Understanding the use of metaphors by parents of children with cancer in blogs: a qualitative analysis

Childhood cancer is a significant global health concern, impacting not only children but also their families. Parents of children with cancer face immense psychological and financial burdens, including depression, anxiety, and financial strain due to treatment costs. The internet, particularly online platforms like blogs, serves as a crucial source of social support and connection for these parents. Metaphorical language is a powerful tool for expressing complex emotions and experiences, and it is increasingly recognized as playing a vital role in health communication. Existing research has mainly focused on metaphors used by healthcare professionals and patients themselves, leaving a gap in understanding the metaphorical language employed by caregivers, especially parents of children with cancer. This study aims to fill this gap by analyzing the metaphors used by parents of children with cancer in their online blogs, to gain insight into their experiences and emotional landscape and explore how this understanding can facilitate more effective support systems.

Conceptual Metaphor Theory, originating from Lakoff and Johnson's work, posits that metaphors are not merely linguistic devices but fundamental cognitive tools shaping our understanding of the world. Metaphors map elements from a familiar source domain onto an unfamiliar target domain, aiding comprehension of abstract concepts. Studies have shown the use of metaphors in health communication, particularly in cancer contexts, to enhance understanding, reduce fear, and improve patient motivation. Previous research has focused primarily on metaphors used by healthcare professionals and patients; this study uniquely examines the metaphors employed by parents of children with cancer, a previously under-researched area. The study’s approach uses qualitative content analysis, drawing heavily on the Conceptual Metaphor Theory as a framework for analyzing metaphors which are systematic, consistent, and unified.

This qualitative study used content analysis to examine metaphors in blogs written by parents of children with cancer on the Chinese social media platform, "Little Red Book." Data was collected from 2019 to 2022 using keyword and snowball sampling, resulting in a final sample of 33 parents (29 female, 4 male). Inclusion criteria included blogs from 2019-2022, parents of children (0-14 years old) with cancer actively involved in their child's care, and publicly available information. The data comprised a total of 16,027 words in Chinese, which was then translated into English (2,890 words). Researchers meticulously identified metaphors within sentences, determining source and target domains. Inter-rater reliability was ensured through consensus-building among researchers in case of disagreements. Thematic analysis of the metaphors identified four main themes: game, war, journey, and plant metaphors. The data analysis followed the steps outlined by Graneheim and Lundman (2004) ensuring credibility, dependability, and transferability. Ethical considerations included using only publicly available data, de-identifying personal information, and translating the text to further enhance privacy. The study adhered to COREQ guidelines. The final analysis assessed the frequency and usage of these themes across the dataset and analyzed the prevalence of mixed metaphors, as well as exploring any gender differences in metaphor usage.

Analysis revealed 181 metaphorical expressions, with 132 (73%) falling under the four main themes: Game (48, 36%), War (46, 34%), Journey (19, 15%), and Plant (19, 15%). Game and war metaphors were significantly more frequent than journey and plant metaphors. **Game Metaphors:** These frequently portrayed cancer as a monster to be defeated, with children, parents, and medical professionals as warriors. Treatment was also framed as a game with levels and obstacles to overcome. **War Metaphors:** Predominantly described cancer treatment as a war, hospitals as battlefields, medical staff and patients as soldiers, and medicine as weapons. It also encompassed the internal battles against negative emotions. **Journey Metaphors:** Described life, treatment, and the emotional/psychological journey. The treatment journey presented obstacles to overcome on the way to a hopeful end point. **Plant Metaphors:** These often likened the child's body to a plant, emphasizing growth, nurturing, and the need to remove obstacles to growth, as well as describing tumor growth as the spreading of a plant. The study also found that parents frequently used mixed metaphors, combining different thematic frameworks. A comparison of metaphor use between male (n=4) and female (n=29) participants revealed that women used more game metaphors, while men more frequently employed war metaphors. However, the small sample size of male participants limits the generalizability of these gender-based observations.

The findings highlight the prevalence of game and war metaphors, challenging the existing literature which often focuses solely on war and journey metaphors in cancer narratives. The incorporation of game metaphors suggests a strategy for coping with cancer treatment by reframing it in terms familiar and potentially more positive for children. The unique prevalence of plant metaphors is especially relevant within the Chinese cultural context, reflecting long-standing cultural associations between plants and the growth and development of children. The study's focus on parents' perspectives provides valuable insights into the emotional landscape of this understudied group. The use of metaphors helps parents express their complex emotions and concerns, while encouraging their children to fight the disease. The results demonstrate how caregivers adapt and leverage metaphorical language to cope with the emotional and psychological challenges associated with childhood cancer.

This study contributes to the literature by examining metaphors used by parents of children with cancer, revealing a complex interplay of game, war, journey, and plant metaphors. Understanding these metaphors offers valuable insights into the parents' emotional processing and coping strategies. Future research should focus on larger, more gender-balanced samples to further investigate gender differences and explore how metaphor use evolves over the course of cancer treatment and beyond. The study’s findings suggest that supporting these parents requires understanding their lived experiences as conveyed through their metaphors, enabling healthcare professionals to better tailor interventions and support. The use of publicly available data presents some limitations in generalizability; however, this study remains significant in its unique investigation of metaphor use in this specific group.

The study's primary limitation is the imbalanced gender distribution in the sample, with a much larger number of female than male participants. This restricts the generalizability of findings regarding gender differences in metaphor usage. Additionally, the reliance on blogs from a specific social media platform might not fully capture the range of metaphors used by all parents of children with cancer. While efforts were made to ensure the accuracy of translations, some subtle nuances might have been lost in the translation process. Future research could address this by collecting data in multiple languages and using multiple methods of data collection. Furthermore, this study only analyzed data from the years 2019-2022 and did not examine the potential impact of age on metaphor choice.