Abstract
Background and aims
Families play an important role in the evolution of gambling and are also adversely affected by the disordered gambling of any one of their members. The aims of this study were to explore both the role families play in gambling initiation, maintenance, and help-seeking, and the harm caused to families by the gambling behavior using a qualitative approach.
Methods
Regular older adult gamblers were included in the study. In-depth interviews were conducted with 25 older adults to gain an understanding of gambling from their perspective. Older adult gamblers described their lived experience of gambling ranging from initiation to harm and attempts to cut down or limit gambling. Data were analyzed using thematic network analysis.
Results
The mean age of the 25 participants was 66.2 years. The majority were male (n = 18), of Chinese ethnicity (n = 16), had secondary education (n = 9), were married (n = 20), and currently employed (n = 15). Four organizing themes related to the role of families in initiation and maintenance of gambling, harm caused to family members, and their role in help-seeking were identified.
Discussion and conclusions
The study emphasizes the role of Asian families in both initiation and maintenance of gambling. Hence, families must be involved in prevention and outreach programs. Family members must be educated, so that they can encourage help-seeking to ensure early treatment and recovery. There is a need for interventional studies for reducing stress and improving coping among family members.
Introduction
Gambling is a widely accepted recreational activity across many countries in the world today and it ranges from games like playing cards organized in informal settings to casino and online gambling (Productivity Commission, 2010). Gambling behavior also varies widely and ranges across a spectrum from recreational or social gambling to gambling disorder. The majority of individuals gamble for a limited time and incur acceptable losses and generally do not have any long-term problems related to gambling – a phenomenon often referred to as social or recreational gambling (National Research Council, 1999). Gambling disorder, on the other hand, is recognized as a mental disorder characterized by a pattern of continued gambling, despite significant negative physical, psychological, and social consequences not just for the individual but for the family and community at large (American Psychiatric Association, 2013).
Research has increasingly shown that gambling and gambling disorder is common among older adults (Subramaniam, Wang, et al., 2015; Tse, Hong, Wang, & Cunningham-Williams, 2012); reasons postulated include both person level and environmental factors (Ariyabuddhiphongs, 2012). Personal factors included the desire to win money, relax, seek excitement, socialize, meet new people, escape boredom and feelings of grief and loss (Clarke, 2008; Clarke & Clarkson, 2008; Florida Council on Compulsive Gambling Inc., 2004; Hong, Sacco, & Cunningham-Williams, 2009; McNeilly & Burke, 2000; Moore, 2001; Southwell, Boreham, & Laffan, 2008; Wiebe, Single, Falkowski-Ham, & Mun, 2004); whereas environmental factors include easy access to and the availability of gambling venues (Pearce, Mason, Hiscock, & Day, 2008; Thomas et al., 2010). However, older adults may be at an increased risk of developing gambling disorder due to a number of unique factors, such as loneliness, fixed incomes, not being part of the workforce, and cognitive decline (McNeilly, 2007; Southwell et al., 2008); gambling disorder, in turn, can result in immense harm to the health of the older adult (McNeilly & Burke, 2002).
A family is defined as a social group of individuals “tied together through their common biological, legal, cultural and emotional history and their implied future together” (McGoldrick, Gerson, & Shellenberger, 1999). Family members have a profound effect on each other’s development, functioning, and well-being. Families play an important role in the evolution of gambling and are also adversely affected by the disordered gambling of any one of their members. While a growing body of research suggests that genetics play a significant role in the risk for the development of problem gambling (Grant, Leppink, Redden, Odlaug, & Chamberlain, 2015; Lang et al., 2016), psychosocial factors play an equally significant role in gambling initiation. Magoon and Ingersoll (2006) found that parental gambling was related to levels of past year gambling as well as an increased likelihood of being classified as a problem gambler among adolescent gamblers. Ohtsuka and Chan (2014) in their study on older adult gamblers in Hong Kong found that older adults had often been introduced at a young age to gambling by extended family members. Gambling was an accepted behavior in their families and was not stigmatized; furthermore, development of gambling skills was even encouraged at a young age. Research also suggests that gamblers often turn to families when they experience problems, but they might also be thwarted from doing so due to perceived barriers related to loss of self-esteem and the perception of not meeting family members’ expectations, both of which may limit help-seeking (McMillen, Marshall, Murphy, Lorenzen, & Waugh, 2004). A number of studies have identified negative impacts of disordered gambling on the family that include relationship problems, conflicts, financial hardship, and intimate partner violence (Dowling, Smith, & Thomas, 2009; Hodgins, Shead, & Makarchuk, 2006; Kalischuk, Nowatzki, Cardwell, Klein, & Solowoniuk, 2006; Suomi et al., 2013).
