Resilience among parents whose child died of cancer–Investigating its role on psychological distress and prolonged grief disorder: Results from a cross-sectional survey in Switzerland

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However, factors such as resilience—defined as the capacity to adapt to adversity—are less explored. Resilience may mitigate grief-related distress. This study aimed to: (a) describe and compare resilience levels between bereaved parents and parents of childhood cancer survivors (CCS parents), (b) identify sociodemographic and cancer-related determinants of resilience among bereaved parents, and (c) investigate resilience’s association with psychological distress and prolonged grief disorder. Methods This is a cross-sectional study done in Switzerland. Bereaved parents were recruited from three hospitals and through patient advocacy group. CCS parents were taken from a nationwide, population-based study (Swiss Childhood Cancer Survivor Study-Parents). Resilience, psychological distress, and prolonged grief disorder were assessed using the Connor-Davidson Resilience Scale (CD-RISC 10), Brief Symptom Inventory-18 (BSI-18), and Prolonged Grief 13 (PG-13), respectively. Regression analysis (linear and logistic) was used to identify factors associated with resilience, and the association of resilience with psychological distress and prolonged grief disorder (adjusted for age, sex, and time since death). Results We included 103 bereaved parents and 345 CCS parents in the analysis. Bereaved parents were younger compared to CCS parents (mean 53.7, SD 8.3 vs. 62.5, SD 6.7 years, p<0.001), with both groups predominantly female (66% and 58%). Bereaved parents reported higher resilience scores than CCS parents (crude mean: 29.8 vs. 27.9; p=0.005), with adjusted analyses confirming this finding. High risk of poverty was the only significant determinant of lower resilience (adjusted β = -7.37, 95% CI: -11.21, -3.54; p<0.001). Higher resilience was associated with lower likelihood to report psychological distress (adjusted OR = 0.83, 95% CI: 0.74, 0.93, p = 0.002) and prolonged grief disorder (adjusted OR = 0.73, 95% CI: 0.58, 0.92, p = 0.008). Conclusion Bereaved parents exhibited higher resilience than CCS parents. Resilience in bereaved parents was strongly associated with reduced psychological distress and lower likelihood of having prolonged grief disorder. Targeting modifiable factors such as poverty may enhance resilience and thereby help to improve mental health outcomes for bereaved parents. bereavement parents resilience childhood cancer Figures Figure 1 Figure 2 INTRODUCTION The death of a child from cancer is a devastating experience for parents ( 1 , 2 ). While grief is a normal reaction to a child’s death, around 10–20% of parents suffer from emotional turmoil resulting in adverse psychological outcomes, such as anxiety, depression, and post-traumatic distress ( 3 , 4 ). Other long-term effects include marital and family problems ( 5 ), socio-economic hardships ( 6 ), and an overall lower quality of life ( 7 ). However, few studies have investigated at the impact of the child’s death on parental resilience ( 1 , 2 , 8 ). The American Psychological Association defines resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress”( 9 ). It is an internal resource that could protect a person from developing psychological distress allowing them to cope successfully when faced with subsequent stresses in life ( 1 , 2 , 10 ). Previous studies have shown that parents may develop resilience after the death of their child ( 2 , 8 , 11 ). Social support and strong partner relationships were identified as factors associated with resilience among bereaved parents ( 2 , 11 , 12 ). Studies have further shown that bereaved parents who present high levels of resilience are less likely to suffer from depression and anxiety and have higher social functioning ( 11 , 13 ). There are various gaps in the existing literature on resilience and bereaved parents. First, the impact of child loss on parental resilience has rarely been explored quantitatively ( 1 , 2 , 8 ). Quantitative analysis is needed so that sociodemographic and cancer-related factors influencing resilience can be investigated more systematically, and comparison of relevant population can be done. Second, it is still unclear whether there are differences in parental resilience according to the survival outcome of their child with cancer (mortality versus survival). Most studies had no comparison group or had chosen parents of healthy children as comparison ( 2 , 12 ). Knowing the difference in resilience on special groups would help tailor support strategies. Third, few studies have investigated the association of parental resilience and psychosocial outcomes after their child’s death from cancer ( 11 , 14 ). Finally, most studies have focused on short-term bereavement (< 3 years after death) ( 11 , 15 ) and thus did not investigate the long-term effects of child’s death up to 10 years or more ( 2 , 8 ). We aimed to (a) describe the level of resilience of bereaved parents and compare it with that of parents of childhood cancer survivors, (b) identify sociodemographic and cancer-related factors potentially influencing resilience among bereaved parents and examine their association with time since the child’s death, and (c) investigate the association of resilience with psychological distress and prolonged grief disorder among bereaved parents. METHODS We conducted a cross-sectional survey among bereaved parents and parents of childhood cancer survivors (CCS parents). We have presented our study following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines ( 16 ) (See Appendix ). Sample and procedure For the bereaved parents, eligible participants included parents of children who (a) were diagnosed with cancer, as defined by the International Classification of Childhood Cancer, Third Edition (ICCC-3) ( 17 ), (b) were ≤ 18 years of age at time of diagnosis, (c) received treatment in Switzerland, and (d) died of cancer at least one year prior to study participation. To identify potential participants, the Swiss Childhood Cancer Registry (ChCR) ( 18 ) provided a list of eligible cases to the participating hospitals from German-speaking regions that were involved in the study. These hospitals confirmed the parents’ contact information through their records, excluded individuals deemed unsuitable for participation due to personal or medical reasons, such as vulnerability or distress, and sent eligible parents the study invitation. The invitation package included a study information and written consent, questionnaires (one per parent), and prepaid return envelopes. Parents were encouraged to complete the questionnaires individually, ensuring independent responses from both parents. They were given the option to complete either a paper or an online questionnaire (Qualtrics™, Provo, Utah, US). The survey was conducted from July 2022 to July 2023. The hospitals followed up with non-responders by making reminder phone calls starting earliest five weeks after the initial mailing. Additionally, cancer and bereavement support organizations helped disseminate information about the study. Responses from printed questionnaires were manually entered into the database by research assistants, with an accuracy check performed on 14.5% of the entries (N = 15). Double entry by two independent study staff showed high accuracy (kappa = 0.93). For CCS-parents, we used data from a previously conducted nationwide population-based study, the Swiss Childhood Cancer Survivor Study – Parents (SCCSS-Parents) ( 19 ). Parents in this study were eligible if their child: (a) was diagnosed with cancer according to ICCC-3 between 1976 and 2009, (b) aged ≤ 16 years, and (c) Swiss resident at diagnosis, (d) had survived at least five years post-diagnosis, and (e) was aged ≥ 20 years at the time of study participation. Eligible survivors were identified through the Childhood Cancer Registry (ChCR), and addresses were verified via an online telephone directory. Parents were invited to participate through their former treating hospital, which sent study information two weeks before mailing questionnaires. Non-responders received reminders after four to six weeks and again after an additional eight weeks. The SCCSS-Parents survey was conducted from January 2017 to February 2018. For this analysis, we used the data from CCS-parents from German-speaking regions and age-range matched with bereaved parents. Measures Resilience was assessed using the Connor-Davidson Resilience Scale (CD-RISC 10), a validated self-report tool measuring an individual’s “ability to adapt to adversity” ( 10 , 20 ). This scale consists of 10 items rated on a 5-point Likert scale (0 = not true at all to 4 = true nearly all the time), yielding a sum score ranging from 0 to 40. Scores were computed by summing the responses, with missing responses (< 5 items) imputed using the median of the remaining items. If ≥ 8 responses were missing, the score was considered invalid. We included three additional questions from long form of CD-RISC (25 items) ( 10 ). These questions were related to spirituality and religiosity. Psychological distress was measured using the Brief Symptom Inventory (BSI-18) ( 21 , 22 ), a psychometric tool validated in the Swiss population ( 23 ). This BSI-18 assesses depression, anxiety, somatization, and overall psychological distress (Global Severity Index, GSI) using 18 items scored on a 5-point Likert scale (0 = not at all to 4 = extremely). Total scores were converted into T-scores (mean = 50, SD = 10) based on norms established in the German population ( 22 ). Caseness indicating significant psychological distress was defined as a GSI T-score ≥ 63 or a T-score ≥ 63 on at least two of the three subscales (depression, anxiety, somatization). Missing subscale responses (1 item) were imputed using the subscale mean, while missing values exceeding this threshold rendered the subscale invalid for inclusion in the analysis ( 21 , 22 ). Prolonged grief disorder was assessed using Prolonged Grief 13 (PG-13) ( 24 ), which is following DSM-V-TR criteria using a diagnostic checklist that included five main components: (a) bereavement event, (b) separation distress, (c) duration of grief, (d) cognitive/emotional/behavioral symptoms, and (e) functional impairment ( 25 ). Bereaved parents automatically fulfilled the bereavement event criterion due to the study’s inclusion criteria. Separation distress was evaluated using two items on yearning and emotional pain, with responses rated on a 5-point Likert scale (1-not at all, to 5-several times a day). The duration of grief is defined by the occurrence of daily feelings of separation distress persisting for at least six months after the loss (yes/no). Cognitive, emotional, and behavioral symptoms were measured using nine items, using 5-point Likert scale (1-not at all, to 5- overwhelmingly). Impairment in social, occupational, or other areas of functioning was assessed using a binary yes/no response. A classification of prolonged grief disorder required meeting all criteria. We did not impute missing responses. Sociodemographic variables collected were sex (male, female), age ( 60 years old), education (compulsory education, vocational training, upper secondary/university), employment (unemployed which includes invalidity claim, housemaker or retired, versus employed which included full-time or part-time employment), risk of poverty (for those living as parent-couples CHF < 6000, for single-parents CHF < 4500; this cut-off was chosen based on the published risk-of-poverty of the Swiss Federal Statistical Office ( 26 ) which was also used in a previous publication ( 27 )), living arrangement (asked if living alone, versus ≥ 2 persons in the household), adhering a religion (yes, no), partnership status (yes [in a partnership], no), and migration background (defined as not being a Swiss citizen, not a Swiss citizen since birth, or a Swiss citizen not born in Switzerland). Child- and cancer-related information, i.e. the child’s sex (male, female), age at diagnosis (< 5 years, 5–9 years, ≥ 10 years), cancer type (leukemia/lymphoma, central nervous system tumor, and other solid tumors), and time since diagnosis (< 20 years, ≥ 20 years). For bereaved parents, bereavement-specific variables, including the child’s age at death (< 5 years, 5–9 years, ≥ 10 years), location of death (home versus hospital or health facility), and time since death (< 10 years, ≥ 10 years), were also reported by the parents in the questionnaire. Data Analysis We described the sociodemographic and cancer-related characteristics of both bereaved parents and CCS parents using means and SD or proportions. Bereavement or death related characteristics were only described for bereaved parents. We followed the analysis framework in Appendix Figure S1 . To compare resilience levels (resilience sum score and individual items) among bereaved and CCS parents ( Aim 1 ), we used student’s t- test for continuous variables and chi-square tests for categorical responses. Marginal means were also computed using linear regression, adjusting for sociodemographic variables that were statistically different between two groups (decided a posteriori from bivariate comparison analysis with p value < 0.05). To identify determinants of resilience ( Aim 2 ), we used univariable linear regression using resilience as dependent variable/outcome and the sociodemographic, child- and cancer-related characteristics as independent variables/predictors. Variables with p < 0.10 were included in multivariable linear regression models to identify independent predictors. We also explored non-linear associations between time since death and resilience sum score using restricted cubic spline regression for bereaved parents. We plotted