1. Introduction

Cancer in its definition refers to a number of illnesses characterizing an uncontrollable development of cells that has the ability to destroy normal tissues. Cancer is a major public health issue in the Philippines, as well as in many other countries around the world. By the estimation of the International Agency for Research on Cancer back in 2018, there are reportedly 17 million cases of cancer and 9.5 million deaths related to cancer globally. In the Philippines in 2018, there were 141, 021 cancer cases and 86, 337 cancer-related deaths, according to statistics (World Health Organization, 2020). A Department of Health data from the year 2015 to 2019 accounted 0.25 percent of total mortality in the SOCCSKSARGEN region from cancer in all its forms. These figures show that there is a growing need to focus on cancer patients’ care. A significant shift that involved the health-care system occurred toward the end of the last century, with the goal of replacing hospital care with outpatient care and delegating responsibility for patient care to families; changes such as these in the health-care system made cancer care not an exemption. When a patient is diagnosed with cancer, both the family members and the patients are typically involved in the care process and in making important medical or health decisions (Qalawa, et al., 2015; Hassan, et al., 2016; Nady, et al., 2017; Mohammed, et al., 2018; Said, et al., 2018; Mohamed, et al., 2019; Masaud, et al., 2021; Farag, et al., 2024).

Caring for a patient in the advanced stages of an illness presents significant challenges to the family caregiver’s personal life and can result in changes in all aspects of the individual's life. Individuals in stressful situations tend to assign meaning or explanation to their stressful experiences based on their worldview. Given the goal of palliative care, which is primarily to improve patients’ and caregivers’ quality of life, and in line with development programs aimed at assisting caregivers in providing quality care to cancer patients, examining the various challenges faced by family caregivers is critical. The present study, therefore, was conducted to investigate the challenges faced by Filipino family caregivers of patients with cancer during their caregiving processes (Nemati et al., 2017; Hassan, et al., 2021; Nady, et al., 2018; Atwa, et al., 2019; Abd El Salam, et al., 2021; Ali, et al., 2021; Ramadan, et al., 2021).

Cancer is the leading cause of mortality around the globe, which by the year 2020 accounted for nearly one in every six deaths, with approximately 10 million fatalities recorded. Among the common cancers are those in the colon, lung, rectum, breast, and prostate (World Health Organization, 2022). Cancer affects 189 of every 100,000 Filipinos in the Philippines, with four Filipinos dying of cancer every hour, or 96 cancer patients every day. This is stated in a study undertaken by the University of the Philippines’ Institute of Human Genetics, National Institutes of Health. As reported in the 2015 Philippine Cancer Facts and Estimates, the most common cancer is breast cancer accounting to 20,267 cases and the third leading cause of cancer-related deaths (7,384 cases) among Filipinos, next to lung and liver cancer.

Cancer is among the four epidemic non-communicable diseases (NCDs) or lifestyle-related illnesses (LRDs), which also include type 2 diabetes, chronic respiratory diseases, and cardiovascular diseases. Cancer is a term used to describe conditions in which defective cells divide uncontrollably and invade neighboring tissues. These cells can also metastasize to different areas of the body via the circulatory and lymphatic systems. Non-communicable diseases are now considered a massive “silent disaster” ravaging the Filipino population, claiming 300,000 lives per year, 800 per day, and 33 per hour. It has been compared to “two 747 planes packed with passengers colliding every day” in terms of human cost. Such diseases share several risk factors, which includes inadequate physical activity, an unhealthy diet, use of tobacco, and harmful alcohol use (Flores, 2022).

Cancer cells have evolved mechanisms to avoid being destroyed by the body’s immune system. Researchers from all over the world are working on various strategies to circumvent these complex mechanisms (Diamond Light Source, 2022).

As accounted in the year 2018, with 22.9% of cancers in females and over 2 million cases, breast cancer in women is the most common malignancy and the second most common cancer in the world (Seward and Wild, 2014). Although the prevalence is higher in Western Europe and North America, it’s increasing in developing countries as a result of increased life expectancy, urbanization, and the adoption of Western lifestyles. According to the American Cancer Society (2020), the five-year survival rate of 63% as of 1960 has recently improved to 90%, owing to an early detection of cancer through mammogram screening, as well as improved surgery and adjuvant treatment. As evidenced, breast cancer mortality rates fell to 6.6% in 2018 (Global Cancer Observatory, 2020; Kamal, et al., 2021; Nady, et al., 2018; Elzeblawy, et al., 2021).

When a patient is diagnosed with cancer, it does not only significantly affect the patients but their family members as well. The source of emotional and social support for patients primarily comes from family caregivers. They have a relevant impact on how well patients cope with their illness. Along with these are the increasing cases of patients being left to self-manage their illnesses, which often makes them suffer the debilitating side effects of treatment at home, as hospital stays are becoming shorter. As a consequence, cancer patients’ family caregivers’ burden of responsibility has increased, emphasizing the significance of their role in supporting the patient. This review defines a family caregiver as ‘who the patient says it is'. Thus, FCs can encompass a wide range of relationships, including blood relatives, friends, neighbors, and others. Family Caregivers are indeed an important and valuable source of essential and unpaid support, supplementing other formal health care services (Hu et al., 2018).

A reform from a family-as-patient perspective should be implemented, which includes family caregivers, given the critical role they play in illness management and the recovery of the patient. FCs have a significant contribution on clinical outcomes. Thus, we benefit patients indirectly by supporting family caregivers. Now, the question at hand is how to best assist family caregivers. FCs face a slew of issues and burdens associated with caregiving.

With high morbidity and mortality rates, cancer affect patients and their families in a variety of aspects which places it as one of the most feared diseases. Cancer, as a life-threatening and long-lasting illness with various treatment modalities, forces families to deal with the physical, emotional, social, and financial burden it imposes (Abbasi et al., 2020; Lee Wong et al., 2020). Because cancer affects the entire family, the majority of caregivers for cancer patients were first-degree relatives. Caregivers, also patients, face numerous physical, social, mental, and economic challenges.

Because cancer is a complex and multifaceted disease, a cancer diagnosis in a family member alters the daily routines of other members of the family and exposes them to new situations. As stated in the study of Üzar Özçetin and Dursun (2020), although most family caregivers willingly do these tasks and with a sense of accomplishment for tending to their dear family member, the burden and stress of providing care becomes evident as the caregiving process progresses. Numerous researches have shown that the burden of caregiving has a physical, social, and psychological impact on caregivers’ lives (Hsu et al., 2014; Vahidi et al., 2016; Govina et al., 2015, 2019; Lee Wong et al., 2020).

The struggles of caregivers with the disease process also includes health care procedures, treatment appointments, witnessing the suffering of the patient and approaching death, their constant fear of losing their patient, and financial issues (Abbasi et al., 2020). They may decide to make amends in their daily life routines, business and social lives, take on new responsibilities, or give up previous hobbies, all of which contribute to an emotional effect that causes anxiety and depression (Geng et al., 2018; Govina et al., 2015; Lee Wong et al., 2020).

According to Keramatikerman (2020), identified as one of the world’s most fatal diseases, cancer affects millions of people each year. Newly diagnosed cancer patients may face a slew of unknown difficulties, including physical and emotional issues that may impair the quality of their lives and lead to anxiety and problems specifically depression, and other issues. Patients are not the only ones managing health-related issues; families also play an important role in illness management because their time is majorly spent at home supporting clients. The status of a family caregiver is expected to be a supportive individual who is unpaid that provides medical and emotional assistance in addition to disease treatment.

They deal with cancer at every stage, including diagnosis, treatment, monitoring, and patient follow-up. According to a research, one-fourth of family caregivers of patients diagnosed with colorectal cancer experience varying levels of stress during diagnostic procedures. Unmet needs such as expenses, the burden of the disease emotionally, side effects of chemotherapy and the treatment process may all contribute to stress. Patients’ spouses are the most likely family caregivers to be significantly affected by cancer, with 38.9% experiencing depression while caring for their partners. One more research found that large amount of time spent caring for cancer patients has a greater effect on female spouses than those of their counterpart because aside from illness, additional tasks are carried on by females at home. Apart from that, the fear of the cancer recurring even after survivorship is evident. This makes their level of strain distress increased than that of patients, which also puts them at a higher chance to suffer from cardiovascular and infectious diseases as a result of stress and a weakened immune system (Keramatikerman, 2020).

In the simplest manner, a diagnosis of a certain disease like cancer changes the overall health of not only the diagnosed patient, but also of families and their caregivers. This disease to a person means a pivotal or even life-changing experience that for the whole course of the illness may include distress and other health issues. It is a situation in a patient’s life which alters many aspects of their routines, from roles at the working place, at school if the patient is still a student, and most especially at home. Recognizing these significant changes in someone’s way of living can help them throughout their hardships and provide them assistance when they need it (American Cancer Society, 2022). Not only does cancer scar a patient, it also imposes a burden, economically that is substantially increasing as a consequence of many factors including the expenditure involving caring for a cancer patient. This economic struggle begins right from the moment a person is diagnosed with cancer and is maintained throughout the patient’s disease process (Yabroff et al., 2012).

Although, as research suggests, some family caregivers chose the ineffective coping attitude in the form of avoidance isolation and can be classified as emotional actual and biochemical. The preference of the majority still leans on the effective coping attitude identified as religious asylum, seeking external aid, acceptance cognitive restructuring, and active planning. The experience of caring is perceived by these people to be multidimensional. Caregiving can result in positive outcomes such as a boost in affection and intimacy, personal development, improvement of close relationships, satisfaction, social support from others, and self-esteem, as well as negative outcomes such as psychological, physical, emotional, social, and economic issues (Karabulutlu, 2014).