Singapore is an island city nation in southeast Asia, with a population of about 5.6 million of which 3.9 million are Singapore residents. Of these residents, the majority are of Chinese descent followed by those of Malay, Indian, and other ethnicities (Singapore Department of Statistics, 2016). Studies have examined the prevalence of gambling within Singapore’s population and identified sociodemographic factors like male gender, Chinese ethnicity, and younger age group as being more likely to be associated with gambling (National Council of Problem Gambling, 2015; Subramaniam, Abdin, et al., 2015). Gambling is culturally acceptable among the Chinese with the activity being part of important events, such as the Chinese New Year (CNY) and other festivities. Games, such as Mahjong, are often played with families and friends; thus, many of them perceive gambling as a form of social bonding and relationship building. On the other hand, stigma and concern of “losing face” is especially significant among Asians. Attempts to keep up appearances of normal functioning in the community by not seeking help might lead to the development of gambling disorder (Sue & Sue, 1987; Scull & Woolcock, 2005). However, few studies have examined the role families’ play in the evolution of the phenomenon or what the effects on the family are from the perspective of the gambler; data on the role that families play in help-seeking are also limited. The aims of this study were to explore both the role families play in gambling initiation, maintenance, help-seeking, and the harm caused to families by the gambling behavior of older adults using a qualitative approach.
Methods
This study is part of a larger study exploring the initiation and maintenance of gambling in older adults in Singapore. Since the phenomenon of older adult gambling had not been explored in the local population, an interpretivist approach was adopted. An understanding of gambling was sought from the perspective of the older adult gambler “as interpretive researchers assume that access to reality (given or socially constructed) is only through social constructions such as language, consciousness, shared meanings, and instruments” (Myers, 2008, p. 38). A qualitative approach using in-depth interviews was adopted.
Sample and setting
Inclusion criteria for the study included those aged 60 years and above; Singapore residents (citizen or permanent resident); able to speak in English, Chinese, Malay, or Tamil; and being current or past regular gamblers, i.e., those who gambled at least weekly (Winters, Stinchfiel, & Fulkerson, 1993). The mean age of the 25 older adult gamblers who participated in the study was 66.2 years. The majority were male (n = 18), of Chinese ethnicity (n = 16), had a secondary education (n = 9), were married (n = 20), and were employed (n = 15) either in a full-time or part-time job. The mean age of gambling initiation was 24.5 years. Eleven of them reported that other family members had gambling-related problems. Nine participants met the criteria for probable pathological gambling (in their lifetime) using the South-Oaks Gambling Screen (SOGS).
Strategies for recruitment included referrals from the clinicians in the National Addiction Medical Services in Singapore who provide treatment to those with gambling disorder across Singapore, approaching “older adults” (based on appearance) at gambling venues and inviting them to the study using flyers as well as by requesting older adults who participated in the study to refer their friends or acquaintances who met the inclusion criteria for the study.
Data collection
After conducting a simple screening to ensure that the respondent met the inclusion criteria, participants were administered the following questionnaires:
South-Oaks Gambling Screen (SOGS) (Lesieur & Blume, 1987)
The SOGS comprises 20 scoring questions. Participants respond to each of these questions with a “yes” or “no” and affirmative responses are then added up to obtain the total score. The scoring items include questions about going back another day to win back money lost, gambling more than intended, being criticized by others over gambling, feeling guilty about gambling, having difficulty stopping gambling, and losing time from work because of gambling. SOGS has been validated locally (Abdin, Subramaniam, Vaingankar, & Chong, 2012) and a total SOGS score of 5 and above indicates a lifetime diagnosis of probable pathological gambling (Lesieur & Blume, 1987).
Sociodemographic questionnaire
The questionnaire collected information on the respondent’s age, age of onset of gambling, gender, ethnicity, marital status, education, and employment. While both the SOGS and the sociodemographic instrument were self-administered, the interviewer was available to answer any queries or provide clarifications where needed.
