Asthma is a widespread public health problem and the most common chronic illness in childhood and adolescence. According to the Global Asthma Report 2011(Masoli, Fabian, Holt, Beasley, 2011), the number of people with asthma in the world may be as high as 235 million. ISAAC (2015) reported that about 14% of the world’s children were likely to have had asthmatic symptoms in 2013. A WHO survey (2003) estimated that 4.3% respondents aged 1845 reported a doctor’s diagnosis of asthma, 4.5% had reported either a doctor’s diagnosis or that they were taking treatment for asthma, and 8.6% reported that they had experienced attacks of wheezing or whistling breath (symptoms of asthma) in the preceding 12 months. The highest prevalence was observed in Australia, Northern and Western Europe and Brazil.
Introduction
Statement of the problem
Asthma is a widespread public health problem and the most common chronic illness in childhood and adolescence According to the Global Asthma Report 2011(Masoli, Fabian, Holt, & Beasley, 2011), the number of people with asthma in the world may be as high as 235 million ISAAC (2015) reported that about 14% of the world’s children were likely to have had asthmatic symptoms in 2013 A WHO survey (2003) estimated that 4.3% respondents aged 18-45 reported a doctor’s diagnosis of asthma, 4.5% had reported either a doctor’s diagnosis or that they were taking treatment for asthma, and 8.6% reported that they had experienced attacks of wheezing or whistling breath (symptoms of asthma) in the preceding 12 months The highest prevalence was observed in Australia, Northern and Western Europe and Brazil
Having children with asthma is challenging for caregivers, especially their parents (Kaugars, Klinnert, & Bender, 2004) Elevated levels of stress in parents are associated with poor impacts for both parents and their children Parenting distress affects children’s quality of life, onset and the course of asthma, behavior and emotional functioning (Roddenberry & Renk, 2008) On the other side,parents, especially mothers who are always primary caregivers of children with asthma, tend to be more overprotective, overindulgent and rejecting than those of children without asthma (Carson & Schauer, 1992) They perceive more stress in their relationship with their spouse than did those of children without asthma(Carson & Schauer, 1992) A decreased quality of life including missed days of work, limited activities, inadequate sleep, frequent night awakening and decreased emotional health was also acknowledged among parents of asthmatic children(J.Walker, Winkelstein, Cassia, Lewis-Boyer, Quartey, Pham, & Butz, 2008)
Background and significance of the study
In recent years, Vietnam is one of South Asian countries having growing incidence of asthma among school age children Few studies in Ha Noi, the capital of Vietnam, and other large provinces in 1998 showed an estimate of 2.7%-7% childhood population acquiring asthma (Le, Phan, & Nguyen, 1998; Nguyen,
1998) By the next ten years later, although there were not generic statistics for the whole countries, several studies conducted in different provinces showed an increased number of asthmatic children A study in Hai Phong reported an asthmatic prevalence of 9.3% among children under 18 years (H Q Pham & Dinh,
2002) Three studies in Ha Noi were carried out and the findings showed a growing number of asthma children by the time in which the proportion of asthma increased from 10.3% in 2003 to 11.2% in 2006 (L T Pham, 2005; Phan & Ton, 2006; Ton, 2003).
A large portion of Vietnamese studies on asthma in children focus mainly on identifying prevalence and incidence of asthma in general population and children subgroups as well (Hoai & Nguyen, 2010; N H Tran & Minh, 2009; T H Tran &
Vu, 2012) A similar portion tried to explore asthma-related factors and asthma management among children and adolescences (Doan, 2008; T H Tran & Ho,2012; T H Tran & Vu, 2013) Few current studies put more concerns on asthma knowledge of caregivers (Hoai, 2009; T T Tran, 2010) and quality of life of children with asthma (Hoai, Tran, & Do, 2011; T B Tran, 2012) However, to date there are no studies on parenting stress among parents taking care of asthmatic children The reason may be that parenting stress may be not considered as a contributor affecting to the course of asthma and treatment by both parents and professionals as well.
In the light of the above settings, it is necessary to conduct an innovative study on parental stress among parents caring children with asthma What are found in this study may implicate the extent of parental stress and related factors having impacts on parental stress Furthermore, the findings of the study will be used as baseline data on which health professionals in Hospital of TropicalDiseases, where the study is carried out, could develop proper intervention strategies to help parents of children with asthma overcoming stressors occurring during their caring.
Aim of the research
The main purpose of this study is to explore the frequency of parental stress among parents of asthmatic children and related factors that may influence to the development of parenting stress To achieve this purpose the following objectives are described below:
1 To explore what stress, social supports and well-being among parents of asthmatic children are,
2 To examine relationships among demographic characteristics, stress, social supports and well-being among parents of asthmatic children, and
3 To investigate the significant predictors of stress among parents of asthmatic children.
Research questions
1 What are demographic characteristics, stress, social supports and well-being among parents of asthmatic children?
2 Are there associations between demographic characteristics stress, social supports and well-being among parents of asthmatic children?
Definition of term
Stress: traditionally, stress is defined as “a relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being.”(Lazarus & Folkman, 1984).
Demographic characteristics: they are characteristics of parents such as age, gender, marital status, family income and child characteristics such as age of child, age of onset, and severity of asthma.