Evidence from past scientific efforts suggests that family caregivers of cancer patients experience increased levels of negative emotions and psychological distress, which also includes anxiety and depression. A percentage of 46.5 of caregivers manifest anxiety while depression was found in 42.3% of them, according to Geng et al. (2018). Furthermore, Perez-Ordóez et al. (2016) discovered that anxiety can reach up to 76% among them. It is common for cancer caregivers to employ a variety of techniques when it comes to coping that can lessen or may discard the negative effects of depression and anxiety-causing issues; however, some coping techniques may also exacerbate these same problems (Aydogan et al., 2016).

Coping has long been a problem around the world in terms of cancer care. It is the process defined as the management challenges and needs caused by the overall experiences undergone by a person, using behavioral and cognitive efforts to formulate solutions not only to personal dilemmas but also to interpersonal issues, and in the pursuit of stress management and reduction. Coping manages the distress that is brought about by a specific problematic context, through managing issues that cause strain, also by changing the factors that affect stress. Satisfaction is achieved by receiving coping training by which contains learning strategies in coping. As a result, this is evidenced by more efficient approaches in coping. According to research, family caregivers of these patients utilize a variety of techniques in order to cope with the challenges they face (Rachel et al., 2022).

As it can affect anyone in the population, cancer is a disease of major concern. In any parts of the world, unfortunately, specific population groups suffer more from the disease and its impacts. This is referred to as cancer disparities. In order to determine these disparities, we will have to consider aspects such as ethnicities/race, age, sex, and socioeconomic status. In the United States, black American men account for the highest rate for cancer cases than that of women in the country amounting to 484.7 per 100,000 men every year. As compared to women accounting for 419.9 per 100,000 women every year. The same research finds that, with the combination of the different aspects, the diagnosis of cancer and death from it leans on men than women (National Cancer Institute, 2015).

Focusing on Philippine context, the diagnosis of cancer in liver, lung/respiratory, prostate, colon/rectum, leukemia, and stomach are among the common sites in men. On the other hand, in Filipino women, common sites reported are found in the breast, lung/respiratory, cervix, ovary, colon/rectum, and liver (Department of Health, 2012).

According to the Department of Health (2012), it stated that cancer prevalence for both men and women results to 0.3%. It is noted in the publication that this prevalence is elevated in urban areas and occurs greater in higher class populations which was stated to be 0.5% and in the National Capital Region which is 0.5% as documented.

Theoretical Framework

A fundamental concept connected in this study is Jean Watson’s Theory of Caring. According to Watson (1997), the core of the Theory of Caring is that “humans cannot be treated as objects and that humans cannot be separated from self, other, nature, and the larger workforce.” Encompassing Watson’s theory is the entire field of nursing, emphasizing on the interpersonal relationship between the caregiver and the care recipient. The focus of this theory is on “the centrality of human caring and on the caring-to-caring transpersonal relationship and its healing potential for both the one who is caring and the one who is being cared for” (Watson, 1997). Lower-order biophysical needs, such as the need for food and fluid, elimination, and ventilation, are at the bottom of Watson’s hierarchy of needs. The lower-order psychophysical needs are then addressed, which include the need for activity, inactivity, and sexuality. Finally, there are higher order needs, which are psychosocial in nature. The need for achievement, affiliation, and self-actualization are included in this classification.

This study is also anchored on the Transactional Model of Lazarus and Folkman. According to this model, stressful situations are dealt by people by appraisals of stressors and resources. The primary appraisal addresses the individual meaning of the specific stressor, which in this case are the challenges faced by family caregivers. The secondary appraisal examines the individual’s abilities and resources to deal with the situation. Individual coping efforts are employed on this basis to deal with the stressful situation. According to research, caregiver burden typically includes tasks above and beyond assisting with activities of daily living.

The consequences of a care situation are determined by the imbalance between the challenges or difficulties encountered and the resources of the family caregiver. Caring for a cancer patient can result in both positive and negative experiences. Caregiving for chronically ill patients may present difficulties for family caregivers. The difficulties that family caregivers go through are frequently overlooked.

From a scientific standpoint, the hardships that family caregivers face are a theoretical construct. The Transactional Model of Lazarus and Folkman serves as the conceptual foundation for the assessment of the situation. The subjective evaluation of family caregivers’ experiences is critical for the delivery and improvement of appropriate care.

To create an effective discourse, it is necessary to first identify the factors that are central to a person’s stress management and the methods that effectively target these factors. The transaction between people and their external environment is central to the interpretation of stress by Lazarus and Folkman. According to this model, stress may not be a stressor if the person perceives the stressor as positive or even challenging rather than a threat. Furthermore, if the person possesses or is capable of using adequate coping skills, stress may not be a result of or developed as a result of the stressor. As proposed by the model, people can be taught to manage their stress and cope with their stressors. They may learn to alter their perception of the stressor, giving them the ability, strength, and confidence to improve their respective lives and deal with all types of stressors. Stress can result from both negative and positive stressors. The severity and duration of stress vary according to the circumstances and emotional state of the person experiencing it.

Objectives of the Study

The purpose of this narrative study was to investigate and understand the challenges faced by family caregivers of cancer-diagnosed patients. In this research, challenges of the family caregivers will be generally defined as problems and issues that interfere with the quality of care or ability to achieve goals in caring for the cancer patient. Specifically, it aims the illumination of the following: First, what are the family caregiver’s demographic data and the patient’s medical profile; second, what are the challenges faced by the family caregiver in caring for the patient with cancer; third, how does the challenges affect the family caregiver’s lifestyle and outlook in life; and lastly, how does the family caregiver cope with the existing challenges.

Limitations of the Study

The present study was conducted on Filipino family caregivers of cancer patients, regardless of ethnicity and religion, residing in SOCCSKSARGEN region. The results cannot be generalized to caregivers from other nationalities and residents outside the region or to other informal caregivers. Repeating the study on these said groups can help identify context-appropriate coping strategies and the factors influencing them among caregivers and therefore enable the caregivers to provide better patient care and improve quality of life both for themselves and for their patient.

2. Methodology

This section focuses on presenting the research design, role of the researcher, research participants and materials, data collection, and data analysis utilized in the study.

Research Design

This research employed the qualitative phenomenological research design utilizing adapted interview questionnaire technique. The definition of phenomenological study is the approach a researcher takes as means to do an exploration of what people have experienced and how they understand a phenomenon. It is utilized as a form of analysis of the lived experiences of people in the world and to explain the behavior, motivations, and characteristics of people and situations in a target group. This design was used since the study’s purpose was to determine the respondents’ experienced challenges in caring for patients with cancer, how it affected them, and their way of coping with those difficulties.

Role of the Researcher

In the conduct of the study, the researcher attempted to access the thoughts, feelings, and experiences of the participants. It proved not an easy task for the researcher, as it involved asking the respondents to talk about things that were very personal to them. The researcher set aside biases, explicate beliefs, and personal opinions. Securing consent was given by the participants and assured them of confidentiality of information collected and established rapport to acquire trust and in-depth communication.

Research Participants and Materials

This research study focused on determining, exploring, and understanding the difficulties and challenges experienced by family caregivers of cancer-diagnosed patients in order to profoundly comprehend contexts of care especially in complex cases.

Participants were residents of SOCCSKSARGEN region in the Philippines, a family caregiver of a patient with cancer, equally male and female, regardless of sexual orientation, of good mental status, and consent was fully considered. The researcher included a total number of 7 participants, coming from any province in the region. It was considered that the family caregiver’s patient is diagnosed in the III or IV stage of cancer, any cancer types, regardless if the cancer-diagnosed patient was living or deceased. The study utilized an adapted questionnaire that was self-administered by the researcher to the respondents. A one-on-one interview was arranged consisting of open-ended questions that probed the respondents’ experiences which were answered truthfully and with informed consent by the participants.

Data Collection

The respondents were selected using purposive sampling technique from bona fide residents anywhere in SOCCSKSARGEN region.

The researcher first obtained an approval from the Program Chairman of Bachelor of Science in Nursing to commence the research study in the locale. After determining the participants, an informed consent was given to them stating the purpose, goal, and nature of the study with the researcher tending to every question of the participants. A one-on-one interview was arranged by the researcher consisting of questions which were answered by the participants. Each interview lasted for an hour and a half through videoconference and was conducted during the months of June to July. The researcher met the participants once or until sufficient data was gathered. Afterwards, the data collected was analyzed using thematic analysis. All materials, methods, and data gathered were subject for scrutiny to obtain approval from the research ethics board.

In the course of the one-on-one interview as the mode of data collection, an informed consent was obtained and secured in accordance with the Data Privacy Act of 2012 otherwise known as Republic Act No. 10173, thus maintaining confidentiality.

Ethical Considerations

Ethics refer to governing moral principles which influences the behavior of a person or the conducting of an activity. In order to adhere to the ethical standards of research throughout the duration of the study, the researcher followed appropriate steps.

Before the conduct of the study, the participants were made fully aware and informed of the background and purpose of the research they are participating into. A voluntary informed consent was obtained containing additional information as to the benefits, risks, and expected outcomes of the study. The informed consent letter contained adequate information and emphasized on the participant’s choice on whether or not to enroll in the study. The letter also provided assurance to the participants that no human rights shall be violated, their privacy upheld all of the time, identities and interview answers remain confidential throughout the research study.

