Coming to Terms: Korean Mothers’ Adaptation to Child Loss from Cancer

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Introduction
Te death of a child is among the most traumatic experiences parents can have [1].Due to the unique nature of the strong attachment between parents and their children, parental grief is more intense and complicated than other forms of loss [2].Bereaved parents experience this unique grief, which increases the risk of psychological symptoms [3], physical health challenges [4], and even morbidity and mortality [5,6].
Evidence shows that bereaved parents use various coping skills, such as cherishing positive memories of the child, maintaining a spiritual bond with the deceased child, caring for bereaved siblings, spending time with family, staying connected with support systems, and expressing emotions [7][8][9].Tey also frequently employ distraction to mitigate the emptiness that follows the death of a child [10].Parents often engage in activities, such as work, sports, and hobbies, or make environmental changes, like relocating, to divert their attention from the pain of grief [11,12].Tis approach is particularly prevalent during the early stages of the grief process, when the emotional burden can be overwhelming [13].It is important to recognize the positive aspects of coping skills throughout the bereavement process because positive emotions can bufer against negative psychosocial responses to loss [14].For instance, the integration of humor, laughter, and the pursuit of happiness in daily life has been linked to more positive adjustments during bereavement [15].
Of the many coping skills employed by bereaved parents, peer support and religious support have been identifed as among the most common.Te benefts of support groups in aiding bereaved people have been extensively documented [16].For example, to maintain a bond with their deceased child, parents report the beneft of having a safe space where they can openly discuss their loss without judgment [17][18][19].Some parents assist others in similar circumstances as a means of transforming their sufering into love [20].Parents have reported that not only receiving but also providing support to another family felt healing, viewing it as a legacy of their child [21].Although bereavement support groups ofer a platform for parents to share their grief, not all evidence regarding their efect is positive.Previous studies, such as those by Maruyama and Atencio [22], have indicated that these interventions may not be universally benefcial.Online grief support groups, which are increasingly popular due to their accessibility, anonymity, and ability to address limited local support [23], present additional challenges.Misunderstandings can occur in these settings due to reliance on written communication, which lacks nonverbal cues like facial expressions or tone of voice.Other issues include distress and the potential for prolonged grief, with some members becoming entrenched in their grieving process [24].
Finding support through religion or spirituality is another common coping strategy among bereaved parents [19].Tese parents often fnd comfort and peace in God and the belief that there is life after death, which helps them cope [21].Tey pray for the possibility of reuniting with their deceased child in the afterlife, which brings them comfort [7,25].
Studies have reported positive outcomes when interpreting the death of a child in the context of religious or spiritual beliefs.For example, parents with higher spirituality or religious beliefs and those who reported having made sense of their child's death report lower intensity of grief and depression [26][27][28].Many bereaved parents struggle to make sense of their loss because the death of a child disrupts the natural order of life, where children are expected to outlive their parents, shattering their assumptive worldview [28].As bereaved parents progress through their grief journey, they often seek answers to reconcile their shattered view of life and the world.Tis involves coming to terms with their understanding of the meaning of death and the purpose of their lives.
Tis concept of meaning making is crucial for understanding parental grief [28] and the process of readjusting to life without their child [29].According to the meaning reconstruction model [30], bereaved individuals reconstruct narratives regarding the loss, the self, and their relationship with the deceased in their grief journey.Tis model delineates three key meaning-making processes: sense making, beneft fnding, and identity change [31,32].
Sense making is the process of questioning and making sense of the loss [31].Gerrish and Bailey [33] reported that some parents stopped searching for answers as to why their child died and instead focused on fnding meaning for the death in relation to the signifcance the child brought to their lives, and this helped them cope better with the loss.Spirituality plays a crucial role in shaping new meanings for these parents because they perceive the death as a component of a broader divine plan-a signifcant event meant to convey a message of love and provide support to other grieving parents [9,20].
On the other hand, beneft fnding can relate to positive changes resulting from the loss, typically emerging sometime after the death [31,34].When a death occurs, bereaved people attempt to build new meaning structures to adapt to their changed life.Parents have reported that their child's death altered their priorities and perspectives [21,35] and relationships with others [7,33,35].What they once considered important no longer holds the same signifcance, and they place greater importance on family, community, and concern for others [8].Tey report heightened appreciation of life and strive to stay in the moment [28].
Bereaved parents often experience transformative changes, including becoming more sympathetic and compassionate [29].Tis newfound ability often extends to aiding others who face similar losses.Such a transformation in self-perception represents the third aspect of meaning making in response to loss, known as identity change [31].Tese positive developments are aligned with the concept of posttraumatic growth, which is defned as the benefcial personal evolution arising from traumatic experiences [36].Growth transcends simple beneft fnding, encompassing a holistic enhancement of personal strengths, increased appreciation for life, improved relationships, deepened spirituality, and refned life goals.Many bereaved parents report a reinforcement of their spiritual or religious beliefs following the death of their child [28,33].Such transformative experiences often bring a sense of peace amid their grief.
To assist parents in their grief journey, it is essential to comprehend the progression of their bereavement experiences of coping, sense making, beneft fnding, and identity change as they navigate the loss and strive to restore a sense of purpose in a world without their deceased child.It is important to recognize that the bereavement process for parents evolves over time.Calderwood and Alberton [37] described this journey as beginning even before the child's death, initially characterized by feelings of helplessness.Tis progresses to a period of disorientation, often referred to as a "fog," between the death and the funeral.Following this is a state of turmoil, which can last up to about a year.Te journey then moves into a transition phase, during which parents confront reality and start redefning their lives, leading to a "new beginning."In this stage, parents focus on redefning their identity.Eventually, they reach a period of stability, when enjoyment of life becomes possible again.Notably, the process for bereaved parents is not fnite and often includes maintaining a bond with the deceased child.
Although previous research has delved into the complex bereavement experiences of parents with children who died of cancer, little is known about how Korean mothers cope with loss and integrate it into their redefned lives.Korean culture features a notable reluctance to discuss death, coupled with stigmatized attitudes toward parents who have lost a young child.Such deaths are traditionally labeled as "problematic," and bereaved people, particularly mothers, are often perceived as having failed in their parental duties.Tis perception is so ingrained that these mothers are sometimes unjustly labeled as "sinners" for outliving their children, especially in cases where the loss is due to illness [38].Tey are frequently subjected to criticism and questioning about their parenting, with a prevalent belief that their actions were directly responsible for the child's death.Tis often leads grieving Korean mothers to experience overwhelming guilt and shame [39].A study involving 2 Health & Social Care in the Community bereaved Korean mothers revealed many instances in which they encountered a lack of empathy for their pain and further hurt from insensitive responses from others [18].Tis societal stigma contributes to the isolation of bereaved parents, leaving them without a space to express their grief.Terefore, this qualitative study explored how Korean bereaved mothers come to terms with their child's death from cancer by exploring their bereavement and adaptation processes.