Social supports: these are supports from surrounding environment that could have impacts on parenting stress They include informal supports from caregivers’ friend and relatives and formal supports from social networks and health professionals.
Chapter summary
Asthma is a widespread public health problem and the most common chronic illness in childhood and adolescence Taking care of children with asthma may cause a lot of stress for their parents Parenting stress not only cause bad impacts on children but also their parents In Vietnam, asthma among children population is now growing Most studies on asthmatic children focus on epidemiology, treatment and prevention of asthma among children, whereas no studies investigate the parenting stress among caregivers Therefore, a study on parenting stress is necessary in Vietnam The finding will be used as baseline data on which health professionals in Hospital of Tropical Diseases, where the study is carried out, could develop proper intervention strategies to help parents of children with asthma overcoming stressors occurring during their caring.
Literature Review
Introduction
Parenting stress has been recognized for years as an important factor that could have bad effects on both physical and mental health of both children and their caregivers For many chronic diseases and disabilities, parenting stress could contribute to depression symptoms and decreased quality of life among caregivers of suffered children For asthma, parenting stress contribute to worse onset and course of the disease in children with asthma Additionally, parents themselves experience psychological problems during their care of children
A large number of assessment tools of parenting stress have been developed recently Of those, parenting stress index and parenting stress scale are popular used among researchers to evaluate parenting stress among parents of children with variation of disabilities and chronic conditions including asthma Each of these assessment tool has its advantages and disadvantages; therefore the usage of assessment tool need to be consider to the aim and research questions
In general, there are a number of factors contributing to develop of parenting stress among parents of asthmatic children and they may categorize into three aspects: (1) child characteristics such as age of child, age of onset, severity of asthma; (2) demographic factors; and (3) parent characteristics All of these factors will have important impacts on developing of parenting stress among parents of asthmatic children.
Parental stress
2.2.1 The concepts of stress and parenting stress
Lazarus and Folkman (1984)define psychological stress as “a relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being.”(p.19). They also note that personal characteristics and environmental factors influence the person-environment relationship and cause psychological stress with different levels Many researchers so far have been developing conceptual models to understand the nature of stress and its effect on man health as well Some supposed that conceptualizations of stress fall into three primary approaches: (1) objective (or environmental) characteristics, (2) subjective characteristics, and (3) biologic responses(Cohen, Kessler, & Gordon, 1995) Of the three, probably the most common approach is defining stress by the events that happen to an individual. Events that are judged by consensus to place demands on an individual are labeled as ‘‘stressors.’’ This approach labels objective events that occur in individuals’ lives as stress The second approach argues for the importance of factoring in the individual’s subjective reactions to the stressor This approach states that the amount of stress experienced depends in large part on how an individual interprets, or appraises, a situation and that the same objective event may cause different stress reactions in different individuals depending on their perceived ability to handle the stressor (Lazarus & Folkman, 1984).The third approach relies on the ability to detect a biologic response to stress This approach acknowledges that the same stressor may cause different reactions in different individuals but relies on biologic indicators of stress rather than an individual’s self-report of stress
Others, however, developed a concept of stress including four domains: (a) the stressor, or any event or situation that exceeds an individual's coping abilities;(b) strain, or the physical and emotional symptoms of a stressful event, including fatigue, irritability, muscle strain, and headaches (Sheridan & Radmacher, 1998);(c) coping resources, or those things that an individual can use to help mediate and manage the effects of a stressor, such as social support networks, intrapersonal strengths and skills, and educational contacts and resources (Sheridan &
Radmacher, 1998); and (d) coping strategies, or the specific ways that an individual uses the available coping resources to avoid or reduce the effects of stressors Examples of coping strategies might include attending a parent support group, hiring a respite care worker, or simply discussing fears and concerns with a friend or family member.
Given general conceptual models of stress, researchers have sought to provide a useful conceptualization for a particular type of stress, parenting stress Abidin (1995)acknowledges the assumption that stressors are multi-dimensional both in source and kind He notes that this assumption led to the identification of three major source domains of stressors for parents: 1) Child Characteristics; 2) Parent Characteristics, and 3) Situational/Demographic-Life Stress Furthermore, the emotional interpretation of situations by parents is also play an important role in developing parenting stress As a result, there has been great variability in how researchers have chosen to operationalize the construct of parenting stress (Anastopoulos, Guevremont, Shelton, & DuPaul, 1992; Lavee, Sharlin, & Katz,
1996) which has made it difficult in some cases to make cross-study comparisons
2.2.2 Parenting stress and chronic illnesses
A number of studies have documented associations between parenting stress and child psychological sequelae For children, parenting stress was shown to moderate the relationship between perceived vulnerability and depressive symptoms in youth with diabetes(Mullins, Fuemmeler, Hoff, Chaney, Van Pelt, &Ewing, 2004), rheumatoid arthritis(Anthony, Bromberg, Gil, & Schanberg, 2011),and sickle cell disease (Barakat, Patterson, Daniel, & Dampier, 2008) It also has many impacts on managements of a child’s chronic condition (Streisand,Braniecki, Tercyak, & Kazak, 2001) Barakat et al (2007) found that greater parenting stress in caregivers of children with sickle cell disease was associated with greater disease severity and more frequent health care utilization 1 year later
For parents, studies on children with different chronic conditions showed that greater general and disease-related parenting stress was associated with psychological distress (e.g., depressive and anxiety symptomology) in caregivers of children with arthritis(Manuel, 2001), cystic fibrosis (Driscoll, Johnson, Barker, Quittner, Deeb, Geller, & Silverstein, 2010; Thompson, Gustafson, Hamlett, & Spock, 1992), and diabetes (Driscoll, et al., 2010; Hansen, Schwartz, Weissbrod, & Taylor, 2012; Helgeson, Becker, Escobar, & Siminerio, 2012; Patton, Dolan, Smith, Thomas, & Powers, 2011; Streisand, Mackey, Elliot, Mednick, Slaughter, Turek, & Austin, 2008) Kazak and Barakat (1997)reported positive associations between general parenting stress and parenting state anxiety and posttraumatic stress disorder symptoms in caregivers of children with cancer.