a spline modeling using resilience sum score as dependent variable (outcome) and time since death as independent variable (predictor). Penalization and smoothing parameters were applied, and graphical plots were generated to visualize these relationships. Missing data were handled using full information maximum likelihood, assuming data were missing at random. Additional questions on religiosity and spirituality were also described. Finally, to determine the association between resilience ( Aim 3 ), and psychological distress and prolonged grief disorder, regressions were also fitted using linear regression for continuous outcomes (GSI-18, anxiety, depression, and somatization) and logistic regression for binary outcomes (Caseness with psychological distress, prolonged grief disorder). Separate models were fitted for each subscale of psychological distress, with crude and adjusted estimates reported. Age, sex, and time since death were included in adjusted models to minimize bias. All analyses were conducted using Stata 18.5 (StataCorp, TX). Statistical significance was set at p < 0.05 for two-tailed tests. All analyses are exploratory, and no adjustments for multiple testing were applied. Ethical considerations Ethical approval for the Bereaved Parents Survey was granted by the Ethics Committee of Northwest and Central Switzerland (EKNZ 2021 − 00906, 4 August 2021). Similarly, ethical approval for the SCCSS-Parents study was obtained from the same committee (EKNZ 2015-075, 26 March 2015). RESULTS The study population included 103 bereaved parents (of 81 childhood cancer deaths) and 345 parents (of 217 cancer survivors) (Table 1 , Fig. 1 ) . Participating bereaved parents were younger on average (mean age 53.7 years, SD 8.3) compared to CCS parents (mean age 62.5 years, SD 6.7, p < 0.001). Both groups were predominantly female, with similar levels of vocational and higher education. Employment rates were comparable (25.5% vs. 26.0%), but a lower proportion of bereaved parents were at risk for poverty compared to CCS parents (11.8% vs. 31.3%, p < 0.001). Religion and migration background differed significantly, with fewer bereaved parents having a religion (69.6% vs. 82.3%, p = 0.005) and more bereaved parents with migration background (20.0% vs. 8.2%, p = 0.003) (Table 1 ). Table 1 Characteristics of study participants Bereaved Parents N = 103 Parents of childhood cancer survivors (CCS parents) N = 345 p-value 1 Sociodemographic characteristics Sex • Male 35 (34.0%) 145 (42.0%) 0.144 • Female 68 (66.0%) 200 (58.0%) Age in years (mean, SD) 2 53.7 (8.3) 62.5 (6.7) < 0.001 Age categories • < 50 years 30 (29.7%) 4 (1.2%) 60 years 26 (25.7%) 211 (61.5%) Education • Compulsory education 5 (4.9%) 32 (10.0%) 0.188 • Vocational training 66 (64.7%) 181 (56.7%) • Upper secondary or university education 31 (30.4%) 106 (33.2%) Employment status 3 • Employed 76 (74.5%) 248 (74.0%) 0.923 • Unemployed 26 (25.5%) 87 (26.0%) Risk of poverty 4 • Low risk 90 (88.2%) 224 (68.7%) < 0.001 • High risk 12 (11.8%) 102 (31.3%) Living arrangement • Alone 5 (4.9%) 25 (7.7%) 0.339 • Shared 97 (95.1%) 301 (92.3%) Having a religion 5 • With religion 71 (69.6%) 284 (82.3%) 0.005 • Without religion 31 (30.4%) 61 (17.7%) Partnership status • No 8 (7.8%) 30 (9.0%) 0.709 • Yes 94 (92.2%) 302 (91.0%) Migration background 6 • No 60 (80.0%) 301 (91.8%) 0.003 • Yes 15 (20.0%) 27 (8.2%) Clinical and cancer-related characteristics N = 81 cancer deaths N = 217 cancer survivors Child’s sex • Male 46 (56.8%) 116 (53.5%) 0.607 • Female 35 (43.2%) 101 (46.5%) Child age at diagnosis • < 5 years 31 (38.3%) 85 (39.2%) 0.986 • 5–9 years 22 (27.2%) 59 (27.2%) • ≥ 10 years 28 (34.6%) 73 (33.6%) Cancer diagnosis • Leukemia/lymphoma 22 (27.2%) 118 (54.4%) < 0.001 • CNS tumor 36 (44.4%) 24 (11.1%) • Other solid tumors 23 (28.4%) 75 (34.6%) Time since diagnosis, years (mean, SD) 2 20.4 (7.6) 23.4 (7.3) 0.001 Time since diagnosis • /= 20 years 43 (53.1%) 154 (71.0%) Bereavement or death-related characteristics Age at death • < 5 years 23 (22.6%) • 5–9 years 28 (27.5%) • ≥ 10 years 51 (50.0%) Location of death • Home 45 (55.6%) • Healthcare facility 36 (44.4%) Time since death, years (mean, SD) 11.0 (5.5) Time since death • < 10 years 35 (43.8%) • ≥ 10 years 45 (56.2%) Abbreviations: CCS, childhood cancer survivor; CNS, central nervous system; SD, standard deviation 1 p-values were derived from chi-squared test for comparison of proportion, unless specified otherwise. 2 p-values for continuous variables were obtained from students t-test 3 Employment status: Employed included those with full-time or part-time employment. Unemployed included those who are on unemployed, on invalidity claims, in training/education, or retired. 4 Risk of poverty: For those parent-couples CHF < 6000, for those single-parents CHF < 4500. This were chosen based from the published risk-of-poverty of the Swiss Federal Office of Statistics which are 3,933 CHF for single parents with two children aged < 14 years and 5,163 CHF for parent couples and was also used in a previous publication 5 Having a religion: Participants who indicated a religious denomination were classified as “with religion”. Those identify as no religion, or no answer were classified as “without religion”. 6 Migration background: We classified individuals with migration backgrounds as those who are not Swiss citizens, were not born in Switzerland, or were not Swiss at birth. A diagnosis of CNS tumors (44.4%) was higher in bereaved parents compared to CCS parents, where diagnoses of leukemia/lymphoma dominated (54.4%, p < 0.001) (Table 1 ). The average time since diagnosis to survey date was shorter for bereaved parents (20.4 years, SD 7.6) than for CCS parents (23.4 years, SD 7.3, p < 0.001). For bereaved parents, the average time since their child’s death was 11.0 years (SD 5.5). More deaths occurred at home (55.6%) than in healthcare settings. Additionally, 50% of children died after the age of 10 years. Comparison of resilience (Aim 1) The resilience sum score was significantly higher among bereaved parents compared to CCS parents (mean 29.8, SD 6.6 vs. mean 27.9, SD 5.5, p = 0.005) (Fig. 2 ). Item comparison can be found in Appendix Table S1 . Adjusted resilience sum scores (adjusted for different ages, risk of poverty, having a religion, and migration background distribution), consistently revealed higher resilience in bereaved parents compared to CCS parents (Fig. 2 ). Comparisons of additional resilience items on religiosity and spirituality are described in Appendix Table S2 . Bereaved parents exhibit a bimodal distribution in their responses to the religiosity question. They have a higher proportion of individuals who do not believe in God (42.7% vs. 29.9%) and a higher proportion of believers (20.4% vs. 13.9%) compared to CCS parents. Bereaved parents reported lower levels of a strong sense of purpose in life compared to CCS parents (p < 0.001), while they were more likely to report having at least one close and secure relationship (p = 0.017). There is no difference between belief in fate or God which helps them in their life (p = 0.374) Determinants of resilience in bereaved parents (Aim 2) Among sociodemographic variables, only risk of poverty was significantly associated with resilience (Table 2 ). Parents at high risk of poverty had a lower resilience sum score compared to those at low risk for poverty (Univariable regression coefficient: -7.86, 95% CI: -11.59 to -4.13, p < 0.001 multivariable model coefficient: -7.37, 95% CI: -11.21 to -3.54, p < 0.001) (Table 2 ). None of the cancer-related characteristics showed significant associations with resilience (Table 2 ). Table 2 Determinants of resilience for bereaved parents Univariable regression 1 Multivariable regression 2 Mean score 3 Coefficient 95% confidence interval P value Coefficient 95% confidence interval P value Sociodemographic characteristics of bereaved parents Sex (male) 30.8 • Female 29.2 -1.55 (-4.28, 1.18) 0.263 Age ( 60 years 30.6 2.21 (-1.30, 5.72) 0.215 Risk of poverty (low risk) 30.6 • High-risk 22.7 -7.86** (-11.59,-4.13) < 0.001 -7.37 (-11.21, -3.54) < 0.001 Living arrangement 27.2 • Shared 29.8 2.61 (-3.40, 8.63) 0.391 Education category (Compulsory-vocational) 27.6 • Upper secondary 29.0 1.42 (-4.62, 7.45) 0.643 • University 31.4 3.85 (-2.42,10.12) 0.226 Employment (unemployed) 30.6 • Employed 29.3 -1.35 (-4.33, 1.63) 0.371 Partnership 25.5 • Yes 30.0 4.54 (-0.22, 9.31) 0.061 2.48 (-2.11, 7.08) 0.287 Migration background (None) 29.7 • With migration 31.0 1.35 (-2.40, 5.10) 0.475 Religion (no) 30.3 • Yes 28.3 -1.96 (-4.77, 0.85) 0.169 Time since death • Continuous - 0.01 (-0.22, 0.24) 0.909 Cancer-related characteristics Sex of the child (male) 29.7 • Female 29.9 0.22 (-2.40, 2.83) 0.871 Age at death • Continuous - 0.08 (-0.13, 0.30) 0.435 Diagnosis at death (CNS tumor) 28.9 • Non-CNS tumor 30.6 -1.69 (-4.89, 1.51) 0.298 • others 30.2 -0.47 (-3.97, 3.04) 0.792 Location of death (health facility) 29.2 • Home 30.3 1.10 (-1.54,3.75) 0.411 *Categories inside parenthesis “(category)” are the reference group. P values > 0.05 are in BOLD 1 Univariable linear regression using Resilience sum score as dependent/outcome variable and sociodemographic and cancer-related characteristics as independent/predictor variable. 2 Multivariable linear regression included independent/predictor variables from univariable regression with p values < 0.10. 3 Based on marginal means of univariable linear regression We plotted a spline to determine non-linear association between time since death and resilience sum score. Overall, we found no change in resilience sum score over time since death ( Appendix Figure S2 ) Association of psychological distress and prolonged grief disorder with resilience (Aim 3) Lower resilience scores were associated with higher psychological distress (Table 3 ). For the global severity index (GSI) as an outcome, each unit increase in resilience was associated with a reduction in GSI by 0.71 (adjusted β = -0.71, 95% CI: -0.96, -0.46, p < 0.001). Similarly, depression (adjusted β = -0.74, 95% CI: -0.99, -0.49, p < 0.001), anxiety (adjusted β = -0.63, 95% CI: -0.88, -0.38, p < 0.001), and somatization (adjusted β = -0.44, 95% CI: -0.69, -0.20, p < 0.001) were inversely associated with resilience scores. Table 3 Association of resilience (CD-RISC 10) with psychological distress (BSI18) and prolonged grief disorder (PG-13) in bereaved parents Crude Adjusted* Outcome Coefficient 95% CI P value Coefficient 95% CI P value Global severity index 1 -0.70 (-0.94,-0.45) < 0.001 -0.71 (-0.96,-0.46) < 0.001 Depression 1 -0.68 (-0.93,-0.43) < 0.001 -0.74 (-0.99,-0.49) < 0.001 Anxiety 1 -0.66 (-0.91,-0.42) < 0.001 -0.63 (-0.88,-0.38) < 0.001 Somatization 1 -0.45 (-0.68,-0.21) < 0.001 -0.44 (-0.69,-0.20) < 0.001 Outcome Odds ratio 95% CI P value Odds ratio 95% CI P value Psychological distress (case) 2 0.83 (0.75, 0.93) 0.001 0.83 (0.74, 0.93) 0.002 Prolonged grief disorder 0.76 (0.63, 0.91) 0.003 0.73 (0.58, 0.92) 0.008 *Adjusted for age, sex, and time since death 1 Using linear regression, psychological distress was fitted as the dependent variable with T scores of GSI, somatization, anxiety, and depression as continuous variables, and resilience sum score as dependent variable, also as continuous variable. 2 Using logistic regression, caseness (BSI-18) and prolonged grief disorder were modeled as the dependent variable in a dichotomous format, while the resilience sum score was treated as a continuous variable. Higher resilience was associated to a lower likelihood to be a case with psychological distress (adjusted OR = -0.83, 95% CI: 0.74, 0.93, p = 0.002) or prolonged grief disorder (adjusted OR = 0.73, 95% CI: 0.58, 0.92, p = 0.008) with every unit increase in resilience sum scores (Table 3 ). A summary of psychological distress (BSI-18) scores and prolonged grief disorder (PG-13) of bereaved parents can be found in Appendix Table S3 . DISCUSSION Our study revealed that bereaved parents report higher resilience than CCS parents. Risk of poverty is associated with lower resilience in bereaved parents, suggesting the impact of financial vulnerabilities on resilience. Accordingly, higher resilience is associated with lower psychological distress and lower risk of prolonged grief disorder. Thus, higher resilience could be a protective factor for adverse mental health outcomes. Bereaved parents experience intense emotions after the death of their child. The irreversibility of their loss may lead them to develop unique coping mechanisms and psychological resources to refocus their lives, and experience posttraumatic growth (“positive changes”) ( 28 ). These positive changes can include appreciation of life, strengthening established relationships, and looking for possibilities – opportunities that were previously not or rarely considered in life - or refocusing one’s life, all of which might be associated with their resilience ( 28 ). Resilience of CCS parents may develop differently; coping may focus on caring for their child who had cancer and include strategies such as planful and active problem-solving, self-control, and accepting responsibility ( 29 ). Families might face new challenges after treatment, including greater need for information on late effects and tumor recurrence, financial burden from ongoing healthcare, difficulties with school and social reintegration, and decreasing psychosocial ( 30 ). These challenges can result in lower sense of competence (or self-efficacy) and perception of control over life events, both of which are important components of resilience ( 31 , 32 ). Several resilience-building resources, such as strong partnership and social support, were identified in the literature as contributing to resilience ( 2 , 33 ). In our study, we identified the economic situation as a major factor influencing the resilience of bereaved parents. Research