In-depth interviews
In-depth interviewing is a qualitative research technique comprising a purposeful conversation between a researcher and a respondent. The social interaction encourages respondents to talk in-depth about the topic under investigation without the researcher’s use of predetermined, focused questions. In-depth interviews are especially useful when the topic that is being investigated is sensitive as informants are more comfortable to share such information in a one-to-one setting and in a language that is comfortable to them (Boyce & Neale, 2006; Legard, Keegan, & Ward, 2003). Face-to-face interviews were conducted by the first author maintaining a non-judgmental and conversational approach. An interview guide was used to guide the conversation (Table 1) and participants were probed when necessary. Probing comprised follow-up questions that helped clarify, specify, or further expand on the information provided by the respondent (Legard et al., 2003). The narratives comprised rich descriptions of the older adult’s lived experience of gambling starting from the very first time they gambled, the progression over time, the consequences across the life span of the behavior, help-seeking, as well as barriers to seeking care for the problem. Interviews ranged from 45 min to 2 hr in duration. All the interviews were conducted in English at a venue that was convenient to the participant. Interviews were audio-recorded and subsequently transcribed verbatim. The study has been further described in detail in an earlier article (Subramaniam et al., 2017).
Guide for in-depth interview
| 1 | Tell me how you first started to gamble? |
| 2 | Would you say there was anything that contributed to your gambling? |
| 3 | What was going on in your life then? What kind of person would you describe yourself at that point? |
| 4 | Did anyone influence your decision to gamble? |
| 5 | Why did you continue to gamble? |
| 6 | Can you tell me about the good and bad things that have happened in your life that you think are related to your gambling? |
| 7 | Tell me about your gambling nowadays. Why do you gamble? |
| 8 | Tell me about the kind of person you are now? Do you think you have changed since you were N (age when first started gambling) years old? |
| 9 | When you look back can you think of any significant events associated with your gambling? |
| 10 | (If the person has talked about problems associated with gambling) – Have you sought help for the problems such as that you had mentioned to me? |
| 11 | What has been most helpful for you to deal with these problems? |
| 12 | Where do you see yourself 5 years from now? |
| Is there anything else you want to tell me? | |
| Is there anything you want to ask me? | |
Text analysis
Thematic network analysis methodology proposed by Stirling (2001) was adopted to analyze the data. Thematic network analysis brings together basic themes, which are the lowest-order themes, and groups them into organizing themes. Organizing themes are then arranged into a superordinate, global theme, which reflects a major point in the text. These basic, organizing, and global themes are then portrayed visually as a network. The fourth stage involves describing and exploring the networks generated, where the content of each network is described and supported by relevant quotes. Each network is summarized in the fifth stage and finally the key conceptual findings in the summaries of each thematic network are woven together and used to answer the original research questions.
Codes were identified in the text by familiarization with the data through active reading and re-reading of all the interview transcripts. Salient statements representing processes that were relevant to the role of family in gambling were identified. For example, the code – “Parental gambling” included texts such as – “My father played Mahjong, poker, and all those things” and “My father bet on horses. He was a habitual gambler.” Coding of all the transcripts was done by the first author (MS). Another researcher (ST) independently coded the first five transcripts. Codes were discussed and refined for the creation of the codebook. All the transcripts were then uploaded into the qualitative data analysis software package NVivo (version 10) and texts were dissected using the coding framework developed by the investigators.
After the first 10 transcripts were coded, the more abstract basic themes were applied to the coded text segments. Thus, 37 codes were grouped into 12 basic themes. These basic themes were further refined to ensure that they were discrete and did not overlap with each other, yet broad enough to incorporate a set of coherent ideas to generate the four organizing themes. The four organizing themes – role of family in gambling initiation, maintenance, help-seeking, responsible gambling, and harm – were then arranged into the global theme of family and gambling (Table 2). The role of family in the adoption of responsible gambling by the older adult gambler has been described in a previous article (Subramaniam et al., 2017).