The most frequently used coping strategy to against parenting stress is reframing or the ability to redefine onerous situations so that parents were more manageable for the family In contrast, the least used strategy is the external strategy focused on a search for spiritual support (Luther, Canham, & Cureton, 2005; Sikorová & Polochová, 2014)
2.2.3.1 The impacts of parental stress on children with asthma
Numerous studies demonstrate that parental stress may influence the onset and course of a child’s asthma Parenting stress is associated with an increased risk of asthma or wheeze in childhood (Kozyrskyj, Xiao-Mei, McGrath, HayGlass,Becker, & MacNeil, 2008; Wright, Cohen, Carey, Weiss, & Gold, 2002).Additionally, parenting stress contributes significantly to asthma onset in childhood (Mrazek, Schuman, & Klinnert, 1998) Other studiesfound that children experienced parenting difficulties from their parents were more likely to have a greater number of lifetime hospitalizations(Chen, Bloomberg, Fisher, & Strunk,2003; Weil, Wade, Bauman, Lynn, Mitchell, & Lavigne, 1999).Lower caregivermental health scores wereassociated with caregiverreports of their children’s experiencing more asthmasymptoms and more acute care visits for asthma in theprevious year, when compared to those caregivers withhigher mental health scores(Wood, Smith, Romero, Bradshaw, Wise, & Chavkin, 2002). Furthermore, few studies (Bartlett, Krishnan, Riekert, Butz, Malveaux, & Rand, 2004; Schobinger, Florin, Reichbauer, Lindemann, & Zimmer, 1993; Wood, et al., 2002)demonstrated that increased frequency of asthma attacks and asthma severity were associated with parenting stress Finally, increased parenting stress has been shown to be associated with poor asthma control among asthmatic children (Sharp, Curtis, Mosnaim, Shalowitz, Catrambone, & Sadowski, 2009).
The second impact of parenting stress is on children emotional functioning. Chiou and Hsieh (2008) compared children’s self-concepts and parenting stress between families of children with asthma and epilepsy They found that parenting stress can significantly contribute to the child’s levels of emotional competence by which children with asthma had lower global self-worth scores than children with epilepsy
The third impact of parenting stress is on behavior of asthmatic children A meta analysis of adjustment of ~5000 children with asthma indicates that the level of behavioral difficulties was higher in asthmatic than healthy children (Mc Quaid, Kopel, & Nassau, 2001) Kumari et al (2011) showed that asthmatic children withstressful parents are restless, show symptoms of distractibility and difficulty in concentrating on their homework assignments.
2.2.3.2 The impacts of stress on parents themselves
Carson and Schauer(1992) examined perceptions of parenting stress and mother-child relationships They found that the mothers of children with asthma tended to be more overprotective, rejecting, and overindulgent than mothers of children without asthma Not only did mothers perceive more stress in child attachment but they also perceived more stress in their relationship with their spouse than did mothers of children without asthma
Kumari et al (2011) used Parenting Stress Index (PSI) tool to assess stress level of parent caring children with asthma They found that parents showed significantly higher scores as compared to their matched controls, indicating that they experience the parenting role, as restricting their freedom and frustrating when inflammation causes recurrent episodes of wheezing, breathlessness and tightness in the chest of their child These parents show symptoms of depression that relates to guilt and unhappy feelings Higher level of stress was also associated with lack of support from the spouse, family, relatives and friends, limited time for personal activities and parenting health problems.
Howard et al (2009) reported that parents of asthmatic children complained about difficulties in sleeping, night awakening and being stressed by watching their child during medical visits/ procedures
2.2.4 The assessment instrument of parenting stress
A number of assessment instruments have been created so that parenting stress levels can be systematically measured and quantified The information provided in a stress assessment can play an important role in determining what type of intervention and services will be most beneficial to the child and the family However, stress assessment can also be used throughout the course oftreatment A stress assessment could be used as a measure of program effectiveness both during and at the end of treatment A stress assessment might also be useful in determining extraneous variables that may be affecting a child's performance in treatment.
Table 1 Some popular assessment tools of parenting stress
Parenting stress index Abidin(1997) Assess the impact that the parenting role has on an individual's stress level
Reliability and validity have been checked by many studies
Focus specifically on the stress generated by the parenting role.
Saving time with short questionnaire.