Method
2.1.Participants.Tis study included mothers whose children had died of cancer.Te sample consisted of 15 mothers, aged between 34 and 61 years.Tese mothers had served as primary caregivers, residing with their children with cancer before their death.All but two participants were full-time stay-at-home mothers at the time of their involvement in the study.Te most prevalent diagnoses among their children were leukemia (n � 6) and brain tumors (n � 6).Te remaining diagnoses included non-Hodgkin lymphoma, neuroblastoma, and myelodysplastic syndrome.Te average age of the participants' children at the time of bereavement was 11.1 years, with ages ranging from 2 to 22 years.Te period between bereavement and the time of the study spanned 8 months to 13 years.

2.2.
Procedures.Tis qualitative study was conducted as part of a larger project that employed a mixed-method approach to understand the journey of bereavement and grief experienced by mothers who lost their children to childhood cancer.Te current study's fndings were derived from part of the qualitative analysis, focusing on narratives pertaining to coping and meaning-making experiences.Using snowball sampling, the study involved 15 mothers recruited from support groups for bereaved mothers of children with cancer.Study fyers were distributed to members of the support group, and participants voluntarily contacted the principal investigator to express interest in participation.Te initial participants recommended peers in the support group for participation.
Participants engaged in comprehensive, in-person interviews that lasted 76 minutes on average, ranging from 50 minutes to 1 hour and 40 minutes.During these sessions, mothers were asked about the psychosocial impact of the loss of their child on their life.Based on the rich qualitative data collected from this project, several research papers have been written on topics such as the mothers' ongoing relationship with their deceased children and their familial dynamics [40,41].One main interview question addressed their coping strategies following the loss of their child to cancer, the responses to which are examined and discussed in the present paper.Ethics approval for the study was obtained from the research ethics committee of the university afliated with the principal investigator at the time of the study (Approval No. MJU-2018-05-003-02).

Analysis.
Te participants' narratives were analyzed using a data-driven, inductive thematic approach to identify recurring patterns and themes across participants [42].We followed Braun and Clarke's [43] approach, which involved becoming familiar with the interview data, generating initial codes, identifying and reviewing common themes, and writing the report while incorporating exemplar excerpts from the data.Using ATLAS.ti, the frst author deductively generated open codes that captured prominent phenomena in the data relevant to the participants' adaptation to child loss.All codes identifed were grouped by the frst and second authors through constant discussions to address any inconsistencies.Te higher level codes were then clustered to form subthemes and overarching themes.In the fnal step, these themes were defned through a thorough and iterative review process.Te analysis was conducted in Korean, and participants' quotes were translated by a bilingual-bicultural researcher not involved in the analysis.To ensure anonymity, pseudonyms were assigned to the participants throughout the study.

Findings.
Trough our analysis of individual interviews, we identifed three salient themes associated with how the mothers came to terms with the death of a child, involving 14 subthemes.As shown in Figure 1, three major themes were deeply intertwined in the experiences of mothers who lost a child.Te frst theme focused on how bereaved mothers coped with the grief of losing a child through specifc actions.Te second theme delved into how they comprehended and attributed meaning to their child's death in a particular manner.Te third theme explored what they gained throughout this process.Tese themes revolved around how the mothers coped with the loss of a child and attributed meaning to the death.Each theme is discussed using the participants' narratives, expressed using pseudonyms for them and their children.

