transformation in Contexts of Change: Oxford University Press; 2021. p. 0. doi:10.1093/oso/9780190095888.003.0007. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial29Oct2025.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 22 Dec, 2025 Reviews received at journal 19 Dec, 2025 Reviews received at journal 17 Dec, 2025 Reviewers agreed at journal 08 Dec, 2025 Reviewers agreed at journal 06 Dec, 2025 Reviewers agreed at journal 04 Dec, 2025 Reviews received at journal 19 Nov, 2025 Reviewers agreed at journal 19 Nov, 2025 Reviewers agreed at journal 17 Nov, 2025 Reviewers agreed at journal 17 Nov, 2025 Reviewers invited by journal 11 Nov, 2025 Editor invited by journal 06 Nov, 2025 Editor assigned by journal 05 Nov, 2025 Submission checks completed at journal 29 Oct, 2025 First submitted to journal 29 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7846728\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":547662037,\"identity\":\"4a1316d3-c93e-4be3-a6d6-5b5acac46643\",\"order_by\":0,\"name\":\"Peter Francis Raguindin\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Lucerne\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Peter\",\"middleName\":\"Francis\",\"lastName\":\"Raguindin\",\"suffix\":\"\"},{\"id\":547662038,\"identity\":\"ea7e9442-e081-4e45-9da7-70a7828f9047\",\"order_by\":1,\"name\":\"Anne Maas\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Lucerne\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Anne\",\"middleName\":\"\",\"lastName\":\"Maas\",\"suffix\":\"\"},{\"id\":547662039,\"identity\":\"f3b625f7-ba52-4920-8caf-dae6276dabdc\",\"order_by\":2,\"name\":\"Anica Ilic\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Lucerne\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Anica\",\"middleName\":\"\",\"lastName\":\"Ilic\",\"suffix\":\"\"},{\"id\":547662040,\"identity\":\"281f74dd-ca03-405a-afd5-0de25aadf4ab\",\"order_by\":3,\"name\":\"Cristina Priboi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Lucerne\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Cristina\",\"middleName\":\"\",\"lastName\":\"Priboi\",\"suffix\":\"\"},{\"id\":547662041,\"identity\":\"74d43fd9-d38c-493a-8f6b-9c0c40c6c3e0\",\"order_by\":4,\"name\":\"Katharina Roser\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Lucerne\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Katharina\",\"middleName\":\"\",\"lastName\":\"Roser\",\"suffix\":\"\"},{\"id\":547662042,\"identity\":\"1d5c0eb8-bf75-4631-acf4-e93dee6e678b\",\"order_by\":5,\"name\":\"Ahmed Farrag\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Children’s Hospital of Central Switzerland\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ahmed\",\"middleName\":\"\",\"lastName\":\"Farrag\",\"suffix\":\"\"},{\"id\":547662043,\"identity\":\"0e4e2f21-33f0-445c-a3b4-c387db03b563\",\"order_by\":6,\"name\":\"Freimut Schilling\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Children’s Hospital of Central Switzerland\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Freimut\",\"middleName\":\"\",\"lastName\":\"Schilling\",\"suffix\":\"\"},{\"id\":547662044,\"identity\":\"22ccedaa-7891-4ee3-a34b-1a2375cf7328\",\"order_by\":7,\"name\":\"Ursula Tanriver\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University Children’s Hospital Basel\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ursula\",\"middleName\":\"\",\"lastName\":\"Tanriver\",\"suffix\":\"\"},{\"id\":547662045,\"identity\":\"e9164ab4-2c1d-4754-8822-125c4fe95ce3\",\"order_by\":8,\"name\":\"Tamara Diesch-Furlanetto\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University Children’s Hospital Basel\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Tamara\",\"middleName\":\"\",\"lastName\":\"Diesch-Furlanetto\",\"suffix\":\"\"},{\"id\":547662046,\"identity\":\"50a74f98-6da8-4186-b450-b8638aa56b0e\",\"order_by\":9,\"name\":\"Katrin Scheinemann\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Lucerne\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Katrin\",\"middleName\":\"\",\"lastName\":\"Scheinemann\",\"suffix\":\"\"},{\"id\":547662050,\"identity\":\"3e781285-195e-485a-a205-e8597365539a\",\"order_by\":10,\"name\":\"Gisela Michel\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYDACZiB+AMRsDDxARgWQwQ7kMTYQ0JIA05JwBshgJqSFAaqFAaQlsQ1qCD4t8u7sDx8k1DBE87GfPfggcd7hPD5mHgOGnztwazE8zGNskHCMIbeNJy/ZIHHb4WI2oBbG3jN4tDTzsEkksAG1SPCYSQC1JLYBtTAztuHTwv78R8I/sBbzH4lziNAiz8xgBvI12BaGxAYitBgw8xhLJPZJAP2SYyyRcCwdqIWt4GAvPlv6jz/88OGbTe789jOGHz7UWCfOb2/e+OAnPlsOgCkJVNEDuDUAbWnAJzsKRsEoGAWjAAQAWnRJQtBw2zcAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"University of Lucerne\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Gisela\",\"middleName\":\"\",\"lastName\":\"Michel\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-10-13 08:53:36\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-7846728/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-7846728/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":96603880,\"identity\":\"101379b0-6125-483b-ad8a-c02d1475a9ec\",\"added_by\":\"auto\",\"created_at\":\"2025-11-24 09:11:56\",\"extension\":\"docx\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":119044,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Manuscript29Oct2025.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/81883035c0543aed4b80040f.docx\"},{\"id\":96491115,\"identity\":\"2be68d8d-f7ec-4d4d-9a6c-03b156f28a58\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 17:50:02\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":272810,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Figures8Oct2025.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/050bb36c4a80886f325ff1bd.docx\"},{\"id\":96491117,\"identity\":\"475ee2e7-96c0-411c-813a-19f60eac1fbe\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 17:50:02\",\"extension\":\"docx\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":47900,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Tables8Oct2025.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/8d71bc1e490dccb5310451d9.docx\"},{\"id\":96604108,\"identity\":\"f0ec0e3c-7493-40f8-914b-0cbe2deb4bb4\",\"added_by\":\"auto\",\"created_at\":\"2025-11-24 09:12:47\",\"extension\":\"json\",\"order_by\":3,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":12595,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"231f4e6462dc4644baeedd1c1f665007.json\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/6b715785b021bd883b7bf525.json\"},{\"id\":96603596,\"identity\":\"0f47eaad-fd3b-4a12-b845-c756b61237b5\",\"added_by\":\"auto\",\"created_at\":\"2025-11-24 09:10:32\",\"extension\":\"docx\",\"order_by\":4,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":506085,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryMaterial29Oct2025.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/54e0950be71523bdff5c225f.docx\"},{\"id\":96603900,\"identity\":\"2c511765-fa80-44d7-b54e-99a3ff432666\",\"added_by\":\"auto\",\"created_at\":\"2025-11-24 09:12:01\",\"extension\":\"xml\",\"order_by\":5,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":147770,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"231f4e6462dc4644baeedd1c1f6650071enriched.xml\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/910ccf3b7f1f30be0071ac28.xml\"},{\"id\":96603933,\"identity\":\"36fedc25-0fc3-448d-bd79-506d640fc063\",\"added_by\":\"auto\",\"created_at\":\"2025-11-24 09:12:06\",\"extension\":\"jpeg\",\"order_by\":6,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":1074,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"floatimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/6e4ec002557db39ee63f25ae.jpeg\"},{\"id\":96491127,\"identity\":\"b06f8ff6-526d-42cb-9dd3-774962d5eeb8\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 17:50:02\",\"extension\":\"png\",\"order_by\":7,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":81128,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"floatimage2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/0c97b8dd8e5ecb3c028ff3eb.png\"},{\"id\":96491122,\"identity\":\"63d9ef32-bf43-4463-bca3-f218cf61cf00\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 17:50:02\",\"extension\":\"png\",\"order_by\":8,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":77890,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"floatimage3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/c7e6f8db69302417f2a79709.png\"},{\"id\":96604253,\"identity\":\"47e27af5-b706-41d1-8aca-c256c4624f61\",\"added_by\":\"auto\",\"created_at\":\"2025-11-24 09:13:22\",\"extension\":\"jpeg\",\"order_by\":9,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":38492,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"groupimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/b70df27e908e6e1ee5321a54.jpeg\"},{\"id\":96603869,\"identity\":\"91802b54-9d9e-443f-8ff3-5cbc9a23447f\",\"added_by\":\"auto\",\"created_at\":\"2025-11-24 09:11:55\",\"extension\":\"png\",\"order_by\":10,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":935,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Onlinefloatimage1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/bb742a2b8acf591ad7481db3.png\"},{\"id\":96491129,\"identity\":\"4384d7b4-b125-42e9-b1d7-b879dc7eff27\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 17:50:02\",\"extension\":\"png\",\"order_by\":11,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":23181,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Onlinefloatimage2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/e002f54d9ab898f0d55baa62.png\"},{\"id\":96491123,\"identity\":\"92206655-bbae-451a-9c20-778e1aabbdac\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 17:50:02\",\"extension\":\"png\",\"order_by\":12,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":35465,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Onlinefloatimage3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/5d69801b8329b7b34e686d8c.png\"},{\"id\":96491125,\"identity\":\"84d7b12e-fdd6-41f2-b3db-c980c755b236\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 17:50:02\",\"extension\":\"png\",\"order_by\":13,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":27293,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Onlinegroupimage1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/aead5780520ed6e79621615d.png\"},{\"id\":96603820,\"identity\":\"087a3270-c438-40d1-a357-47ff154fa2f6\",\"added_by\":\"auto\",\"created_at\":\"2025-11-24 09:11:39\",\"extension\":\"xml\",\"order_by\":14,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":145140,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"231f4e6462dc4644baeedd1c1f6650071structuring.xml\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/16da9f6fe2998b925110adc0.xml\"},{\"id\":96491131,\"identity\":\"0653b8ad-4949-4772-8c42-d499eae687cd\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 17:50:03\",\"extension\":\"html\",\"order_by\":15,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":157462,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"earlyproof.html\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/c0cada3b10485d98e1f07b7f.html\"},{\"id\":96603797,\"identity\":\"878232d3-b878-4654-ba29-334f97e9c9ad\",\"added_by\":\"auto\",\"created_at\":\"2025-11-24 09:11:34\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":44271,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFlowchart of study participants\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/d6f9c8305aa8771a06535327.png\"},{\"id\":96491111,\"identity\":\"51d97b15-d870-4e13-aea5-1a8949c70c04\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 17:50:02\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":32971,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eResilience sum score in each time point for respective resilience trajectory.