shows that financial stability plays a critical role in mitigating stressors and uncertainties, particularly during the grieving process as it promotes autonomy and perception of control ( 34 ). Access to a sufficient and stable income and savings enhances one’s ability to meet basic needs but also allows families to rebuild a sense of life normality and focus on healing ( 35 ). For example, it may allow parents to take time off work for grieving, seek therapy, or participate in support groups ( 34 , 35 ). It allows them to have a sense of control and autonomy that is crucial for maintaining psychological wellbeing ( 10 ). Resilience, as a construct, remained stable over time since the child’s death. Although our data were not longitudinal, this aligns with prior research suggesting that resilience is a relatively stable trait ( 36 ), though it can be modified following significant adversities ( 37 , 38 ). In comparison with CCS parents who had lower resilience, we hypothesize that the experience of losing a child may foster the development of resilience, which is subsequently maintained over time. Spirituality is an important component of resilience ( 10 , 39 ), yet the data on bereaved parents’ religiosity and spirituality is challenging to interpret. The bimodal distribution revealed that bereaved parents either believe or not in an omniscient being with clearer distinction, as compared to more mixed responses from the CCS parents. This can be interpreted that the experience of loss has a significant impact that made their beliefs clearer and delineated compared to the CCS parents. Moreover, bereaved parents reported a lower sense of purpose in life but expressed greater trust and a stronger sense of security in their relationships. This provides a more nuanced understanding of the high resilience of bereaved parents that comes from resistance (or handling negative emotions, trusting one’s instincts, and perceived benefits of stress) and positivity (having a positive attitude to change and secure relationships) that is different from CCS parents. In line with previous research, our study revealed a strong association of resilience and mental health outcomes. Resilience has been identified as a protective factor that prevents the person to develop adverse mental health outcomes ( 2 , 11 , 12 ). Bereaved parents with higher resilience tend to report better adjustment to grief and healthier psychological functioning ( 2 , 11 ). In contrast, bereaved parents with lower resilience are at increased risk of prolonged grief disorder, anxiety, and depression ( 11 ). Factors such as age and socioeconomic status may also influence the relationship between resilience and psychological outcomes in bereaved parents ( 40 ). Strengths and Limitations Our study provides insights into the resilience of bereaved parents, contributing to the limited quantitative studies on this topic. Our analysis quantifies the strength and magnitude of associations and provides empirical and data-driven understanding of resilience in this population. Our registry- and population-based control group (CCS parents) was a methodological improvement from previous studies resulting in higher reliability and accuracy. To reduce potential confounding, our results were adjusted for sociodemographic differences between groups (CCS parents and bereaved parents) and restricted the analysis to the German-speaking Swiss population. This approach minimized cultural and regional influences, strengthening the internal validity of the study. This study had several limitations that should be acknowledged in the interpretation of our findings. First, the cross-sectional nature of the analysis precluded the establishment of temporality. As such, we could not determine whether low resilience leads to prolonged grief disorder or vice versa, limiting causal interpretations. Second, our recruitment strategy does not allow us to conclude anything about recruitment rate, recruitment pattern, and selection bias. We have no information about the sociodemographic characteristics of those who were not approached by the survey. Participation could have been potentially skewed towards those with better mental health outcomes and, thus, may have resulted in an overestimation of resilience in this population. Fourth, a period bias may have affected the results due to the significant time lapse between data collection for CCS-parents and bereaved parents. The bereaved parents’ data were collected during or after the COVID-19 pandemic, while CCS-parents’ data were collected before the pandemic. This temporal discrepancy introduces a potential historical bias. Finally, while restricting the analysis to German-speaking participants reduced culture as a confounding variable, this restriction also resulted to limited generalizability to other regions in Switzerland. Implications of the study and outlook Our findings emphasize the importance of understanding unique adaptive mechanisms following bereavement, as they may serve as valuable psychological resources for coping with future stress and challenges. Resilience building strategies, including cognitive behavioral therapy, mindfulness and social support interventions ( 41 , 42 ), could benefit both bereaved parents and parents of survivors. Our results suggest that by enhancing resilience, there could be reduction of grief-related psychological disorders (for bereaved parents), reduction of overall distress, and thereby increase general wellbeing. Moreover, the significant impact of financial vulnerabilities on resilience underlines the importance of addressing socio-economic determinants in bereavement care ( 34 , 35 ). Providing direct and indirect financial support to bereaved parents may enhance resilience and mitigate psychological distress and prolonged grief disorder ( 34 , 35 ). Direct financial support could include assistance over housing and daily living expenses ( 43 ), while indirect financial support could include subsidized counselling services or providing job security both of which could significantly benefit the bereaved parents ( 35 ). Healthcare systems could also be improved through the establishment of comprehensive bereavement services including resilience-based screening, tailored support, and sustained connection with social workers. CONCLUSION Bereaved parents had higher overall resilience compared to CCS parents, and risk of poverty is associated with lower resilience. Additionally, higher resilience is associated with reduced psychological distress and a lower risk of prolonged grief disorder, suggesting its protective role against adverse mental health outcomes. Abbreviations BSI-18, Brief Symptom Index (18 items) CCS, childhood cancer survivor CD-RISC 10, Connor Davidson Resilience Scale (10 items) ChCR, Swiss Childhood Cancer Registry DSM-V-TR, Diagnostic and Statistical Manual of Mental Disorders, 5 th edition, Text revision EKNZ, Ethikkomission Nordwest- und Zentralschweiz (Ethics Commission of Northwest and Central Switzerland) GSI, global severity index ICCC-3, International Classification of Childhood Cancer, Third Edition OR, odds ratio PG-13, Prolonged Grief Questionnaire (13 items) PGD, prolonged grief disorder SCCSS-Parents, Swiss Childhood Cancer Survivor Study – Parents SD, standard deviation STROBE, Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines Declarations Ethics approval For the bereaved parents survey, ethical approval was granted through the Ethics Committee of Northwest and Central Switzerland (EKNZ 2021 − 00906; 04 August 2021). For SCCSS-Parents, ethical approval was granted through the Ethics Committee of Northwest and Central Switzerland (EKNZ 2015-075; 26 March 2015). Consent for publication Not applicable Funding Bereaved parent survey has received funding from the Swiss Cancer Research (Grant no. KFS-4995-02-2020) and Cancer League Central Switzerland. The Swiss Childhood Cancer Survivor Study – Parents (SCCSS-Parents) was funded by the Swiss National Science Foundation (Grant no. 100019_153268/1) and the Kinderkrebshilfe Schweiz. Additional funding was available from Swiss National Science Foundation (Grant No: 10001C_182129/1). The funding agencies had no role in the analysis and interpretation of the findings. Acknowledgements We thank the participating hospitals and the parents who participated in our survey. We also acknowledge and appreciate the help of our interns Katja Rueesch, Simone Walde-Foehn, Kathleen Ostheim, and Laura Haxhosaj. Author Contribution PFR & GM conceptualized the idea. EDC, AKV, ECP, CB provided inputs on the analysis plan. PFR cleaned the dataset, planned and executed the analysis, and plotted the graphs. PFR, EDC, AKV, ECP, CB & GM wrote the first draft. KS, EMT, EB, AOB provided expert advice and revised the draft. EMT, EB & GM secured the funding. All authors approved the final version of the manuscript. Acknowledgement We thank the participating hospitals and the parents who participated in our survey. We also acknowledge and appreciate the help of our interns Katja Rueesch, Simone Walde-Foehn, Kathleen Ostheim, and Laura Haxhosaj. Data Availability Data can be made available upon reasonable request from the corresponding author. References Jaaniste T, Coombs S, Donnelly TJ, Kelk N, Beston D. Risk and Resilience Factors Related to Parental Bereavement Following the Death of a Child with a Life-Limiting Condition. Child (Basel). 2017;4(11). Vegsund HK, Reinfjell T, Moksnes UK, Wallin AE, Hjemdal O, Eilertsen MB. Resilience as a predictive factor towards a healthy adjustment to grief after the loss of a child to cancer. PLoS ONE. 2019;14(3):e0214138. Kochen EM, Jenken F, Boelen PA, Deben LMA, Fahner JC, van den Hoogen A, et al. When a child dies: a systematic review of well-defined parent-focused bereavement interventions and their alignment with grief- and loss theories. BMC Palliat Care. 2020;19(1):28. October T, Dryden-Palmer K, Copnell B, Meert KL. Caring for Parents After the Death of a Child. Pediatr Crit Care Med. 2018;19(8S Suppl 2):S61–8. Oliver LE. Effects of a Child's Death on the Marital Relationship: A Review. OMEGA - J Death Dying. 1999;39(3):197–227. Rogers CH, Floyd FJ, Seltzer MM, Greenberg J, Hong J. Long-term effects of the death of a child on parents' adjustment in midlife. J Fam Psychol. 2008;22(2):203–11. Song J, Floyd FJ, Seltzer MM, Greenberg JS, Hong J. Long-term Effects of Child Death on Parents' Health Related Quality of Life: A Dyadic Analysis. Fam Relat. 2010;59(3):269–82. Infurna FJ, Luthar SS. Parents' adjustment following the death of their child: Resilience is multidimensional and differs across outcomes examined. J Res Pers. 2017;68:38–53. 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. Snaman JM, Mazzola E, Helton G, Feifer D, Morris SE, Clark L, et al. Early Bereavement Psychosocial Outcomes in Parents of Children Who Died of Cancer With a Focus on Social Functioning. JCO Oncol Pract. 2023;19(4):e527–41. Rasouli O, Vegsund HK, Eilegård Wallin A, Hjemdal O, Reinfjell T, Moksnes UK, et al. Bereaved parents' quality of life: resilience and professional support. BMJ Support Palliat Care. 2024;13(e3):e1029–37. Rosenberg AR, Wolfe J, Bradford MC, Shaffer ML, Yi-Frazier JP, Curtis JR, et al. Resilience and psychosocial outcomes in parents of children with cancer. Pediatr Blood Cancer. 2014;61(3):552–7. Rosenberg AR, Baker KS, Syrjala KL, Back AL, Wolfe J. Promoting resilience among parents and caregivers of children with cancer. J Palliat Med. 2013;16(6):645–52. Snaman J, Morris SE, Rosenberg AR, Holder R, Baker J, Wolfe J. Reconsidering early parental grief following the death of a child from cancer: a new framework for future research and bereavement support. Support Care Cancer. 2020;28(9):4131–9. 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. Steliarova-Foucher E, Stiller C, Lacour B, Kaatsch P. International Classification of Childhood Cancer, third edition. Cancer. 2005;103(7):1457–67. Michel G, von der Weid N, Zwahlen M, Adam M, Rebholz CE, Kuehni CE. The Swiss Childhood Cancer Registry: rationale, organisation and results for the years 2001–2005. Swiss Med Wkly. 2007;137:502–9. Baenziger J, Roser K, Mader L, Harju E, Ansari M, Waespe N, et al. Post-traumatic stress in parents of long-term childhood cancer survivors compared to parents of the Swiss general population. J Psychosoc Oncol Res Pract. 2020;2(3):e024. 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. J Trauma Stress. 2007;20(6):1019–28. Derogatis LR. BSI 18, Brief Symptom Inventory 18: Administration, scoring and procedures manual. NCS Pearson, Incorporated; 2001. Franke GH, Jaeger S, Glaesmer H, Barkmann C, Petrowski K, Braehler E. Psychometric analysis of the brief symptom inventory 18 (BSI-18) in a representative German sample. BMC Med Res Methodol. 2017;17(1):14. Michel G, Baenziger J, Brodbeck J, Mader L, Kuehni CE, Roser K. The Brief Symptom Inventory in the Swiss general population: Presentation of norm scores and predictors of psychological distress. PLoS ONE. 2024;19(7):e0305192. Prigerson HG, Maciejewski PK. Prolonged Grief Disorder (PG-13) scale. In: Institute D-FC, editor. Boston, U.S.2008. Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, Goodkin K, et al. Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med. 2009;6(8):e1000121. Bundesamt für Statistik. Armut in der Schweiz: Konzepte, Resultate und Methode-Ergebnisse auf der Basis von SILC 2008 bis 2010 [Poverty in Switzerland: concepts, results and methods]. 2012. 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). Pedraza EC, Raguindin PF, Vokinger AK, De Clercq E, Hendriks MJ, Tinner EM et al. Post-traumatic growth in parents long after their child’s death from cancer - A cross-sectional survey in Switzerland (Submitted Manuscript). 2024. Norberg AL, Lindblad F, Boman KK. Coping strategies in parents of children with cancer. Soc Sci Med. 2005;60(5):965–75. 