Coping Strategies in Grief
2.5.1.Seeking Serenity and Inner Peace.Many participants sought to calm their emotions and counteract painful memories of the loss of their child through activities such as gardening, reading books, walking, or hiking.Tey tried to fnd emotional stability and solace by engaging in these activities.In particular, some participants endeavored to manage their fuctuating emotions by reading books about loss, thereby seeking to understand and anticipate their feelings and states.

"I went up and down the mountain for a walk. No one talks to me when I walk alone. My thoughts calm down when I walk while looking at the ground. I noticed that my intense emotions settled as I sweated, without dwelling on them too much. I try not to think about it [the death of my son] and put it to sleep. I think it's time to let go of the emotions that are rising. (Oksoon, 45 years old, 7 years and 1 month of bereavement)"
Four participants found comfort in raising pets.At times, they perceived the companionship of animals, whether dogs or cats, as a reminiscent connection to the child they had lost.By caring for and interacting with these pets, they found a source of emotional consolation.
"Te cats I adopted last year hold a special place in my heart akin to that for my son.Teir arrival came not long after my son's passing.I care for them as I did for my son.In many ways, they are like my sons to me.(Eunjoo, 43, 2 years and 9 months of bereavement)" 2.5.2.Expressing Emotions for Emotional Release.Some participants chose to confront and express, rather than suppress or avoid, their emotions and thoughts about the loss of their child.Although they acknowledged that reliving the past and being reminded of their child's death was painful, they also said that suppressing their natural emotions and thoughts due to this pain was not helpful.Tus, they endeavored to naturally face, feel, express, and even cry and let go of difcult emotions and feelings of missing their child as they came up.Many participants mentioned they could freely express their emotions when they were alone at home.During this time, they intentionally sought to express their emotions openly, looking at their child's photos, touching their child's belongings, and freely expressing their longing for their departed child.Trough this process, they experienced relief of their emotional pain.

"At frst, all that remained were thoughts and the memories of painful days. It was vivid and challenging compared to the good days. When painful memories resurfaced, I used to distract myself with other thoughts and avoid thinking about them. However, I later realized that this approach didn't solve the problem. So, I just let myself think about how difcult those painful days were. I just let it be. (Sora, 35, 10 months of bereavement)"
Although many participants said that their grief for their deceased child would inevitably persist until their own death, they reported that their grief and distress over the loss of their child got better over time through the process of crying and fully expressing themselves.Tey said such actions relieved their stress, and they felt as though their minds were cleansed afterward.Some participants even reported that by expressing their emotions just as they were, they felt like they were reuniting with their deceased child.