Need more studies on evaluating reliability and validity
Identify attitudes and emotions affecting parenting behaviors
Further information concerning its validity and reliability Global Inventory of Stress
Examination of coping resources, environmental stressors, and the perception of stress
The reliability and validity has been demonstratedwidely Perceived stress scale Cohen, Kamarck and Mermelstein(1983)
Assess the respondent's beliefs about stressors
Further information concerning its validity and reliability Family inventory of life events and changes
Assess the presence of stressors
Measure coping resources in dealing with parenting stress
Indicate the frequency at which disease-related parenting stressor occurs, and the difficulty-level of each stressor
Further information concerning its validity and reliability
The Parenting Stress Index (PSI) was developed by Abidin(1997)and is intended to assess the impact that the parenting role has on an individual's stress level The PSI is a 120-item instrument that is available in both a paper version and a computer program The 120 items are divided into the three separate sections of child characteristics, parent characteristics, and a stressful life events scale The stressful life events scale is optional and does not have to be completed to obtain a valid score The items in the child characteristics domain are further divided into the subscales of adaptability, demandingness, mood, distractibility/hyperactivity, acceptability of child to parent, and child's reinforcement of parent The items in the parent characteristics domain are divided into the subscales of depression, attachment to child, social isolation, sense of competence in the parenting role, relationship with spouse/parenting partner, role restrictions, and parenting health. Both the parent and the child characteristics sections are scored on a 5-point Likert-type scale, with a response of 5 indicating "strongly agree" and 1 meaning
"strongly disagree." Responses to the stressful life events scale are recorded in a yes/no format The results are presented with asubscore for each category and a total score, which can be interpreted using the computer program or information provided in the test manual The PSI was originally intended for use with parents who have at least a fifth-grade reading level and who have children between the ages of 6 months to 10 years A short version of the PSI is available and consists of
36 items drawn from the original version (Abidin, 1997).
Chapter summary
Parenting stress is an important problem occurring during parents’ care of children with disabilities or chronic diseases including asthma The most recog- nized impacts of parenting stress on children with asthma are worse course of asthma, psychological problems, impaired emotional functioning, and behavioral disorders For parents of asthmatic children, they also have experience psychological distortions such as depression and anxiety, life limitations and a decreased quality of life such as difficulties in sleeping and night awakening
There are numerous of assessment tools for evaluating different aspects of parenting stress While Parenting Stress Index and Parenting Stress Scale focus on assessing level of parenting stress through questions related to parent role during children care, other instruments such as Cleminshaw-Guidubaldi parent satisfaction scale, Global Inventory of Stress, Perceived stress scale measure frequency of stressors, attitudes and beliefs of parents about stressors, or coping resources in dealing with parenting stress Each tool has its role, advantages and disadvantages in evaluating parenting stress, so the choice of which tool applying in the study is depend on the aims of the study.
In general, a number of factors could play important role in determining parenting stress development in caregivers of asthmatic children They could be classified into three categories: (1) child characteristics; (2) parent characteristics; and (3) social supports Several child characteristics demonstrated to have associations with parenting stress include age of child, age of onset, and sleep problems Also, age of parents, marital status, family income, number of children in home, education have strong associations with parenting stress Finally, social supports which include informal and formal supports are factors that directly influence to level of parenting stress.
Research Methology
Introduction
In this chapter all aspects of research methodology are discussed in a detail manner The research design and research framework that are the base from which the authors develop ideas for the study are mentioned firstly Sample issues are the next topics that need to be described to outline steps of sampling and ways of collecting data Data management discussing about systematic error reduction and data analysis highlighting statistic methods applied in the study are crucial parts in this chapter Finally a description of ethical issues is also included at the end of the study.
Research design
A cross-sectional design was considered as the appropriate method for this study.
Research framework
Based on literature, factors that could affect to the occurrence of parenting stress may divide into three categories: (1) child characteristics; (2) parent characteristics; and (3) social supports
Child characteristics are properties that belong to children with asthma that may have impacts on parenting stress There are many of child characteristics could be explored; however, in this study characteristics chosen to investigate include age of child, age of onset of asthma, and the severity of asthma
Like child characteristics, parent characteristics are those that belong to parents of children with asthma that could influence the development of stress In this study, the relationship with asthmatic child, age, marital status, duration of marriage, education, occupation, number of children, family income, religion and depression status are included in the study framework The depression status means the level of depression that respondents experienced during their care of asthmatic child The depression status will be evaluated by the Patient Health Questionnaire-9 (PHQ-9) that was commonly used to diagnose the depression level
Social supports are factors existing in surrounding environment that also determine the development of parenting stress In this study, social supports could be classified into Informal Supports (relative, friends), Formal Supports (public and private services), and Informational Supports.
3.3.1 The hypotheses of this research
There are five hypotheses are developed in this study They are including:
1 Parent and child characteristics have associations with social supports.
2 Parent and child characteristics have association with parenting stress
3 Parent and child characteristics have association with depression status
4 Social supports has an association with parenting stress
5 Parenting stress has an association with depression status of parents
Age of onset of asthma
Figure 1 The conceptual framework of parenting stress developed in the study
Sampling and setting
All children patients who visited the hospital with the suspects of asthma would have complete physical examinations at clinical unit or ICU After initial diagnosis and temporary treatment, pediatric patients might go home for follow-up treatment if their symptoms were light or transferred to Pediatric D Unit where they received more specific treatments Thus, the sample included parents of pediatric outpatient and of pediatric inpatient
The convenient sampling technique was used to recruit participants in the study. Every parent of children diagnosed with asthma visited the hospital between 15 April and 15 May 2015 were potential participants for the study.
