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Figure 1. The conceptual framework of parenting stress developed in the study

Figure 1. The conceptual framework of parenting stress developed in the study

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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


Cronbach’s α




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


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Figure 1. The conceptual framework of parenting stress developed in the study

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