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\begin{document}

\title{Identifying latent classes of parents of children with hematological
malignancies with respect to caregiving ability: a latent class analysis}



\author[1]{Jingting Wang}%
\author[1]{Xuanyi Bi}%
\author[2]{Jichuan Wang}%
\author[3]{Xianlan Zheng}%
\author[4]{Yingwen Wang}%
\author[5]{Huifang Wu}%
\author[5]{Qi Yang}%
\author[4]{Fang Liu}%
\author[3]{Linyu Ma}%
\author[6]{Changrong Yuan}%
\affil[1]{Naval Medical University}%
\affil[2]{Children's National Medical Center}%
\affil[3]{Children’s Hospital of Chongqing Medical University}%
\affil[4]{Children's Hospital of Fudan University}%
\affil[5]{Children’s Hospital of Soochow University}%
\affil[6]{Fudan University}%


\vspace{-1em}



  
  \date{May 08, 2024}


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\selectlanguage{english}
\begin{abstract}
Objectives: This study aimed to identify unobserved subgroups of parents
of children with hematological malignancies with respect to caregiving
ability and examine the associations of the latent class membership with
individual characteristics. Methods: A total of 392 parents of children
with hematological malignancies in China were surveyed with the
Hematologic Malignancies' Family Caregiver Skills Scale and a
study-specific demographic information questionnaire. Latent class
analysis(LCA) was applied to identify latent classes of parents based on
caregiving ability measures. Multinomial logistic regression model was
used to investigate the associations of socio-demographic and clinical
characteristics with the latent class membership. Results: Results from
the LCA suggested a 3-class solution: Class 1-``high caregiving
ability'' class(n=131, 33.4\%), Class 2-``medium caregiving ability''
class(n=170,43.4\%), and Class 3-``low caregiving ability'' class(n=91,
23.2\%). Socio-demographic and clinical characteristics, such as having
lower level of education, being married, having higher household income,
more daily caregiving time, and having older children, as well as
children not diagnosed with leukemia, had significantly larger odds of
being classified in Class 1 than in Class 3. When comparing Class 2 with
Class 3, the findings remained basically unchanged except that the
effect of gender of parent became statistically significant, and the
effect of diagnosis of children became insignificant. Conclusion: There
existed three distinct priori unknown classes of parents of children
with hematological malignancies in regard to caregiving ability. The
class membership was significantly associated with parent's
socio-demographics and child's clinical measures. These findings may be
helpful in the development of personalized caregiving ability
interventions.%
\end{abstract}%



\sloppy


\textbf{Introduction}

The incidence and mortality of childhood cancer have increased annually
over the past decade, making it surpass accidental trauma as the leading
cause of childhood death in 201611Bray F, Ferlay J, Soerjomataram I, et
al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and
mortality worldwide for 36 cancers in 185 countries. CA Cancer J
Clin.2018; 68(6):394-424.\textsuperscript{-}22Kyu HH, Stein CE, Boschi
Pinto C, et al. Causes of death among children aged 5-14 years in the
WHO European Region: a systematic analysis for the Global Burden of
Disease Study 2016. Lancet Child Adolesc Health.2018; 2(5):321-337.. The
overall annual incidence of childhood cancer varied between 46 and 165
per million33Rodriguez GC, Friedrich P, Alcasabas P, et al. Toward the
cure of all children with cancer through collaborative efforts:
pediatric oncology as a global challenge. J Clin Onco, 2015; 33(27):
3065-3073.. Hematological malignancy is the most common cancer among
children younger than 15 years old44World Cancer Report: Cancer Research
for Cancer Prevention. International Agency for Research on Cancer
Publications Website. https://publications.iarc.fr/586. Updated Feb 4,
2020. Accessed Sep 16, 2020.. However, with the advances in treatment
over the past decade, the 5-year and 10-year survival rates for
childhood cancer are more than 80\% in high-income countries55Dixon SB,
Bjornard KL, Alberts NM. Factors influencing risk-based care of the
childhood cancer survivor in the 21st century. CA Cancer J Clin. 2018;
68(2):133-152.\textsuperscript{,}66Bhakta N, Force LM, Allemani C, et
al. Childhood cancer burden: a review of global estimates. Lancet Oncol.
2019; 20(1): e42-e53.\textsuperscript{,}77Ward ZJ, Yeh JM, Bhakta N, et
al. Global childhood cancer survival estimates and priority-setting: a
simulation-based analysis. Lancet Oncol. 2019; 20(7):972-983.. Based on
current and long-term survival rates, the number of childhood cancer
survivors is expected to reach 500,000 by 202088Robison LL, Hudson MM.
Survivors of childhood and adolescent cancer: life-long risks and
responsibilities. Nat Rev Cancer. 2014; 14(1):61-70..