Parents of children under 15 years and having asthma were recruited in the study Additionally, parents who were willing to participate in the study and signed in the informed consents were enrolled in the study.
Persons who took the children to the hospital for examination and were not their parents were excluded from the study Moreover, parents who could not adopt for interview since physical impairments such as blind, deaf and dumbness were also excluded from the study.
Research instruments
A structured questionnaire is designed for data collection This questionnaire included four sections:
Parent characteristics: This part included 9 items investigating parent characteristics (relationship with asthmatic child, age, marital status, years of marriage, educational level, occupation, number of children, family income, and religion)
Child characteristics: this part consisted of 7 items relating to age of child, age of onset, and severity of asthma.
Asthma severity was assessed using questions about the frequency of asthma symptoms, frequency of night-time symptoms, exacerbations, missed days of school and emergency room visits (Howard, 2009) Responses were rated on a 4 point scale, with a 4 indicating high severity Each of the 4 point scale severity questions are averaged for a total severity score The total severity score was then rounded to the nearest whole number For scores of 1, participants were classified as mild intermittent, for scores of 2 participants were classified as mild persistent, for scores of 3 participants were classified as moderate persistent, and for scores of
4 participants were classified as severe persistent.
The Carolina Parent Support Scale (CPSS) (Bristol, 1979) was used as a measure of social support The CPSS was a 21-item questionnaire for which parents indicated both availability of supports and the degree of helpfulness of various supports on a five point Likert-scale Separate scores can be obtained for the three dimensions of support including informal support (e.g spouses, friends, neighbors), formal support (e.g from professionals, institutions and agencies), and informational support (e.g from books, video, or radio) Each source of support was rated from 0 (not at all helpful) to 4 (extremely helpful) Parents were able to indicate if a source of support is considered unavailable to them by crossing through the item.
Responses could be summed to yield separate scores for the level of helpfulness of Informal Supports, Formal Supports, Informational Supports, and Total Supports, as well as a score for the size of the available support network The Informal Supports score was the summary score for items one through seven. Bristol (1979) defined informal support as interpersonal support which takes place without formal organizational structure or the outlay of any public or private monies It included the reported helpfulness of the parent’s spouse, his/her relatives, the spouse’s relatives, friends, his/her own children, other unrelated children, and parents of other children who are disabled or non-disabled The range of possible scores for this subcategory is 0-28.
The Formal Supports scale included summing items eight through fifteen.
These services implied an organizational structure and/or the outlay of public or private monies This sub-scale included the reported helpfulness of parent groups, education programs, private doctor, public health services, paid babysitting, church or synagogue, and public and private social services The range of scores possible on Formal Supports was 0-32.
The third sub-score was Informational Supports This sub-score was found by summing the ratings for items 16-21 This included reported helpfulness of lectures, meetings, books, magazines, newspapers, radio and television The range of possible scores on this section is 0-24 Finally, a Total Supports Score could be computed by summing the ratings for all 21 items with scores ranging from 0 to
To date few studies were conducted to check the questionnaire’s reliability and validity The CPSS has been shown to be related to many aspects of functioning in families of children with disabilities, including stress, quality of parenting, and depression (Bristol, 1985) Beckman (1991) reported its effectiveness in predicting hypotheses of a significant negative relationship between levels of parenting stress and social support Walker (2000) in his study also used CPSS as the assessment instrument of social supports and he concluded a association between parenting stress and all aspects of CPSS
Since this study was the first one assessing parenting stress and its relationship with social supports as well, a comprehensive instrument of assessing social supports like CPSS was necessary With three aspects of Informal Supports, Formal Supports and Informational Supports, the researcher hoped the CPSS could cover all information that was necessary to give a clear picture about social supports for caregivers of children with asthma
The Parenting Stress Scale (PSS) was applied to explore the level of parenting stress among respondents (Berry & Jones, 1995) The PSS consisted of
18 items that described the parent-child relationship and the parent's feelings regarding it A Likert-type scale was used, with 1 indicating a strong disagreement and 5 indicating a strong agreement To compute the parental stress score, items 1,
2, 5, 6, 7, 8, 17, and 18 should be reverse scored as follows: (1=5) (2=4) (3=3) (4=2) (5=1) The item scores were then summed The overall possible scores on the scale range from 18 – 90 A low total score means a low level of stress and a high total score indicated a high level of stress
Tests of the scale's validity were performed with the standardization sample and several independent samples, during which Berry and Jones (1995) discovered that scores on the Parenting Stress Scale were significantly correlated with scores on other measurements of stress, such as the Perceived Stress Scale (PSS) and the PSI In addition, scores on the Parenting Stress Scale effectively discriminated between the parents of typically developing children and parents of children with developmental delays and disabilities, as well as children with behavior problems. The validity of the scale was also assessed by comparing it to measures of emotion, social support, and role satisfaction, with the results indicating that the scores on the Parenting Stress Scale were significantly correlated with the results on the additional measures (Berry & Jones, 1995).