Engaging in Sorrow-Alleviating Activities.
Many participants attempted to alleviate their grief by embracing new learning experiences.Tey discovered that remaining at home caused them to be consumed by thoughts of their child, compelling them to seek solace by venturing outside and engaging in new activities.Some turned to yoga or exercise to invigorate their body, discovering that focusing on physical activity aided in dispelling distressing thoughts and enhancing their mood.For others, engaging in activities they enjoyed or acquiring new crafting skills provided a sense of healing through complete absorption.Most participants focused on creative pursuits, such as quilting, knitting, sewing, calligraphy, and French embroidery.Some focused on reading books and writing blogs, whereas others found that reading alone was not always enough of a distraction.A few pursued vocational trainings to advance the caregiving activities they had done while caring for their child.Regardless of their chosen pursuits, all participants reported experiencing a sense of healing and uplifted mood through their dedication to these activities.) was a space where they could naturally and comfortably reveal their emotions and thoughts about the loss of their child.Tus, they found it extremely benefcial for their mental well-being and comfort.Tese mothers were the primary caregivers for their sick children, so they understood one another's pain and difculties without the need for detailed explanations about their experiences.Tis mutual understanding allowed them to open up comfortably during these meetings.Tey engaged in deep conversations and shared the intimate and painful experiences of losing a child with individuals who truly comprehended their sadness and pain.Some participants found that discussing not only the loss of their children but also their inner wounds during these gatherings formed a healing experience, aiding in the recovery of their inner scars.
"We were able to understand each other without saying a word.Whatever I expressed, I didn't feel any regret about it.I felt incredibly grateful for the experience.Simply being able to express my inner thoughts in that gathering was immensely helpful.I could freely share various thoughts and emotions there.(Yerim, 51, 3 years and 10 months of bereavement)" Many participants said that the support group provided a safe space to talk about their deceased child when they met with other bereaved mothers.Many participants noted being cautious about even mentioning the deceased child's name in other settings because people often perceived that talking about deceased people makes them sad.However, they found comfort in having a platform through this gathering where they could openly discuss topics like the illnesses their deceased child had sufered from, their grieving following the loss, and cherished memories of their departed loved child, all without feeling any pressure.Tey appreciated that they could freely speak the name of their bereaved child, addressing one another as the mothers of these children and comfortably sharing stories about them.Tis environment allowed these women to continue their identity as the mother of their lost child, who still held a place in their hearts, ofering them signifcant comfort and solace.
"We rarely bring up the names of our deceased children outside of our support group.Te longer our children have been gone, the less frequently their names are mentioned.Many families also avoid saying their names at home.It feels like a painful sting when the deceased child's name is mentioned-it brings about a sudden silence among everyone present.However, in the support group setting, I am known as 'Min [daughter's name]'s mom,' and that's what I like about attending the meeting.(Yerim, 51, 3 years and 10 months of bereavement)" Some participants emphasized that they could see both their future and past through the other bereaved mothers they met in the support group, and simply being in the same space with them provided comfort.Tey also felt empowered by knowing other people who wanted to support them.Seeing others living the same journey helped them envision how they would move forward in their own lives, which was benefcial.Tey also wanted to extend their support to other mothers in similar situations.Knowing that their existence as grieving mothers could be of help to someone else allowed them to have positive thoughts.Meeting people who understood and thought about them in challenging situations was heartwarming, and it made them feel as if they were receiving gifts from their children.Simply sitting among understanding individuals provided them with strength.
"Just knowing that there are people who care about mothers who have lost their children was something I was thankful for.Meeting these people makes me feel that I'm not alone.I feel like it's a gift that my child sent to me.Tese are people I wouldn't have met if my child hadn't been unwell.(Jisook, 57, 3 years and 4 months of bereavement)" 2.5.5.Accepting Spiritual and Religious Comfort.Many participants experienced support from their church community.Tey spent time with fellow church members, receiving emotional and practical assistance, including funeral support.Additionally, some of them received material support to pay hospital bills through the broad social network in their church.Notably, one participant highlighted that material support from unfamiliar individuals in the church was deeply appreciated, and they found it more valuable than mere verbal comfort.
"During challenging times, my religious beliefs have been a signifcant source of support.In my faith community, the companionship of fellow church members and friends has proven immensely benefcial.My family, siblings, and even my in-laws were able to navigate that difcult period due to my unwavering faith.Trough these relationships, I was able to endure while maintaining and upholding my spiritual life.(Mija, 54, 3 years and 9 months of bereavement)" Some participants accepted the death of their child through a religious interpretation.Tey acknowledged that life and death were determined by the will of God, and they Health & Social Care in the Community prayed, beseeching to be rescued from the darkness of their hardships.Tey continued in their prayers, admitting their sins and pleading for God to save them.Tey endeavored to accept that death could be embraced according to the will of God, regardless of age.While listening to sermons, they tried to embrace the religious principle that their lives unfold not according to their will but rather that of God.