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e*The y-axis was rescaled to allow closer examination of the declining trend at higher values. Lines (red and bleu) depicts the trend in resilience sum scores across time Accurate linear equations can be found in the Appendix Table S3 (Model fit indices).\\u003c/em\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/81959928cb544feff51f7683.png\"},{\"id\":96603769,\"identity\":\"7f0fa709-6059-4e3b-b5a2-e49b55e6201a\",\"added_by\":\"auto\",\"created_at\":\"2025-11-24 09:11:29\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":46125,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePost-traumatic stress (IES-R) between Low-stable and High-decreasing level of resilience. Boxplot shows median, interquartile range, and range. Values in mean and standard deviation, p value from Student’s t-test\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/39984f1e5f8874372782f4be.png\"},{\"id\":96912948,\"identity\":\"31efe690-6c02-4eb2-832a-6f9e5c2a18e5\",\"added_by\":\"auto\",\"created_at\":\"2025-11-27 13:43:50\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1095007,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/6281a784-f15f-4bfc-9398-39688b0add25.pdf\"},{\"id\":96491119,\"identity\":\"ca34ea11-3065-49cc-8123-0e9fc8538712\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 17:50:02\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":506085,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryMaterial29Oct2025.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7846728/v1/8dd444055949a700e63537fb.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Resilience and post-traumatic stress symptoms in grandparents following their grandchild’s cancer diagnosis from a multicenter cohort study in Switzerland (The GROkids Project)\",\"fulltext\":[{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003eResilience can be defined as \\u0026ldquo;the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility and adjustment to external and internal demands.\\u0026rdquo;(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) It reflects an ongoing process of adaptation, shaped by both internal and external resources, that enables individuals to maintain or regain functioning in the face of adversity (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). Resilience is not a fixed trait but a dynamic process that varies across life stages and contexts (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). Studies have shown that resilience increases with age (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e), possibly due to accumulated life experiences that are shaped through time. Older adults rely on both internal (personal) and external (social) psychological resources that help them maintain stability during stress (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). High resilience in this age group is hypothesized to be linked to lower post-traumatic stress symptoms, largely through the use of effective coping strategies that support adaptive functioning after adversity (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eThe diagnosis of childhood cancer is a stressful event for the child and the family (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). Within the family system, grandparents are involved in the care of their grandchildren at the time of diagnosis and throughout treatment (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). They provide logistical support with childcare, emotional support to parents, and financial assistance when needed (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Despite their involvement, few studies have investigated the psychosocial impact of childhood cancer on grandparents (\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eGiven the intensity of the psychosocial impact of childhood cancer diagnosis on the family, understanding how grandparents cope with these challenges is essential. A cancer diagnosis in a child can lead to a series of changes within the family, such as changes in childcare responsibilities, household chore responsibilities, employment and financial resources (\\u003cspan additionalcitationids=\\\"CR14\\\" citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e). This may require family members, including grandparents, to adapt in various ways. While several internal (personal) factors, such as economic status, general health, health literacy, and information provision (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e), as well as external (social) resources, such as partnership status and quality, religious affiliation, and perceived social support (\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e), had been shown to contribute to resilience, their role in grandparents of children with cancer is yet unknown.\\u003c/p\\u003e\\u003cp\\u003eTo date, no studies have explored resilience in older adults whose grandchildren are diagnosed with a serious illness. In particular, no research has investigated resilience trajectories following a childhood cancer diagnosis, nor how these trajectories influence post-traumatic stress reactions in grandparents.\\u003c/p\\u003e\\u003cp\\u003eTherefore, we aimed to: \\u003cb\\u003e1\\u003c/b\\u003e) identify trajectories of resilience in grandparents of children with cancer, \\u003cb\\u003e2\\u003c/b\\u003e) determine the association between resilience trajectories and post-traumatic stress symptoms, and \\u003cb\\u003e3\\u003c/b\\u003e) identify internal (personal) and external (social) resources and contextual factors that influence resilience.\\u003c/p\\u003e\"},{\"header\":\"METHODS\",\"content\":\"\\u003cp\\u003eThis was a multicenter cohort study from a cohort of grandparents whose grandchildren were recently diagnosed with cancer in Switzerland (18). We followed the STROBE Statement Checklist for transparent reporting of study methods and results (19). (Clinical trial number: not applicable)\\u003c/p\\u003e\\n\\n\\u003ch2\\u003eSample and procedures\\u003c/h2\\u003e\\n\\u003cp\\u003eWe included grandparents whose grandchild was recently diagnosed with cancer and was undergoing cancer treatment. Eligibility criteria included having a grandchild who: was under 18 years of age, had received a cancer diagnosis within the past three months, was treated at one of eight participating pediatric oncology centers in Switzerland, and the grandparent was fluent in German, French, or Italian.\\u003c/p\\u003e\\n\\n\\u003cp\\u003eRecruitment was facilitated through hospital staff at the participating clinics, who either directly approached eligible grandparents or asked parents to provide contact information for the grandparents. Upon contact with the study team, grandparents received an information letter detailing the study\\u0026rsquo;s objectives along with a consent form. We sent questionnaires to those who provided consent at four time points: 3 months (T1), 6 months (T2), 12 months (T3), and 24 months (T4) post-diagnosis. Summary of the tools and time point of measurement can be found in the Appendix (\\u003cstrong\\u003eAppendix Table S1\\u003c/strong\\u003e).\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eFollow-up reminders were sent after four weeks and phone calls were conducted if necessary. To support cohort retention, we sent greeting cards to the grandparents for major holidays and regular study updates . A clinical psychologist was available if needed. Enrollment was open from October 2020 to March 2023; follow-up was continued until December 2024.\\u0026nbsp;A designated research staff member entered all results, and 20% of responses were double-checked for accuracy. All datasets are stored on secure University servers with access restricted to authorized staff. Detailed study procedures can be found in a separate publication (18).\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch2\\u003eOutcomes \\u0026nbsp;\\u003c/h2\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eResilience\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eResilience was assessed at T1-T4 using the Connor-Davidson Resilience Scale (CD-RISC 10), a 10-item self-report measure evaluating \\u0026ldquo;positive adaptation in the face of stress or trauma\\u0026rdquo; (20, 21). Items were rated on a 5-point Likert scale (0=not true at all, 4=true nearly all the time) and summed to create a resilience score. Missing responses were imputed using the mean of completed items when \\u0026lt;25% of items were missing. Summary of items can be found in the Appendix (\\u003cstrong\\u003eAppendix Table S2\\u003c/strong\\u003e).\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003e\\u003cem\\u003ePost-traumatic stress symptoms\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ePost-traumatic stress symptoms were measured at T3 and T4 using the Impact of Event Scale-Revised (IES-R), a 22-item self-report measure assessing subjective distress following traumatic events (22). For the current study, we revised the IES-R, such that the traumatic event focused on the grandchild\\u0026rsquo;s recent diagnosis. The scale comprises three subscales: intrusion (8 items), avoidance (8 items), and hyperarousal (6 items). Items were rated on a 5-point Likert scale (0-4) Missing data (\\u0026le;20% within a subscale) was imputed using the mean of completed subscale items. We only used the total score for this analysis ranging from 0-88, with higher scores indicating higher post-traumatic stress symptoms.