Thematic network analysis – codes, basic theme, and organizing themes
| Codes | Basic themes | Organizing themes | |
|---|---|---|---|
| 1 | Parental gambling | Early exposure to gambling | Role of family in gambling initiation |
| 2 | Learning to gamble by watching the adults | ||
| 3 | Accompanying the adults to gambling venues when young | ||
| 4 | Involvement in adult gambling by being allowed to participate | ||
| 5 | Involvement in adult gambling by being given part of winnings | ||
| 6 | Memories of playing with family members when young | Family event | |
| 7 | Playing together with family members during Chinese New Year (CNY) | ||
| 8 | Playing Mahjong with family members | ||
| 9 | Sense of togetherness | ||
| 10 | Bonding with family | ||
| 11 | Family members encourage or invite respondents to take part in gambling activities | ||
| 12 | Chinese like to gamble during CNY | Cultural relevance | |
| 13 | Association of Ang Pao with CNY | ||
| 14 | Gambling due to cultural beliefs during CNY | ||
| 15 | Family event | Socializing | Role in maintenance of gambling |
| 16 | Gambling with friends and family during CNY gatherings | ||
| 17 | Fun | ||
| 18 | Friendly atmosphere | ||
| 19 | Social event | ||
| 20 | To escape life’s problems | Escape | |
| 21 | A place to hide | ||
| 22 | To get away from controlling behavior | ||
| 23 | Disappointing spouse as unable to sustain household needs | Financial hardship | Gambling-related harm |
| 24 | Inability to pay household expenses | ||
| 25 | Inability to pay mortgage/rent of dwelling | ||
| 26 | Borrowing from spouse/children/parents | ||
| 27 | Pawning household valuables and jewelry | Economic crimes against family | |
| 28 | Stealing from spouse/parents | ||
| 29 | Family member’s religious sentiments are hurt as they have strong views against gambling due to their religious beliefs | Family conflicts | |
| 30 | Arguments or altercations with spouse/children/parents over gambling | ||
| 31 | Not spending time with wife/children | Breakdown of relationships | |
| 32 | Losing respect of family members due to gambling | ||
| 33 | Separation/divorce from spouse | Breakdown of marriage | |
| 34 | Family makes them aware of treatment options | Motivation to seek help | Role in help-seeking |
| 35 | Family compels treatment | ||
| 36 | Ashamed to talk to family members about problems | Stigma | |
| 37 | Concealing gambling-related problems from family |
Ethics
Ethical approval for the study was obtained from the National Healthcare Group Domain Specific Review Board, Singapore. Written informed consent was obtained from all participants before carrying out any study related procedures.
Results
The four organizing themes related to the influences of family on the respondent’s gambling are described below (Figure 1).
Gambling initiation
Early family exposure to gambling and gambling as a family event emerged as strong basic themes that played a role in gambling initiation. Many of the participants had been exposed to gambling at an early age by one or more family members who gambled when they were young. Eleven out of the 25 people interviewed had been exposed to gambling within the family as children. While some people grew up in families where gambling was organized by a parent or other relatives in the house, others accompanied and watched their parents and/or other relatives’ play and learned how to gamble. Gambling was part of family gatherings and hence was perceived as an enjoyable social activity that fostered bonding and communication. Playing during the CNY was seen by all Chinese participants as a family event with cultural overtones.
“So when we were young we already know how to play ….. at the age of nine I could play those games.” (PG1016)
“I was quite sickly and my grandmother looked after me. And she brought me to all these places where they sat down and gambled on the floor. They always had Betel nut, Betel leaf and then they will eat and play and I caught up with that and that’s where I learnt to play the Cherki” (a card game played with a deck of 60 cards). (PG1017)
Chinese respondents also mentioned beliefs and customs practiced by family members that encouraged gambling during CNY.
“My mom loved to play little card games with us during Chinese New Year. And so we were allowed because we are given ‘ang pao’ (refers to a red envelope, red packet, (Hokkien word) which has a monetary gift which is given during special occasions including CNY), so we started. So, every Chinese new year my eldest brother made sure that we got one day to gamble.” (PG 1010)
Maintenance of gambling
“Yes, my mother loves Mahjong. I stayed with my cousins and my aunty for a while. And they all know how to play the game. It’s like a favourite pastime of the family”. (PG1008)
“I always go with my nephew… always 3 of us, 3 to a room… with my two nephews (Referring to casino trips to Malaysia). Sometimes… among the three of us one of us will win something then we go on an eating spree”. (PG1011)
“I go with my sister, sometimes there are other cousins. We have wine, dinner in a nice restaurant and then we go and gamble”. (PG102)
Women talked about using gambling to escape from relationship-related problems and grief. This included using gambling as a means to escape a difficult relationship, the grief associated with the loss of a relationship, or boredom. Some of the points raised by the respondents included,
“So I go and hide… because I cannot get along with my father-in-law, so every day I have problems you see, so I go and gamble, then come back late, they are asleep ….. that type of thing”. (PG1016)
“My husband passed away suddenly, no children. This was the time I noticed I was playing more and more online gambling. I realised it was very easy to lose money and track of time.” (PG1021)
Gambling-related harm
“I lost so much money to my bookmaker that my family had to help me out”. (PG1024)
“I could not pay all my bills, I… I mean I could not buy whatever I wanted. Then I had to withdraw from my wife’s bank account without her knowledge. Withdraw the money to gamble. See, until such time you know, I owe her money. Withdraw her money… without her knowledge to go and gamble”. (PG1002).