"I've come to recognize that I've placed too much importance on myself.Recognizing this has made me acknowledge the necessity of reevaluating my priorities.Seeking solace in attending church and listening to sermons once or twice a week has been comforting.Faith appears to hold profound strength.Seeing how my faith helps me cope with my child's passing is indeed a blessing.Tose who haven't gone through such an experience may not grasp its profound impact.Going through this without faith would undoubtedly have intensifed the difculty.(Yuna, 45, 1 year of bereavement)" Grief responses were also understood from religious perspectives.One participant said she found peace by understanding her constant bad dreams in the religious context of salvation, awakening with a deep conviction that her daughter exists in a peaceful state in heaven and reinforcing her belief in the presence of God.
"I was surrounded by darkness and deep despair, feeling as though I was on the brink of death. . . .Ten, in a dream, my daughter appeared-not as a spirit, but with a radiant, vivid presence, as if she were genuinely alive and breathing.Upon waking, I was struck by the profound sense that she truly exists, peacefully resting in heaven.It was as if she conveyed to me, 'Don't cry,' reassuring me of her well-being.Te memory remains incredibly vivid.In that moment, she seemed to foat, with a staircase behind her, enveloped in a radiant light in my room.I asked her, 'Are you alright?Are there any pain, worries, sadness, or tears?'As I continued, I awoke, realizing, 'God exists, and she is in heaven.' (Hana, 45, 3 years and 10 months of bereavement)" 2.6.Signifcance of the Child's Death 2.6.1.Seeking Meaning in the Child's Legacy.Some participants tried to comprehend the signifcance of their child's brief life and death.However, they encountered difculty in reaching an answer and found the process distressing.Tey discovered an internal struggle, persistently attempting to grasp the implications of their deceased child's life and the reasons behind their premature departure even though they acknowledged the possibility of no defnitive answers.One participant endeavored to fnd insights by delving into philosophical books.Nonetheless, confronting the question of why certain young children who yearn for a long life like everyone else must instead endure sufering in hospitals for a considerable part of their short lives before passing away proved to be a challenge.
"I still grapple with the question of why my daughter had to die.Why did it happen?I'm on a quest for those answers.I hesitate to accept any explanation as a defnitive answer, nor do I wish to imply that there is one.Any reasoning signifcant enough to elucidate my daughter's passing remains elusive.Yet this pursuit has recently fostered in me an inclination to persist in seeking answers, even though I'm aware that they may not exist.(Eunjin, 44, 3 years and 11 months of bereavement)" In their pursuit of understanding their child's life and death, many participants found it challenging to accept words from others that attributed meaning to the child's passing.Tey struggled even more to interpret the death through their preexisting religious perspectives, often leading to the negation of their established beliefs and thoughts.Particularly, those with faith said they believed in an afterlife where heaven was a better place and that everything in life was happening because God loved them and intended it for them.However, when faced with their child's death, they realized the difculty of accepting such interpretations and struggled to comprehend the child's death.Teir longing to see their child again was so profound that they questioned the signifcance of the child's life or even God's love, holding skeptical thoughts.
"People often say that there might be a reason why some older people die or children live only a short life-to prevent something worse from happening or to bring about a greater good.However, I really hated hearing those words.Why does it have to be my child who bears that burden, among all others?I ponder this question frequently.I'm also attempting to come to terms with it.(Sora, 35, 10 months of bereavement)" 2.6.2.Recognizing the Child as a Blessing.Some participants, once they had come to accept the death of their child, shifted their focus to the fact that their deceased child had once existed with them and the happiness they had experienced during that time.Trough this lens, they reframed their child not as a possession but rather a feeting gift they had cherished.Tese participants acknowledged the moments of joy and shared laughter with their children, not only times of illness.Teir source of meaning rested in the profound truth that they had shared precious time with their cherished and delightful children.Among those with religious convictions, the notion of their children being gifts from God became prominent.Tey expressed gratitude for having received this divine gift, even if it was for a limited duration.Tis perspective led them to understand their child's presence as an entrusted gift rather than a personal possession, ultimately guiding them to release and let go.Some of them viewed physical illness as something that could happen to anyone.During the process of seeking meaning in the death of their child, several participants grappled with emotional sufering by linking their child's passing with their own wrongdoings.Tey held themselves responsible, believing that their mistakes and improper life choices had led to their child's premature death.For some, this perspective extended to viewing their child as a symbolic victim of their sins, as if their child's sacrifce was necessary for their redemption.Tis outlook further intensifed their inner distress.Participants who expressed a belief that their child resides in heaven said that by living their lives with purpose, they could ensure a reunion beyond life.Driven by this belief, they gathered strength and maintained a relentless commitment to living virtuously, all in the hope of eventually reuniting with their departed child.Teir days were marked by resolute prayers and a deep anticipation of the moment when they would once again be united in the realm beyond.