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. Neugebauer C, Mastergeorge AM. The Family Stress Model in the Context of Pediatric Cancer: A Systematic Review. J Child Fam stud. 2021;30(5):1099–122. Rosenberg AR, Starks H, Jones B. I know it when I see it. The complexities of measuring resilience among parents of children with cancer. Support Care Cancer. 2014;22(10):2661–8. Luo Y, Li HCW, Xia W, Cheung AT, Ho LLK, Chung JOK. The Lived Experience of Resilience in Parents of Children With Cancer: A Phenomenological Study. Front Pediatr. 2022;10:871435. Davis ES, Wimberly CE, Towry L, Johnston EE, Walsh KM. Financial hardships and psychosocial outcomes among parents of children who die of cancer. Pediatr Blood Cancer. 2023;70(2):e30066. Dussel V, Bona K, Heath JA, Hilden JM, Weeks JC, Wolfe J. Unmeasured costs of a child's death: perceived financial burden, work disruptions, and economic coping strategies used by American and Australian families who lost children to cancer. J Clin Oncol. 2011;29(8):1007–13. Kohne S, Engert V, Rosendahl J. Stability of resilience in times of the COVID-19 pandemic. Personal Ment Health. 2023;17(1):55–66. Kalisch R, Cramer AOJ, Binder H, Fritz J, Leertouwer I, Lunansky G, et al. Deconstructing and Reconstructing Resilience: A Dynamic Network Approach. Perspect Psychol Sci. 2019;14(5):765–77. Almedom AM, Glandon D. Resilience is not the Absence of PTSD any More than Health is the Absence of Disease. J Loss Trauma. 2007;12(2):127–43. Windle G, Bennett KM, Noyes J. A methodological review of resilience measurement scales. Health Qual Life Outcomes. 2011;9(1):8. Jho HJ, Choi JY, Kwak KS, Chang YJ, Ahn EM, Park EJ, et al. Prevalence and Associated Factors of Anxiety and Depressive Symptoms Among Bereaved Family Members of Cancer Patients in Korea: A Nation-Wide Cross-Sectional Study. Med (Baltim). 2016;95(22):e3716. Forbes S, Fikretoglu D. Building Resilience: The Conceptual Basis and Research Evidence for Resilience Training Programs. Rev Gen Psychol. 2018;22(4):452–68. Vanhove AJ, Herian MN, Perez ALU, Harms PD, Lester PB. Can resilience be developed at work? A meta-analytic review of resilience‐building programme effectiveness. J Occup Organizational Psychol. 2015;89(2):278–307. Monterosso L, Kristjanson L, Phillips M. The supportive and palliative care needs of Australian families of children who die from cancer. Palliat Med. 2009;23(6):526–36. Additional Declarations No competing interests reported. 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2","display":"","copyAsset":false,"role":"figure","size":80873,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of resilience between bereaved parents and parent CCS (covariate adjustment in a linear regression for factors that are different between groups, namely, age, risk of poverty, religion, migration, time since diagnosis)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6311953/v1/c3b26d07f19cd225e7823cdd.png"},{"id":88814158,"identity":"e6d6dcd8-2511-4933-9b13-d1fe706455fa","added_by":"auto","created_at":"2025-08-11 16:07:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1526183,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6311953/v1/85fdf273-2800-4e37-bda3-17ac62512dcc.pdf"},{"id":82130548,"identity":"e7a8c6aa-d658-4ae3-96d1-0b11eb98d21e","added_by":"auto","created_at":"2025-05-07 05:28:30","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":311497,"visible":true,"origin":"","legend":"","description":"","filename":"Resiliencebereavedparentsappendix17March2025CLEAN.docx","url":"https://assets-eu.researchsquare.com/files/rs-6311953/v1/d6cbc8e3676ab812ef0e2b71.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eResilience among parents whose child died of cancer–Investigating its role on psychological distress and prolonged grief disorder: Results from a cross-sectional survey in Switzerland\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe death of a child from cancer is a devastating experience for parents (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). While grief is a normal reaction to a child\u0026rsquo;s death, around 10\u0026ndash;20% of parents suffer from emotional turmoil resulting in adverse psychological outcomes, such as anxiety, depression, and post-traumatic distress (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Other long-term effects include marital and family problems (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), socio-economic hardships (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and an overall lower quality of life (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, few studies have investigated at the impact of the child\u0026rsquo;s death on parental resilience (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe American Psychological Association defines resilience as \u0026ldquo;the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress\u0026rdquo;(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). It is an internal resource that could protect a person from developing psychological distress allowing them to cope successfully when faced with subsequent stresses in life (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Previous studies have shown that parents may develop resilience after the death of their child (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Social support and strong partner relationships were identified as factors associated with resilience among bereaved parents (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Studies have further shown that bereaved parents who present high levels of resilience are less likely to suffer from depression and anxiety and have higher social functioning (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e There are various gaps in the existing literature on resilience and bereaved parents. First, the impact of child loss on parental resilience has rarely been explored quantitatively (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Quantitative analysis is needed so that sociodemographic and cancer-related factors influencing resilience can be investigated more systematically, and comparison of relevant population can be done. Second, it is still unclear whether there are differences in parental resilience according to the survival outcome of their child with cancer (mortality versus survival). Most studies had no comparison group or had chosen parents of healthy children as comparison (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Knowing the difference in resilience on special groups would help tailor support strategies. Third, few studies have investigated the association of parental resilience and psychosocial outcomes after their child\u0026rsquo;s death from cancer (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Finally, most studies have focused on short-term bereavement (\u0026lt;\u0026thinsp;3 years after death) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and thus did not investigate the long-term effects of child\u0026rsquo;s death up to 10 years or more (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe aimed to (a) describe the level of resilience of bereaved parents and compare it with that of parents of childhood cancer survivors, (b) identify sociodemographic and cancer-related factors potentially influencing resilience among bereaved parents and examine their association with time since the child\u0026rsquo;s death, and (c) investigate the association of resilience with psychological distress and prolonged grief disorder among bereaved parents.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eWe conducted a cross-sectional survey among bereaved parents and parents of childhood cancer survivors (CCS parents). We have presented our study following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e) (See \u003cstrong\u003eAppendix\u003c/strong\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eSample and procedure\u003c/h2\u003e\n \u003cp\u003eFor the bereaved parents, eligible participants included parents of children who (a) were diagnosed with cancer, as defined by the International Classification of Childhood Cancer, Third Edition (ICCC-3) (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e), (b) were \u0026le;\u0026thinsp;18 years of age at time of diagnosis, (c) received treatment in Switzerland, and (d) died of cancer at least one year prior to study participation. To identify potential participants, the Swiss Childhood Cancer Registry (ChCR) (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e) provided a list of eligible cases to the participating hospitals from German-speaking regions that were involved in the study. These hospitals confirmed the parents\u0026rsquo; contact information through their records, excluded individuals deemed unsuitable for participation due to personal or medical reasons, such as vulnerability or distress, and sent eligible parents the study invitation. The invitation package included a study information and written consent, questionnaires (one per parent), and prepaid return envelopes. Parents were encouraged to complete the questionnaires individually, ensuring independent responses from both parents. They were given the option to complete either a paper or an online questionnaire (Qualtrics\u0026trade;, Provo, Utah, US). The survey was conducted from July 2022 to July 2023. The hospitals followed up with non-responders by making reminder phone calls starting earliest five weeks after the initial mailing. Additionally, cancer and bereavement support organizations helped disseminate information about the study.\u003c/p\u003e\n \u003cp\u003eResponses from printed questionnaires were manually entered into the database by research assistants, with an accuracy check performed on 14.5% of the entries (N\u0026thinsp;=\u0026thinsp;15). Double entry by two independent study staff showed high accuracy (kappa\u0026thinsp;=\u0026thinsp;0.93).\u003c/p\u003e\n \u003cp\u003eFor CCS-parents, we used data from a previously conducted nationwide population-based study, the Swiss Childhood Cancer Survivor Study \u0026ndash; Parents (SCCSS-Parents) (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). Parents in this study were eligible if their child: (a) was diagnosed with cancer according to ICCC-3 between 1976 and 2009, (b) aged\u0026thinsp;\u0026le;\u0026thinsp;16 years, and (c) Swiss resident at diagnosis, (d) had survived at least five years post-diagnosis, and (e) was aged\u0026thinsp;\u0026ge;\u0026thinsp;20 years at the time of study participation. Eligible survivors were identified through the Childhood Cancer Registry (ChCR), and addresses were verified via an online telephone directory. Parents were invited to participate through their former treating hospital, which sent study information two weeks before mailing questionnaires. Non-responders received reminders after four to six weeks and again after an additional eight weeks. The SCCSS-Parents survey was conducted from January 2017 to February 2018. For this analysis, we used the data from CCS-parents from German-speaking regions and age-range matched with bereaved parents.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eResilience was assessed using the Connor-Davidson Resilience Scale (CD-RISC 10), a validated self-report tool measuring an individual\u0026rsquo;s \u0026ldquo;ability to adapt to adversity\u0026rdquo; (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). This scale consists of 10 items rated on a 5-point Likert scale (0\u0026thinsp;=\u0026thinsp;not true at all to 4\u0026thinsp;=\u0026thinsp;true nearly all the time), yielding a sum score ranging from 0 to 40. Scores were computed by summing the responses, with missing responses (\u0026lt;\u0026thinsp;5 items) imputed using the median of the remaining items. If\u0026thinsp;\u0026ge;\u0026thinsp;8 responses were missing, the score was considered invalid. We included three additional questions from long form of CD-RISC (25 items) (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e). These questions were related to spirituality and religiosity.\u003c/p\u003e\n\u003cp\u003ePsychological distress was measured using the Brief Symptom Inventory (BSI-18) (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e), a psychometric tool validated in the Swiss population (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). This BSI-18 assesses depression, anxiety, somatization, and overall psychological distress (Global Severity Index, GSI) using 18 items scored on a 5-point Likert scale (0\u0026thinsp;=\u0026thinsp;not at all to 4\u0026thinsp;=\u0026thinsp;extremely). Total scores were converted into T-scores (mean\u0026thinsp;=\u0026thinsp;50, SD\u0026thinsp;=\u0026thinsp;10) based on norms established in the German population (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). Caseness indicating significant psychological distress was defined as a GSI T-score\u0026thinsp;\u0026ge;\u0026thinsp;63 or a T-score\u0026thinsp;\u0026ge;\u0026thinsp;63 on at least two of the three subscales (depression, anxiety, somatization). Missing subscale responses (1 item) were imputed using the subscale mean, while missing values exceeding this threshold rendered the subscale invalid for inclusion in the analysis (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eProlonged grief disorder was assessed using Prolonged Grief 13 (PG-13) (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e), which is following DSM-V-TR criteria using a diagnostic checklist that included five main components: (a) bereavement event, (b) separation distress, (c) duration of grief, (d) cognitive/emotional/behavioral symptoms, and (e) functional impairment (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). Bereaved parents automatically fulfilled the bereavement event criterion due to the study\u0026rsquo;s inclusion criteria. Separation distress was evaluated using two items on yearning and emotional pain, with responses rated on a 5-point Likert scale (1-not at all, to 5-several times a day). The duration of grief is defined by the occurrence of daily feelings of separation distress persisting for at least six months after the loss (yes/no). Cognitive, emotional, and behavioral symptoms were measured using nine items, using 5-point Likert scale (1-not at all, to 5- overwhelmingly). Impairment in social, occupational, or other areas of functioning was assessed using a binary yes/no response. A classification of prolonged grief disorder required meeting all criteria. We did not impute missing responses.