Despite the better survival rates, the diagnosis of hematological
malignancy is undoubtedly a heavy blow to the children and their
families. Due to the complexity and particularity of hematological
malignancy, children are suffering from a series of discomforts caused
by the disease and the long-term chemotherapy99Abedin S, Altman JK.
Acute promyelocytic leukemia: preventing early complications and late
toxicities. Hematology Am Soc Hematol Educ Program. 2016;
2016(1):10-15.\textsuperscript{,}1010Berger AM, Mitchell SA, Jacobsen
PB, et al. Screening, evaluation, and management of cancer-related
fatigue: Ready for implementation to practice? CA Cancer J Clin. 2015;
65(3):190-211.. As the primary caregivers, the parents need to
participate in children's physical and mental support and all-round care
throughout the diagnosis and treatment1111Wang JT, Shen NP, Zhang XY, et
al. Care burden and its predictive factors in parents of newly diagnosed
children with acute lymphoblastic leukemia in academic hospitals in
China. Support Care Cancer.2017; 25(12):3703-3713.. However, caring for
children with hematological malignancies is a rare and challenging
experience for parents without medical training, and most parents are
seeking professional assistance to improve their caregiving
ability1212Wang JT, Yao NL, Wang YY, et al. Developing ``Care
Assistant'': A smartphone application to support caregivers of children
with acute lymphoblastic leukemia. J Telemed Telecare.2016;
22(3):163-171.\textsuperscript{,}1313Wang JT, Howell D, Shen NP, et al.
mHealth Supportive Care Intervention for Parents of Children with Acute
Lymphoblastic Leukemia: Quasi-Experimental Pre- and Postdesign Study.
JMIR Mhealth Uhealth. 2018; 6(11):e195..

Caregiving ability refers to the knowledge and skills that the caregiver
has acquired to supply the patient what he or she needs1414Clarke DJ,
Hawkins R, Sadler E, et al. Introducing structured caregiver training in
stroke care: findings from the TRACS process evaluation study. BMJ Open.
2014: 4(4):e004473.. Parents' caregiving ability directly affects the
rehabilitation process and the prognosis of their children1515Aburn G,
Gott M. Education given to parents of children newly diagnosed with
acute lymphoblastic leukemia: a narrative review. J Pediatr Oncol Nurs.
2011; 28:300--305.. However, existing studies mostly focused on
caregivers of adult patients with cancer and aimed at improving their
caregiving ability1616Mazanec SR, Sandstrom K, Coletta D, et al.
Building Family Caregiver Skills Using a Simulation-Based Intervention:
A Randomized Pilot Trial. Oncol Nurs Forum. 2019;
46(4):419-427.\textsuperscript{,}1717Potter P, Olsen S, Kuhrik M, et al.
A DVD program on fall prevention skills training for cancer family
caregivers. J Cancer Educ. 2012; 27(1):83-90.. Studies on caregiving
ability in parents of children newly diagnosed with leukemia in China
have showed that parent's caregiving ability was at a low level1818Wu
HF, Bi XY, Li J, et al. Analysis on care ability and its influencing
factors for parents of children with leukemia. Nurs J Chin PLA. 2020;
37(2):18-22.. However, the findings were based on average statistics and
did not necessarily mean that all the parents of children with
hematological malignancies have a low level of caregiving ability.
Importantly, the statistical analyses conducted in those studies assumed
the patents were a homogeneous population regarding caregiving
abilities. Thus, the statistical results in the studies might be
biased.\textsuperscript{18,}1919Shen M, Liang PR, Ma JL, et al.
Influencing factors of caregiving ability of family caregivers of
leukemic children. Modern Clinical Nursing. 2018;
17(9):50-55.\textsuperscript{,}2020Mao ZQ, Xiao RT, Yang L, et al.
Investigation on the influence of caregivers' care ability on children
with leukemia. Today nurse. 2018; 25(6):43-45.. In order to better
understand the populations, the present study used latent class analysis
(LCA) to test the heterogeneity of this special population, i.e.,
parents with children with hematological malignancies, identify the
unobserved distinct sub-populations/latent classes in the target
population, and examine the characteristics of parents in different
classes. The study armed to provide useful implications for development
of a targeted and group-centered intervention for parents to improve
their caregiving ability.