Conflict of Interest. The conduct of this study upheld the highest ethical standards and credibility. The researcher made sure there are no conflicts of interest throughout the research study. The researcher was responsible for all expenses spent throughout the study.

Informed Consent Process. In this study, participants were given the freedom to participate or decline after the researcher has adequately provided all relevant information related to the study, its purpose, and method of collecting data. An informed consent form was obtained after a thorough explanation of the research has been provided. In the informed consent formed contained necessary information relevant to the study and the participant’s cooperation in the research. It stated that the participation is voluntary and the participants were given the time to decide and ask questions to the researcher.

Confidentiality. In line with this, everything the participants provide in the conduct of this study such as interview answers and/or records will be kept confidential. Any information obtained related to the participants and the patients with cancer will remain private, only the researcher and the participants have access to in the exception of the events which prove significant of protecting the participants’ rights and welfare.

Potential Risks, Adverse Events and Discomforts. Along the course of the interview, the participants may feel discomfort and feelings of sadness brought about by the sensitive nature of the topic. If the participants feel the questions being asked towards them make them feel uneasy, uncomfortable, or bring to them emotional distress, the participants have the right to reject answering and withdraw from the study. This study emphasizes the participant’s welfare and dignity throughout the study.

Potential Benefits to Participants, Respondents, and/or to Society. As a result of the endeavors of this study, the struggles being faced by family caregivers caring for cancer patients will be profoundly understood, thus, opportunities for better policy making in government will be realized, betterment of providing services and care in the nursing profession, newfound information that may be incorporated in the education of nurses, and acceptance and empathy in our society.

Participation / Withdrawal of Participants / Respondents. The participant’s participation is voluntary. Their refusal to participate will involve no penalty or loss of benefits to which they are otherwise entitled. The participant may withdraw his/her consent at any time and discontinue participation without penalty. They are not waiving any legal claims, rights or remedies because of your participation in this research study.

Data Analysis

The data gathered and utilized were analyzed using thematic analysis to arrive at main themes exploring the challenges faced by family caregivers in caring for cancer-diagnosed patients. The socio-demographic details were presented in a table format showing the participants’ and patients’ relevant personal data.

Thematic Analysis’ accessibility and flexibility makes it an increasingly convenient and popular analysis of qualitative data (Braun & Clarke, 2006). In the course of the analysis, the researcher first had a familiarization of the data collected from which generation of initial codes will originate. The researcher probed on relevant information using inquiries of their personal data, lived experiences, and how they managed through the adversities. Afterwards, themes contained in the data were determined and reviewed extensively by which were defined at the last part of the analysis. From the raw data arose codes that were later grouped and identified as themes that explained and answered the study’s queries. This method places emphasis in the identification, analysis, and interpretation of patterns contained within the qualitative form of data.

Validity

In this study, validity and reliability of the study were examined thoroughly by the researcher and the criteria suggested. To establish credibility, the researcher has had adequate cooperation and engagement with the participants. Reviews were implemented by the help of the research adviser and the adviser’s additional comments were also used. The researcher checked the dependability of the data through performing activities such as consultations with the research adviser for material review. Confirmability had been done by diminishing, as much as possible, all presumptions and prejudices. The findings’ validity was also verified by the study’s participants.

3. Results and Discussion

This chapter focuses on presenting the results synthesized following the conducted one-on-one interviews with the participants. This part includes presenting the findings of the interviews, the themes with which emerged from those accounts, and discussions of each related topic. Also, this chapter offers a description of the obtained results of the study. Throughout the conduct of the interviews, the participants of the study were freely given the choice to converse their thoughts, experiences, and insights in the language of their preference or what we refer to as ‘mother tongue’. In accordance with the aims outlined in this research, the results of each research question are further discussed.

The sociodemographic characteristics of the interviewed family caregivers are described first, followed by the medical profile of patients diagnosed with cancer, and thereafter the results and themes of the succeeding research questions are presented. In this current study, there are eight (8) emerging themes identified; Physical Burden, Psycho-emotional Burden, and Spiritual Crisis transpired from the experienced challenges of family caregivers; Significant Human Relationships, Changes in Lifestyle, and Spiritual Coherence came up in exploring the outcomes of caregiving in their lives; and Active Coping, and Social Support as the family caregivers’ coping mechanisms in the context of caring for the patient with cancer.

Socio-demographic Characteristics

The sociodemographic characteristics of the participants and the profile of the patients diagnosed with cancer were gathered through the one-on-one interviews with the aid of the semi-structured questionnaire. The data gathered in this section rightfully contribute to the analysis of the results of this study. The sociodemographic details of the interviewed participants are separated from that of the details of the patients with cancer and are discussed further in this section. In this part, the researcher put into account significant information pertaining to the context of care of family caregivers such as length of caring for the patient, the estimation of expenses at the period of care, and the membership of the patients in any insurance plan. Also, the cancer patients’ demographic details and medical profile are laid out to identify their diagnosis, when were they diagnosed, and other pertinent data.

Socio-demographic Details of Interviewed Family Caregivers. Of the 7 participants in this study, 4 of the family caregivers were male and 3 were female. The majority of the participants range from the ages 22-32 years old which accounts for 5 of the family caregivers. The remaining 2 participants age from 39-42 years of age. The youngest participant was 22 years old and the oldest participant in the sample was 42 years old. With regards to their ethnicities, 5 family caregivers are Ilonggo, while 1 participant as Ilonggo-Ilocano, and the other 1 identify as Mandayan-Tausug. In the aspect of religion, among the 7 family caregivers, 4 are Roman Catholics, 1 is a member of the Iglesia Filipina Independiente (IFI), 1 participant belong to the Islam religion, and 1 participant belonging to the Alliance Church. Pertaining to their marital status, 5 participants are single, 1 participant is married, and 1 is widowed.

The sample consisted of 3 individuals who are unemployed, 2 participants reporting they were still a student at the time of rendering care to the patient, 1 participant was self-employed, and 1 was employed as a nurse. Aside from the role of being a caregiver, 4 family caregivers are children of the cancer patient, 1 participant is the patient’s grandson, 1 participant being the patient’s wife, and 1 participant is a nephew. Upon investigation, all 7 participants involved in this study cared for the cancer patient in a span of 1-3 years. At the time of the illness and its progression, both the family caregiver and the care recipient lived under the same home. All of the participants (7) stated that they own the house they live in.

Having to juggle work and life situations is no easy task for family caregivers especially that they are faced with a daunting challenge in caring for a cancer patient. As discussed in the study of A. Fuchsia Howard et al. (2022), deciding on whether to seek or revamp their employment or stay unemployed to focus solely on caregiving can result to a sense of loss or grief. This situation does not entail a voluntary choice or move for the family caregivers but rather a decision mostly considering the welfare of the terminally-ill patient. In the study’s sample, most participants committed to the service of providing care to their loved ones diagnosed with cancer.

Among 7 participants, 3 reported to have an estimated monthly income of 30,000 and above, 2 individuals were earning 8,000 to 15,000 per month, and 2 participants with a 15,000 to 30,000 income. With the diagnosis of the patient with cancer came the cost of treatment and other necessities for the patient, majority or 6 participants estimated that they spent 10,000 and above for expenses every month, with only 1 reporting they spent only between 5,000 to 10,000 every month. With this, cancer patients of 5 family caregivers had health insurance specifically PhilHealth.

The emergence of financial struggles may come from expenses in treatment and other necessities that are not covered under government universal health care assistance or private insurances. According to Abrams et al. (2021), indirect costs that may involve transportation and living expenditures contribute to the escalating expenses and in turn these situations offer burden and somehow distress to many families. Enrolling the patient into an insurance plan may alleviate costings, which in this study, proved worthy for family caregivers in supporting them amid financial hurdles.

Table 1. Socio-demographic Details of Interviewed Family Caregivers

Table 1.1. Socio-demographic Details of Interviewed Family Caregivers

Medical Profile of Cancer-diagnosed Patients. Along with the acquisition of demographic details in family caregivers, the researcher also gathered information related to the cancer-diagnosed patient and their medical profile. Family caregivers delivered care to cancer-diagnosed patients with which they are closely related to, among which, as results show, were 6 female and 1 male. Data gathered showed that 3 of the cancer patients belong in the age bracket of 33 to 50 years old. Meanwhile, the remaining 4 participants age between 52 to 65 years old. In these results, we can refer that the youngest cancer patient in the sample is 33 years old and the oldest cancer patient is 65 years old.

Unfortunately, 6 of these patients are now deceased and can no longer be with us. The deceased patients already passed between 2-11 years ago. 7 of these patients belong in the Ilonggo ethnic group, with only 1 identifying as Waray-Tausug. As compared to the religious affiliation of the family caregivers prior to this section, 5 belong to the Roman Catholic Church, 1 belongs to Islam, and 1 was a member of the Alliance Church. In the beginning of the interview, the family caregiver reported the medical diagnosis of their patient; 1 Stage III Colon Cancer, 1 Stage III Rectal Cancer, 1 Stage III Cervical Cancer, 1 Stage IV Rectal Cancer, 1 Stage IV Breast Cancer, 1 Stage IV Ovarian Cancer, and 1 was diagnosed with Stage III Lymphatic Carcinoma. These patients were diagnosed, majority (4), way back the year 2019, and the remaining from the year 2012, 2013, and 2018.