\u003c/p\u003e\n\u003cp\u003eSociodemographic variables collected were sex (male, female), age (\u0026lt;\u0026thinsp;50 years, 50\u0026ndash;60 years, \u0026gt;\u0026thinsp;60 years old), education (compulsory education, vocational training, upper secondary/university), employment (unemployed which includes invalidity claim, housemaker or retired, versus employed which included full-time or part-time employment), risk of poverty (for those living as parent-couples CHF\u0026thinsp;\u0026lt;\u0026thinsp;6000, for single-parents CHF\u0026thinsp;\u0026lt;\u0026thinsp;4500; this cut-off was chosen based on the published risk-of-poverty of the Swiss Federal Statistical Office (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e) which was also used in a previous publication (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e)), living arrangement (asked if living alone, versus \u0026ge;\u0026thinsp;2 persons in the household), adhering a religion (yes, no), partnership status (yes [in a partnership], no), and migration background (defined as not being a Swiss citizen, not a Swiss citizen since birth, or a Swiss citizen not born in Switzerland). Child- and cancer-related information, i.e. the child\u0026rsquo;s sex (male, female), age at diagnosis (\u0026lt;\u0026thinsp;5 years, 5\u0026ndash;9 years, \u0026ge;\u0026thinsp;10 years), cancer type (leukemia/lymphoma, central nervous system tumor, and other solid tumors), and time since diagnosis (\u0026lt;\u0026thinsp;20 years, \u0026ge; 20 years). For bereaved parents, bereavement-specific variables, including the child\u0026rsquo;s age at death (\u0026lt;\u0026thinsp;5 years, 5\u0026ndash;9 years, \u0026ge;\u0026thinsp;10 years), location of death (home versus hospital or health facility), and time since death (\u0026lt;\u0026thinsp;10 years, \u0026ge;\u0026thinsp;10 years), were also reported by the parents in the questionnaire.\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eData Analysis\u003c/h2\u003e\n \u003cp\u003eWe described the sociodemographic and cancer-related characteristics of both bereaved parents and CCS parents using means and SD or proportions. Bereavement or death related characteristics were only described for bereaved parents.\u003c/p\u003e\n \u003cp\u003eWe followed the analysis framework in \u003cstrong\u003eAppendix Figure \u003cspan class=\"InternalRef\"\u003eS1\u003c/span\u003e.\u003c/strong\u003e To compare resilience levels (resilience sum score and individual items) among bereaved and CCS parents (\u003cstrong\u003eAim 1\u003c/strong\u003e), we used student\u0026rsquo;s t- test for continuous variables and chi-square tests for categorical responses. Marginal means were also computed using linear regression, adjusting for sociodemographic variables that were statistically different between two groups (decided a posteriori from bivariate comparison analysis with p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n \u003cp\u003eTo identify determinants of resilience (\u003cstrong\u003eAim 2\u003c/strong\u003e), we used univariable linear regression using resilience as dependent variable/outcome and the sociodemographic, child- and cancer-related characteristics as independent variables/predictors. Variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.10 were included in multivariable linear regression models to identify independent predictors. We also explored non-linear associations between time since death and resilience sum score using restricted cubic spline regression for bereaved parents. We plotted a spline modeling using resilience sum score as dependent variable (outcome) and time since death as independent variable (predictor). Penalization and smoothing parameters were applied, and graphical plots were generated to visualize these relationships. Missing data were handled using full information maximum likelihood, assuming data were missing at random. Additional questions on religiosity and spirituality were also described.\u003c/p\u003e\n \u003cp\u003eFinally, to determine the association between resilience (\u003cstrong\u003eAim 3\u003c/strong\u003e), and psychological distress and prolonged grief disorder, regressions were also fitted using linear regression for continuous outcomes (GSI-18, anxiety, depression, and somatization) and logistic regression for binary outcomes (Caseness with psychological distress, prolonged grief disorder). Separate models were fitted for each subscale of psychological distress, with crude and adjusted estimates reported. Age, sex, and time since death were included in adjusted models to minimize bias.\u003c/p\u003e\n \u003cp\u003eAll analyses were conducted using Stata 18.5 (StataCorp, TX). Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for two-tailed tests. All analyses are exploratory, and no adjustments for multiple testing were applied.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eEthical approval\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003efor the Bereaved Parents Survey was granted by the Ethics Committee of Northwest and Central Switzerland (EKNZ 2021\u0026thinsp;\u0026minus;\u0026thinsp;00906, 4 August 2021). Similarly, ethical approval for the SCCSS-Parents study was obtained from the same committee (EKNZ 2015-075, 26 March 2015).\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe study population included 103 bereaved parents (of 81 childhood cancer deaths) and 345 parents (of 217 cancer survivors) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. Participating bereaved parents were younger on average (mean age 53.7 years, SD 8.3) compared to CCS parents (mean age 62.5 years, SD 6.7, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Both groups were predominantly female, with similar levels of vocational and higher education. Employment rates were comparable (25.5% vs. 26.0%), but a lower proportion of bereaved parents were at risk for poverty compared to CCS parents (11.8% vs. 31.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Religion and migration background differed significantly, with fewer bereaved parents having a religion (69.6% vs. 82.3%, p\u0026thinsp;=\u0026thinsp;0.005) and more bereaved parents with migration background (20.0% vs. 8.2%, p\u0026thinsp;=\u0026thinsp;0.003) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u0026nbsp;\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 study participants\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\u003eBereaved Parents\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;103\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eParents of childhood cancer survivors (CCS parents)\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;345\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003csup\u003e1\u003c/sup\u003e\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\" colspan=\"4\"\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\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 \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (34.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e145 (42.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (66.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e200 (58.0%)\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\u003eAge in years (mean, SD)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.7 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.5 (6.7)\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge categories\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u0026lt;\u0026thinsp;50 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (29.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (1.2%)\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; 50\u0026ndash;60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (44.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e128 (37.3%)\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\u003e\u0026bull; \u0026gt;\u0026thinsp;60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e211 (61.5%)\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\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 \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Compulsory education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.188\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Vocational training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (64.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e181 (56.7%)\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\u003e\u0026bull; Upper secondary or university education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (30.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e106 (33.2%)\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\u003eEmployment status\u003csup\u003e3\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 \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76 (74.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e248 (74.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.923\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Unemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (25.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87 (26.0%)\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\u003eRisk of poverty\u003csup\u003e4\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 \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Low risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90 (88.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e224 (68.7%)\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; High risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102 (31.3%)\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\u003eLiving arrangement\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.339\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Shared\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97 (95.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e301 (92.3%)\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\u003eHaving a religion\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 \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; With religion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 (69.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e284 (82.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Without religion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (30.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 (17.7%)\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\u003ePartnership status\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (7.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (9.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.709\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94 (92.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e302 (91.0%)\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\u003eMigration background\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 \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e301 (91.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (8.2%)\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\" colspan=\"4\"\u003e\n \u003cp\u003eClinical and cancer-related characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;81 cancer deaths\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;217 cancer survivors\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\u003eChild\u0026rsquo;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 \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (56.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e116 (53.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.607\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (43.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e101 (46.5%)\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\u003eChild age at 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 \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u0026lt;\u0026thinsp;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (38.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85 (39.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.986\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; 5\u0026ndash;9 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (27.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 (27.2%)\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\u003e\u0026bull; \u0026ge;\u0026thinsp;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (34.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73 (33.6%)\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 \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Leukemia/lymphoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (27.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e118 (54.4%)\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; CNS tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (44.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 (11.1%)\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\"\u003e\n \u003cp\u003e\u0026bull; Other solid tumors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (28.