Latent class analysis (LCA) is an appropriate method to classify parents
according to their caregiving ability, considering population
heterogeneity. Based on the responses on explicit test questions LCA
identifies the optimal number of latent classes of parents and the
prevalence of each class2121Miranda VPN, Dos Santos Amorim PR, Bastos
RR, et al. Evaluation of lifestyle of female adolescents through latent
class analysis approach. BMC Public Health.2019; 19(1):184.. Tillery et
al used LCA to classify caregivers of childhood cancer survivors aged 10
to 18, based on the parent-child relationship functioning. Their
findings would help to improve psychological and social outcomes in
young survivors of childhood cancer2222Tillery R, Willard VW, Howard
Sharp KM, et al. Impact of the parent-child relationship on
psychological and social resilience in pediatric cancer patients.
Psychooncology. 2020; 29(2):339-346.. However, no existing studies used
LCA to analyze the caregiving ability in parents of children with
hematological malignancies.

In the present study, we used LCA to identify a priori unknown latent
classes of parents of children with hematological malignancies based on
caregiving ability measures. Once latent classes were identified, the
multinomial logistic model was used to examine the effects of
socio-demographic and clinic characteristics on latent class membership.
The findings of this study will be helpful for studying disparities in
parents' caregiving ability and provide targeted interventions to
parents in the different caregiving ability subgroups.

\textbf{Methods and materials}

\textbf{Sample and data collection}

Participants were 392 parents of children with hematological
malignancies recruited from three children's hospitals in Shanghai,
Jiangsu, and Chongqing, China. The survey was conducted from May 2018 to
April 2020. The eligible criteria for parents and children were as
follows: (1) the child met the diagnostic criteria for hematological
malignancy11Zhang ZN, Shen T. Diagnostic and therapeutic criteria of
hematologic diseases. Beijing: Science Press; 2007. by bone marrow
cytology, immunohistochemical and genetic analysis, or histochemical
staining, (2) the child was under treatment and was less than 15 years
old, (3) the child had no other serious or chronic diseases, (4) the
parent had high school diplomas or higher education, and could
communicate fluently in Mandarin, (5) the parent took the major
responsibility for the daily caregiving of the child, (6) the parent
volunteered for the survey. This survey received ethical review approval
from the Naval Medical University (NO.HJEC-2018-YF-001). The
participants were informed of the aim of this study before the survey
was conducted. No procedures were performed until participants signed
the informed consent.

\textbf{Measures}

Information about the socio-demographic and clinical characteristics of
parents and their children were collected in survey. Parents' caregiving
ability was measured based on their last week's experience, using the
Hematologic Malignancies' Family Caregiver Skills Scale (HMFCGSS) that
was previously validated in hematologic malignancies' family caregivers
in China (Cronbach's \selectlanguage{greek}α \selectlanguage{english}= 0.920)11Qian SJ. The adaptation of hematologic
malignancies family caregiver skills scale. Master thesis. Soochow
University, Suzhou, Jiangsu, China, 2016.. HMFCGSS consists of 6 domains
with a total of 23 items: disease cognitive ability (DCA) with 3 items,
general approaches to caregiving (GAC) with 3 items, person-centered
care skills (PCS) with 5 items, emotional management ability (EMA) with
4 items, appraising supportive resources (ASR) with 3 items, balancing
caregiving needs and one's own needs (BCN) with 5 items (see Appendix).
Each of the 23 items was measured on a 5-point scale ranging from not
difficult (1) to very difficult (5). In the present study, all the items
were recoded as dichotomous indicator of parent's caregiving ability:
1-''no difficulty'' (if item score [?]2) vs. 0-''at least some
difficulty'' (if item score[?]3).

