This study aimed to determine the effect of mothers' education and skills development according to TSE on their caring behavior for a child with cancer and its continuation in Bandar Abbas Pediatric Hospital as the only pediatric cancer center in the province The present study enjoys innovations in the methodology and application of TSE to enhance the caregiving power of mothers, caring behavior for children with cancer in Iran.
The results indicated that there was a significant difference in the mean score of self-efficacy after the intervention because parents need to be more sensitive to their children's needs and emotions, of the fact pay full attention to their children. The ability of parents to provide adequate nutrition for their children, provide preventive and corrective health care, diagnose the signs and symptoms of illness in children, develop habits to maintain cleanliness, and encourage children to get proper rest time and outdoor activities for their children. These are things that should be considered in children with cancer because of their special needs. This finding is in line with the results of some studies [15–18]. Also, studies aimed at investigating the effect of family-centered education on increasing parental awareness and self-efficacy in weight control and physical activity and caring for a child with asthma and epilepsy, showed that education can increase self-efficacy and improve home care effectively [19–22]. Self-efficacy is a principle that links knowledge and behavior. For this reason, a sense of self-efficacy enables individuals to do extraordinary work using skills to overcome obstacles. Performance requires both skill and belief in the ability to perform that skill. Self-efficacy is a pre-requisite to a behavior; so special attention should be paid to increasing self-efficacy [21]. In the present study, considering that the follow-up was done in two stages with the intervals of 3 and 6 months, the mean scores of self-efficacy in the first and second stage follow-up had no significant differences, which indicates the stability of self-efficacy [26]. Consistent with the results of a clinical trial conducted on the continuation of mothers' breastfeeding self-efficacy, our findings revealed that the mean scores of self-efficacy after educational intervention increased at two follow-up intervals [24]. In contrast, another study aiming to examine the impact of parental education on the self-efficacy of mothers of children with autism showed that mothers' education did not significantly increase their self-efficacy in the first and second follow-ups. The results further indicated that parental education and nurturing skills were not effective in enhancing parental self-efficacy [25]. This difference can be due to little attention to emotional problems of parents, marital problems, the lack of social support during the implementation of the program, and the compactness of the treatment and content sessions, as well as the questions that examine the general feeling of parental self-efficacy rather than measuring parental self-efficacy in managing child problems.
The difference between the mean scores of caring behavior before and after the intervention in the two stages shows the effect of educational intervention to improve mother' caring behavior, which is consistent with the results of other studies [29–31]. Another study on the effect of education of mothers of children with cancer undergoing chemotherapy on prevention of the gastrointestinal side effects of chemotherapy showed that educational intervention had a significant impact on reducing the effects of chemotherapy [6, 32]. An investigation on the effect of educational intervention on the home care behavior of parents having children with cancer undergoing chemotherapy, indicated that the intervention was effective in reducing the effects of chemotherapy [33]. In the present study, the parents received educations about caring behaviors on how to reduce the side effects of chemotherapy at home. The results showed that the educational intervention had an effect on parental caring behaviors, which included reducing the effects of chemotherapy. The second stage findings revealed, that parental caring behavior, in addition to being persistent, was also increased over time, probably due to the experiences they have gained and used during this period. In a study performed on the parents of children with diarrhea, vomiting and pneumonia, the effect of training on parents' performance and satisfaction showed that the training program had a significant effect on parental care Comparing to the control group [34]. Furthermore, in a study designed to empower parents in caring for a child with leukemia, the results indicated that the intervention could be effective in parental satisfaction (especially in the mother) on how to care for a child with leukemia and decrease the side effects of chemotherapy [35]. The result of a study of caregivers of people undergoing bypass surgery showed that the intervention led to increased self-efficacy, improved care behavior, and thus, increased care for patients undergoing surgery [36].
The results showed that with increasing the duration of the study and even after the intervention at the time of follow-up, the mothers' caring behavior was still significantly related to self-efficacy. In other words, mothers are aware of their role in caring for their children and do consider this ability as intermittent. They are able to maintain the continuity of behavior by maintaining and promoting self-efficacy in promoting caring behavior. Bandura argued that people with high self-efficacy are more likely to face challenges that need to be controlled and threats that need to be avoided. Given this confidence, the ability to increase their ability to cope with a variety of challenges will be relatively easier. Thus, as a hypothesis, this sense of confidence for success in solving the challenge is associated with lower levels of negative emotional reactions both before and after intervention [37–39].
The Linear Mixed Model results showed that an increase in family size was inversely related with mothers' caring behavior. In fact, in families with smaller populations, the mothers caring behavior was better and the relationship became more meaningful. In other words, in larger families, the mother could not be more focused on caring for her child, and providing services. This would reduce the mother's caring behavior. In addition, she would not be able to benefit from various trainings to perform caring behavior and overcome obstacles [40, 41]. The number of chemotherapy sessions was also effective in performing caring behavior. However, there is the fact that caring behavior is very important in treatment and chemotherapy is done to reduce the invasion of cancer cells to other tissues. This will be achieved by completing the course of chemotherapy. The data analysis results also confirmed such a relationship. On the other hand, the high number of chemotherapy sessions can be attributed to the severity of the disease and that the mother would be able to accompany the child to perform chemotherapy with more ability due to understanding the severity of the disease [42, 43].
This study had some limitations, including a small sample size that may influence the attendance of all children with a single treatment center as well as the death of patients or discontinuation of treatment, and the difficulty of working with parents with special psychological conditions( including caring for a child with cancer, problems with parenting, and attending classes), as well as having too many questions and distributing questionnaires, and not having a control group to better evaluate intervention.