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (34.6%)\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\u003eTime since diagnosis, years (mean, SD)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.4 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.4 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime since 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 \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u0026lt;\u0026thinsp;20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (46.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 (29.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u0026gt;/= 20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (53.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e154 (71.0%)\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=\"4\"\u003e\n \u003cp\u003eBereavement or death-related characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge at death\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u0026lt;\u0026thinsp;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (22.6%)\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\u0026bull; 5\u0026ndash;9 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (27.5%)\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\u0026bull; \u0026ge;\u0026thinsp;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (50.0%)\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\u003eLocation of death\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (55.6%)\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\u0026bull; Healthcare facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (44.4%)\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\u003eTime since death, years (mean, SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.0 (5.5)\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\u003eTime since death\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u0026lt;\u0026thinsp;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (43.8%)\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\u0026bull; \u0026ge;\u0026thinsp;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (56.2%)\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 \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eAbbreviations: CCS, childhood cancer survivor; CNS, central nervous system; SD, standard deviation\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e1\u003c/sup\u003e p-values were derived from chi-squared test for comparison of proportion, unless specified otherwise.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e2\u003c/sup\u003e p-values for continuous variables were obtained from students t-test\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e3\u003c/sup\u003e Employment status: Employed included those with full-time or part-time employment. Unemployed included those who are on unemployed, on invalidity claims, in training/education, or retired.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e4\u003c/sup\u003e Risk of poverty: For those parent-couples CHF\u0026thinsp;\u0026lt;\u0026thinsp;6000, for those single-parents CHF\u0026thinsp;\u0026lt;\u0026thinsp;4500. This were chosen based from the published risk-of-poverty of the Swiss Federal Office of Statistics which are 3,933 CHF for single parents with two children aged\u0026thinsp;\u0026lt;\u0026thinsp;14 years and 5,163 CHF for parent couples and was also used in a previous publication\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e5\u003c/sup\u003e Having a religion: Participants who indicated a religious denomination were classified as \u0026ldquo;with religion\u0026rdquo;. Those identify as no religion, or no answer were classified as \u0026ldquo;without religion\u0026rdquo;.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e6\u003c/sup\u003e Migration background: We classified individuals with migration backgrounds as those who are not Swiss citizens, were not born in Switzerland, or were not Swiss at birth.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eA diagnosis of CNS tumors (44.4%) was higher in bereaved parents compared to CCS parents, where diagnoses of leukemia/lymphoma dominated (54.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The average time since diagnosis to survey date was shorter for bereaved parents (20.4 years, SD 7.6) than for CCS parents (23.4 years, SD 7.3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). For bereaved parents, the average time since their child\u0026rsquo;s death was 11.0 years (SD 5.5). More deaths occurred at home (55.6%) than in healthcare settings. Additionally, 50% of children died after the age of 10 years.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eComparison of resilience (Aim 1)\u003c/h2\u003e\n \u003cp\u003eThe resilience sum score was significantly higher among bereaved parents compared to CCS parents (mean 29.8, SD 6.6 vs. mean 27.9, SD 5.5, p\u0026thinsp;=\u0026thinsp;0.005) (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Item comparison can be found in \u003cstrong\u003eAppendix Table \u003cspan class=\"InternalRef\"\u003eS1\u003c/span\u003e\u003c/strong\u003e. Adjusted resilience sum scores (adjusted for different ages, risk of poverty, having a religion, and migration background distribution), consistently revealed higher resilience in bereaved parents compared to CCS parents (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eComparisons of additional resilience items on religiosity and spirituality are described in \u003cstrong\u003eAppendix Table S2\u003c/strong\u003e. Bereaved parents exhibit a bimodal distribution in their responses to the religiosity question. They have a higher proportion of individuals who do not believe in God (42.7% vs. 29.9%) and a higher proportion of believers (20.4% vs. 13.9%) compared to CCS parents. Bereaved parents reported lower levels of a strong sense of purpose in life compared to CCS parents (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while they were more likely to report having at least one close and secure relationship (p\u0026thinsp;=\u0026thinsp;0.017). There is no difference between belief in fate or God which helps them in their life (p\u0026thinsp;=\u0026thinsp;0.374)\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eDeterminants of resilience in bereaved parents (Aim 2)\u003c/h3\u003e\n\u003cp\u003eAmong sociodemographic variables, only risk of poverty was significantly associated with resilience (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Parents at high risk of poverty had a lower resilience sum score compared to those at low risk for poverty (Univariable regression coefficient: -7.86, 95% CI: -11.59 to -4.13, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 multivariable model coefficient: -7.37, 95% CI: -11.21 to -3.54, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). None of the cancer-related characteristics showed significant associations with resilience (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\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 for bereaved parents\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eUnivariable regression\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMultivariable regression\u003csup\u003e2\u003c/sup\u003e\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMean score\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCoefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% confidence interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCoefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% confidence interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cem\u003eSociodemographic characteristics of bereaved parents\u003c/em\u003e\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 (male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e30.8\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e29.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-4.28, 1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.263\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (\u0026lt;\u0026thinsp;50 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e28.4\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; 50\u0026ndash;60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e30.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-1.26, 4.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.242\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; \u0026gt;\u0026thinsp;60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e30.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-1.30, 5.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.215\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRisk of poverty (low risk)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e30.6\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; High-risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e-7.86**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(-11.59,-4.13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e-7.37\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e(-11.21, -3.54)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLiving arrangement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e27.2\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Shared\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e29.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-3.40, 8.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.391\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducation category (Compulsory-vocational)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e27.6\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Upper secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e29.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-4.62, 7.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.643\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; University\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e31.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-2.42,10.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.226\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmployment (unemployed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e30.6\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e29.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-4.33, 1.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.371\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\" colspan=\"2\"\u003e\u0026nbsp;\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\" colspan=\"2\"\u003e\n \u003cp\u003e25.5\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-0.22, 9.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-2.11, 7.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.287\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMigration background (None)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e29.7\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; With migration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e31.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-2.40, 5.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.475\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReligion (no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e30.3\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-4.77, 0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.169\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTime since death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\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\"\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\u003e\u0026bull; Continuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-0.22, 0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.909\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"9\"\u003e\n \u003cp\u003e\u003cem\u003eCancer-related characteristics\u003c/em\u003e\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 of the child (male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e29.7\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e29.9\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(-2.40, 2.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.871\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge at death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\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\"\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=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Continuous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-0.13, 0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.435\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiagnosis at death (CNS tumor)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e28.9\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Non-CNS tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e30.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-4.89, 1.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.298\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e30.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-3.97, 3.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.792\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocation of death (health facility)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e29.2\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\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e30.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-1.54,3.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.411\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\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003e*Categories inside parenthesis \u0026ldquo;(category)\u0026rdquo; are the reference group. P values\u0026thinsp;\u0026gt;\u0026thinsp;0.05 are in \u003cstrong\u003eBOLD\u003c/strong\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003e\u003csup\u003e1\u003c/sup\u003eUnivariable linear regression using Resilience sum score as dependent/outcome variable and sociodemographic and cancer-related characteristics as independent/predictor variable.