\textbf{Data analysis}

The 23 dichotomous caregiving ability indicators were used for Latent
Class Analysis (LCA)1125 Wang J, Wang X. Structural Equation Modeling:
Applications Using Mplus, 2d Edition. New York: John Wiley; 2020.. The
LCA analysis was started with a single-class solution and increased the
number of classes (to four) while comparing model fit. Model fit
statistics and indices include the Akaike Information Criterion (AIC),
Bayesian Information Criterion (BIC), adjusted Bayesian Information
Criterion (aBIC), Bootstrapped Likelihood Ratio Test (BLRT),
Vuong-Lo-Mendell-Rubin likelihood ratio test (LMR), Lo-Mendell-Rubin
adjusted LRT test(aLMR) and entropy score\textsuperscript{25}. Lower
values on AIC, BIC and aBIC indicate better model fit; significant
p-values on the BLRT, LMR, and aLMR indicate the k class model is more
preferable than the k-1 class model\textsuperscript{25}. BIC and BLRT
perform better than other fit statistics/indices in determining the
number of latent classes. The entropy statistic measures the certainty
of class classification. The values of entropy range from 0 to 1, and a
value closer to 1 indicating better classification\textsuperscript{25}.
For a LCA model with entropy [?]0.80, the latent class membership
estimated from the model can be saved as ''observed'' categorical
variables for further analysis22Clark SL. Mixture Modeling with
Behavioral Data. Doctor thesis. University of California, Los Angeles,
CA, 2010.. In the present study, we used a multinomial logistic
regression model to examine the effects of demographic and clinical
variables on the latent class membership. LCA was estimated using Mplus
7.0, and other analyses were conducted using SPSS 22.0. All tests of
statistical significance were 2-sided at \selectlanguage{greek}α\selectlanguage{english}=0.05 level.

\textbf{Results}

\textbf{Socio-demographic characteristics}

A total of 392 parents of children with hematological malignancies who
completed the questionnaires were eligible for this survey. The
socio-demographic characteristics of parents and children are described
in Table 1.

\textbf{Latent class analysis}

Mode fit statistics/indices are shown in Table 2. The single-class model
had the largest AIC, BIC, and ABIC, compared to all other models. In
addition, the LR tests of the 2-class model were all statistically
significant (LMR \emph{P} \textless{}0.0001, aLMR\emph{P}
\textless{}0.0001, and BLRT \emph{P} \textless{}0.0001), indicating the
population is not homogeneous, but heterogeneous. Comparing the 2-class
and 3-class models, the latter had smaller information criterion indices
(AIC, BIC, and ABIC) and all significant LR tests (LMR \emph{P} =0.0021,
aLMR \emph{P} =0.0021, and BLRT\emph{P} \textless{}0.0001). We,
therefore, rejected the 2-class model in favor of 3 or more classes.
Comparing the 3-class and the 4-class models, BIC (9705.262), LMR
(\emph{P} =0.7261), and aLMR (\emph{P} =0.7265) favored the 3-class
model, but AIC, aBIC, and BLRT favored the 4-class model. On the balance
of model fit, model parsimony, and clinical interpretability of the
results, the three-class model was selected. Figure 1 displays the
results of the 3-class solution. The attribution probabilities of the
model were 0.923, 0.948 and 0.958, respectively, and entropy=0.872
indicating good quality of class classification. The plot of item
response probabilities endorsing ''no difficulty'' for the 23 caregiving
ability indicators in each of the classes shows explicit patterns of
caregiving ability in the parents of children. The probabilities of
endorsing ''no difficulty'' in Class 1 (n=131, 33.4\%) are all high
across six domains. We, therefore, labeled this class as ``high
caregiving ability'' class. The other two classes (Classes 2 and 3) were
labeled ``medium caregiving ability'' (n=170, 43.3\%) and ``low
caregiving ability'' (n=91, 23.2\%) classes, respectively, based on the
item response probabilities in the classes.