Table 2. Medical Profile of Cancer-diagnosed Patients

Table 2.2. Medical Profile of Cancer-diagnosed Patients

Challenges Faced by Family Caregivers

A defined goal of this research is to explore, investigate, and analyze experienced challenges of family caregivers in caring for the patient with cancer. In this study, participants gave self-reports of the challenges they have undergone through the one-on-one interviews. To examine the challenges of caregiving for the cancer patient, the researcher looked at different perspectives as evidenced by extracting both positive and negative aspects of their experiences. Caregiving challenges are intertwined with the physiological and psychosocial effects of caregiving towards the caregiver.

Three (3) emerging themes were identified that categorized the challenges of caregivers in caring for the patient with cancer; Physical Burden, Psycho-emotional Burden, and Spiritual Crisis.

Physical Burden

In this research, physical burden pertains to the observable negative occurrences, constraints of many forms, and disruptions which are directly connected to the patient’s condition. The role of caregiver consists of tasks that needed to be carried out to care for the patient. These tasks came difficulties that the family caregiver would have to live through in order to adequately provide service to the care recipient. Under this major theme emerged three (3) subthemes identified as Decline in Physical Health, Disturbance in Sleep Patterns and Increase in Physical Demands.

Decline in Physical Health. A number of participants shared that the situation had significant burdens and consequences on their physical health. Their role as caregiver negatively influenced their physical health to the extent that some participants suffered weight loss and exhaustion brought about by lack of rest and sleep, among others. The main reason for this is the caregiver’s change in routine to accommodate new responsibilities.

During the one-on-one interview, participant 7 expressed:

“May mga joint pain, back pain na ko because of lack rest and sleep, and maybe lack of nutrition pa kay wala na ko gana magkaon. Kulang pa gid sa tubig, so, na-alter gid ang akon health kag immune system.”

Translation

“I had joint pain and back pain because of the lack of rest and leepand maybe due to lack of nutrition because I was not eating adequately. It definitely altered my health and compromised my immune system.”

Participant 6 also expressed:

“Sobra na gid ka kulang ang tulog ko. Naapektuhan man ang pagkaon ko tungod sa kulang tulog kag malantaw ko kung gis-a sarili ko sa salamin daw silhig na ko. Nagsobra pa gid pagniwang ko sato.”

Translation

“I extremely lacked enough sleep. My eating habits was extremely affected because of the lack of sleep and I can already see myself in the mirror how much weight I had lost. I lost much weight that time.”

According to published studies, the association of being a family caregiver and physical health are well-established. In relation to this, accepting responsibilities in caregiving proved stressful and burdensome in participants. This progressed into physiologic changes and impaired health habits which affected them to an extent. As stated by the National Council on Aging (2022), to alleviate stressors, caregivers must recognize that their health must also be a priority.

Disturbance in Sleep Patterns. Upon examining the participants and their difficulties in providing care, the reports show that participants experience the lack of appropriate sleep related to the patient’s care. In the period of care for the patient, participants found it difficult to sleep for long periods of time due to the demands of their patient’s condition. Another factor that influenced their sleep was the lack of assistance to relieve them of their caregiver duties for the night. Throughout the night, cancer patients most often feel pain and need assistance in repositioning or addressing issues in continence, thus requiring monitoring and in turn disrupting caregiver’s sleep.

Participant 1 shared her sleep disturbances while caring for the patient.

“Satong nag-atipan ko kay mama, wala ko tulog halos pirmente. Kapoy pa gid siya kay waay sing may magbulos sa akon kaayo sa pagbantay kay mama.”

Translation

“At that time I cared for my mother, I haven’t had enough sleep always. Also, I was exhausted because there was no one to relieve me of my responsibilities.”

Participant 1 added:

“Budlay man pa gid mag-atipan lalo na kung kulang ka sa tulog kag hindi tarong ang imo kaon kag labaw sa tanan nang kapoy ka.”

Translation

“Indeed, it was difficult to render care especially if you lack sleep and can’t eat properly and most importantly exhausted.”

Another participant (P3) responded: “Pati akong pagtulog ato kay putol-putol, daw wala koy eight hours straight nga tulog kay biskan matulog ko taud-taud mamukaw na na siya. Murag tulog manok kaayo ko ato.”

Translation

“My sleep was always interrupted, I didn’t have eight hours sleep because my mother kept on waking me to tend to her needs.”

Participant 4 revealed in her statement:

“Pwerti ka kapoy, siguro makatulog lang ko mga minutes lang, mga half hour lang siguro mga amo-amo lang gid na adlaw-adlaw sa one year ko nga alaga sa iya.”

Translation

“It was extremely exhausting, I only got the chance to sleep for minutes to half an hour everyday in a year that I cared for him.”

Participant 5 shared in the interview:

“Gina-agwanta ko nalang eh, di ko katulog kay dugay-dugay lantawon mo naman kung nagaginhawa pa siya. Makatulog ka pero dugay-dugay batyagan mo naman siya nga gabatyag sakit. Gapanawag nalang ko kis-a nga buslan ko para katulog ko pila ka oras pagtapos kay ako naman magbantay.”

Translation

“I endured the inadequacy of my sleep and having to check from time to time if he was still breathing. I sleep for some time but I always check if she feels pain. I call for assistance if I wanted to rest and sleep and afterwards I continue working.”

Participant 6 stated briefly in his interview:

“Sobra pa gid ka kulang na ang tulog ko.”

Translation

“I, indeed, was not having enough sleep.”

In the care process of a person diagnosed with cancer especially in the terminal stage of the disease progression, the occurrence of sleep disturbances is highly evident and can be easily emphasized by family caregivers. There are factors that came to play in the disruption of their sleep routines. Those were the presence of caregiver burden and responsibilities required for the care and safety of the patient, and it was also influenced by their physical status and feelings of sadness. According to a study conducted by Byun et al. (2016), parameters of measure manifested short sleep durations and the frequency of night awakenings which in turn can contribute to negative health outcomes.

Increase in Physical Demands. Physical demands refer to the activities involved in the care process of the cancer patient for which the family need to deliver to ensure safety and comfort for the patient. These includes an array of tasks such as assisting the client in activities of daily living such as bathing, eating, dressing, toileting, and many others. Some participants stated that their roles included tasks which were somehow difficult for them to accomplish. The patients needed to be repositioned from time to time to avoid bed sores, to alleviate pain, and to provide comfort. This proved burdensome for some participants and it required assistance from others to accomplish the task.

In the interview, Participant 1 stated that:

“Ako halos tanan ga-assist kay mama sa iya mga gawi. For example, sa pagpaligo sa iya, pagpakaon kag kung ano pa himuon sa iya lalo na kung iplastar siya sa higdaan kay bug-at abi ti mangayo lang ko sina bulig maghakwat sa utod ko. Ako man nagaluto sa kung ano kaunon ni mama tapos gusto niya abi ako mabantay sa iya kag ako man that time ang available.”

Translation

“I assisted my mother in her daily activities. For example, I would bathe her, feed her, and reposition her in her bed with the help of my siblings. I was also tasked to cook for my mother because she wanted me to take care of her.”

A participant (P2) revealed in his account:

“Kaka-graduate ko lang nun, kailangan pag-graduate mo pahinga ka muna, syempre yung katawang lupa mo nasa schooling pa after that nagka-obligations ka na bantayan yung lola mo na cancer patient at tsaka physical din kasi nakakapagod gumising ng maaga para pumila sa mga consultations at chek-ups, kung ano na yung report ng mga nangyayari sa katawan niya.”

Translation

“I just graduated then when I accepted my role as caregiver. Immediately, I had this task to be my grandmother’s caregiver and it’s physically demanding because it’s exhausting having to wake up early to queue for consultations to monitor her progress.”

Participant 3 also shared:

“Ang magpaligo sa iyaha, isa man pud na nga struggle kasi katung pag-abot nako sa iyaha, ano naman gud siya kanang nagahigda na ba, lisod na sa iya magtindog so mao tung igsoon niya sa Davao katabang nako magpaligo pero tung time nga murag di na niya kaya kay kung magpaligo tugnawan na kaayo siya. Gina-ano ko nalang siya ginapunas tapos kanang mag-tootbrush siya di na man kaya sang lawas niya kaya gina-punas-punas nalang nako siya.”

Translation

“One struggle I went through during those times was bathing her. She was already bedridden when I took care of my mother and I had the privilege of having my mother’s sibling in helping me bathe her. She already cannot tolerate the cold of taking a shower and in regards to her hygiene practices, I just wipe her mouth with a clean cloth and also wipe her body with a clean cloth.”

The participant added:

“Sobra ka physically demanding ang obra. Kay usahay mag-ingon ako mama nga magpaluto siya kanang naa siya nga requests nga kailangan nako i-attend, usahay tubig, tapos kanang di gud niya mapunggan nga maka-bowel siya. Kung mag-change ko diaper no, mga after ten or thirty minutes naa na pud. Somehow makaingon ko nga physically strained ko kay wala koy idea ba unsa ba ang proper like unsaon ba nako pag-approach nga di siya masakitan.”

Translation

“It was physically demanding. Sometimes, my mother would have requests which I need to attend such as water or continence issues. I had to change her diaper every after ten to thirty minutes. Somehow, I can say I was physically strained because I didn’t have the idea on how to approach the situation to avoid causing discomfort.”

Participant 6 shared in his interview:

“Ang pulaw, ang pagpangita sang pagkaon nga gusto niya kag ang scheduling sang pagbantay sa iya. For example maligo siya, ti syempre babae kag magpailis sa iya kag kung tapos na siya maligo, kung magkaon na, ako naman na. Lutuan ko siya kag kung gusto niya maglakat sa amo ni ga i-wheelchair siya. Sang mga months before siya napatay, gina-assist na siya sa iya mga paggawi. Ako na nagahungit sa iya kung magkaon siya.”