"A pastor once asked me if I considered this child as a gift, and I found myself unable to answer. I always perceived my child as my own. I hadn't truly contemplated him as a gift. However, now, I fnd myself replaying every moment from
"As believers, we hold onto the dream of reuniting with my daughter in heaven.It's a hope that fuels our daily lives.We frmly believe in the possibility of a reunion in the afterlife.To realize this aspiration, we feel the necessity to immerse ourselves more profoundly and sincerely in God's work.(Narae, 57, 10 years and 4 months of bereavement)" 2.7.Growth through Tragedy 2.7.1.Shifting Life Priorities after Loss.Many participants pointed out that their values and life priorities underwent a profound shift after the loss of their child.Previously, they had pursued a life focused on external expectations, such as achieving material comfort, chasing success, and outpacing their peers.However, in the aftermath of their child's passing, they came to a profound realization that these things were not as important.Tey let go of pursuits like money and success.Tey underwent a transformation, valuing maintaining health, doing what they wanted, enjoying what they loved, ensuring their families' joy and comfort in the present, and placing importance on a leisurely and relaxed state of mind.

"What has changed for me is my decision to release the pressure of meeting various expectations I once struggled with. I used to live intensely, driven by those expectations. However, I came to realize that living that way didn't truly alter anything. Consequently, I've adopted a more easygoing and relaxed approach, understanding that I don't have to conform to those pressures. In terms of fnancial matters or similar concerns, I've learned to let go of such worries. (Oksoon, 45, 7 years and 1 month of bereavement)"
Te participants also pointed out that their previous emphasis on their child's achievements had shifted toward considering the current happiness of their family and wellbeing of their remaining children.Tey shared that in the past, like many others, they had dedicated themselves to guiding their children toward a promising future, sometimes even subjecting them to academic pressures in the pursuit of a prestigious education.However, the tragic loss of their child led them to a profound realization-that these eforts seemed futile.What emerged as paramount were actions that could be taken in the present: ensuring their surviving child's emotional well-being and nurturing a meaningful parent-child relationship.Tis change in perspective guided them toward altering their approach to raising their surviving child and reshaping the dynamics in their familial connections.

"My values have undergone a complete transformation. Prior to my child falling ill, I invested immense efort in
Health & Social Care in the Community

striving for her admission to prestigious universities. Education held utmost importance, alongside my husband's career advancements. It felt like I was doing the best I could. However, I've since relinquished everything. Te most valuable aspect became sharing a family meal together.
Tat time held immense value, but unfortunately, it's something I can no longer experience.(Yerim, 51, 3 years and 10 months of bereavement)" 2.7.2. Engaging in Altruistic and Fulflling Activities.Many participants developed an interest in activities that assist children who are sufering, similar to their deceased child.Tey provided advice to parents with terminally ill children, drawing from their experiences and knowledge gained from caring for their sick child.Tese participants also engaged in volunteer activities aimed at helping children in pain and parents who have lost their children.Some of them even pursued healthcare training to volunteer at hospice hospitals.Trough their interactions with patients, caregivers, healthcare staf members, and other bereaved parents facing similar situations at the hospital where their child spent long periods receiving treatment, they cultivated a sense of ongoing connection with their deceased child.When ofering support to sick children, struggling caregivers, and grieving parents, they described experiences that evoked feelings reminiscent of when their child was alive.