An advantage of PSS was its simplicity, clarity and short-time consumption.With only 18 items, it may take less time for respondents to complete the whole questionnaire as compared with PSI (120 items) or PSI-SF (36 items) This study was conducted in a clinical setting in which parents of children with asthma may have little time for interviews As the questionnaire was too time-consuming, the respondents could not wait until their turn of being interviewed Thus, the researcher applied the PSS in this study to explore the parenting stress among parents of asthmatic children.
To measure the depression level of respondents, the Patient Health Questionnaire-9 (PHQ-9) was employed (Kroenke, Spitzer, & Williams, 2001 ). The PHQ-9 was a 9-item self-reported questionnaire designed to evaluate the presence of depressive symptoms during the previous 2 weeks and was effectively used to measure depression both in the clinic and the general population (Martin, Rief, Klaiberg, & Braehler, 2006) The PHQ-9 had 9 items asking patients about problems occurred within last 2 weeks such as “little interest or pleasure in doing things”, feeling bad about yourself…” The PHQ-9 was the depression module, which scores each of the nine items as "0" (not at all) to "3" (nearly every day). Respondents were classified as severe, moderately severe, moderate, mild and none depression if the total score of 20-27, 15-19, 10-14, 5-9, and 0-4, respectively.
A number of studies on the validity and reliability of PHQ-9, as a diagnostic measure as well as its utility in assessing depression severity and in monitoring treatment responses have been published in different settings (Lee, Schulberg, Raue, & Kroenke, 2007; Martin, et al., 2006) A current Indian study examined the diagnostic accuracy, reliability, and validity of the PHQ-9 when pediatricians used it among Indian adolescents The findings showed that PHQ-9 score of ≥ 5 was ideal for screening (sensitivity, 87.1%; specificity, 79.7%) In addition to good content validity, PHQ-9 had good 1-month test–retest reliability (r = 875) and internal consistency (Cronbach's α = 835) (Ganguly, Samanta, Roy, Chatterjee,Kaplan, & Basu, 2013) Similarly, Zhang et al (2013) examined the validity and reliability of the Patient Health Questionnaire-9 (PHQ-9) and Patient HealthQuestionnaire-2 (PHQ-2) The internal consistency values of PHQ-9 and PHQ-2 were 0.854 and 0.727, respectively The test–retest reliability values of PHQ-9 andPHQ-2 were 0.873 and 0.829, respectively Thus, with high reliability and validity and simplicity, it is obviously to apply the PHQ-9 in this study.
Research Progress
Six data collectors with different backgrounds (2 doctors and 4 nurses working at Hospital of Tropical Diseases) joined the team of data collection. Before participating in the study as investigators, they attended a two-days training course on data collection held by the researcher Ways of mining information and scoring PSS, CPSS and PHQ-9 are included in the training course
To check the content validity of the questionnaire, the researcher consulted three psychological experts, including Nguyen Van Hai PhD Dr (Psychological Header of Mental Hospital Ho Chi Minh city), ………PhD Dr (Hospital of Tropical Diseases), and ……… Dr (Researcher of Hospital of Tropical Diseases), for consistency of the questionnaire Each expert was fulfilled a form of expert consultation in which they were asked to give opinion about the fitness of items in the questionnaire For items asked about demographic characteristic of patients and children (9 items) and the severity of asthma, all of experts agreed that those need to be added in the questionnaire Similarly, items in CPSS, PSS and PHQ-9 were also received the high consensus among experts Thirty parents were then recruited in a pilot study with the aim of clarifying the questionnaire and checking the reliability of the questionnaire as well
After parents of asthmatic children completed their child examinations, the data collectors will inform the purpose of the study and asked them whether they took part in the study If mother or father of the asthmatic child refused to take part in, he or she would excluded from the study and the next visit parents would be asked to join the study
The selected parents would be invited to a separate and quiet room for face- to-face interviews The room was near to the clinical unit so that parent after their child examinations could save time to reach the interview room Six collectors seated at well-spaced tables so that six parents could be interviewed at the same time without influencing each other Parent would be signed in the informed consent and the estimate time for each interview was about 15 minutes.
Data management and data analysis strategy
For PHQ-9, CPSS, and PSS a two-way translation procedure is applied in which two English questionnaires will be translated into Vietnamese and back translated into English The translators will be two health professionals who have high understanding of academic English and psychological domain Vietnamese questionnaires of two translators will be compared to choose the most appropriate meanings compared to the original version in English.
Thirty parents who visited the Hospital of Tropical Diseases were interviewed in the pilot study to examine the reliability of the questionnaire The reliability of PSS, PHQ-9 and CPSS were measured by Cronbach’s α Table 1 described the results of reliabilities analysis of three subscales
Table 2 The results of reliability analysis of PSS, PHQ-9 and CPSS
The Carolina Parent Support Scale (CPSS) 0.77
The Patient Health Questionnaire-9 (PHQ-9) 0.89
Data was entered, managed and analyzed by SPSS v16 Descriptive analysis included mean and standard deviation for quantitative variables and frequency and percent for categorical variables One-way analyses of variance (ANOVAs) or t- test were conducted on continuous demographic variables (potential covariates) such as family income, age of child, and age of parents in order to determine if there were any significant differences between these variables prior to parenting stress Pearson’s correlations were calculated to measure the association between social support scores and parenting stress level and between parenting stress and depression scores Finally, a multiple linear regression was carried out to find which the potential predictors of parenting stress are P-value of 0.05 was used as level of statistical significance.