Translation

“I experienced challenges like staying up at night, finding food appropriate for her and tour schedule in caring for our patient. For example, when she needs to bathe, my female cousin is the one tasked in that and afterwards I would take charge in feeding her. I would cook for her and take her to places she desires. Months before her demise, I assisted her in her hygienic practices and feeding.”

Terminally-ill patients are the type of care recipients which are technically demanding in terms of the provision of care. They require more tending to, attention, comfort measures, and interventions related to securing their safety and towards the direction of stable health. The patients’ self-care activities were of the most attention-required aspect of the participants’ caregiving duties. We classified these family caregivers as belonging in the “high burden” classification of informal caregivers. These manifestations meant that increasing burden in family caregivers could exacerbate existing conditions and compromise their health status (Darragh et al., 2013).

Psycho-emotional Burden

When an individual is put into a significant position of being chosen as a caregiver for a patient diagnosed with cancer, different facets of care must be put to consideration. In the care of such patients, if objective burdens are present, it is automatically understood that these burdens create consequences on the psyche of a person (Ton, 2012). In a manner, the exhaustion of participants with their roles often led to emotional disturbances. Therefore, we can infer that physiological burdens can exacerbate emotional distresses. Under this major theme emerged two (2) subthemes; Personal Stresses and Anxieties, and Regret of Wanting to Provide More.

Personal Stresses and Anxieties. Focusing on providing care for the cancer patient may provide emotional exhaustion to the family caregivers. This, in result, led to caregivers losing track or neglecting their emotional health. Participants stated that somehow, they were overwhelmed of the situation due to the constant demands of the condition and worrying for their loved ones was common. The family caregivers expressed feelings of sadness, anxiety, and stress from the burdens of caregiving and the responsibilities tasked upon them. Participants showed concern that certain behaviors would lead to the development of depression as in some cases they become irritable and reluctant to socialize as a result of exhaustion from caregiving. In some cases, it created unrealistic expectations in family caregivers that when not met can result in worries or in the worst scenario, anxiety.

One participant (P3) revealed that:

“Ang akoang dako na struggle is how to stay firm and unaffected while attending sa iyahang situation kasi nga I really cannot yung maging emotional kaayo ko while attending kay di siya gusto.”

Translation

“My biggest struggle was how to stay firm and unaffected while attending to her situation because I cannot really take it being emotional while attending to her mainly because she doesn’t approve of it.”

He (P3) added:

“Naa puy kaisa nga nag-breakdown ko pero wala ko nag-breakdown nga nakita niya, siguro dira lang ko nag-breakdown kung mag-CR ko kasi nga maluoy ko sa akong mother at that time sa iayahang situation.”

Translation

“There was a moment that I had a breakdown however I didn’t let her see my vulnerabilities because I felt pity towards my mother.”

Another participant (P4) said:

“Unstable ko, kay that time wala na ko obra. Ti tapos may bata ko diin ko kuhaon ang ibuhi ko sa iya kag tapos paano na ko kag if ever ano matabo, nahadlok ko sato kay wala tana tatay akon bata. Daw nahadlok ko sato mag-isa ba. Ang doubt nga makaya ko ba kung wala akon bana.”

Translation

“I was unstable that time because I had no work. Apart from that, I have a child to provide for and if anything ever happens to my husband, I was afraid my child would grow up not having a father. I was afraid of being alone. I had doubts on my capability if my husband ever dies.”

Participant 4 also stated that:

“Tapos that time, daw naga-suffer ako, perti gid akon kasubo. Daw gusto ko nalang mag-abat sa iya satung napatay na siya. Kalain-kalain gid tana. Gamay lang nga kibot grabe na ang epekto sa akon. Naging irritable takon tapos satong natabo sa bana ko.”

Translation

“And then that time, I suffered extreme sadness. I wanted to go with him in the grave. It was an awful feeling. I became irritable and sensitive to shock after what happened to my husband.”

Participant 5 in the interview said that:

“Biskan totally damaged na gid ko, gina-heads up ko lang gid sarili ko nga kinahanglan ko maging matatag para sa nanay ko.”

Translation

“Even though I was damaged internally, I always keep my head up and stay firm for my mother.”

Participant 7 stated that:

“Daw kabudlay taking care of your mother na syempre your own blood. So amo na ang mga challenges na piliton mo ang sarili mo nga i-care siya pero bug-at kay makita mo ang iya suffering.”

Translation

“It seemed daunting taking care of someone especially if it’s your own blood. That is one of the challenges hatyou have to endure whilst caring for your patient and seeing that person suffering.”

He added:

“Syempre normal lang naman magka-anxiety or mild sadness pero hindi gid siya ma-diagnose nga depression pero sadness kag loneliness, part gid siya sang grieving process.”

Translation

“I thought it was normal to have feelings of sadness and anxiety, however, we can’t diagnose it as depression but it was a part of the grieving process.”

Participant 7 further expressed that:

“There was a time nga gusto ko naman magmukmok nang daw kumbaga wala na pag-asa. Biskan gani cellphone ko di ko na masapak so mapabay-an ko na friends ko pati mga reminders sa work ko.”

Translation

“There was a time that I wanted to isolate because I kind of lost hope. I was not able to tend to my friends and reminders from work.”

In this study, participants reported to experience distresses in their mental health. The psychological health of the carer can be negatively affected in their provision of care. They were exposed in vulnerability because the demands of caregiving may tax their mental health. Family caregivers ought to engage in preventive health behaviors as to not neglect their own mental health (American Psychological Association, 2015).

Ethical dilemmas brought about by the caregiving situation of the individuals created stress and basically another challenge the individuals had to overcome. Moral distress is a topic that has been increasingly prevalent in healthcare discussions and also proved important in the cases of this study’s sample. In some participants, morally troubling situations led to distress as they were torn apart conflicting sides. Prior to accepting the role of being caregiver to the cancer-diagnosed patient, the participants were bound to tasks different from that of their current role as family caregiver. It was noted that caring for a loved one with cancer, the service they provide is unpaid and was done purely out of love, concern, gratitude, and compassion. Participants expressed changes to their everyday roles. Some participants related to managing their roles of being an income-earner and a family caregiver. Participants emphasized that there was prioritization and management to accommodate their expanding responsibilities.

As compared to the study of Longacre et al. (2019), there are similarities of ways family caregivers approach the care of patients with cancer. Caregivers trying to balance earning to provide needs tend to deliver shorter hours of care than those unemployed family caregivers focused solely in the caregiver role. However, the demand of assistance for the patient’s ADL seem to be equivalent. Still, the feeling of burden for these caregivers loom over them.

Participant 7’s experience on balancing work-caregiving responsibilities as stated was:

“Kailangan ko mag-work para ka-income pero amo na gani kailangan ko man atipanon akon mother, I also experienced nga daw kulang ang ginahatag ko sa company where I was working. Pero since I am a nurse, bal-an ko paano i-counteract or i-process ang mga naagyan.”

Translation

“I had to work to earn income but I also had to care for my mother. I also experienced feeling inadequate at work but since I am a nurse, I know how to counteract and process what I have encountered.”

One participant (P6) also expressed a similar concern:

“Sa routine ko sa pang-adlaw-adlaw, dako gid ang effect eh. Kay parehas sina halimbawa, kailangan ko i-juggle magbantay sa tiya ko kag sa obra ko sa amon uma. Hindi na ko makabulig-bulig kay papa sa uma namon sa kung ano man pwede mabulig kay diri nalang gid ko. Diri lang gid naglibot-libot ang kabuhi namon sa mga panahon nga to.”

Translation

“It had a great effect on my everyday routine. Say for example, I had to juggle being a caregiver and help my father in our farm. I cannot help my father in farm work because my life revolved around caregiving.”

Participant 3 added to the discussion:

“Kasi at that time estudyante pa ko diba, I’m about to finish my thesis man gud, habang nag-attend ko sa iyaha, dili nako mabuhat-buhat akong paper. Nakaingon ko ato nga unya na nang thesis nga ni, unahon sa nako ang kinabuhi sang akong mother.”

Translation

“Because at that time, I was still a student and about to finish my thesis. I was not able to work on my thesis while tending to her and I decided to set aside my thesis work and prioritize my mother.”

Caring for a patient diagnosed with cancer is a tough obstacle for any person to encounter, especially coming to terms with the patient’s imminent demise and confrontation with the deterioration of their condition. The participants’ definitiveness and realizations of the situation that their patients will consummate with the inevitable and would no longer improve resulted to the gradual acceptance in the caregiver and the family.

While caregiving for the patient, Participant 3 realized:

“Sa point gud nga ato, murag na-accept ko na nga cancer for me is murag ang pinakatraydor nga sakit so murag na-accept nako to. Sa tanan gid nga tabang nga gihatag nako sa iya, nga sa kapahuwayan na gud siya padulong, murag mao gud na ako na-realize.”

Translation

“At that point, I accepted that cancer is a treacherous disease and although I was hurt, I accepted the situation. All of the care I had given to her, I understood that she was headed to the inevitable.”

Another participant (P5) added:

“Although hindi man makaya, kung gis-a gatalikod nalang ko pero ang perseverance kag hope nga tani maging okay man. Wala kami sing iban nga mabuhat kundi magpangamuyo nga tawhay man ang iya nga pagplastar someday kay sa paglala sang iya sakit, daw ma-amat-amat na namon baton ang kamatuoran.”

Translation

“Although it was difficult, sometimes I had to turn away but I insisted on having perseverance and hope that everything will be fine. We cannot do anything else but to pray that she would find her refreshment someday because during the progress of her disease, we gradually accepted the truth.”