\textbf{Analysis of caregiving ability by latent class}

Table 3 shows the mean scores of the 6 caregiving ability domains by
latent classes. In each class, the GAC mean score was the lowest,
compared to other domain scores. This indicated that parents all had
higher level of ability of general caregiving on average. In Class 3
(the ``low caregiving ability'' class) and Class 2 (the ``medium
caregiving ability'' class), the ASR score was higher than other domain
scores, indicating that parents had lower ability of appraising
supportive resources in the two classes. Although the DCA mean score in
Class 1 (the ``high caregiving ability'' class) was lower than those in
the other two classes, this score was much higher than other domain
scores in Class 1, indicating that parents in this class also had some
difficulty in disease cognitive.

\textbf{The multinomial logistic regression model}

Selected results of the multinomial logistic regression model are shown
in Table 4. Parents with lower education (e.g., high school or junior
college) and married status were more likely to be classified in the
``high caregiving ability'' class than in the ``low caregiving ability''
class. The corresponding ORs are: OR=2.679 (95\%CI 1.116, 6.430) for
high school; OR=3.734 (95\%CI 1.473, 9.463) for junior college; and
OR=4.298 (95\%CI 1.070, 17.256) for married parents (see the second
column of Table 5). On the contrast, parents with the following
characteristics were less likely to be in the ``high caregiving
ability'' class, but in the low caregiving ability class: parents with
average monthly household income of 2000-5000CNY (\$285-713) (OR=0.245,
95\%CI 0.087, 0.691) or 5000-8000CNY (\$713-1411) (OR=0.207, 95\%CI
0.071, 0.608), daily caregiving time of less than 12h (OR=0.308, 95\%CI
0.140, 0.675) or 12 to 18h (OR=0.293, 95\%CI 0.115, 0.750), children
aged less than 3 years old (OR=0.137, 95\%CI 0.053, 0.355) and with a
diagnosis of leukemia (OR=0.056, 95\%CI 0.006, 0.520).

Model results for comparing ``medium caregiving ability'' class with the
``low caregiving ability'' class are shown in the third column of Table
5. Parents who were married (OR=5.447, 95\%CI 1.588, 18.687), fathers
(OR=2.399, 95\%CI 1.162, 4.956), had high school education (OR=3.032,
95\%CI 1.348, 6.818) or junior college (OR=5.416, 95\%CI 2.269, 12.930)
were more likely to be classified in the ``medium caregiving ability''
class than in the ``low caregiving ability'' class. Parents with average
monthly household income of 2000-5000CNY (\$285-713) (OR 0.245, 95\%CI
0.087, 0.691) or 5000-8000CNY (\$713-1411) (OR 0.207, 95\%CI 0.071,
0.608), daily caregiving time less than 12h (OR 0.237, 95\%CI 0.113,
0.499) or 12 to 18h (OR 0.422, 95\%CI 0.185, 0.965), and children
younger than 3 years old (OR 0.420, 95\%CI 0.180, 0.981) were more
likely to be in the ``low caregiving ability'' class than in the
``medium caregiving ability'' class.

\textbf{Discussions}

\textbf{The latent classes of parents of children with hematological
malignancies}

To the best of our knowledge, this is the first study that used the LCA
to identify unobserved subpopulations/classes of parents of children
with hematological malignancies in China. Parents in the study were
classified into 3 distinct a priori unknown classes regarding to
caregiving ability measured by HMFCGSS: Class 1-''high caregiving
ability'' class; Class 2-''medium caregiving ability'' class; and Class
3-''low caregiving ability class''. Class 1 accounted for 33.4\% (n=131)
of the sample. The members in Class 1 had a medium level of DCA and high
levels of the other five domains. Class 2 accounted for 43.4\% (n=170)
of the sample. Overall, the parents in Class 2 had a medium level of
DCA, EMA, ASR and BCN, and relatively high levels of GAC and PCS. Class
3 accounted for 23.2\% (n=91) of the sample. Parents in Class 3 had a
medium level of GAC and low levels of all the other domains. For parents
in the ``low caregiving ability'' class, caring for children with
hematological malignancies was really challenging.