"I sense the importance of leading a purposeful life of my own. Having spent signifcant time in hospitals, thoughts of those children often fll my mind. I strongly feel that children are the ones who require the most support. Tey lack the ability to fend for themselves, and their plight isn't due to any fault of their own. Contemplating the hardships faced by children deeply pains my heart. (Eunjin, 44, 3 years and 11 months of bereavement)"
One participant went so far as to put her body to use in helping others in painful situations, much like her deceased child.She donated blood, signed up for posthumous organ donation, and eventually, after donating a kidney, said that she fnally regained her sense of reliance and confdence in life.
"Following my son's passing, I decided to make a posthumous organ donation pledge, something I hadn't considered before. . . .Additionally, I engaged in blood donations, hematopoietic stem cell donation, and similar contributions.Last year, I underwent kidney donation. . . .Tis step alleviated the burden of feeling like I hadn't done enough for my child.It seemed like hitting rock bottom, but then the slow ascent began.Eventually, I began to feel empowered, sensing a newfound desire for life stirring within me.I started to believe that I could achieve anything.(Oksoon, 45, 7 years and 1 month of bereavement)" 2.7.3.Focusing on Living in the Present.Many participants, having come to the realization that death is an indiscriminate and ever-present possibility, reported a reduction in their fear of death.Tis shift in perspective enabled them to focus more on fulflling their immediate desires and pursuing happiness.Tey expressed an understanding that the diference between life and death is ultimately inconsequential, likening it to the simple distinction between breathing and not breathing.Moreover, they said they had previously believed that once a person dies, that would be the end, but upon the death of their child, they came to understand that death was not fnal.Building on these lessons, they strived to live more freely, pursuing what they wanted instead of postponing desired actions.Tey put efort into ensuring their current well-being and their family's happiness.In the past, they had pushed their desires and happiness aside, thinking they would earn more money, buy a house, wait until their kids grew older, and only then pursue their goals.However, they found they had constantly deferred their present happiness for another task.Teir child's death prompted this refection on their past approach to life, and they realized that ultimately, nobody knows what will happen to them and their families in the future.

"As I witnessed my daughter's journey to heaven, a profound realization struck me-the boundary between life and death hinges on the simple act of breathing or not. It's merely a one-sided distinction between existence and passing away. . . . Te fear of death seems to have vanished. I now feel a sense of peace, as if I'd be at peace even if my
time were to end tomorrow.Tis fearlessness toward death is deeply profound.Honestly, I no longer hold onto attachments.If death arrives, so be it.I've developed a sense of having no lingering regrets, a feeling of embracing and acceptance, even in the face of death.(Soonja, 38, 8 months of bereavement)" 2.7.4. Developing Empathy and Compassion.Participants stated that through the experience of their child's death, they became more mature and better individuals.None of the participants considered the immense tragic cost of their child's death as justifed by their personal growth, and they deeply mourned this fact.Nevertheless, despite undergoing such challenging experiences, they developed empathy for others' difculties, became more patient and generous toward people including their families, learned to inspect their faws, and adopted an attitude of valuing not only their wellbeing but also the lives of others.Tey willingly ofered their heart and held an attitude of giving for the beneft of others.

"Te loss of my child has left an enduring impact on my mental state, plunging me into a continuous emotional void. During moments of comfort, my thoughts used to narrow to my well-being. Currently, I grapple persistently
with mental anguish, sorrow, and fatigue.Sustaining such a state of mind has humbled me, allowing me to approach interactions with my husband and family from a place of mental humility, fostering forgiveness.Consequently, I've cultivated a deeper sense of compassion for them, which has signifcantly contributed to my emotional well-being.

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Moreover, this mindset transcends personal relationships; witnessing others' struggles prompts me to ofer prayers on their behalf, extending empathy to those in need. (Hana, 45, 3 years and 10 months of bereavement)"
In particular, some participants noted that in the past, they frequently interpreted negative outcomes as a personal fault or responsibility.However, after experiencing the death of their child, they shared that upon encountering someone facing difculties, their initial response shifted from judgment to ofering help.Tis shift in perspective had lessened their feelings of anger and frustration arising from social interactions, nurturing an increased sense of consideration and patience toward others.Tey acknowledged the need to demonstrate love for others.
"Pain exists in every household, each with its unique circumstances.Trough all this, my approach to interacting with others appears to have evolved.I fnd myself less annoyed by other people's actions.Previously, when someone made a mistake, I'd get upset, but now I view such incidents as relatively inconsequential.When someone becomes agitated, I think to myself, 'Does it truly matter?' Once the moment passes, it seems insignifcant.(Jisook, 57, 3 years and 4 months)" 2.7.5. Strengthening Spiritual Beliefs and Experiences.Many participants said that the death of their child was incredibly painful.However, through the child's death, their faith deepened.After the death of their child, they gradually found recovery and stability in the emotional pain and confusion.Tey developed an attitude of gratitude for things they had previously taken for granted, thus achieving new meaning in life and death.Tey said that all these experiences were part of a process of salvation and that their child had opened the door to that salvation for them and their family.During their child's illness, some fervently prayed and evangelized, becoming more engaged in their faith activities.In that sense, some participants said that God chose them for that purpose.Tey learned to fnd gratitude even in small things, such as eating rice or walking.Tis process made them realize the smallness of their existence.Based on their faith, they said they strongly believed that they would reunite with their child at some point.One participant said that as a result, their deceased child remained with them as love, rather than pain.
"I've come to accept that his early departure was a means for God to deepen my faith.I believe his presence played a part in strengthening the faith of our family, including my mom and dad.Despite the pain of witnessing his illness, God taught us to appreciate even the smallest blessings, like being able to eat a spoonful of rice or take a single step forward.(Mija, 54, 3 years and 9 months of bereavement)"