Ethical Consideration
Prior to implementing the study, the researcher has to submit the proposal to the Expert Committee of Hospital of Tropical Diseases and received the permission of conducting the study on May 2015 To participants, the investigators informed patients that they have been enrolled in the study and described the purposes of the study as well as the benefits that patients received so that the patients voluntarily agreed to participate in by signing on informed consent If the patient did not agree, they would be excluded from the study After the interviews, if patients had parenting stress, the investigators provided useful consultants to help parents overcome stressors during their child care Additionally, all information related to participants was solely used in the present study, not for any purposes.
Chapter summary
A cross-sectional study was conducted from 15 April and 15 May 2015 atHospital of Tropical Diseases The sampling population was parents of children with asthma visiting the hospital within the study time A structured questionnaire was developed to serve as instruments used in face-to-face interviews Three well- designed assessment tools used to evaluate social supports, parenting stress, and parents’ depression level were also included in the questionnaire Data was entered, managed and analyzed by SPSS v16 Descriptive analysis included mean and standard deviation for quantitative variables and frequency and percent for categorical variables, whereas ANOVAs or t-test and Pearson’s correlations were used to measure associations between independent and dependent variables. Furthermore, a multiple linear regression was carried out to find potential predictors of parenting stress For ethical issues, approval from Expert Committee of Hospital of Tropical Diseases was achieved prior to implement the study.Additionally, informed consents were obtained from and psychological counseling was delivered to respondents.
Results
Introduction
This chapter discussed about all findings in this study The first part displayed the findings related to demographic characteristic of participants The second section displayed social support score of parents with asthmatic children. The third one showed parenting stress score of participants and the fourth one summarized depression score of participants The final section showed relationship between parenting stress and interested factors in this study Finally, a summary of this chapter was present so that the readers had a clear picture about what achieved in this study.
Demographic characteristic of parents of asthmatic children
Among 171 participants, 79.53% were asthmatic child’s mother Generally, the age of participants was relative young with 77.19% were under 39 years of age. Most of respondents (94.15%) were married and lived with their spouses There were 38.01% participants who had length of marriage lasted from 5 to 10 years and 36.26% had lived together with their spouses more than 10 years
The education level of most of participants was not high with the proportions of participants who completed elementary school or secondary schools and participants who completed high school were 30.41% and 42.11%, respectively
It could be said that workers and officers were two main occupations in this study (32.75% and 22.22%, respectively), while housewives and manual labor occupied 27.49% Nearly ninety percent of participants (86.55%) had from 1 to 2 children The proportion of participants who had monthly income over 2.5 million VDN was 91 Buddhism and Catholic were the most popular religions among study population with the rate of 67.84% and 21.64%, respectively
Table 3 Demographic characteristics of parents (n1)
There were 65.5% asthmatic children under 5 years of ages in this study. The age of acquiring asthma of children was mainly under 5 years as well (81.29%) Based on severity assessment, most of children had mild intermittent and mild persistent (65.5% and 27.49%, respectively).
Social support for parents of asthmatic child
It seem to be that parents of asthmatic child received largest support from their spouses (3.18 ± 1.19), followed by their spouses’ relatives, and their relatives (1.99± 1.33; 1.59 ± 1.45, respectively) However, participants received less supports from their friends, their own children and other children As a result, the informal support score was relative low (8.16 ± 4.12).
Table 5 Source of informal supports and informal support score among parents of asthmatic children (n1)
Sources of informal supports Mean ± SD (range)
Other parents of children with asthma 0.37 ± 0.77 (0-4)
Generally, parents of asthmatic children received little supports from formal source such as private and public social services, church or synagogue. Consequently, the formal support score was merely 1.77 ± 2.65
Table 6 Source of formal supports and formal support score among parents of asthmatic children (n1)
Sources of formal supports Mean ± SD (range)
Magazine and newspapers are the most popular information source among parents of asthmatic children (0.89 ± 1.04), followed by television (0.81 ± 1.04) and books (0.77 ± 1.02) However, in general the informational support score of participants was not high (3.12 ± 3.76).
Table 7 Source of Informational supports and Informational support score among parents of asthmatic children (n1)
Sources of informational supports Mean ± SD (range)
A sum of Informal support, Formal support and Informational support was used to measured total social supports Since three subscale score were not high, the total social support score was solely 13.05 ± 7.71 (2-44).
Table 8 Subscale of social support and total social support score among parents of asthmatic children (n1)
Stress among parents caring asthmatic child
Most of participants confirmed that caring asthmatic takes more time and energy than they thought (4.31 ± 1.19) Most of them also recognized that whether they cared their children enough (3.71 ± 1.39), they could not fulfill different responsibilities due to caring of their children (3.05 ± 1.49), and especially asthmatic children was the major source of stress in their life (3.03 ± 1.66) The results showed that the mean total parenting stress score among parents of asthmatic children was 39.17 ± 9.69 with a range varied from 21 to 58 point.