\textbf{Caregiving ability of parents in three latent classes}

As shown in Table 3, parents in all the 3 classes had a higher level of
GAC than the other domains of caregiving ability, indicating that
caregivers were more capable in general approaches of caregiving than
other aspects of caregiving. These results showed that all parents had
confidence in providing daily routine care and offering timely help when
their children needed. In the ``medium caregiving ability'' class and
``low caregiving ability'' class, parents' lowest caregiving ability was
ASR, which indicated that the most difficult part of taking care of
their children in these two classes was to appraise supportive
resources. While in the ``high caregiving ability'' class, caregivers'
lowest caregiving ability is DCA, which indicated that the greatest
difficulty in caregiving in this class was cognitive related, such as
the assessment of the children's condition and the observation of
changes in the children's condition, learning information on disease
treatment and caring for the children, and contacting with the
professional healthcare providers. The measurement tool, HMFCGSS, is a
self-reported scale with six domains. A high total score of HMFCGSS may
not necessarily mean that the parents have high caregiving ability in
all the aspects. Professional healthcare providers need to pay attention
to whether the parents have low ability in any aspect of caregiving, and
what targeted support need to be provided to the parents.

\textbf{Association between socio-demographic and clinic characteristics
and latent class membership}

While fathers of the children in the study were more likely to be in the
``medium caregiving ability'' class, mothers were more likely to be in
the ``low caregiving ability'' class. In literature, mothers are more
often than fathers to take care of sick children and take children to
hospital11Yayan EH, D\selectlanguage{ngerman}üken ME. A comparison of caregiving burden and
social support levels of parents of children undergoing liver
transplant. J Pediatr Nurs. 2019; 47:e45-e50.. In Chinese traditional
culture, mothers are expected to be the primary caregivers for children
in family and in general provide more practical daily care and emotional
care for sick children. In our study, 281 mothers (71.7\%) took the
major responsibility of the daily caregiving of their sick children. In
a tragic situation when a child of a family is diagnosed with cancer, it
would be very likely for the mother, the primary caregiver, to confront
with more new challenges in caregiving for the sick child. These new
challenges might lead to mothers' feeling of low caregiving ability.

Divorced, widowed or separated parents were more likely to be in the
``low caregiving ability'' class. Studies indicated that married parents
had more access to social support, especially for the support from their
partner, and tended to report lower caregiving burden22Arab M, Bernstein
C, Haghshenas A, et al. Factors associated with caregiver burden for
mothers of children undergoing Acute Lymphocytic Leukemia (ALL)
treatment. Palliat Support Care.2019; 1-8.\textsuperscript{,}33Wiener L,
Viola A, Kearney J, et al. Impact of caregiving for a child with cancer
on parental health behaviors, relationship quality, and spiritual faith:
do lone parents fare worse? J Pediatr Oncol Nurs. 2016; 33(5):378-386.
In addition, married parents usually have less financial burden caused
by the children's disease treatment, so they could concentrate on taking
care of their children, which could help to improve their caregiving
ability44Granek L, Nathan PC, Rosenberg-Yunger ZR, et al. Psychological
factors impacting transition from paediatric to adult care by childhood
cancer survivors. J Cancer Surviv. 2012; 6(3):260-269..

Parents who received lower education (high school or just junior
college) were more likely to be classified in the ``high caregiving
ability'' class. In the present study, almost half (46.7\%) of the
sample (n=183) with lower education (high school or junior college) had
more than one child. Therefore, they had more caregiving experience in
taking care of their children. In contrary, parents with higher
education (bachelor degree or above) were more likely to have a single
child, more co-caregivers, and less daily caregiving time. This may
explain their less caregiving experience and low caregiving ability.

Lower income had a significant effect on the likelihood of being in the
``low caregiving ability'' class. Parents confronted with a high medical
cost for their child disease treatment, expenses of caregiving needs,
and often change in employment status following a child's cancer
diagnosis. All those might reduce the financial stability of the
family55Tsimicalis A, Stevens B, Ungar WJ, et al. Shifting Priorities
for the Survival of My Child: Managing Expenses, Increasing Debt, and
Tapping Into Available Resources to Maintain the Financial Stability of
the Family. Cancer Nurs.2020; 43(2):147-157.. Moreover, the financial
burden on parents of children with hematological malignancies is much
heavier than that of any other cancer66Pagano E, Baldi I, Mosso ML, et
al. The economic burden of caregiving on families of children and
adolescents with cancer: a population-based assessment. Pediatr Blood
Cancer.2014; 61(6):1088-1093.. A study on caregivers of adolescents and
young adults with complex medical conditions found that family income
directly predicted family functioning and greatly contributed to
caregivers' caregiving ability77Deatrick JA, Hobbie W, Ogle S.
Competence in caregivers of adolescent and young adult childhood brain
tumor survivors. Health Psychol.2014; 33(10):1103-1112.. So medical
insurance with a high reimbursement rate and more financial help for the
parents are needed, which will also have positive effect on improving
parents' caregiving ability.