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch2\\u003eCovariates\\u003c/h2\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eSociodemographic and contextual factors (at T1)\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe collected sociodemographic or contextual factors, namely, age, gender (male, female), language region (German, French/Italian), migration background (no migration background: those born in Switzerland and Swiss at birth, with migration background: all others), hospital proximity to the house of the grandparents (travel time measured in \\u0026lt;0.5 hour, or \\u0026ge;0.5 hours), and number of grandchildren (\\u0026le;2, \\u0026gt;2 grandchildren) all were collected at T1. Grandchild\\u0026rsquo;s gender (male, female), grandchild\\u0026rsquo;s age, cancer diagnosis (leukemia/lymphoma, other tumors), and therapy (chemotherapy, others) were all obtained from medical records.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003e\\u003cem\\u003eInternal (personal) resources\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe also collected internal resources, namely, household income satisfaction (\\u0026ldquo;exceeds needs\\u0026rdquo;;\\u0026ldquo;meets needs\\u0026rdquo;), education (compulsory school/vocational training, upper secondary/university), employment (unemployed/retired, employed), information received (medical information), general health, and health literacy.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eInformation needs and preferences were assessed at T1-T4 using a validated scale adapted from the Grandparents Information Needs Questionnaire (23). The instrument evaluated information needs across multiple domains:\\u0026nbsp;9 medical items (cancer type, treatment, treatment goals, side-effects, disease progression, relapse, survival chance, late effects, palliative care) and 5 psychosocial items (communication with family, support for parents, support for grandchildren, own support, peer support). Participants indicated if they had received information (yes/no) for each domain. We calculated a score by counting the number of domains in which the participant received information. \\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eGeneral well-being was assessed using the first item of the Short Form-36 (SF-36) (24): \\u0026quot;In general, would you say your health is?\\u0026quot; rated on a 5-point Likert scale (1=poor, 5=excellent).\\u003c/p\\u003e\\n\\n\\u003cp\\u003eHealth literacy was measured at T3 using the European Health Literacy Survey Questionnaire (HLS-Q12) (25) consisting of 12 items and assessing perceived difficulty in accessing, understanding, evaluating, and applying health information across healthcare, disease prevention, and health promotion domains. Items were rated on a 4-point Likert scale (1=very easy, 4=very difficult) and reverse-coded so higher scores indicated higher health literacy (sum score range: 12-48). Missing values were imputed using the median of the available responses when \\u0026gt;80% of items were completed.\\u003c/p\\u003e\\n\\n\\u003cp\\u003e\\u003cem\\u003eExternal (social) resources\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe collected external resources, namely, partnership status (no partner, in partnership), partnership quality, and social support.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003ePartnership quality was assessed using the Relationship-specific Attachment Scale for Adults (Beziehungsspezifische Bindungsskalen fur Erwachsene) (26), comprising 14 items rated on a 5-point Likert scale (1=completely disagree, 5=completely agree). Two subscales measured attachment security (6 items) and perceived available support (8 items). Negatively phrased items were reverse-coded. Subscale scores were summarized using means and standard deviations.\\u003c/p\\u003e\\n\\n\\u003cp\\u003ePerceived social support was measured at T1 using the Multidimensional Scale of Perceived Social Support (MSPSS)(27), a 12-item self-report measure assessing support from three sources (three subscales), namely, family, friends, and significant others (4 items each). Items were rated on a 7-point Likert scale (1=very strongly disagree, 7=very strongly agree). Missing data (if \\u0026le;1 item per subscale missing) was imputed using the mean of the completed items within the respective subscale. We summarized the response through sum score of all the items. Mean scores were calculated by averaging responses within each subscale.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch2\\u003eData analysis\\u003c/h2\\u003e\\n\\u003cp\\u003eA framework for the analysis can also be found in the appendix (\\u003cstrong\\u003eAppendix Figure S1\\u003c/strong\\u003e). Stata 19.5 (StataCorp, TX) was used for the analysis.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003cp\\u003eFor aim 1, we used group-based trajectory modeling (GBTM) to identify trajectories of resilience. GBTM uses finite mixture models with censored normal distributions, treating the resilience sum score as a continuous variable. Trajectories were modeled using linear, quadratic, and cubic polynomial functions of time. Parameters were estimated using maximum likelihood estimation. Model fit was evaluated using AIC, BIC, and entropy. For participants with at most one missing response on the resilience scale, last observation carried forward imputation was applied. Analyses were conducted using the\\u0026nbsp;traj\\u0026nbsp;package (28).\\u003c/p\\u003e\\n\\n\\u003cp\\u003eFor aim 2, we examined the associations between resilience trajectory group membership (identified in aim 1) and post-traumatic stress symptoms using Student\\u0026rsquo;s t-test and linear mixed models (LMMs). For LMM, the IES-R sum score at T3 and T4 (continuous outcome) served as the dependent variable, and resilience trajectory group (categorical) as the independent variable. A random-intercept model was specified to account for repeated measures, with time included as a fixed effect. Models adjusted for age and sex were also fitted.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp; \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eFor aim 3, we assessed associations of internal and external resources with resilience using linear mixed-effects models, with the resilience sum score as the continuous outcome. Univariable linear mixed-effects models were fitted for each predictor. Fixed effects included time points (categorical, T1-T4), sociodemographic and contextual factors, internal resources, and external resources. A random-intercept model was used to account for repeated measures nested within participants.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\\u003ch2\\u003eEthical considerations\\u003c/h2\\u003e\\n\\u003cp\\u003eThe study was approved by the Ethics Committee of Northwest and Central Switzerland (EKNZ 2020-01409, 26 August 2020). The study was done according to the Declaration of Helsinki and relevant national regulations. All participants provided written informed consent.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003eOf 85 grandparents invited to participate, 37 grandparents (25 grandmothers (61%); mean age: 67.6 years, range 55\\u0026ndash;80) of 20 grandchildren with cancer participated in the study (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e, Fig. \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Total follow-up time has a mean of 21.4 months (SD 1.6) ranging from 18.2\\u0026ndash;24.5 months. Most participants were unemployed or retired (n\\u0026thinsp;=\\u0026thinsp;23; 59%), and nearly all were in a partnership (n\\u0026thinsp;=\\u0026thinsp;35, 90%). The grandchildren were predominantly female (n\\u0026thinsp;=\\u0026thinsp;12, 63%) with a mean age of 6.0 years at diagnosis. Leukemia was the most frequent diagnosis (n\\u0026thinsp;=\\u0026thinsp;10, 53%).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003c/p\\u003e\\n\\u003ctable id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eCharacteristics of participating grandparents (n\\u0026thinsp;=\\u0026thinsp;37) and their grandchildren with cancer (n\\u0026thinsp;=\\u0026thinsp;20).\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003eSociodemographic characteristics and contextual factors, n\\u0026thinsp;=\\u0026thinsp;37\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAge, years\\u003c/p\\u003e\\n \\u003cp\\u003emean (SD)\\u003c/p\\u003e\\n \\u003cp\\u003erange\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e67.6 (6.3)\\u003c/p\\u003e\\n \\u003cp\\u003e55\\u0026ndash;80\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSex\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e39%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e61%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eLanguage region\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGerman\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e31\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e76%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eFrench/Italian\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e24%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMigration background\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e34\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e87%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e13%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eHospital proximity\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.5 hour\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e27%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026ge;0.5 hour\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e27\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e73%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGrandparent kinship\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMaternal grandmother\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e34%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMaternal grandfather\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e29%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePaternal grandmother\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e27%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePaternal grandfather\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e10%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eNumber of grandchildren\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026le;2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e42%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026gt;\\u0026thinsp;2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e22\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e58%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003eChild- and cancer-related characteristics, n\\u0026thinsp;=\\u0026thinsp;20\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGrandchild\\u0026apos;s