“I told my wife we did not need such a big house, let us move to a smaller unit. She became suspicious when I did not buy another house even after 1-year. I had to tell my wife and children that I had sold the house to settle the gambling debts”. (PG 1023).
Many of the gamblers reported having problems in their relationships and the breaking down of family relationships. Most resulted from financial losses and neglect of the family. They reported that the deception they had resorted to, such as lying about the time or money spent in gambling, also led to altercations with the family. Family fights also erupted when members tried to convince the older adults to limit or stop their gambling. The deceptions as well the failure to support the family both emotionally and financially led to a loss of respect and trust. Two gamblers reported borrowing money from loan sharks who threatened harm to their family members, if the loan was not repaid promptly.
“Every month end means… no salary. I bring back nothing home, so my wife was very sad. So, I start borrowing from my mother, my brother saying…. just telling them stories… I need money, I am broke, I will pay you. My wife cannot stand that, yeah. So, she asked me to split… divorce”. (PG1005).
“Asked me to stop, I refused to stop. So, they… they distrust me. Don’t trust me anymore. So when I tell them, I don’t gamble, they won’t believe me. See, no trust in me… The children… my children don’t trust me”. (PG1002).
Help-seeking for gambling problems
Then…then she called me from US and said, ‘Daddy, you better go for some counseling now.’ (PG1002)
My brother called me up, he said, ‘Come back (respondent was asked to leave his home by the family). Think of what you do. I want to tell you, you go and reform yourself.’ (PG018)
Some of the respondents also talked about how no one knew about their gambling problem. While two of them felt that their families suspected that they were gambling, they were determined not to let their families find out about the extent of their gambling or problems as they felt a sense of shame and were also afraid of the consequences.
I just have that comfort that my wife and my children are with me and hope that they are well, so I have to pretend forever until I die. (PG1003)
Thematic network representing family and gambling
Citation: Journal of Behavioral Addictions 6, 4; 10.1556/2006.6.2017.082
Discussion
Gambling initiation has been associated with a family history of gambling; the influence being mediated through genetic factors (Blanco, Ibanez, Saiz-Ruiz, Blanco-Jerez, & Nunes, 2000) as well as through a social-learning paradigm (Oei & Raylu, 2004). Eight of the 25 older adults interviewed endorsed that a first-degree relative had gambling problems, although this study did not examine genetic factors in any detail. Early family exposure to gambling as part of family gatherings; an adult gambling at home; or the young person accompanying the older adult to a gambling venue led to awareness of gambling and subsequent modeling. Gambling was described as a part of festivities, such as CNY, when the family members would gather and gamble and children were allowed to join in and even bet with money. Thus, gambling in these older adults was perceived as “normal” family events, which often led them to learn by observation, participation, or mimicking the play. Kearney and Drabman (1992) similarly found that modeling increased the chances of risk taking/gambling-like behavior in children as young as 4–5 years old. The role of family has also been identified in a qualitative study on Australian gamblers who reported that gambling was a frequent activity in their family, and that it was regarded as a pastime that helped family bonding (Victorian Responsible Gambling Foundation, 2012). In their study on older adult gamblers in Hong Kong, Ohtsuka and Chan (2014) similarly found that many of the older adults started gambling when they were young and that gambling was considered a part of family activities. There was no stigma associated with gambling; in fact, it was associated with positive memories. Loo, Raylu, and Oei (2008) in their review on gambling among Chinese concluded that sanction as well as familiarity with certain gambling activities that are part of the Chinese culture could be maintained by passing the values and beliefs about gambling from one generation to another. Reith and Dobbie (2011) refer to it as the “generational transmission” of habits, norms, and beliefs from one generation to the next; in the context of this study, this was evident in the interplay between family, culture, and normalization of gambling, which encourages the initiation of gambling.