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003e\u003csup\u003e2\u003c/sup\u003eMultivariable linear regression included independent/predictor variables from univariable regression with p values\u0026thinsp;\u0026lt;\u0026thinsp;0.10.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003e\u003csup\u003e3\u003c/sup\u003eBased on marginal means of univariable linear regression\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eWe plotted a spline to determine non-linear association between time since death and resilience sum score. Overall, we found no change in resilience sum score over time since death (\u003cstrong\u003eAppendix Figure S2\u003c/strong\u003e)\u003c/p\u003e\n\u003ch3\u003eAssociation of psychological distress and prolonged grief disorder with resilience (Aim 3)\u003c/h3\u003e\n\u003cp\u003eLower resilience scores were associated with higher psychological distress (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). For the global severity index (GSI) as an outcome, each unit increase in resilience was associated with a reduction in GSI by 0.71 (adjusted \u0026beta; = -0.71, 95% CI: -0.96, -0.46, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, depression (adjusted \u0026beta; = -0.74, 95% CI: -0.99, -0.49, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), anxiety (adjusted \u0026beta; = -0.63, 95% CI: -0.88, -0.38, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and somatization (adjusted \u0026beta; = -0.44, 95% CI: -0.69, -0.20, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were inversely associated with resilience scores.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation of resilience (CD-RISC 10) with psychological distress (BSI18) and prolonged grief disorder (PG-13) in bereaved parents\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\" colspan=\"3\"\u003e\n \u003cp\u003eCrude\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eAdjusted*\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\u003eOutcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCoefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCoefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGlobal severity index\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-0.94,-0.45)\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\"\u003e\n \u003cp\u003e-0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-0.96,-0.46)\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-0.93,-0.43)\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\"\u003e\n \u003cp\u003e-0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-0.99,-0.49)\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-0.91,-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\"\u003e\n \u003cp\u003e-0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-0.88,-0.38)\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSomatization\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-0.68,-0.21)\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\"\u003e\n \u003cp\u003e-0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(-0.69,-0.20)\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOdds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOdds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePsychological distress (case)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.75, 0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.74, 0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProlonged grief disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.63, 0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.58, 0.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e*Adjusted for age, sex, and time since death\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003csup\u003e1\u003c/sup\u003eUsing linear regression, psychological distress was fitted as the dependent variable with T scores of GSI, somatization, anxiety, and depression as continuous variables, and resilience sum score as dependent variable, also as continuous variable.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003csup\u003e2\u003c/sup\u003e Using logistic regression, caseness (BSI-18) and prolonged grief disorder were modeled as the dependent variable in a dichotomous format, while the resilience sum score was treated as a continuous variable.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eHigher resilience was associated to a lower likelihood to be a case with psychological distress (adjusted OR = -0.83, 95% CI: 0.74, 0.93, p\u0026thinsp;=\u0026thinsp;0.002) or prolonged grief disorder (adjusted OR\u0026thinsp;=\u0026thinsp;0.73, 95% CI: 0.58, 0.92, p\u0026thinsp;=\u0026thinsp;0.008) with every unit increase in resilience sum scores (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eA summary of psychological distress (BSI-18) scores and prolonged grief disorder (PG-13) of bereaved parents can be found in \u003cstrong\u003eAppendix Table S3\u003c/strong\u003e.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e Our study revealed that bereaved parents report higher resilience than CCS parents. Risk of poverty is associated with lower resilience in bereaved parents, suggesting the impact of financial vulnerabilities on resilience. Accordingly, higher resilience is associated with lower psychological distress and lower risk of prolonged grief disorder. Thus, higher resilience could be a protective factor for adverse mental health outcomes.\u003c/p\u003e \u003cp\u003eBereaved parents experience intense emotions after the death of their child. The irreversibility of their loss may lead them to develop unique coping mechanisms and psychological resources to refocus their lives, and experience posttraumatic growth (\u0026ldquo;positive changes\u0026rdquo;) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). These positive changes can include appreciation of life, strengthening established relationships, and looking for possibilities \u0026ndash; opportunities that were previously not or rarely considered in life - or refocusing one\u0026rsquo;s life, all of which might be associated with their resilience (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Resilience of CCS parents may develop differently; coping may focus on caring for their child who had cancer and include strategies such as planful and active problem-solving, self-control, and accepting responsibility (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Families might face new challenges after treatment, including greater need for information on late effects and tumor recurrence, financial burden from ongoing healthcare, difficulties with school and social reintegration, and decreasing psychosocial (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). These challenges can result in lower sense of competence (or self-efficacy) and perception of control over life events, both of which are important components of resilience (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral resilience-building resources, such as strong partnership and social support, were identified in the literature as contributing to resilience (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In our study, we identified the economic situation as a major factor influencing the resilience of bereaved parents. Research shows that financial stability plays a critical role in mitigating stressors and uncertainties, particularly during the grieving process as it promotes autonomy and perception of control (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Access to a sufficient and stable income and savings enhances one\u0026rsquo;s ability to meet basic needs but also allows families to rebuild a sense of life normality and focus on healing (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). For example, it may allow parents to take time off work for grieving, seek therapy, or participate in support groups (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). It allows them to have a sense of control and autonomy that is crucial for maintaining psychological wellbeing (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eResilience, as a construct, remained stable over time since the child\u0026rsquo;s death. Although our data were not longitudinal, this aligns with prior research suggesting that resilience is a relatively stable trait (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), though it can be modified following significant adversities (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). In comparison with CCS parents who had lower resilience, we hypothesize that the experience of losing a child may foster the development of resilience, which is subsequently maintained over time.\u003c/p\u003e \u003cp\u003eSpirituality is an important component of resilience (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), yet the data on bereaved parents\u0026rsquo; religiosity and spirituality is challenging to interpret. The bimodal distribution revealed that bereaved parents either believe or not in an omniscient being with clearer distinction, as compared to more mixed responses from the CCS parents. This can be interpreted that the experience of loss has a significant impact that made their beliefs clearer and delineated compared to the CCS parents. Moreover, bereaved parents reported a lower sense of purpose in life but expressed greater trust and a stronger sense of security in their relationships. This provides a more nuanced understanding of the high resilience of bereaved parents that comes from resistance (or handling negative emotions, trusting one\u0026rsquo;s instincts, and perceived benefits of stress) and positivity (having a positive attitude to change and secure relationships) that is different from CCS parents.\u003c/p\u003e \u003cp\u003eIn line with previous research, our study revealed a strong association of resilience and mental health outcomes. Resilience has been identified as a protective factor that prevents the person to develop adverse mental health outcomes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Bereaved parents with higher resilience tend to report better adjustment to grief and healthier psychological functioning (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In contrast, bereaved parents with lower resilience are at increased risk of prolonged grief disorder, anxiety, and depression (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Factors such as age and socioeconomic status may also influence the relationship between resilience and psychological outcomes in bereaved parents (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eOur study provides insights into the resilience of bereaved parents, contributing to the limited quantitative studies on this topic. Our analysis quantifies the strength and magnitude of associations and provides empirical and data-driven understanding of resilience in this population. Our registry- and population-based control group (CCS parents) was a methodological improvement from previous studies resulting in higher reliability and accuracy. To reduce potential confounding, our results were adjusted for sociodemographic differences between groups (CCS parents and bereaved parents) and restricted the analysis to the German-speaking Swiss population. This approach minimized cultural and regional influences, strengthening the internal validity of the study.\u003c/p\u003e \u003cp\u003eThis study had several limitations that should be acknowledged in the interpretation of our findings. First, the cross-sectional nature of the analysis precluded the establishment of temporality. As such, we could not determine whether low resilience leads to prolonged grief disorder or vice versa, limiting causal interpretations. Second, our recruitment strategy does not allow us to conclude anything about recruitment rate, recruitment pattern, and selection bias. We have no information about the sociodemographic characteristics of those who were not approached by the survey. Participation could have been potentially skewed towards those with better mental health outcomes and, thus, may have resulted in an overestimation of resilience in this population. Fourth, a period bias may have affected the results due to the significant time lapse between data collection for CCS-parents and bereaved parents. The bereaved parents\u0026rsquo; data were collected during or after the COVID-19 pandemic, while CCS-parents\u0026rsquo; data were collected before the pandemic. This temporal discrepancy introduces a potential historical bias. Finally, while restricting the analysis to German-speaking participants reduced culture as a confounding variable, this restriction also resulted to limited generalizability to other regions in Switzerland.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImplications of the study and outlook\u003c/h2\u003e \u003cp\u003eOur findings emphasize the importance of understanding unique adaptive mechanisms following bereavement, as they may serve as valuable psychological resources for coping with future stress and challenges. Resilience building strategies, including cognitive behavioral therapy, mindfulness and social support interventions (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), could benefit both bereaved parents and parents of survivors. Our results suggest that by enhancing resilience, there could be reduction of grief-related psychological disorders (for bereaved parents), reduction of overall distress, and thereby increase general wellbeing.