sex\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e63%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e37%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGrandchild\\u0026rsquo;s age at diagnosis, yrs\\u003c/p\\u003e\\n \\u003cp\\u003emean (SD)\\u003c/p\\u003e\\n \\u003cp\\u003erange\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e6.0 (4.6)\\u003c/p\\u003e\\n \\u003cp\\u003e0\\u0026ndash;15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCancer diagnosis\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eLeukemia/lymphoma\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e53%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCNS/solid tumors/others\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e47%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eTherapy\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eChemotherapy\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e32%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCombination/ surgery/ radiotherapy\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e68%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003eInternal (personal) resources\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eHousehold income satisfaction\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;Exceeds needs\\u0026rdquo;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e74%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;Meets needs\\u0026rdquo;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e26%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eEducation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCompulsory school/Vocational training\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e23\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e60%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eUpper secondary education/University\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e40%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eEmployment\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eUnemployed/retired\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e23\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e59%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eEmployed\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e41%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGeneral health\\u003csup\\u003e2\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.28 (0.72)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eHealth literacy\\u003csup\\u003e3\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e57.2 (34.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInformation received\\u003csup\\u003e4\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e7.5 (4.9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMedical information\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e5.4 (3.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePsychosocial information\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.1 (2.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003eExternal (social) resources\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePartnership\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e10%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e35\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e90%\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePartnership quality\\u003csup\\u003e5\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAttachment security\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.7 (0.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePerceived partner support\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3.3 (0.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSocial support\\u003csup\\u003e6\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOverall\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e5.9 (0.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eFamily\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e5.9 (0.9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSignificant others\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e6.0 (1.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eFriends\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e6.0 (1.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003ctfoot\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\"\\u003e\\u003csup\\u003e1\\u003c/sup\\u003e Migration background are classified into none or Swiss: born in Switzerland and not naturalized or Swiss at birth. Otherwise, respondent is classified as someone with migration background.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\"\\u003e\\u003csup\\u003e2\\u003c/sup\\u003e General health was assessed using the first question of Short Form-36 (SF-36) with (1\\u0026thinsp;=\\u0026thinsp;excellent to 5\\u0026thinsp;=\\u0026thinsp;poor). Expressed in mean and SD\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\"\\u003e\\u003csup\\u003e3\\u003c/sup\\u003e Health literacy measured using European Health Literacy Survey Questionnaire (HLS-Q12), expressed as percentage of ease of getting information for each domain (health care, disease prevention, and health promotion). Expressed in mean and SD\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\"\\u003e\\u003csup\\u003e4\\u003c/sup\\u003e Information received measured using Grandparents Information Needs Questionnaire. It contains 14 items in total \\u0026minus;\\u0026thinsp;9 items medical information (cancer type, treatment, treatment goals, side-effects, disease progression, relapse, survival chance, late effects, palliative care) and 5 psychosocial information (communication with family, support for parents, support for grandchild, own support, peer support) items. Expressed in mean and SD\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\"\\u003e\\u003csup\\u003e5\\u003c/sup\\u003e Partnership quality measured using Relationship-specific Attachment Scale for Adults (Beziehungsspezifische Bindungsskalen fur Erwachsene) with a scale of 1\\u0026ndash;5, including subscales. Expressed in mean and SD.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\"\\u003e\\u003csup\\u003e6\\u003c/sup\\u003e Multidimensional scale of perceived social support scale (MSPSS) assessed support from family, significant other, and friends (1\\u0026thinsp;=\\u0026thinsp;strongly disagree to 7-strongly agree)\\u003cbr\\u003eAbbreviations: SD, standard deviation; CNS, central nervous system\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tfoot\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003c/p\\u003e\\n\\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eTrajectories of resilience (Aim 1)\\u003c/h2\\u003e\\n \\u003cp\\u003eDetailed item responses of the participants on CD-RISC 10 can be found in the Appendix (\\u003cstrong\\u003eAppendix Table S2\\u003c/strong\\u003e). We identified two distinct trajectories of resilience among grandparents. The first trajectory, observed in 17 grandparents (43%), was characterized by consistently low resilience over time (low-stable trajectory). The second trajectory, observed in 23 grandparents (57%), started with higher resilience levels that declined over time (high-declining trajectory) (Fig. \\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cstrong\\u003eAppendix Figure S2\\u003c/strong\\u003e). Model fit indices and parameters for model selection can be found in the appendix (\\u003cstrong\\u003eAppendix Table S3\\u003c/strong\\u003e).\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eAssociation of resilience trajectories with post-traumatic stress symptoms (Aim 2)\\u003c/h2\\u003e\\n \\u003cp\\u003eThe low-stable trajectory group had higher IES-R scores compared to the high-declining trajectory group at 12 months (mean\\u0026thinsp;=\\u0026thinsp;43.2 SD\\u0026thinsp;=\\u0026thinsp;18.5 vs mean\\u0026thinsp;=\\u0026thinsp;19.4 SD\\u0026thinsp;=\\u0026thinsp;16.2, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and 24 months from the diagnosis (mean\\u0026thinsp;=\\u0026thinsp;38.4 SD\\u0026thinsp;=\\u0026thinsp;15.9 vs mean\\u0026thinsp;=\\u0026thinsp;22.6 SD\\u0026thinsp;=\\u0026thinsp;16.3, p 0.014) (Fig. \\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). Linear mixed models confirmed that those with low-stable resilience trajectory had higher post-traumatic stress symptoms compared to high-declining trajectory (\\u0026beta;: -19.8, 90% CI -29.2, -10.4, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001; age-sex-adjusted model; \\u0026beta;: -19.2, 90% CI -29.3, -9.1, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001; \\u003cstrong\\u003eAppendix Table S4\\u003c/strong\\u003e).\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eDeterminants of resilience (Aim 3)\\u003c/h2\\u003e\\n \\u003cp\\u003eHigher health literacy (\\u0026beta;: 0.3, 90% CI 0.20, 0.42, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), information received on more domains (\\u0026beta;: 1.53, 90% CI 1.27, 1.79, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), and household income that \\u0026ldquo;meets needs\\u0026rdquo; (\\u0026beta;: 7.56, 9% CI 1.86, 13.26, p 0.029) were all associated with higher resilience (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). The finding on information received was consistent regardless of whether the information was medical or psychosocial. In contrast, none of the external resources were significantly associated with resilience in grandparents.\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003c/p\\u003e\\n \\u003ctable id=\\\"Tab2\\\" border=\\\"1\\\" class=\\\"fr-table-selection-hover\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eDeterminants of resilience (resilience sum score) among grandparents of grandchildren with cancer (n\\u0026thinsp;=\\u0026thinsp;37; from univariable linear regression).