Discussion
Tis study delved into bereaved mothers' experiences in coping with the loss of their children to cancer and constructing meaning from their children's death.Te participants in our research, despite having varied durations of bereavement after the loss of their child, tried to cope in their own ways and at their own pace.Tey engaged in meaning making and personal growth, which were closely interconnected in their experiences, occurring simultaneously and overlapping rather than being distinctly separate.Tis has signifcantly advanced our knowledge on coping during bereavement and the process of deriving meaning from a child's death.
First, our participants reported diverse ways of coping with the profound loss of a child to cancer.Tey engaged in various activities aimed at either diverting their attention from the intense pain of their child's passing or expressing that pain.Tey sought to forget their pain by engaging in various activities, such as seeking inner peace, freely expressing their emotions when alone, or focusing on other activities.Tis fnding is consistent with previous studies that noted distraction and refocusing strategies as commonly associated with child loss [10].Asians tend to employ avoidant coping strategies more frequently compared to people from other cultural backgrounds [44,45]; thus, it is possible that they are likely to employ distraction strategies as a means of emotional control and self-reliance, in alignment with Asian values [46].In the Korean context, where mothers confront daunting social stigma linked to child loss [18] compounded by institutional factors like insufcient support from family, friends, and formal social services, it becomes plausible that many mothers would turn to distraction strategies as a response to this lack of other support.
Given these situations, in addition to their predominantly self-reliant coping strategies, these mothers also sought the only available yet invaluable external assistance of peer support groups and leaned on their religiosity.Tese coping strategies, similar to fndings reported among bereaved families worldwide, were frequently reported to be benefcial [21,47].In particular, in the context of Korean society, which carries a cultural taboo surrounding open discussions about deceased children, the participants primarily turned to their religiosity and fellow bereaved mothers who shared similar experiences and challenges [18].Tey distinctly perceived these situations as a "safe space" for expressing their emotions and acted accordingly, aligning with the fndings of Stevenson et al. [47].Tis reliance on shared experiences and faith may be driven by the understanding that talking openly about their loss is stigmatized in society.In contrast to previous research, in which mothers who had lost a child often shared their emotions with family and friends and received substantial support from them [10,48], we found that they expressed discomfort Health & Social Care in the Community and a sense of taboo even when discussing their child with their family members, which is similar to fndings in the context of Chinese families [49].Speaking openly about their loss, without the weight of societal stigma, facilitated a sense of connection with their deceased child and was often identifed as a helpful coping mechanism for bereaved parents grappling with the aftermath of loss [47].
Regarding bereavement support in Korea, our fndings indicate a preference for support groups, which contrasts with the broader trend toward individual programs rather than group formats [50].Tis broader preference may stem from a cultural inclination toward privacy, such that many Koreans are hesitant to share personal experiences in a group.Te collective nature of such discussions may cause discomfort, thus inhibiting individuals from openly expressing their grief.Tis cultural tendency is particularly prominent in the context of child death, which is viewed as an abnormal event in Korean culture [51].Te societal perception of child loss as a uniquely difcult experience can exacerbate the challenges for bereaved parents in openly discussing their emotions and navigating the complexities of grief.Our participants might have gravitated toward group settings where their suferings could only be understood, despite cultural norms.
Second, participants in our study coped with the profound grief of losing a child by turning to religious and spiritual practices.Tis aligns with fndings from previous studies, such as Kenny et al. [21], in which parents made signifcant eforts to fnd meaning in their child's passing, seeking solace amid their pain.However, many participants still struggled with this quest for meaning, resonating with the observations of Lichtenthal et al. [28].Regarding religious afliation, Korea is particularly noted for its Protestant population yet has diverse religious practices [52].Among Koreans, Christianity is the most prevalent, followed by Buddhism.According to Statistics Korea [53], 43.9% of the total population identifes with a religion.Of 2.1 million religious adherents, 44.9% are Protestant and 18.0% are Catholic; thus, Christians cumulatively represent 61.9% of the religious population.Tis Christian predominance is especially marked in Seoul, the location of our study, where 52.1% of religious adherents identify as Protestant and 23.1% as Catholic (thus, 75.2% as Christians).
Tose unable to fnd meaning exhibited emotions of anger or denial toward their religious beliefs, a response noted by Parkes [54] and Wortmann and Park [55].Despite these challenges, similar to existing literature highlighting spirituality and religious beliefs as the most common themes in sense making [28], our participants did not solely perceive their child as their own.Some even attributed the death to their sins, leading them to transfer their longing to the hope of reuniting with their child in heaven.Religious faith may have adverse efects on bereaved parents' ability to cope by causing them to view the death of a child as a punishment from God [56], and the struggle to make sense of such a loss can further intensify symptoms of prolonged grief disorder, as observed by Milman et al. [57] and Rozalski et al. [58].On the other hand, engaging in the process of meaning making can facilitate bereaved parents' recovery from the profound sorrow and pain caused by the loss of a child [59].
Notably, the time elapsed since the loss of their child varied considerably among the participants in the study.Schwartz et al. [60] highlighted that the duration since the loss can afect the manifestation of grief symptoms in bereaved individuals.Specifcally, studies such as those by Boerner et al. [61] and Carnelley et al. [62] have noted a decrease in the search for meaning as time progresses.Tus, it is imperative for future investigations to further our study fndings by considering the potential impact of time since the loss on experiences of grief among bereaved mothers.
Tird, this study unveiled a sense of growth among bereaved mothers in the aftermath of their child's traumatic death.Tis fnding is congruent with prior research that demonstrated similar growth and shifts in perspective among bereaved family members of cancer patients in Japan [63] and bereaved mothers in Korea [64].Building on the literature, which suggests that posttraumatic growth subsequent to the loss of a child is more likely among women (mothers) and those with strong continuing bonds [65], the mothers in our study, who occupied the role of primary caregiver for a long period, appeared to develop robust emotional bonds with their children throughout their child's cancer treatment and passing.Bereaved mothers may invest time in reconstructing the meaning of their child's loss, and this process could foster personal growth.
Tis study confrmed the benefts of Neimeyer's [66] meaning reconstruction approach in grief therapy for mothers who have experienced traumatic bereavement.To promote growth and recovery, trained professionals could implement meaning-oriented psychotherapy [67].Considering the strong social stigma against mothers who have lost children in Korea and the evident lack of support for bereaved mothers in Korean society [18], it is crucial to recognize that mothers who have experienced child loss face a very high risk of mental health issues.Additionally, because child loss involves a lifelong process of bereavement, it is essential to address the dynamic mental health needs of these individuals over an extended period.Although women often seek understanding and support from friends and family, societal and cultural infuences in Korea often lead family members to deal with their grief individually, resulting in a lack of mutual support in families.
It is crucial to extend support beyond individual family members by implementing programs and counseling that encompass the entire family unit.Tis holistic approach can foster an environment conducive to mutual understanding and support among family members as they navigate the challenges of loss.Additionally, it is essential to establish feasible, acceptable, and sustainable community-based interventions.Tese interventions can play a pivotal role in supporting bereaved parents at risk of mental health issues in the community.As bereaved parents reintegrate into their daily and social lives outside of clinical settings, they should have continuous access to services provided by communitybased bereavement support agencies.Such support is vital to 10 Health & Social Care in the Community facilitate their adjustment and coping in the aftermath of their child's death.Tis study has notable limitations, primarily stemming from potential biases resulting from participant selection.Te time elapsed since the loss of the children varied, ranging from 8 months to 13 years.Given this broad spectrum, bereaved mothers who experienced this loss may be at diferent stages in their mourning process, potentially infuencing their responses and experiences.Subsequent studies should undertake an in-depth exploration of mourning experiences, analyzing diferences based on the length of time that has passed since the child's death.All participants were recruited through snowball sampling from support groups for bereaved mothers of children with cancer.Tis method likely skewed the fndings toward shared coping strategies.For instance, it was not surprising that seeking support from peers was the prevalent method of coping, given the nature of the recruitment.Mothers who are not involved in support groups may employ alternative coping strategies.Additionally, the prominence of participants with religious ties possibly tilted the fndings toward spiritual coping and meaning-making responses.
Moreover, the study's limitations might be compounded by its cross-sectional design.Although this design allowed for a snapshot of coping strategies at a specifc time, it did not provide insights into how these strategies evolved over time.For a more layered understanding of the sequence-potentially starting with coping, transitioning to meaning making, and culminating in growth-a longitudinal study would be more informative.Tis extended approach would ofer deeper insights into the evolving nature of coping, the journey of fnding meaning, and eventual personal growth over time.Coping with the loss of a child and fnding meaning out of pain and trauma may bring growth to bereaved parents.Although such pain and trauma may not disappear in their life, it is important for them to adapt and move forward through the process of fnding meaning following the death of a child.Tere is a pressing need for professional support tailored to help them fnd solace and meaning.Acknowledging and incorporating cultural nuances in these coping mechanisms can signifcantly bolster our knowledge base, paving the way for culturally informed interventions.Such a holistic approach could be indispensable for mothers wrestling with the overwhelming grief of child loss in varied cultural contexts.
Figure 1: Mothers' grief journey after losing a child from cancer.
4 Health & Social Care in the Community "During the two hours of exercising, there are times when I don't think about anything at all.I just blankly let my mind rest and return home without any thoughts.At other times, I keep thinking about my child while exercising.It feels like that place has become my own personal world.Shall I call it healing?I don't like feeling drained.I hate feeling sluggish.