Participants of this study dedicated their time, effort, and energy to achieve ways in managing the health and safety of their patients. As a result of this, their lives often, if not always, revolved around the complex situations of caregiving, thus, rose problems such as exhaustion, feelings of anxiety, feelings of intense stress and withdrawn from the world. Also, as expressed by the participants, they balance the weight of professional responsibilities and the significant role of caregiving. This aspect is under-acknowledged or often taken for granted in many health-related discussions. Dealing often with the toll of accepting the end stage of the patient were one of the struggles the caregivers had to internalize (Carewise Solutions, 2023).

Regret of Wanting to Provide More. Manifestations of regret relate to the family caregiver’s feelings of inadequacy, later realizations pertinent to the provision of care towards the patient, and personal exhaustion. In this case, regret revolved around the concept of end-of-life care and bereavement. Participants reported in the interviews that regret sourced out from some things they were not able to do for the patient, and not insisting on providing even more adequate care for them.

Participant 1 shared in her interview:

“Naapektuhan man ko emotionally, feel ko abi wala gid ko nakabawi kay mama kay satong nagmasakit siya wala pa ko ka-graduate. Nag-wish ko nga tani man lang naabutan niya ko mag-graduate. Nanghinayang ko sa part nga tani dugay pa siya nga upod ko para mahatag ko man ang mga gusto niya.”

Translation

“I was affected emotionally because I felt I never had the chance to give back to my mother and the fact that I haven’t graduated yet. I hoped that she would still be alive if I graduate. I regretted that I didn’t get to be with her for a long time to be able to provide for her.”

Another participant (P7) shared:

“Looking back, daw kulang pa gani ang care or time nga nahatag ko sa akon mother kay naga-work bi ako samtang naga-care man sa iya. Dapat tani nag-leave nalang ako. Kung tani mas dugay ko pa siya nabantayan kay para matutukan ko gid siya.”

Translation

“Looking back, I hope I delivered much adequate care for my mother because I was working while caring for her. I realized I should have filed for a leave from work so that I had focused on providing care for her.”

Spiritual Crisis

Participants had an experience of disturbance in harmony and conflict between their hopes, values, and beliefs in the Almighty that led to crisis in their spirituality. In their statements, they accounted that they questioned the reason why their patient was diagnosed with such an incurable illness and that medications aimed to alleviate the patient’s symptoms cause little to no effect. This shortfall of treatments directed an indifference in family caregivers on the improvement of the cancer patient. The disorder in their belief system then emerged two (2) subthemes identified as the Inability to Justify the Disease and Futility of Treatments.

Inability to Justify the Disease. Upon examination of the sample of family caregivers in this research, results show that they were finding it difficult to comprehend the reason behind the affliction of the disease on the patient. In relation to this, they questioned God on the cause of the disease. As family caregivers, they tend to seek answers to their inquiries and shed light into their doubts and fears.

Participant 5 told the researcher:

“Tanan kami that time nag-abot sa gin-question namon ngaa si nanay? Kag ngaa amo gid ni nga sakit kag si nanay pa gid? Na-question gid na namon that time.”

Translation

“All of us that time arrived in questioning why our mother was diagnosed with cancer? Why must it be our mother and why cancer? We questioned that at that time.”

Participant 7 also shared a similar experience:

“Sa una, sa denial kag anger stage nakahambal gid ako nga ngaa si mama pa Lord? Sa kadamo-damo sang sakit ngaa cancer pa gid nga indi mabulong?”

Translation

“At first, I was in denial and angry because why does it have to be my mother. Of all the diseases, why does it have to be cancer which is incurable.”

If ever placed in a position of caring for someone diagnosed with cancer, always put in mind to always prioritize what is urgent and necessary. Family caregivers were within their loved one’s best interest. Therefore, placing their utmost trust in their care providers (Burow, 2019). Their expressed feelings in the interviews regarding wanting to provide adequate care because they felt they lacked in it were not justifications that they were incompetent. Rather, they were constrained by the new experience of caregiving, and the limits caused by the patient’s condition.

Futility of Treatments. Along the cancer trajectory of the patients, family caregivers found some medications or treatment regimen ineffective or unable to prolong comfort in cases of the attack of severe pain. This does not fulfill the intended goals of care for the patient and thus creates an assumption in the minds of the caregivers that improvement of the cancer patient is far from reachable.

Participant 5 shared in her interview:

“Nag-abot gid kami sa point nga halos tanan kami nag-give up na kay everytime nga mabatian mo ang hibi kag sakit nga mabatyagan niya, hindi ka man katulog kay bisan ano mo siya kahatag sang bulong, useless gihapon. Daw di enough nga para madula ang sakit nga ginabatyag niya.”

Translation

“We got to a point where almost all of us gave up because we can hear her cry and suffer from pain. In turn, I cannot sleep because whatever medication we were giving, it was useless. The medication was not enough to alleviate the pain she was feeling.”

There was much difficulty in the part of the care provider to witness the patient suffer the complications of their illness. This aspect discussed a major issue concerning end-of-life ethical decision-making. It was also difficult for family caregivers to experience and gradually realize that treatment regimens for their patient no longer serve its purpose and was becoming pointless. In the study of Aghabarary (2016), it has reached a state in which medications can no longer delay or ignore a patient’s imminent death. It is particularly difficult to absorb as being a caregiver on how to process with the reality and coping up with such.

Table 3. Challenges Faced by Family Caregivers

Outcomes of Caregiving on Family Caregivers

One of the goals of this study was to explore the results and consequences of cancer and the role of caregiving in the lives of the family caregivers. Upon the diagnosis of the patient, it does not only influence the patient but also the caregiver and can cause multifaceted outcomes on the lifestyle of the individual. These can affect the family caregiver’s effectiveness and functioning which can make them lose control of their lives. According to Litzelman (2019), caregiving plays a great influence on caregiver well-being and this may contribute directly or indirectly on the quality of care given to patients. This is due to the provision of the family caregiver of different supportive functions and assistance with care-related activities. This study recognizes that cancer influences beyond that of the diagnosed patient and there is growing need to provide continuous support to family caregivers. In this study, the participants expressed the dimension of having to confront the ripples of caregiving and how it caused changes in their lives. The major themes developed under this aspect of the study are Significant Human Relationships, Changes in Lifestyle, and Spiritual Coherence.

Significant Human Relationships

Forming and maintaining relationships among other people is critical in developing a positive environment. Nurturing this environment facilitates opportunities for growth and achieving connection with one another. In the context of caregiving for the cancer patient, relationships proved important in alleviating burden in caregivers and the flourishing of close ties that rose from the phenomenon of caregiving. This major theme has one (1) identified subtheme namely Strengthening of Bonds.

Strengthening of Bonds. In the course of caregiving, participants found the role as a way to build and fortify relationships between the patient, family members, and the community. Securing strong connections with others is important in preventing emotional distress in caregiving and form trusting and loving connections. Participants defined their relationship with their patients even more, that they understood the purpose of why they are chosen as family caregivers.

One of the participants (P3) said in his statements:

“Naging pivotal point atong situation sa akoang mama. Actually, na-strengthen gyud ang relationship namo as mother and son and murag it went beyond.”

Translation

“It became a pivotal moment with what happened to my mother. Actually, it strengthened our relationship as mother and son and it went beyond.”

Participant 5 shared what consequence it had in her family:

“Na-realize namon ang importansya sang unity kag ano pa gid ang importansya sang pamilya nga ginatawag.”

Translation

“We realized the importance of unity and the importance of family.

One of the positive outcomes caregiving for a cancer-diagnosed patient had towards family caregivers was the strengthening and reinforcement of their relationships. Even though, a debilitating and fatal disease plagued their loved ones, it was a vessel for them to forge profound connections different from their past bond with their cancer patients. According to Stengl (2023), the best way for family caregivers to overcome hurdles in the care process was to communicate effectively. Being able to communicate properly with the patient, they facilitated sharing of feelings and voicing of needs which resulted to better delivery of care. At the end of their roles, they ultimately fulfilled reinforcing their emotional bonds.

Changes in Lifestyle

As family caregivers, upon the start of their duties came new routines and a new environment for both the patient and caregiver. This theme pertains to how the caregiver carried out his day to day life with the sudden changes that came with their roles. This was influenced by the nature of the patient’s illness and the caregiver’s outlook in life. Under this major category emerged two (2) subthemes such as Shift to Independency and Changes in Perception and Attitude.

Shift to Independency. Participants reported that before transitioning into the role of family caregiver, they were dependent especially to their patients. Most of the patients were parents or significant others with whom provided for the family and at the onset of the disease gradually lost the ability to do so. Participants stated that at the beginning of their roles, they started to change their ways and became more independent and less reliant on others.

Participant 1 responded:

“Na-challenge all of a sudden ang maturity ko as a person. Kay perti bi ko ka salig or dependent kay mama. Nasanay ko ba nga kung ano need ko ara gid si mama para buligan ako. Ti sang nabigla siya diagnose, daw na-shift bigla nga magka-responsibilities na ko.”

Translation

“My maturity as a person was challenged all of a sudden. I was dependent towards my mother. My mother was always there when I needed her then all of a sudden, she was diagnosed with cancer and there was a shift in responsibilities.”

Participant 4 added:

“Bal-an mo sato, puro lang ko salig mo, ga-obra man ko pero natawhayan abi ko kay siya naging bana ko. Gusto guro ni Lord testingan ang pagka-independent ko nga subong nga gaisahanon ko makaya ko nga wala siya.”