\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCoefficient\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e90% CI\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eP value\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\"\\u003e\\n \\u003cp\\u003eSociodemographic characteristics\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAge\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-0.54, 0.35)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.725\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSex\\u003c/p\\u003e\\n \\u003cp\\u003eMale -ref\\u003c/p\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-2.72\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-7.83, 2.40)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.383\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eLanguage region\\u003c/p\\u003e\\n \\u003cp\\u003eGerman -ref\\u003c/p\\u003e\\n \\u003cp\\u003eNon-German\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3.13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-2.68, 8.94)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.376\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMigration background\\u003c/p\\u003e\\n \\u003cp\\u003eNone-ref\\u003c/p\\u003e\\n \\u003cp\\u003eWith\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.69\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-5.18,10.57)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.574\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eHospital proximity\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.5 hour -ref\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026gt;/= 0.5 hour\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-3.75\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-9.66, 2.16)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.297\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eKinship\\u003c/p\\u003e\\n \\u003cp\\u003eMaternal grandmother -ref\\u003c/p\\u003e\\n \\u003cp\\u003eMaternal grandfather\\u003c/p\\u003e\\n \\u003cp\\u003ePaternal grandmother\\u003c/p\\u003e\\n \\u003cp\\u003ePaternal grandfather\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.80\\u003c/p\\u003e\\n \\u003cp\\u003e-0.41\\u003c/p\\u003e\\n \\u003cp\\u003e4.70\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-5.66, 9.28)\\u003c/p\\u003e\\n \\u003cp\\u003e(-8.06, 7.23)\\u003c/p\\u003e\\n \\u003cp\\u003e(-6.06, 15.47)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.635\\u003c/p\\u003e\\n \\u003cp\\u003e0.916\\u003c/p\\u003e\\n \\u003cp\\u003e0.391\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eNumber of grandchildren\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026lt;/= 2 -ref\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026gt;\\u0026thinsp;2 grandchildren\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.98\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-6.45, 4.49)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.767\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGrandchild\\u0026rsquo;s sex\\u003c/p\\u003e\\n \\u003cp\\u003eMale-ref\\u003c/p\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-2.68\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-7.96, 2.60)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.404\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGrandchild\\u0026rsquo;s age at diagnosis\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-0.88, 0.29)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.410\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eDiagnosis\\u003c/p\\u003e\\n \\u003cp\\u003eLeukemia/lymphoma -ref\\u003c/p\\u003e\\n \\u003cp\\u003eOthers\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.65\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-4.61, 5.91)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.840\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eTherapy\\u003c/p\\u003e\\n \\u003cp\\u003eChemotherapy \\u0026ndash; ref\\u003c/p\\u003e\\n \\u003cp\\u003eOthers\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.07\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-5.29, 5.15)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.983\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\"\\u003e\\n \\u003cp\\u003eInternal (personal) resources\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eIncome satisfaction\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026ldquo;Exceeds needs\\u0026rdquo; -ref\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026ldquo;Meets needs\\u0026rdquo;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e7.56*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(1.86,13.26)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.029\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eEducation\\u003c/p\\u003e\\n \\u003cp\\u003eLow -ref\\u003c/p\\u003e\\n \\u003cp\\u003eHigh\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e4.18\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-1.16, 9.52)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.198\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eEmployment\\u003c/p\\u003e\\n \\u003cp\\u003eUnemployed/retired - ref\\u003c/p\\u003e\\n \\u003cp\\u003eEmployed\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.22\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-5.15, 5.60)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.945\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGeneral health\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.55\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-2.13, 5.23)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.488\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eHealth literacy\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.31*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(0.20, 0.42)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInformation received\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.53*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(1.27, 1.79)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMedical information\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.32*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(1.97, 2.67)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePsychosocial information\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2.33*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(1.56, 3.09)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\"\\u003e\\n \\u003cp\\u003eExternal (social) resources\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePartnership\\u003c/p\\u003e\\n \\u003cp\\u003eNo -ref\\u003c/p\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.53\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-4.89, 3.82)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.840\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePartnership quality\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAttachment security\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.86\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-5.51, 9.23)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.678\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePerceived partner support\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-8.24, 8.43)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.985\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSocial support\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOverall\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-2.70, 2.98)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.936\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eFamily\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.86\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-3.86, 2.14)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.638\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSignificant other\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.78\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-1.48, 3.04)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.568\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eFriends\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-0.04\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e(-2.73, 2.65)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.980\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003ctfoot\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003e1\\u003c/sup\\u003e Migration background are classified into none or Swiss: born in Switzerland and not naturalized or Swiss at birth. Otherwise, respondent is classified as someone with migration background.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003e2\\u003c/sup\\u003e General health was assessed using the first question of Short Form-36 (SF-36) with (1\\u0026thinsp;=\\u0026thinsp;excellent to 5\\u0026thinsp;=\\u0026thinsp;poor)\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003e3\\u003c/sup\\u003e Health literacy measured using European Health Literacy Survey Questionnaire (HLS-Q12), expressed as percentage of ease of getting information for each domain (health care, disease prevention, and health promotion)\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003e4\\u003c/sup\\u003e Information received measured using Grandparents Information Needs Questionnaire. It contains 14 items in total, 9 items medical information (cancer type, treatment, treatment goals, side-effects, disease progression, relapse, survival chance, late effects, palliative care) and 5 psychosocial information (communication with family, support for parents, support for grandchild, own support, peer support) items.\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003e5\\u003c/sup\\u003e Partnership quality measured using Relationship-specific Attachment Scale for Adults (Beziehungsspezifische Bindungsskalen fur Erwachsene)with a scale of 1\\u0026ndash;5, including subscales\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003e6\\u003c/sup\\u003e Multidimensional scale of perceived social support scale (MSPSS) assessed support from family, significant other, and friends (1\\u0026thinsp;=\\u0026thinsp;strongly disagree to 7-strongly agree)\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003eAbbreviations: CI, confidence interval; SD, standard deviation; CNS, central nervous system; ref, reference group\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e*p values\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tfoot\\u003e\\n \\u003c/table\\u003e\\n \\u003cp\\u003e\\u003c/p\\u003e\\n\\u003c/div\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eResilience plays an important role in shaping an individual\\u0026rsquo;s response to traumatic stress, such as a grandchild\\u0026rsquo;s cancer diagnosis. In our study, we identified two distinct resilience trajectories among grandparents of children with cancer: one with consistently low levels (low-stable) and another with initially high resilience that declined over time (high-declining). Grandparents in the low-stable group had higher levels of post-traumatic stress symptoms, suggesting that this subgroup may be particularly vulnerable to long-term psychological distress. Income satisfaction, health literacy, and information received are internal resources that were associated with higher resilience in grandparents. Our findings provide novel insights into the psychological adaptation processes of grandparents during their grandchild's cancer trajectory and highlight potential targets for intervention.