Parents with shorter daily caregiving time were more likely to be in the
``low caregiving ability'' class. Parents who had longer daily
caregiving time had a better understanding of the treatment and care,
and accumulated more caregiving experience, which helped to improve
their caregiving ability. However, previous studies indicated that the
care burden would increase gradually as caregivers spent more time
caring for their children with cancer, which had a negative influence on
parents' caregiving ability88Utne I, Miaskowski C, Paul SM, et al.
Association between hope and burden reported by family caregivers of
patients with advanced cancer. Support Care Cancer.2013;
21(9):2527-2535.. So, appropriate daily caregiving time was encouraged
to help primary caregivers achieve a balance between care for their
children and themselves, as a result, improving their caregiving
ability.

Parents with younger children had a higher likelihood of being in the
``low caregiving ability'' class than in the ``medium caregiving
ability'' and the ``high caregiving ability'' class. Younger children
could not express their feelings and needs clearly, and they had lower
self-care ability, which led to more dependence on their parents'
assistance99Xie AW, Chan YY, Yao WY, et al. The investigation of nursing
needs of school-aged children underwent lumbar puncture with Acute
Leukemia. Chinese Nursing Management. 2018; 18(1):103-107.. Parents'
failure in perceiving or satisfying the needs of their children might
led to parents' low self-evaluation on their caregiving ability.

In this study, parents of children with leukemia were more likely to be
in the ``low caregiving ability'' class than in the ``high caregiving
ability.'' This is probably because 59.7\% of the parents in the study
had children diagnosed with leukemia whowere in the early stage (1-3
months) of treatment of leukemia.

\textbf{Clinical Implementation}

Exploring the latent classes of caregiving ability in parents of
children with hematological malignancies and the socio-demographic
characteristics of parents in the latent classes could provide useful
information for the professional healthcare providers to identify
parents who are most likely to have low caregiving ability. Therefore,
early and precise supportive intervention could be provided to the
targeted parents to improve their caregiving ability, which in results,
improving the children's disease prognosis and quality of life.
Moreover, the results of this study also reminded us that parents' with
high self-appraisal of caregiving ability may not have high ability in
all the aspects of caregiving. Therefore, targeted support needs to be
provided to parents based on their needs. Additionally, parents who have
high self-appraisal of caregiving ability may gradually encounter more
caregiving problems and their self-appraisal of caregiving ability will
change. So, healthcare providers are highly suggested to track the
development of parents' caregiving ability.

\textbf{Limitations}

There are some limitations in the study. First, data were collected in
three children's hospitals in Shanghai, Suzhou and Chongqing, China that
are all big cities. Secondly, parents of children with leukemia account
for majority of the sample. As such, the generalizability of our
findings may be limited. Finally, after the diagnosis of their children,
parents' caregiving ability changes across the children's disease
treatment period. The present study is a cross-sectional study and
unable to speculate the trajectory of parents' caregiving ability
development. Therefore, a longitudinal study is needed to explore the
developmental trend of parents' caregiving ability in the future.

\textbf{Conclusion}

Three distinct latent classes of parents of children with hematological
malignancies were identified with regard to caregiving ability. This is
the first study using LCA to examine caregiving ability in this
population in China. Our findings provided useful implications for
healthcare providers to better understand the classes of caregiving
ability among parents of children with hematological malignancies in
China, and help them provide timely supportive intervention to the
parents who have low caregiving ability.

\textbf{Conflict of interest}

There are no potential conflicts of interest known to any of the
contributing authors.

\textbf{Acknowledgments}

This study was supported by the National Natural Science Foundation of
China (project no. 71904195), Shanghai Sailing Program from Science and
Technology Commission of Shanghai Municipality, China (project no.
18YF1429400), and International Science and Technology Cooperation
Program from Science and Technology Commission of Shanghai Municipality,
China (project no. 12410707900).

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