Translation

“You know what, I always depended on my husband, I had my own work but I was reliant because he was my husband. Maybe the Lord wanted to test my independence now that I am on my own if I can carry on without him.”

As implied in the experiences of the family caregivers as they were undergoing the phases of the caregiving trajectory, they saw an unfolding of responsibilities and it shifted their usual participation in life to a focus on the responsibilities of caregiving. This redefined their roles and stance in their lives and facilitated adjustment to accommodate new tasks. For the reason that they now have bigger roles to fill in, some perceived it as pivotal while some saw it oppositely as shocking because of the immediate nature of the situation (National Library of Medicine, 2016).

Changes in Perception and Attitude. According to the study participants, the diagnosis of their family members was one of the keys they started to grow awareness regarding the disease and being mindful of their intake, lifestyle, and manners. Participants began to open their minds and expand their horizons about cancer and how they can better provide care for their patient. This made them knowledgeable individuals and also people capable of navigating through a difficult journey.

Participant 3 expounded in his statement:

“Actually, it really changed my ideas. Sa iyahang sakit, murag nagkaroon ko sang consciousness sa akong ginakaon, nga dili magpa-stress. Naging eye-opener to siya sa akoa kay pagka-diagnose sa akoang mama and then pagkawala niya, I really promised to myself nga bisag unsa ang akon ginaagian, di gyud ko magpadala sa mga problema. I-relieve lang gid nako akong self sa mga nagapahirap. Eat healthy and avoid ang pulaw, mao na.”

Translation

“Actually, it really changed my ideas. I had consciousness regarding the disease and everything I ingest and to not stress myself out. Her diagnosis was an eye-opener and when she died, I promised myself that no matter what I am going through, problem will never get hold of me. I’ll just relieve myself from whatever is stressing me and to eat healthy and avoid sleep-deprivation.”

He further elaborated that:

“Satung buhi pa akoang mama, emotional kaayo ko nga tao, didto nako na realize nga maging logical ko nga tao na hindi magpadala sa stress and as much as possible kung naay problema, may ma-share-an ka sang mga sentiments.”

Translation

“When my mother was still alive, I was a very emotional type of person, from that I realized to become a logical individual and not let myself get swayed by stress and as much as possible when a problem arises, that to share and converse with other individuals of my sentiments.”

From his sentiments, participant 7 said that:

“Siguro mas naging aware ako sa cancer. Sa first three years, mas naging conscious ko sa mga ginagamit ko kag mga ginakaon ko. Dati sa mga first one year halin sang napatay si mama, daw siling ko stop na ako work.”

Translation

“Maybe I became more aware of cancer. In the first three years, my consciousness of the things I utilize and the food I eat became heightened. Back from the first year since my mother died, I even thought of quitting work.”

Participants reported that the increase of awareness of cancer became more prevalent in them. With this, they started shifting their ways to mitigate such illness for themselves as to not let another occurrence of a cancer diagnosis arise again. According to Mei et al. (2013), utilizing ways to maintain a healthy lifestyle and being aware of their diet were relevant ways to combat the disease that would not also lead to family caregiving.

Spiritual Coherence

In the participants’ statements were found accounts of inner harmony and intactness of their belief systems amidst the turbulence in caring for the cancer patient. This allowed participants to be more present and aware of the situation. It is evident in their statements that they found an increase in acceptance of the situation which then made them quality care for their loved one. Two (2) subthemes emerged from this main theme; Faith and Trust in God, and Transcendence.

Faith and Trust in God. The faith and trust in God created an assurance of the constant presence of the divine essence in their lives. The participants believe that when they entrust something to God, whatever obstacle they may encounter, they will surely surpass. Through faith in Him, they believed that the Almighty will provide all the necessities they need to overcome challenges.

One participant (P4) stated:

“Biskan nga financially unstable kami that time, nagasalig lang ko sa Ginoo nga tani ma-supply ni Lord ang needs sang akon nga bana kag sang akon nga bata.”

Translation

“Even though we were financially unstable at that time, I placed my trust in God that He will supply our needs.”

She added:

“Mga pagtilaw lang ni sa kabuhi. Indi niya ni ihatag sakon kung hindi ko kaya. Siya nalang maghatag sa akon sang strength para makayanan namon ang tanan-tanan.”

Translation

“All of these are just trials in life. God wouldn’t give me a challenge I can’t overcome. I’m entrusting myself in Him to give me strength for us to surpass all of this."

The participant’s attitude in entrusting significant things to God sprung an assurance that God will ultimately provide for their lives. They believed that by being loyal servants to God, He wouldn't let any harm affect them. It is formed and strengthened in family caregivers when they are under perilous situations (Nemati, 2017).

Transcendence. Another subtheme that emerged from the interviews was spiritual growth and transcendence resulting from the sincere trust in God and the feelings of gratitude for His presence in their situation. Participants stated that during the course of caring for the cancer-diagnosed patient, it was a chance of spiritual growth from them, transforming from their old selves to a better version of themselves.

A response from Participant 5 discussed about spiritual growth:

“That time nga amuto natabo kay nanay, didto na nakita ang presensya sang kada isa kag nag-grow gid kami spiritually eh. Hindi na kami magdepende sa panahon sang problema para mag-pray or maging thankful. Nangabuhi na kami nga may Ginoo kag may hope man.”

Translation

“When it happened to my mother, I saw each other’s presence and spiritual growth. We no longer depended in times of battle to pray and be thankful for what we have. We changed into living with hope and God.”

Participant 7 shared his sentiment regarding this:

“Naga-novena na kami kag naga-pray kay miracles are possible. Sa spiritual side, na-strengthen gid ang akon faith. Si God gid ang imo someone to lean on.”

Translation

“We started having novenas and praying because we do believe miracles are possible. In the spiritual side, my faith got strengthened. God is truly someone to lean on.”

Perceiving the occurrence of the disease in the lives of the family caregivers as chance for spiritual growth was evident in the participants. For them, it was a way of reconciling with God and building a connection with Him. The situation was a pivotal moment for their lives to strengthen their spirituality. According to Nemati (2017), participants were seeking to gain the satisfaction of God and ultimately giving caregivers answers to their prayers.

Table 4. Outcomes of Caregiving on Family Caregivers

Coping Mechanisms of Family Caregivers

In the context of cancer, family caregivers utilized a number of coping mechanisms to regulate the outcomes of stress and exhaustion on their health and well-being. These caregivers were often unprepared before accepting their roles and so undergone many challenges in caring for the cancer patient. Coping resources are characteristics of the individual’s internal and external environments and developed mechanisms based on what is available around them. In this aspect of the study, two (2) coping strategies were identified being utilized by family caregivers in the sample. They were Active Coping and Social Support.

Active Coping

A mechanism used by participants that involved awareness of stressors and consciously made attempts to reduce their burdens. This was a problem-focused strategy in family caregivers to balance their tasks and to prevent burnout from all the numerous tasks of the caregiver. Participants resorted to the organization of their duties and created a harmonious path for them to take. The subthemes under this major theme are Positive Disposition, and Proper Management of Duties.

Positive Disposition. Amidst the challenges faced in caring for the patient diagnosed with cancer, participants maintained a positive outlook towards life. Although countless adversities had already passed their way, family caregivers upheld their self-motivation to achieve set outcomes for them and their patients. Participants stated that they stayed optimistic despite being aware of the deteriorating condition of their patients to avoid affecting their patient’s mood and therefore not hinder their improvement.

Participant 5 briefly discussed:

“Nag ano lang ko, nag think positive lang gid ko. Kay the more nga gina-attract mo ang negative, the more nga negative ang mabalik sa imo. Bala na kapoy basta mahatag ko lang gid ang ginapangayo ni nanay.”

Translation

“I just thought positively. The more I thought negatively, the more negative things were being thrown my way. I don’t mind the exhaustion just to provide for my mother’s needs.”

Participant 3 shortly added in the interview:

“Ga-think positive lang gyud ko ato. Wala ko gipabay-an akoang mother, tanan niya nga needs provided. Wala lang gid ko gaisip kanang mga negative thoughts.”

Translation

“At that time, I always thought positively. I never became complacent with my mother and all her needs were provided. I never constructed negative thoughts in my mind.”

According to Tjizore (2013), keeping a positive disposition was one of the ways family caregivers approach the caregiving situation. To not delve into negative thoughts and resulting to bad implications, participants tend to maintain optimistic views whilst tending to the cancer patient to not also influence the patient with negativity.

Proper Management of Duties. Having to take care of a terminally-ill patient was a daunting task for family caregivers. With this, they had to begin reshuffling priorities and plan the delivery of care for effective and observable benefit towards the patients. Participants also had to adjust and budget their finance to be able to cope and survive their necessities. Without these interventions, the participants wouldn’t have had overcome their everyday lives and would have had given up their roles.

In the interview, Participant 1 responded:

“Sa kadamo sang hirimuon ko as a caregiver ni mama, tanan to siya gina-cope ko through tama nga pag-manage sang tasks ko kag ginatarong ko budget ang amon kwarta para di ko magastos sa hindi importante.”

Translation

“With all the tasks I had to carry out for my mother, I got through all of it through proper management of tasks and budget planning so I can avoid spending on unnecessaries.”

Participant 4 discussed that:

“Ga-time management ko, sa financial abi ginauna ko ang needs kaysa sa wants tapos gina-isa-isa ko ang trabaho.”

Translation

“I resorted to time management. I prioritized our needs over our wants and finished my tasks individually and by order.”