\\u003c/p\\u003e\\u003cp\\u003eThe high-declining resilience trajectory may reflect two distinct mechanisms. First, the initially elevated resilience may represent an adaptive stress response characterized by rapid mobilization of psychological resources during the acute crisis period compatible with the \\u0026ldquo;shift-and-persist\\u0026rdquo; model (\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e). This model shows that adaptation to stress through techniques like managing one\\u0026rsquo;s emotions (shifting) and endure challenges by staying optimistic and finding purpose (persisting) could be a protective coping mechanism. This could be reflected as high resilience in our study (\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e). This initial surge in resilience may enable grandparents to maintain emotional stability, provide instrumental support to the family, and contribute to family cohesion during the most uncertain phases of diagnosis and treatment initiation. As treatment progresses and uncertainty possibly diminishes, resilience levels may naturally decline and return to pre-crisis baseline levels eventually, reflecting successful adaptation rather than psychological deterioration. This interpretation is supported by the concurrent decline in post-traumatic stress symptoms observed at T4, suggesting resolution of acute stress responses. Second, the resilience decline may reflect the cumulative burden of prolonged stress and emerging challenges during later treatment phases. Continuous or long-term exposure to stress may result in a decline in resilience, consistent with the stress-resilience theory (\\u003cspan additionalcitationids=\\\"CR32\\\" citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e). Treatment completion, while symbolizing medical success, paradoxically removes the structured medical environment that provided clear objectives and frequent professional medical and institutional support. Our previous studies indicate that families continue to worry about recurrence, late effects, and the long-term psychosocial impact (\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e). Grandparents may also face new challenges in the post-treatment phase, such as navigating complex family readjustment processes related to the recovering child\\u0026rsquo;s behavioral and developmental changes, difficulties in sibling adjustment, and intergenerational financial strain accumulated during treatment - all of which may contribute to decreasing resilience.\\u003c/p\\u003e\\u003cp\\u003eThe low stable resilience trajectory represents a particularly vulnerable subpopulation. Grandparents exhibiting this resilience trajectory had elevated levels of post-traumatic stress throughout the study period, potentially indicating inadequate stress processing and difficulty adapting to the cancer experience (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). This pattern aligns with the view that resilience resembles a personality trait and represents a relatively stable construct (\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e). Grandparents in this trajectory may have fewer coping strategies or pre-existing psychological vulnerabilities (\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e). Previous studies also found low resilience to be associated with poorer mental health outcomes, including depression, anxiety, adjustment disorders, and post-traumatic stress disorder (\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e). Interventions improving resilience may help preventing physical and mental health disorders (\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eWe found several factors and resources to be associated with resilience. Grandparents who had received more information about both psychosocial and medical topics showed higher resilience. This is in line with previous studies that demonstrated the importance of information delivery to grandparents of children with cancer (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e). The mechanism underlying this association may involve enhanced cognitive control and reduced uncertainty through improved understanding of disease processes, treatment protocols, and expected outcomes. Access to comprehensible, relevant information enables grandparents to construct coherent mental models of the experience, facilitating predictive coping and proactive problem-solving strategies (\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e). This cognitive clarity enhances self-efficacy beliefs, promoting confidence in their ability to navigate complex medical environments and providing meaningful family support (\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e). Furthermore, knowledge acquisition regarding available psychosocial resources, communication strategies, and other families' experiences contributes to an expanded coping repertoire and reduced feelings of isolation (\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e). The information-resilience association may be bidirectional, as higher resilience may also motivate active information-seeking behavior, creating positive feedback loops that sustain adaptive functioning throughout the treatment trajectory.\\u003c/p\\u003e\\u003cp\\u003eWe also found that grandparents reporting income that \\u0026ldquo;meets needs\\u0026rdquo; showed higher resilience than those reporting income that \\u0026ldquo;exceeds needs.\\u0026rdquo; This finding is counterintuitive, as most research suggests that greater financial resources support resilience (\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e). Our measure was based on self-reported income satisfaction (\\u0026ldquo;how well do you get along with your household income\\u0026rdquo;). Higher resilience among those who reported \\u0026ldquo;meets needs\\u0026rdquo; may reflect positivity and self-efficacy, which are part of the resilience construct (\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e). However, it should be noted that those who report \\u0026ldquo;meets needs\\u0026rdquo; should be interpreted with caution due to limited statistical power.\\u003c/p\\u003e\\u003cp\\u003eThe literature remains inconclusive regarding other determinants of resilience in older adults (\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e). In our study, we observed no associations between social support, partnership quality, and resilience. Given the limited sample size, this null finding may reflect insufficient statistical power, precluding definitive interpretation. However, if true, it could indicate that resilience in grandparents is less influenced by external resources than previously assumed. Older adults typically exhibit higher baseline resilience due to accumulated life experience, repeated adversity, and long-term shaped coping strategies (\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e). Resilience in later life is largely shaped by stable traits and coping patterns, consistent with the developmental timing hypothesis (\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e). Generational differences in help-seeking and social networks may further reduce the impact of current external resources, suggesting other unmeasured factors are more relevant in resilience building for this population.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec18\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStrengths and Limitations\\u003c/h2\\u003e\\u003cp\\u003eTo our knowledge, this study represents the first longitudinal examination of resilience among grandparents of children with cancer. The trajectory analysis approach, a perspective not previously explored in the literature, provides crucial insights into resilience evolution during their grandchild\\u0026rsquo;s cancer journey. Identifying trajectories helped identifying groups vulnerable for higher levels of post-traumatic stress symptoms. The multicenter design enhances representativeness and generalizability within the national context, while the sample size remains substantial given the rare events and recruitment challenges inherent in this population.\\u003c/p\\u003e\\u003cp\\u003eSeveral methodological limitations need to be highlighted to provide context in our findings. Selection bias represents a significant concern, as enrollment occurred through parental recruitment, potentially creating systematic exclusion of grandparents with strained family relationships, geographic barriers, or limited involvement in the child's care. This recruitment strategy may have favored grandparents with stronger emotional investment, better family communication patterns, and greater social support networks, resulting in systematically higher resilience than would be observed in the broader grandparent population. The self-selection nature of participation further reinforces this bias, as grandparents willing to engage in our cohort study may possess inherently different psychological characteristics, including higher baseline resilience, better health status, or greater comfort with emotional disclosure. Thus, resilience estimates for our study may be higher than their true value. Measurement bias is an additional concern. CD-RISC 10 lacks established validation in the elderly Swiss population, raising questions about construct validity, cultural appropriateness, and normative interpretation of scores in the aging population (\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). Age-related cognitive changes, differential item interpretation, and cohort-specific understanding of resilience concepts (\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e) may influence response patterns in ways not captured by existing psychometric evaluations. Finally, limited statistical power precluded some analytical approaches. We were unable to conduct complex multivariable regression analyses that could account for interactions among sociodemographic and contextual factors and resources. Trajectory analysis with only two identified groups may oversimplify the heterogeneity of resilience patterns, potentially masking additional meaningful subgroups or transition points.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eImplications and future research\\u003c/h2\\u003e\\u003cp\\u003eOur findings reveal the impact of a diagnosis of childhood cancer on grandparents\\u0026rsquo; resilience. This underscores the importance of holistic care that includes not only the immediate family, but also grandparents and extended family members who might provide support. To help reduce grandparents\\u0026rsquo; anxiety and stress related to the cancer experience, a tailored information dissemination program is needed addressing grandparent-specific preferences and needs. Healthcare teams should encourage parents to be open to the inclusion of grandparents in family discussions, to ensure a comprehensive and family-centered care.