Many of the older adult gamblers who participated in this study identified gambling as a means of social interaction. The findings are consistent with previous studies that have found gambling to be a means of socializing among older adults (Loroz, 2004; McNeilly & Burke, 2000; Ohtsuka & Chan, 2014). On the other hand, older women reported using gambling as a way to escape the problems in their relationships or to deal with the loss of loved ones and loneliness. Jacobs’ (1986) General Theory of Addictions suggests that use of substance or specific behaviors, such as gambling, helps to create a dissociative state, which explains why some individuals use gambling as a maladaptive coping strategy to deal with their emotional distress and stress/tension.
Langham et al. (2016) defined gambling-related harm as “any initial or exacerbated adverse consequence due to an engagement with gambling that leads to a decrement to the health or wellbeing of an individual, family unit, community or population.” In the current study, “harm” to the family comprised basic themes, such as financial adversity, conflicts, distrust, breakdown of the family unit, loss of assets and property especially housing. Data from this study revealed that financial hardship was a predominant theme and often mentioned by participants. This was due to the fact that financial hardship was significant and often the “primary” harm that triggered further harm across other dimensions. Many other studies have acknowledged that the harm related to gambling extends beyond the person with gambling problems, to their family members and communities (Darbyshire, Oster, & Carrig, 2001; Dowling, Suomim, Jackson, & Lavis, 2016; Productivity Commission, 2010). A qualitative study by Holdsworth, Nuske, Tiyce, and Hing (2013) on partners of gamblers concluded that the financial problems associated with gambling were usually the first to be identified and this led to relationship problems and disruption of family life. Hing, Breen, Gordon, and Russell (2014) analyzed data from 1,259 indigenous Australian adults and similarly identified financial difficulties, relationship, legal, and housing problems associated with problem gambling.
The family played a significant role in the decision to seek help for those with gambling disorder in this Asian setting. Motivations for seeking help included pressure by family members who often guided the respondent to places where they could seek help. Our findings are somewhat different to that reported by Gainsbury, Hing, and Suhonen (2014) among Australian gamblers. Participants in the study indicated financial problems as one of their strongest reason for seeking/intention to seek professional help but pressure from family did not emerge as a significant motivating factor.
Stigma expressed as a sense of shame and wanting to hide the behavior from their family was a barrier to seeking help. A few older adults were determined not to talk about the problem to anyone and not to let their families find out about their gambling as they were too ashamed. In a qualitative study conducted to understand the role of stigma as a barrier to help-seeking, “shame” was cited as a common reason for not seeking help for gambling problems (Carroll, Rodgers, Davidson, & Sims, 2013). The experience of stigma was expressed as fears of exposure, and the consequences of family and friends finding out that they have a gambling problem.
Limitations
The limitations of the study include the fact that it was based on gamblers’ lived experiences rather than the experiences of family members, so it could not capture the experiences and perceptions of their family members. While family violence has been associated with gambling disorder (Dowling, Suomi, Jackson, Lavis, Patford, et al., 2016), none of the gamblers mentioned it; while this may indicate that no violence occurred, it is also possible that they did not want to talk about it due to social desirability bias. Thus, gambling impact must be explored with family members in future studies.
Conclusions
The study emphasizes the role of Asian families in both initiation and maintenance of gambling. Hence, families must be involved in prevention and outreach programs. It is important to present local data on prevalence and harm to the population as it is more relevant and creates a better understanding of the problem. The need for family members to stay vigilant must be emphasized as many families were unaware of the true extent of financial harm caused by gambling; this unawareness was due to older adult gamblers’ reluctance to discuss the magnitude of loss with them. Families must also be taught not to enable gambling out of a sense of filial piety or respect for the older adult. It is also clear that many older adult gamblers modulate their behavior due to the pressure exerted by the family. Family members must be educated so that they can encourage help-seeking to ensure early treatment and recovery. Studies on caregivers that assess the impact of gambling on their physical and mental health as well as health-related quality of life must be conducted. There is also a need for interventional studies for reducing stress and improving coping among family members. Family members must also be encouraged to attend support groups, financial counseling, and marital therapy where necessary.
Authors’ contribution
MS and ST designed the study. MT and SAC conducted relevant literature searches. MS and PS transcribed the interviews. MS conducted the analysis in consultation with ST, SAC, and CJB. MS wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.
Conflict of interest
None.
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