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Figure 1. The conceptual framework of parenting stress developed in the study
3.4.2. Sampling criteria
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.
A structured questionnaire was designed for data collection.This
questionnaire included four sections:
3.5.1. Demographic characteristics
Parent characteristics: This part included 9 items investigatingparent
characteristics (relationship with asthmatic child, age, marital status, years of
marriage, educational level, occupation, number of children, family income, and
Child characteristics: is 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.
3.5.2. Social supports
The Carolina Parent Support Scale (CPSS) (Bristol, 1979) was used as a
measureof social support. The CPSS was a 21-item questionnaire for which parents
indicated both availabilityof 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 informalsupport (e.g. spouses, friends, neighbors),
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
crossingthrough the item.
Responses could be summed to yield separate scores for the level of
helpfulness ofInformal Supports, Formal Supports, Informational Supports, and
Total Supports, as wellas a score for the size of the available support network. The
Informal Supports score wasthe summary score for items one through seven.
Bristol (1979) defined informal supportas interpersonal support which takes place
without formal organizational structure or theoutlay of any public or private
monies. It included the reported helpfulness of the parent’sspouse, his/her relatives,
the spouse’s relatives, friends, his/her own children, otherunrelated children, and
parents of other children who are disabled or non-disabled. Therange 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 outlayof public or
privatemonies. This sub-scale included the reported helpfulness of parent groups,
educationprograms, 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
bysumming the ratings for items 16-21. This included reported helpfulness of
lectures,meetings, books, magazines, newspapers, radio and television. The range
of possiblescores on this section is 0-24. Finally, a Total Supports Score could be
computed bysumming the ratings for all 21 items with scores ranging from 0 to 84.
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 familiesof children with disabilities, including stress, quality of
effectiveness in predicting hypotheses of asignificant 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
aassociation 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.
3.5.3. Parenting stress
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.
3.5.4. Depression status of parents
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 et. al., 2013).Similarly, Zhang
et al. (2013) examined the validity and reliability of the Patient Health
Questionnaire-9 (PHQ-9) and Patient Health Questionnaire-2 (PHQ-2). The
internal consistency values of PHQ-9 and PHQ-2 were .85 and .73, respectively.
The test–retest reliability values of PHQ-9 and PHQ-2 were .87 and .83,
respectively. Thus, with high reliability and validity and simplicity, it is obviously
to apply the PHQ-9 in this study.
3.6. Research Progress
3.6.1. Training the Observers
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, CPSSand PHQ-9 are included in the training course.
3.6.2. Pilot study
To check the content validity of the questionnaire, the researcherconsulted
three psychological experts, including Nguyen Van Vinh Chau PhD. Dr (Hospital
of Tropical Diseases), Lam Minh Yen PhD. Dr (Hospital of Tropical Diseases), and
Tran Thi Nhu ThuyPhD.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.
3.6.3. Data collection procedure
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 faceto-face interviews. This 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.
3.7. Data management and data analysis strategy
3.7.1. Data management
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
translatedinto 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 wereinterviewed
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 present the value
of reliabilities analysis of three subscales.
Table 2. The results of reliability analysis of PSS, PHQ-9 and CPSS
Parenting stress scale (PSS)
The Carolina Parent Support Scale (CPSS)
The Patient Health Questionnaire-9 (PHQ-9)
3.7.2. Data analysis
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 wereconducted 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.
3.8. Ethic issues
Prior to implementing the study, the researcher submited the proposal to the
Expert Committee of Hospital of Tropical Diseasesand 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