\\u003c/p\\u003e\\u003cp\\u003eFuture research should adopt family-centered approaches examining psychosocial outcomes across parents, siblings, and grandparents as integrated units. Additionally, investigation of intrafamilial dynamics and family resilience processes, currently focused on nuclear families, should expand to include grandparent contributions. Larger cohort studies are needed to explore complex associations and interactions and to identify additional factors influencing resilience in this understudied population.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"CONCLUSION\",\"content\":\"\\u003cp\\u003eWe identified two distinct resilience trajectories among grandparents following their grandchild\\u0026rsquo;s cancer diagnosis: one characterized by initially high resilience that gradually declined, and another marked by persistently low resilience. The latter group experienced significantly elevated post-traumatic stress symptoms, underscoring the need for healthcare providers to identify and support this vulnerable population. Tailored, cancer-specific information delivery tailored to grandparents\\u0026rsquo; needs may enhance resilience and help prevent adverse psychological outcomes.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eEthics approval and consent to participate\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was approved by the Ethic Committee of Northwest and Central Switzerland (EKNZ 2020-01409; 26 August 2020). The research was conducted in accordance with the principles of the Declaration of Helsinki. The study is compliant with the Swiss Human Research Act (810.30 Federal Act of 30 September 2011 on Research involving Human Beings) and Federal Regulations on Data Protection (235.1 Federal Act on Data Protection of 25 September 2020). Informed consent was obtained from all study participants before any data collection\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for publication\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAvailability of data and materials\\u003c/p\\u003e\\n\\u003cp\\u003eData used in the study is available to interested parties upon reasonable request from the corresponding author.\\u003c/p\\u003e\\n\\u003cp\\u003eCompeting interest\\u003c/p\\u003e\\n\\u003cp\\u003eAuthors declare no conflicts of interest.\\u003c/p\\u003e\\n\\u003cp\\u003eFunding\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was funded by the Swiss National Science Foundation (Grant No. 10001C_182129/1).\\u003c/p\\u003e\\n\\u003cp\\u003eAuthor contributions\\u003c/p\\u003e\\n\\u003cp\\u003ePFR conceptualized the study. AI \\u0026amp; CP collected the data. PFR cleaned the dataset, performed the analysis, and plotted the graphs. PFR, AM, KR \\u0026amp; GM wrote the first draft. AI, CP, AF, FS, UT, TD \\u0026amp; KS provided expert feedback on the drafts. KS \\u0026amp; GM secured funding. KS \\u0026amp; GM supervised the study. All authors approved the submission of the manuscript.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAcknowledgments\\u003c/p\\u003e\\n\\u003cp\\u003eWe would like to thank the following people for the support offered in recruiting participants for the GROkids project:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eBasel: Prof. Dr. med. Nicolas von der Weid; Dr. med. Bettina Blank\\u003c/p\\u003e\\n\\u003cp\\u003eBellinzona: Dr. med. Pierluigi Brazzola; Pamela Balestra\\u003c/p\\u003e\\n\\u003cp\\u003eBern: Prof. \\u0026nbsp;Dr. med. Jochen Rössler; Dr. med. Eva Maria Tinner Oehler; Rebecca B\\u0026auml;chtold\\u003c/p\\u003e\\n\\u003cp\\u003eGeneva: Prof. Marc Ansari; Maryline Bovero; Rodolfo Lo Piccolo\\u003c/p\\u003e\\n\\u003cp\\u003eLausanne: Prof. Dr. med. Maja Beck Popovic; Dr. Manuel Diezi; El\\u0026eacute;na Lemmel\\u003c/p\\u003e\\n\\u003cp\\u003eLucerne: Katja Bannenberg; Barbara Gantner; Dr. Daniela Dyntar; Nadja Muelebach; Lea Imbach; Dr. Pauline Holmer\\u003c/p\\u003e\\n\\u003cp\\u003eSt. Gallen: Dr. med. Jeanette Greiner\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eAPA Dictionary of Psychology. VandenBos GR, editor. Washington, DC, US: American Psychological Association; 2007. xvi, 1024-xvi, p.\\u003c/li\\u003e\\n\\u003cli\\u003eConnor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18(2):76-82, doi:10.1002/da.10113.\\u003c/li\\u003e\\n\\u003cli\\u003eBonanno GA, Westphal M, Mancini AD. Resilience to loss and potential trauma. Annu Rev Clin Psychol. 2011;7:511-35, doi:10.1146/annurev-clinpsy-032210-104526.\\u003c/li\\u003e\\n\\u003cli\\u003eMacLeod S, Musich S, Hawkins K, Alsgaard K, Wicker ER. The impact of resilience among older adults. Geriatr Nurs. 2016;37(4):266-72, doi:10.1016/j.gerinurse.2016.02.014.\\u003c/li\\u003e\\n\\u003cli\\u003eFino E, Mema D, Russo PM. War trauma exposed refugees and posttraumatic stress disorder: The moderating role of trait resilience. J Psychosom Res. 2020;129:109905, doi:10.1016/j.jpsychores.2019.109905.\\u003c/li\\u003e\\n\\u003cli\\u003eYing L, Wu X, Lin C, Jiang L. Traumatic severity and trait resilience as predictors of posttraumatic stress disorder and depressive symptoms among adolescent survivors of the Wenchuan earthquake. PLoS One. 2014;9(2):e89401, doi:10.1371/journal.pone.0089401.\\u003c/li\\u003e\\n\\u003cli\\u003ePavlacic JM, Buchanan EM, McCaslin SE, Schulenberg SE, Young JN. A systematic review of posttraumatic stress and resilience trajectories: Identifying predictors for future treatment of veterans and service members. Professional Psychology: Research and Practice. 2022;53(3):266-75, doi:10.1037/pro0000451.\\u003c/li\\u003e\\n\\u003cli\\u003eAgaibi CE, Wilson JP. Trauma, PTSD, and resilience: a review of the literature. Trauma Violence Abuse. 2005;6(3):195-216, doi:10.1177/1524838005277438.\\u003c/li\\u003e\\n\\u003cli\\u003eVogt AJ, Bartels L, Grotzer M, Bodenmann G, Leibundgut K, R\\u0026ouml;ssler J, et al. Posttraumatic stress symptoms in parents of children with newly diagnosed cancer: 1-year trajectories and relationship variables as predictors. Journal of Pediatric Psychology. 2024;49(11):818-26, doi:10.1093/jpepsy/jsae077.\\u003c/li\\u003e\\n\\u003cli\\u003eGantner B, Priboi C, Schilling FH, Michel G, Roser K. Systematic review: Care provided by grandparents of children with a chronic disease or a disability. EJC Paediatric Oncology. 2023;2, doi:10.1016/j.ejcped.2023.100126.\\u003c/li\\u003e\\n\\u003cli\\u003eWilson JL. An Integrative Review of Grandparents\\u0026apos; Experiences in Childhood Cancer. J Pediatr Hematol Oncol Nurs. 2024;41(1):67-77, doi:10.1177/27527530231194569.\\u003c/li\\u003e\\n\\u003cli\\u003ePriboi C, Gantner B, Holmer P, Neves da Silva L, Tinner EM, Roser K, et al. Psychological outcomes and support in grandparents whose grandchildren suffer from a severe physical illness: A systematic review. Heliyon. 2022;8(5):e09365, doi:10.1016/j.heliyon.2022.e09365.\\u003c/li\\u003e\\n\\u003cli\\u003eRorbech JT, Tofting-Olesen K, Enskar K, Haslund-Thomsen H, Jensen CS, Dreyer P. Siblings\\u0026apos; lived experiences of transitions between hospital and home in paediatric oncology: A qualitative study. Eur J Oncol Nurs. 2025;76:102853, doi:10.1016/j.ejon.2025.102853.\\u003c/li\\u003e\\n\\u003cli\\u003eMcLoone JK, Wakefield CE, Glasson N, Wiener L, Ortiz R, Ilbawi A, et al. The Lived Experience of Childhood Cancer Survivors and Their Parents: A Multi-National Study of Access to Survivorship Care and Information and Support Needs. Pediatr Blood Cancer. 2025;72(5):e31593, doi:10.1002/pbc.31593.\\u003c/li\\u003e\\n\\u003cli\\u003eErker C, Yan K, Zhang L, Bingen K, Flynn KE, Panepinto J. Impact of pediatric cancer on family relationships. Cancer Med. 2018;7(5):1680-8, doi:10.1002/cam4.1393.\\u003c/li\\u003e\\n\\u003cli\\u003eBonanno GA, Galea S, Bucciarelli A, Vlahov D. What predicts psychological resilience after disaster? The role of demographics, resources, and life stress. Journal of consulting and clinical psychology. 2007;75(5):671.\\u003c/li\\u003e\\n\\u003cli\\u003eHobfoll SE. Social and psychological resources and adaptation. Review of general psychology. 2002;6(4):307-24.\\u003c/li\\u003e\\n\\u003cli\\u003eMichel G, Raguindin PF, Priboi C, Ilic A, Holmer P, Scheinemann K, et al. Acute and long-term psychosocial consequences in grandparents when a grandchild is diagnosed with cancer - the GROKids Project: a population-based mixed-methods study protocol. BMC Psychol. 2023;11(1):280, doi:10.1186/s40359-023-01309-w.\\u003c/li\\u003e\\n\\u003cli\\u003evon Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-9, doi:10.1016/j.jclinepi.2007.11.008.\\u003c/li\\u003e\\n\\u003cli\\u003eDavidson JR. Connor-Davidson Resilience Scale (CDRISC) Manual. Unpublished 2018 [Available from: www.cdrisc.com.\\u003c/li\\u003e\\n\\u003cli\\u003eCampbell-Sills L, Stein MB. Psychometric analysis and refinement of the connor\\u0026ndash;davidson resilience scale (CD-RISC): Validation of a 10-item measure of resilience. Journal of Traumatic Stress. 2007;20(6):1019-28, doi:https://doi.org/10.1002/jts.20271.\\u003c/li\\u003e\\n\\u003cli\\u003eWeiss DS. The impact of event scale: revised. Cross-cultural assessment of psychological trauma and PTSD: Springer; 2007. p. 219-38.\\u003c/li\\u003e\\n\\u003cli\\u003eWakefield CE, Drew D, Ellis SJ, Doolan EL, McLoone JK, Cohn RJ. \\u0026apos;What they\\u0026apos;re not telling you\\u0026apos;: a new scale to measure grandparents\\u0026apos; information needs when their grandchild has cancer. Patient Educ Couns. 2014;94(3):351-5, doi:10.1016/j.pec.2013.10.030.\\u003c/li\\u003e\\n\\u003cli\\u003eMaruish M. User\\u0026rsquo;s Manual for the SF-36v2 Health Survey. Quality Metric Incorporated. 2011;198.\\u003c/li\\u003e\\n\\u003cli\\u003eS\\u0026oslash;rensen K, Van den Broucke S, Pelikan JM, Fullam J, Doyle G, Slonska Z, et al. Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q). BMC Public Health. 2013;13(1):948, doi:10.1186/1471-2458-13-948.\\u003c/li\\u003e\\n\\u003cli\\u003eAsendorpf J, Banse R, Wilpers S, Neyer F. Beziehungsspezifische Bindungsskalen fur Erwachsene (Relationship-specific attachment scales for adults). Diagnostica. 1997;43:289-313.\\u003c/li\\u003e\\n\\u003cli\\u003eZimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. Journal of personality assessment. 1988;52(1):30-41.\\u003c/li\\u003e\\n\\u003cli\\u003eJones BL, Nagin DS. A Stata Plugin for Estimating Group-Based Trajectory Models. . Pittsburgh, PA: Carnegie Mellon University 2012, https://ssrc.indiana.edu/doc/wimdocs/2013-03-29_nagin_trajectory_stata-plugin-info.pdf\\u003c/li\\u003e\\n\\u003cli\\u003eChen E, Miller GE. \\u0026ldquo;Shift-and-persist\\u0026rdquo; strategies: Why low socioeconomic status isn\\u0026rsquo;t always bad for health. Perspectives on psychological science. 2012;7(2):135-58.