Social Support

In this study, this theme was defined as the existence of people readily available to assist the caregiver in various tasks and that caregivers could reply on them. Also, individuals that would let family caregivers know that they care about them, value, and love them. In essence, this comprised any support from external factors, may it be emotional, informational, and instrumental. Participants noted that social Support from family and other members of the community alleviated both physical and emotional burden. The identified subthemes in this main theme are Assistance from Others and Emotional Support.

Assistance from Others. The instrumental support coming from family members and other people from the community played a major role in the prevention of strain and exacerbation of subjective burden in family caregivers. Participants stated that the benefit of having people readily available to lend them a hand reassured them that they were not alone in the delivery of care, that they were people that would go out their way to support them.

Participant 1 stated that:

“Paagi sa paghatag sang other family members ko sa akon sang assistance kung kinahanglan ko kag kung kapoy-kapoy na gid ko bala haw, ara sila para maging karelyebo ko gud para sila anay mag-atipan kay mama samtang nagapahuway ko.”

Translation

“Through the provision of assistance by other family members and when I most needed it especially when I am exhausted, they were there to relieve me of my duties while I recharge.”

Participant 5 in response, stated that:

“Sa pag-prepare sang kinahanglanon kay dati syempre kapoy na ko. Sa pagluto pud, sila galuto kag ang presensya sang kada isa.”

Translation

“In preparing for the necessities because of course I was extremely exhausted. In chores like cooking meals, other family members were present to take up the tasks.”

Participant 6 added:

“Kung free abi ang iban namon nga family members, magkadto na sila diri para magbulig sa amon, sa luto man na o kun atipan sa pasyente.”

Translation

“If some of my family members were free, they would travel to our home and help us out, in chores like cooking and caring for the patient.”

Participant 7 also shared that:

“Sa pag-care ko sa mother ko, ara man sila to assist kag salig man sila kag they support me. Tapos mangkuton na nila ko nga kung basi kapoy na ko kay sila naman, tulog anay ko. Ara sila especially sa pagpulaw kag ga-alternate kami.”

Translation

“When I was caring for my mother, my family were there to assist because they trust and support me. Then they would ask if I was exhausted already because they would shortly replace me in tending to my mother. They were there if I needed someone to take watch of my mother overnight while I rest.”

As caregivers, the participants faced many challenges in delivering adequate and appropriate care towards the patient. However, family caregivers found a lending hand in other people, including family members, friends, and even medical professionals in assisting them in care practices (Smith et al., 2023). It relieved participants and gave them a chance to rest and recharge thus improving their body’s function. Assistance that was given to family caregivers was a testament that indeed, it decreases caregiver burnout.

Emotional Support. Support came from many ways. Participants sourced support from their own family, friends, significant others, and medical professionals. This support network functioned as a mechanism that encouraged them and comforted the family caregivers during challenging moments. The presence of these individuals helped the participants cope with their emotions and experiences by providing them care and compassion.

Participant 2 expressed in his interview:

“Supportive naman yung family namin sa needs namin pati na emotional support. Kasi from time to time, tumatawag naman yung mga anak niya kinakamusta kami sa kalagayan namin.”

Translation

“My family was supportive of our needs and also for emotional support. From time to time, my grandmother’s children would call us and check up on us on our situation.”

Participant 3 responded:

“Siguro kay ang mga support nga makuha nako sa members of the community nga maka-ingon sila sang mga words of motivation. Somehow, na-boost man pud akoang morale.”

Translation

“Perhaps the support I got from the members of the community was when they uttered words of motivation. Somehow, it boosted my morale.”

Participant 6 on the other hand, elaborated that:

“Iba gid abi kung ara sila diri, imbes nga maluya ka gapagsik ka. Malimtan mo tung ka-stress mo ba. Ma-relieve kag ma-comfort man ko sa ila nga presensya kag emotional support.”

Translation

“It was different having them in the house. Instead of carrying the burden and heavy feeling of caregiving, I feel energized and stress-free. I was relieved and comforted seeing their presence and emotional support.”

In the care for the cancer-diagnosed patient, it was overwhelmed with various emotions brought about by the nature of the patient’s condition and external environments. It was not uncommon for the participants to feel lonely and at some point, wanted to isolate themselves. Current research showed that it was definite of those who get emotional support were far better and provided care longer than those who don’t. Participants found safety in the comforting words of their peers, friends, and family members (Home Care Assistance, 2020).

Table 5. Coping Mechanisms of Family Caregivers

4. Conclusions and Recommendations

The results of the study revealed that family caregivers undergo various challenges in context of caring for the cancer-diagnosed patient. Upon investigation of the participants’ statements and answers in the interview, family caregivers go through classified burdens that affect not only their physical aspect but also their psycho-emotional health. Participants were able to share details of their difficulties that was intertwined with the acceptance of the caregiver role. It also manifested issues in regards to their spirituality. During the course of the care process, participants reported to have questioned their faith and the patient’s chance of improvement. In retrospect, their challenges brought about exhaustion that resulted in alterations in health and routine.

The research also probed on the outcomes of the caregiving process and role towards the family caregiver and the data showed that the burden of caregiving had a toll on the participants’ well-being. This pertained to significant changes in the body such as weight, stress, and mood issues. This implies that family caregivers experienced significant exhaustion from the caregiver role. Exhaustion can change many aspects of daily living and it manifested through breakdowns, feelings of extreme sadness, regret, and a period of being hopeless. One of the driving forces for these family caregivers to handle the role is pity, love, and debt of gratitude. They are willing to be involved in any task if it means the welfare of their patients. However, caregiving had not only brought negative results but also positive outcomes on the individuals. Improvement and coherence in one’s spirituality, fortified relationships arose since the beginning of the caregiver role. The support of family caregivers will inevitably create consequences in the quality of care being provided to the patients as this is also critical in the trajectory of the disease. Caregiver burden not only decreases quality of life for caregivers but also indicate a sense of loss of control over their lives.

As the synthesis of the study, family caregivers utilized different coping strategies or techniques in order to maneuver themselves in situations. These mechanisms allowed them to surpass the difficult challenges and made them stronger over time. They maintained a positive outlook in life, properly planned their tasks, and also got help from support networks around them which included their families, friends, and the community.

It is significant for qualitative researches that address the caregiver aspect of care to flourish and get published so that further measures and programs are crafted so that their welfare will be upheld. Based on the findings and conclusion of the study, the following are recommended:

1. The initiation of support groups for family caregivers caring for patients with cancer that will cater their emotional needs and will involve focus group discussions which let caregivers express their experiences with a goal of alleviating suffering, pain, and distress.

2. Planning to include and cater family caregivers strained of caregiver burden in therapy sessions that will further aid them in molding a productive outlook at their situations and thus preventing any adverse consequences of exhaustion.

3. Institutions such as the government or any private organization, may it be through a public-private partnership should establish a Cancer Resource Center for one of the purposes of caregiver support and patient assistance.

4. Nurses and other concerned authorities should initiate for the education, crafting, and implementation of programs that will uphold the status of family caregivers. These could be through programs honing the skills of potential individuals for caregiving.

5. The stern advocacy of a national agenda to develop, fund, and implement inclusive health policies that covers cancer care not only for the provision of the patients but the inclusion of the family care provider.

6. The public’s awareness should be increased for them to be able to comprehend and empathize with family caregivers and their cancer-diagnosed patients. These can be done through cancer and cancer care seminars conducted in the community setting.

7. Future researchers must be staunch promoters on understanding the scope of cancer care through the conduct of more studies.

ACKNOWLEDGEMENTS

This research paper was realized through the constant support, invaluable assistance, and undying motivation of everyone with whom were involved in the drafting of this study, including dear friends, parents, mentors, participants, and the researcher himself. The researcher wishes to extend his acknowledgement and express his gratitude and dedication towards the following individuals for their contributions to the successful completion of this thesis:

To Ma’am Jainah Rose F. Gubac, PhDNS, MAN, RN, for being the researcher’s thesis adviser, for dedicating her time, patience, and diligence throughout the process of the study. Most especially, for enlightening the researcher with her wisdom and expertise in carrying out important tasks of this research.

To Ma’am Jza A. Taposok, MAN, RN, Ma’am Lalyn N. Cabauatan, MAN, RN, and Ma’am Marchie Lou C. Ereje, MAN, RN, for their kind assistance particularly their considered efforts and advice.

To Ma’am Dahlia S. Arancel, MD, DPBA, FPSA, PhD, and other members of the College of Medicine and Allied Health Sciences faculty and administration, for the earnest approval of the conduct and completion of this research study.

To Honey Lyn M. Loria, GJ Pauline L. Buhayan, and Angeline C. Gonzales, the researcher’s friends, for journeying with the researcher throughout various stages of the study and for boosting his morale.

To Marianne L. Yuayan, Carl Michael P. Quidato, and Lovely Alexi L. Dolormente, for their commitment in assisting the researcher during the conduct of the study. The researcher values your time and effort.

To the cancer-diagnosed patients and their family caregivers, for allowing the researcher to create discourse with them and for being the core element of this study. This endeavor would not be fulfilled without their unrelenting support and cooperation.

To Mama Mae Joy A. Gecosala and Papa Reynaldo A. Gecosala, the researcher’s beloved parents, for always having his back and the constant reminders and unconditional love they gave during the labor-intensive hours spent on this study. Truly, they have been incredible research assistants.

To the Almighty God, above all, who continues to shower the researcher with His abundance and mercy, and guidance throughout the journey. His infinite wisdom and loving presence keep the researcher on the right path.