Table 9 Parental stress subscales score and total stress score among parents of asthmatic children(n = 171)
Caring for my child(ren) sometimes takes more time and energy than I have to give 4.31 ± 1.19 (1-5)
I sometimes worry whether I am doing enough for my child(ren) 3.71 ± 1.39 (1-5)
It is difficult to balance different responsibilities because of my child(ren) 3.05 ± 1.49 (1-5)
The major source of stress in my life is my child(ren) 3.03 ± 1.66 (1-5)
Having child(ren) leaves little time and flexibility in my life 3.01 ± 1.63 (1-5)
The behaviour of my child(ren) is often embarrassing or stressful to me 2.97 ± 1.47 (1-5)
I feel overwhelmed by the responsibility of being a parent 2.83 ± 1.57 (1-5)
Having child(ren) has been a financial burden 2.70 ± 1.65 (1-5) Having child(ren) has meant having too few choices and too little control over my life 2.67 ± 1.43 (1-5)
If I had it to do over again, I might decide not to have child(ren) 1.25 ± 0.73 (1-5)
Having child(ren) gives me a more certain and optimistic view for the future 1.23 ± 0.63 (1-5)
I feel close to my child(ren) 1.22 ± 0.46 (1-4)
I find my child(ren) enjoyable 1.19 ± 0.52 (1-5)
I enjoy spending time with my child(ren) 1.18 ± 0.44 (1-4)
My child(ren) is an important source of affection for me 1.10 ± 0.30 (1-2)
There is little or nothing I wouldn't do for my child(ren) if it was necessary 1.09 ± 0.39 (1-5)
I am happy in my role as a parent 1.08 ± 0.29 (1-3)
Depression status among parents caring asthmatic child
In general, the mean scores of depressive subscales were relative low, meaning that participants perceived low depressive status As a result, the mean depressive score among parents was 10.08 ± 7.32
Table 10.The depression status of parents with asthmatic children (n1)
Trouble falling or staying asleep 1.54± 1.15 (0-3)
Little interest or pleasure in doing things 1.51 ± 1.24 (0-3) Feeling tired or having little energy 1.46± 1.14 (0-3)
Moving so slowly or moving around a lot more than usual
Feeling down, depressed, or hopeless 0.95±1.08 (0-3)
Feeling bad about themselves or let themselves down 0.77±1.02 (0-3)
Thoughts about dead, or hurting themselves 0.09± 0.35 (0-3)
Based on classification of PHQ-9, there were 27.49% parents not having depression, 38.6% parents having depression from mild to moderate and 33.88% parents having depression from moderate severe to severe.
Table 11 The severity of depression among parents with asthmatic children (n1)
Relationship among demographic factors, social support, parenting stress
4.6.1 Relationship between d emographic factors and social support
The analysis showed that only number of children had significant association with social supports in which parents with more than 2 children received least social supports (9.39 ± 5.15), while parents with two children received the highest score of social supports (13.94 ± 8.43) Other parent’s characteristics did not relate to social supports (p> 0.05).
Table 12 The relationship between social support and parent characteristics (n1)
*: Analyzed by one-way ANOVA test or t test
No factors related to child characteristics had significant associations with social support among parents of asthmatic children (p> 0.05).
Table 13 The relationship between social supports and child characteristics (n1)
*: Analyzed by one-way ANOVA test or t test
4.6.2 Relationship between demographic factors and parenting stress
The analysis showed that duration of marriage had an significant association with stress score of parents in which parents who had married longer were likely to gain lower stress score than parents with shorter time of marriage (p=0.03). Similarly, parents who had higher education level had lower stress score than parents with lower education (p=0.001) Parents having one child would have lower score of stress than parents with two or more children (0=0.01) Other parent characteristics did not have statistical significant relationship with parenting stress.
Table 14 The relationship between parenting stress and parent characteristics (n1)
*: Analyzed by one-way ANOVA test or t test
Although the stress score of parents with children under 5 years was likely to be higher than parents with children over 5 years (39.73 ± 0.92 versus 38.10 ± 1.25), the difference was not statistical significant (p=0.3) Age of acquiring asthma and the severity of asthma were not related to parenting stress as well (p=0.35 and p=0.95).
Table 15 The relationship between parenting stress and child characteristics (n1)
*: Analyzed by one-way ANOVA test or t test
4.6.3 Relationship between demographic factors and depression
Marital status and religion were related to depression among participants (p
< 0.05) Participants who were divorced or widowed got higher score of depression than participants who were married and lived with their spouses Parents who followed other religions or were non-religious had lower score of depression than parents who were catholic or Buddhism (p< 0.001).
Table 16 The relationship between depression and parent characteristics (n1)
*: Analyzed by one-way ANOVA test or t test
Only age of acquiring asthma had significant association with depression among parents of asthmatic children (p=0.01) No significant associations were found between depression and other child characteristics (p> 0.05).
Table 17 The relationship between depression and child characteristics (n1)
4.6.4 Relationship between social support and parenting stress
A Pearson product-moment correlation coefficient was computed to assess the relationship between Informal Support, Formal Support, Informational Support and Total Support and parenting stress score There was a negative correlation between Informal Support and parenting stress score, r = 0.32, n = 171, p < 0.001. There was a negative correlation between Formal Support and parenting stress score, r = 0.24, n = 171, p=0.001 There was no correlation between Informational Support and parenting stress score, r = 0.1, n = 171, p = 0.19 There was a negative correlation between Total Support and parenting stress score, r = 0.30, n = 171, p