\\u003c/li\\u003e\\n\\u003cli\\u003eChen E, Jiang T, Chen MA, Miller GE. Reflections on resilience. Development and Psychopathology. 2024;36(5):2551-8, doi:10.1017/s0954579424000403.\\u003c/li\\u003e\\n\\u003cli\\u003eSouthwick SM, Charney DS. The science of resilience: implications for the prevention and treatment of depression. Science. 2012;338(6103):79-82, doi:10.1126/science.1222942.\\u003c/li\\u003e\\n\\u003cli\\u003eRusso SJ, Murrough JW, Han M-H, Charney DS, Nestler EJ. Neurobiology of resilience. Nature Neuroscience. 2012;15(11):1475-84, doi:10.1038/nn.3234.\\u003c/li\\u003e\\n\\u003cli\\u003eLazarus RS, Folkman S. Stress, appraisal, and coping: Springer publishing company; 1984.\\u003c/li\\u003e\\n\\u003cli\\u003eMader L, Roser K, Baenziger J, Tinner EM, Scheinemann K, Kuehni CE, et al. Household income and risk-of-poverty of parents of long-term childhood cancer survivors. Pediatr Blood Cancer. 2017;64(8), doi:10.1002/pbc.26456.\\u003c/li\\u003e\\n\\u003cli\\u003eChristen S, Mader L, Baenziger J, Roser K, Schindera C, Tinner EM, et al. \\u0026quot;I wish someone had once asked me how I\\u0026apos;m doing\\u0026quot;: Disadvantages and support needs faced by parents of long-term childhood cancer survivors. Pediatr Blood Cancer. 2019;66(8):e27767, doi:10.1002/pbc.27767.\\u003c/li\\u003e\\n\\u003cli\\u003eAngevaare MJ, Roberts J, van Hout HPJ, Joling KJ, Smalbrugge M, Schoonmade LJ, et al. Resilience in older persons: A systematic review of the conceptual literature. Ageing Res Rev. 2020;63:101144, doi:10.1016/j.arr.2020.101144.\\u003c/li\\u003e\\n\\u003cli\\u003eGorska S, Singh Roy A, Whitehall L, Irvine Fitzpatrick L, Duffy N, Forsyth K. A Systematic Review and Correlational Meta-Analysis of Factors Associated With Resilience of Normally Aging, Community-Living Older Adults. Gerontologist. 2022;62(9):e520-e33, doi:10.1093/geront/gnab110.\\u003c/li\\u003e\\n\\u003cli\\u003eChmitorz A, Kunzler A, Helmreich I, Tuscher O, Kalisch R, Kubiak T, et al. Intervention studies to foster resilience - A systematic review and proposal for a resilience framework in future intervention studies. Clin Psychol Rev. 2018;59:78-100, doi:10.1016/j.cpr.2017.11.002.\\u003c/li\\u003e\\n\\u003cli\\u003eSilveira JM, Winstead-Fry P. The needs of patients with cancer and their caregivers in rural areas. Oncol Nurs Forum. 1997;24(1):71-6.\\u003c/li\\u003e\\n\\u003cli\\u003eTrică A, Golu F, Sava NI, Licu M, Zanfirescu ȘA, Adam R, et al. Resilience and successful aging: A systematic review and meta-analysis. Acta Psychologica. 2024;248, doi:10.1016/j.actpsy.2024.104357.\\u003c/li\\u003e\\n\\u003cli\\u003eSterina E, Hermida AP, Gerberi DJ, Lapid MI. Emotional Resilience of Older Adults during COVID-19: A Systematic Review of Studies of Stress and Well-Being. Clin Gerontol. 2022;45(1):4-19, doi:10.1080/07317115.2021.1928355.\\u003c/li\\u003e\\n\\u003cli\\u003eHolmer P, Muehlebach N, Ilic A, Priboi C, Roser K, Raguindin PF, et al. Exploring grandparents\\u0026apos; psychosocial responses to childhood cancer: A qualitative study. Psycho-Oncology. 2024;33(2), doi:10.1002/pon.6304.\\u003c/li\\u003e\\n\\u003cli\\u003eSchafer SK, Supke M, Kausmann C, Schaubruch LM, Lieb K, Cohrdes C. A systematic review of individual, social, and societal resilience factors in response to societal challenges and crises. Commun Psychol. 2024;2(1):92, doi:10.1038/s44271-024-00138-w.\\u003c/li\\u003e\\n\\u003cli\\u003eMinnett K, Stephenson Z. Exploring the Psychometric Properties of the Connor-Davidson Resilience Scale (CD-RISC). Adversity and Resilience Science. 2024, doi:10.1007/s42844-024-00159-8.\\u003c/li\\u003e\\n\\u003cli\\u003eTimalsina R, Songwathana P. Factors enhancing resilience among older adults experiencing disaster: A systematic review. Australasian Emergency Care. 2020;23(1):11-22, doi:10.1016/j.auec.2019.12.007.\\u003c/li\\u003e\\n\\u003cli\\u003eLi Y-T, Ow YSY. Development of resilience scale for older adults. Aging \\u0026amp; Mental Health. 2021;26(1):159-68, doi:10.1080/13607863.2020.1861212.\\u003c/li\\u003e\\n\\u003cli\\u003eMasten AS. Resilience Theory and Research on Children and Families: Past, Present, and Promise. Journal of Family Theory \\u0026amp; Review. 2018;10(1):12-31, doi:10.1111/jftr.12255.\\u003c/li\\u003e\\n\\u003cli\\u003eMasten AS. Resilience in Developmental Systems: Principles, Pathways, and Protective Processes in Research and Practice. In: Ungar M, editor. Multisystemic Resilience: Adaptation and Transformation in Contexts of Change: Oxford University Press; 2021. p. 0. doi:10.1093/oso/9780190095888.003.0007.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"discover-oncology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"dion\",\"sideBox\":\"Learn more about [Discover Oncology](https://www.springer.com/12672)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Discover Oncology\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Discover Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"resilience, post-traumatic stress, grandparents, family, cancer, childhood cancer\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7846728/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7846728/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cb\\u003eBackground\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eResilience is the dynamic ability to adapt to adversity using personal and social resources. Childhood cancer represents a major family stressor, and grandparents often provide emotional, practical, and financial support. Yet, their psychosocial outcomes and resilience remain poorly understood. We aimed to: (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) identify resilience trajectories, (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) examine their association with post-traumatic stress symptoms, and (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) determine factors influencing resilience.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eMethods\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eThis multicenter cohort study included grandparents of children recently diagnosed with cancer and treated at one of eight participating pediatric oncology centers in Switzerland. Eligible grandparents were recruited and completed questionnaires at 3-, 6-, 12-, and 24- months post-diagnosis. Resilience (CD-RISC-10), post-traumatic stress symptoms (IES-R), information needs, health literacy (EU-HLS-Q12), partnership quality, and social support (MSPSS) were measured. We used group-based trajectory modeling to identify resilience trajectories (Aim 1), linear mixed models to examine associations of resilience trajectories with post-traumatic stress symptoms (Aim 2), and linear mixed-effects models to identify the internal and external resources for resilience (Aim 3). (Clinical trial no: Not applicable)\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eResults\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eWe included data of 37 grandparents of 20 children with cancer. Mean age was 67.6 years; most were grandmothers (n\\u0026thinsp;=\\u0026thinsp;25, 61%), unemployed or retired (n\\u0026thinsp;=\\u0026thinsp;23, 59%), and partnered (n\\u0026thinsp;=\\u0026thinsp;35, 90%). Two resilience trajectories emerged within two years after diagnosis: low-stable (n\\u0026thinsp;=\\u0026thinsp;17, 43%) and high-declining (n\\u0026thinsp;=\\u0026thinsp;23, 57%). Grandparents in the low-stable group reported significantly higher post-traumatic stress symptoms (β: -19.8, 90% CI -29.2, -10.4, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). The following internal resources were positively associated with resilience: higher health literacy (β: 0.31, 90% CI 0.20, 0.42, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), more information received (β: 1.53, 90% CI 1.27, 1.79, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), and having income that meets needs (β: 7.56, 90% CI 1.86, 13.26, p\\u0026thinsp;=\\u0026thinsp;0.029). No external resources showed significant associations.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eConclusion\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eTimely, clear, and tailored information may help strengthen grandparents\\u0026rsquo; resilience and reduce stress.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Resilience and post-traumatic stress symptoms in grandparents following their grandchild’s cancer diagnosis from a multicenter cohort study in Switzerland (The GROkids Project)\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-11-21 17:49:57\",\"doi\":\"10.21203/rs.3.rs-7846728/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-12-22T05:52:36+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-12-19T19:19:42+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-12-17T19:13:39+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"249679559482395431626103694609713141339\",\"date\":\"2025-12-08T15:05:43+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"122133445105535512331585286987233169285\",\"date\":\"2025-12-07T02:25:24+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"214147338799321785212350346161871803194\",\"date\":\"2025-12-05T01:59:06+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-11-19T16:09:30+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"55757286529685734066892596687402371045\",\"date\":\"2025-11-19T06:36:26+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"317521976732664854767885511344508249364\",\"date\":\"2025-11-17T12:38:46+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"211146888028482419130054366527368596425\",\"date\":\"2025-11-17T07:38:04+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-11-11T11:10:23+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-11-06T16:00:33+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-11-05T05:36:03+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-10-29T07:08:27+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Discover Oncology\",\"date\":\"2025-10-29T06:40:29+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"discover-oncology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"dion\",\"sideBox\":\"Learn more about [Discover Oncology](https://www.springer.com/12672)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Discover Oncology\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Discover Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"86a426bd-8c0c-4b44-8e61-93dae59acb33\",\"owner\":[],\"postedDate\":\"November 21st, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-01-20T09:15:23+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-11-21 17:49:57\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7846728\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7846728\",\"identity\":\"rs-7846728\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}