\u003c/p\u003e \u003cp\u003eMoreover, the significant impact of financial vulnerabilities on resilience underlines the importance of addressing socio-economic determinants in bereavement care (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Providing direct and indirect financial support to bereaved parents may enhance resilience and mitigate psychological distress and prolonged grief disorder (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Direct financial support could include assistance over housing and daily living expenses (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), while indirect financial support could include subsidized counselling services or providing job security both of which could significantly benefit the bereaved parents (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Healthcare systems could also be improved through the establishment of comprehensive bereavement services including resilience-based screening, tailored support, and sustained connection with social workers.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eBereaved parents had higher overall resilience compared to CCS parents, and risk of poverty is associated with lower resilience. Additionally, higher resilience is associated with reduced psychological distress and a lower risk of prolonged grief disorder, suggesting its protective role against adverse mental health outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBSI-18, Brief Symptom Index (18 items)\u003c/p\u003e\n\u003cp\u003eCCS, childhood cancer survivor\u003c/p\u003e\n\u003cp\u003eCD-RISC 10, Connor Davidson Resilience Scale (10 items)\u003c/p\u003e\n\u003cp\u003eChCR, Swiss Childhood Cancer Registry\u003c/p\u003e\n\u003cp\u003eDSM-V-TR, Diagnostic and Statistical Manual of Mental Disorders, 5\u003csup\u003eth\u003c/sup\u003e edition, Text revision\u003c/p\u003e\n\u003cp\u003eEKNZ, Ethikkomission Nordwest- und Zentralschweiz (Ethics Commission of Northwest and Central Switzerland)\u003c/p\u003e\n\u003cp\u003eGSI, global severity index\u003c/p\u003e\n\u003cp\u003eICCC-3, International Classification of Childhood Cancer, Third Edition\u003c/p\u003e\n\u003cp\u003eOR, odds ratio\u003c/p\u003e\n\u003cp\u003ePG-13, Prolonged Grief Questionnaire (13 items)\u003c/p\u003e\n\u003cp\u003ePGD, prolonged grief disorder\u003c/p\u003e\n\u003cp\u003eSCCSS-Parents, Swiss Childhood Cancer Survivor Study – Parents\u003c/p\u003e\n\u003cp\u003eSD, standard deviation\u003c/p\u003e\n\u003cp\u003eSTROBE, Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003e For the bereaved parents survey, ethical approval was granted through the Ethics Committee of Northwest and Central Switzerland (EKNZ 2021\u0026thinsp;\u0026minus;\u0026thinsp;00906; 04 August 2021). For SCCSS-Parents, ethical approval was granted through the Ethics Committee of Northwest and Central Switzerland (EKNZ 2015-075; 26 March 2015).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eBereaved parent survey has received funding from the Swiss Cancer Research (Grant no. KFS-4995-02-2020) and Cancer League Central Switzerland. The Swiss Childhood Cancer Survivor Study \u0026ndash; Parents (SCCSS-Parents) was funded by the Swiss National Science Foundation (Grant no. 100019_153268/1) and the Kinderkrebshilfe Schweiz. Additional funding was available from Swiss National Science Foundation (Grant No: 10001C_182129/1). The funding agencies had no role in the analysis and interpretation of the findings.\u003c/p\u003e \u003cp\u003eAcknowledgements\u003c/p\u003e \u003cp\u003eWe thank the participating hospitals and the parents who participated in our survey. We also acknowledge and appreciate the help of our interns Katja Rueesch, Simone Walde-Foehn, Kathleen Ostheim, and Laura Haxhosaj.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003ePFR \u0026amp; GM conceptualized the idea. EDC, AKV, ECP, CB provided inputs on the analysis plan. PFR cleaned the dataset, planned and executed the analysis, and plotted the graphs. PFR, EDC, AKV, ECP, CB \u0026amp; GM wrote the first draft. KS, EMT, EB, AOB provided expert advice and revised the draft. EMT, EB \u0026amp; GM secured the funding. All authors approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank the participating hospitals and the parents who participated in our survey. We also acknowledge and appreciate the help of our interns Katja Rueesch, Simone Walde-Foehn, Kathleen Ostheim, and Laura Haxhosaj.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData can be made available upon reasonable request from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJaaniste T, Coombs S, Donnelly TJ, Kelk N, Beston D. Risk and Resilience Factors Related to Parental Bereavement Following the Death of a Child with a Life-Limiting Condition. Child (Basel). 2017;4(11).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVegsund HK, Reinfjell T, Moksnes UK, Wallin AE, Hjemdal O, Eilertsen MB. 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J Clin Epidemiol. 2008;61(4):344\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteliarova-Foucher E, Stiller C, Lacour B, Kaatsch P. International Classification of Childhood Cancer, third edition. Cancer. 2005;103(7):1457\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMichel G, von der Weid N, Zwahlen M, Adam M, Rebholz CE, Kuehni CE. The Swiss Childhood Cancer Registry: rationale, organisation and results for the years 2001\u0026ndash;2005. Swiss Med Wkly. 2007;137:502\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaenziger J, Roser K, Mader L, Harju E, Ansari M, Waespe N, et al. Post-traumatic stress in parents of long-term childhood cancer survivors compared to parents of the Swiss general population. J Psychosoc Oncol Res Pract. 2020;2(3):e024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\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. J Trauma Stress. 2007;20(6):1019\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDerogatis LR. BSI 18, Brief Symptom Inventory 18: Administration, scoring and procedures manual. NCS Pearson, Incorporated; 2001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFranke GH, Jaeger S, Glaesmer H, Barkmann C, Petrowski K, Braehler E. Psychometric analysis of the brief symptom inventory 18 (BSI-18) in a representative German sample. BMC Med Res Methodol. 2017;17(1):14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMichel G, Baenziger J, Brodbeck J, Mader L, Kuehni CE, Roser K. The Brief Symptom Inventory in the Swiss general population: Presentation of norm scores and predictors of psychological distress. PLoS ONE. 2024;19(7):e0305192.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrigerson HG, Maciejewski PK. Prolonged Grief Disorder (PG-13) scale. In: Institute D-FC, editor. Boston, U.S.2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, Goodkin K, et al. Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med. 2009;6(8):e1000121.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBundesamt f\u0026uuml;r Statistik. Armut in der Schweiz: Konzepte, Resultate und Methode-Ergebnisse auf der Basis von SILC 2008 bis 2010 [Poverty in Switzerland: concepts, results and methods]. 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\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. 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Unmeasured costs of a child's death: perceived financial burden, work disruptions, and economic coping strategies used by American and Australian families who lost children to cancer. J Clin Oncol. 2011;29(8):1007\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKohne S, Engert V, Rosendahl J. Stability of resilience in times of the COVID-19 pandemic. Personal Ment Health. 2023;17(1):55\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalisch R, Cramer AOJ, Binder H, Fritz J, Leertouwer I, Lunansky G, et al. Deconstructing and Reconstructing Resilience: A Dynamic Network Approach. Perspect Psychol Sci. 2019;14(5):765\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlmedom AM, Glandon D. Resilience is not the Absence of PTSD any More than Health is the Absence of Disease. J Loss Trauma. 2007;12(2):127\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWindle G, Bennett KM, Noyes J. A methodological review of resilience measurement scales. Health Qual Life Outcomes. 2011;9(1):8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJho HJ, Choi JY, Kwak KS, Chang YJ, Ahn EM, Park EJ, et al. Prevalence and Associated Factors of Anxiety and Depressive Symptoms Among Bereaved Family Members of Cancer Patients in Korea: A Nation-Wide Cross-Sectional Study. Med (Baltim). 2016;95(22):e3716.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForbes S, Fikretoglu D. Building Resilience: The Conceptual Basis and Research Evidence for Resilience Training Programs. Rev Gen Psychol. 2018;22(4):452\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanhove AJ, Herian MN, Perez ALU, Harms PD, Lester PB. Can resilience be developed at work? A meta-analytic review of resilience‐building programme effectiveness. J Occup Organizational Psychol. 2015;89(2):278\u0026ndash;307.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMonterosso L, Kristjanson L, Phillips M. The supportive and palliative care needs of Australian families of children who die from cancer. Palliat Med. 2009;23(6):526\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\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":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"bereavement, parents, resilience, childhood cancer","lastPublishedDoi":"10.21203/rs.3.rs-6311953/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6311953/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction\u003c/p\u003e\n\u003cp\u003eThe death of a child profoundly impacts parents, often leading to anxiety, depression, and posttraumatic stress. However, factors such as resilience—defined as the capacity to adapt to adversity—are less explored. Resilience may mitigate grief-related distress. This study aimed to: (a) describe and compare resilience levels between bereaved parents and parents of childhood cancer survivors (CCS parents), (b) identify sociodemographic and cancer-related determinants of resilience among bereaved parents, and (c) investigate resilience’s association with psychological distress and prolonged grief disorder.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eThis is a cross-sectional study done in Switzerland. Bereaved parents were recruited from three hospitals and through patient advocacy group. CCS parents were taken from a nationwide, population-based study (Swiss Childhood Cancer Survivor Study-Parents). Resilience, psychological distress, and prolonged grief disorder were assessed using the Connor-Davidson Resilience Scale (CD-RISC 10), Brief Symptom Inventory-18 (BSI-18), and Prolonged Grief 13 (PG-13), respectively. Regression analysis (linear and logistic) was used to identify factors associated with resilience, and the association of resilience with psychological distress and prolonged grief disorder (adjusted for age, sex, and time since death).\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eWe included 103 bereaved parents and 345 CCS parents in the analysis. Bereaved parents were younger compared to CCS parents (mean 53.7, SD 8.3 vs. 62.5, SD 6.7 years, p\u0026lt;0.001), with both groups predominantly female (66% and 58%). Bereaved parents reported higher resilience scores than CCS parents (crude mean: 29.8 vs. 27.9; p=0.005), with adjusted analyses confirming this finding. High risk of poverty was the only significant determinant of lower resilience (adjusted β = -7.37, 95% CI: -11.21, -3.54; p\u0026lt;0.001). Higher resilience was associated with lower likelihood to report psychological distress (adjusted OR = 0.83, 95% CI: 0.74, 0.93, p = 0.002) and prolonged grief disorder (adjusted OR = 0.73, 95% CI: 0.58, 0.92, p = 0.008).\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eBereaved parents exhibited higher resilience than CCS parents. Resilience in bereaved parents was strongly associated with reduced psychological distress and lower likelihood of having prolonged grief disorder. Targeting modifiable factors such as poverty may enhance resilience and thereby help to improve mental health outcomes for bereaved parents.\u003c/p\u003e","manuscriptTitle":"Resilience among parents whose child died of cancer–Investigating its role on psychological distress and prolonged grief disorder: Results from a cross-sectional survey in Switzerland","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 05:27:38","doi":"10.21203/rs.3.rs-6311953/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-26T04:38:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-26T02:23:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-24T19:48:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"157796829921909318122402936234912998355","date":"2025-06-03T00:06:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140847475210388362622271195343728440520","date":"2025-06-02T01:31:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-26T14:05:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"279823491842133603867803310704378204231","date":"2025-04-17T12:09:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-03T03:15:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-02T10:38:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-02T10:25:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-27T12:18:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-03-26T11:28:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"86a426bd-8c0c-4b44-8e61-93dae59acb33","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-11T16:01:29+00:00","versionOfRecord":{"articleIdentity":"rs-6311953","link":"https://doi.org/10.1186/s12904-025-01854-8","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2025-08-04 15:57:30","publishedOnDateReadable":"August 4th, 2025"},"versionCreatedAt":"2025-05-07 05:27:38","video":"","vorDoi":"10.1186/s12904-025-01854-8","vorDoiUrl":"https://doi.org/10.1186/s12904-025-01854-8","workflowStages":[]},"version":"v1","identity":"rs-6311953","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6311953","identity":"rs-6311953","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}