Stress ở người chăm sóc trẻ bị hen phế quản

Meiho University
Graduate Institute of Health Care

Thesis
PARENTAL STRESS: CARING FOR A CHILD
WITH ASTHMA IN VIETNAM

Graduate student: Tran Thi Truc Tam
Supervisor:Assistant Professor. Ya-Fen Lien

July 2015


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PARENTAL STRESS: CARING FOR A CHILD
WITH ASTHMA IN VIETNAM

研研研研Tran Thi Truc Tam
研研研研研Ya-Fen Lien

2015 美 06 美


PARENTAL STRESS: CARING FOR A CHILD
WITH ASTHMA IN VIETNAM
Graduate student: Tran Thi Truc Tam
Supervisor: AssistantProfessor. Ya-Fen Lien.

Meiho University
Graduate Institute of Healthcare
Thesis
A thesis submitted to the Graduate Institute of Health Care of
Meiho University
In partial fulfillment of the requirement for the degree of

Master of Health Care

July2015


Abstract

Asthma is a public health problem beingcommon among children
population.Having children with asthma is challenging for caregivers, especially
their parents. 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. 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.
In recent years, Vietnam is one of South Asian countries having growing
incidence of asthma among school age children. 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. However, to date
there are no studies on parenting stress among parents taking care of asthmatic
children. It is therefore necessary to conduct an innovative study on parental stress
among parents caring children with asthma.
A cross-sectional study was conducted from 15 April to 15 May 2015 at

Hospital of Tropical Diseases. The sampling population is parents of children with
asthma visiting the hospital within the study time. A structured questionnaire with
4


three well-designed subscales (Parenting Stress Scale; PSS; The Carolina Parent
Support Scale; CPSS; and the Patient Health Questionnaire-9; PHQ-9) was
developed to serve as instruments used in face-to-face interviews.
There were a total of 171 parents of asthmatic children enrolled in the study
and most of them were female (79.53%). 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.
In general, participants received little social supports, especially from formal
sources and informational supports.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. The mean depression score among parents was 10.08 ± 7.32. It meant that
33.88% parents having depression from moderate severe to severe. A multiple
linear regression analysis showed that depression, education and duration of
marriage were the predictors of parenting stress among parents of asthmatic
children.
5


Acknowledgements

First of all, I would like to express my deepest gratitude to my supervisor,
Professor. Ya-Fen Lien, and other professors who spent valuable time in instructing
me to complete this thesis. I could not fulfill my thesis without profound
knowledge, invaluable advices and supports from my professors. All of these made
me put more efforts to finish my thesis.
Many special thanks were also sent to the Board of Directors of Nguyen Tat
Thanh University for supporting me during my study. I will always remember all
university officers for their help, cooperation and kindness during my study period
in Viet Nam as well as in Taiwan.
I would like to send my special thanks to health-care staff in departments of
Hospital of Tropical Diseases who have provided precious documents used as
reference in my study. My great gratitude was also given to officers, librarians,
staff of dormitory of Meiho Institute of Technology for their help and sharing as
close friends during my time of studying in Taiwan.
I would like to express my thankfulness to all participants who had no
hesitation in giving help and useful information during the data collection of the
study process.

6


Finally, I am eternally indebted to my family who have always behind me in
my career advancement and without their helps and concerns I could not complete
my thesis.

7


Contents
Page

Appendix
Appendix 1: The questionnaire
Appendix 2: Informed consent
Appendix 3: Ethical certification for conducting study
Appendix 4: Consultant expert forms

8


List of tables

Pages

9


List of figures
Pages

10


Chapter one. Introduction

1.1. Statement of the problem
Asthma is a widespread publichealth problem and the most common chronic
illness in childhood and adolescence (Masoli, Fabian, Holt, & Beasley, 2011; H. Q.
Pham & Dinh, 2002; World Health Organization (WHO), 2003). According to the
Global Asthma Report 2011(Masoli, et. al., 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,
11


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 et. al., 2008)
1.2. 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 HaiPhong reported an
asthmatic prevalence of 9.3% among children under 18 years (H. Q. Pham & Dinh,
2002). Three studies were carried out in Ha Noi. The findings showed that a
growing number of asthma children by the time in which the proportion of asthma

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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, todate
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 Tropical
Diseases, where the study is carried out, could develop proper intervention
13

strategies to help parents of children with asthma overcoming stressors occurring
during their caring.

1.3.Aimof the research
The 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 three objectives are
described below:
1. To explore stress, social supports and well-being amongparents of asthmatic

children;
2. To examine the relationships among demographic characteristics, stress, social
supports and well-being among parents of asthmatic children;
3. To investigate the significant predictors of stressamong parents of asthmatic
children.
1.4. Research questions
1. What are demographic characteristics, stress, social supports and well-

beingamong parents of asthmatic children?
2. Are there associations amongdemographic characteristics stress, social supports
and well-being among parents of asthmatic children?
1.5. Definition of term
Stress: traditionally, stress is defined as “a relationshipbetween the person
and the environment that is appraised by the person as taxing orexceeding his or
her resources and endangering his or her well-being.”(Lazarus & Folkman, 1984).
14

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.
1.6.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 could develop
proper intervention strategies to help parents of children with asthma overcoming
stressors occurring during their caring.

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Chapter two. Literature Review

2.1. 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 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 various 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
16


important impacts on developing of parenting stress among parents of asthmatic
children.
2.2. Parental stress
2.2.1. The concepts of stress and parenting stress
Lazarus

and

Folkman(1984)define

psychological

stress

as

“a

relationshipbetween the person and the environment that is appraised by the person
as taxing orexceeding his or her resources and endangering his or her wellbeing.”(p.19).

They

also

note

that

personal

characteristics

and

environmentalfactors 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) biologicresponses(Cohen, Kessler, & Gordon, 1995). Of the
three, probably the most common approach is definingstress by the events that
happen to an individual. Events that are judged byconsensus to place demands on
an individual are labeled as ‘‘stressors.’’ Thisapproach labels objective events that

occur in individuals’ lives as stress.The second approach argues for the importance
of factoring in the individual’ssubjective reactions to the stressor. This approach
states that the amount ofstress experienced depends in large part on how an
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individual interprets, orappraises, a situation and that the same objective event may
cause different stressreactions 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 reactionsin different individuals but
relies on biologic indicators of stress rather than anindividual’s self-report of stress.
However, other researchersdeveloped 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
providea useful conceptualization for a particular type of stress, parenting stress.
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Abidin(1995)acknowledges the assumption that stressors are multi-dimensional

both in source andkind. He notes that this assumption led to the identification of
three major source domainsof stressors for parents: 1) Child Characteristics; 2)
Parent Characteristics, and 3)Situational/Demographic-Life Stress. Furthermore,
the emotional interpretation ofsituations by parents is also play an important role in
developing parenting stress. As a result, there has been great variability in
howresearchers 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 tomake cross-study comparisons.
2.2.2. Parenting stress and chronic illnesses
A number of studies have documented associationsbetween parenting stress
and childpsychologicalsequelae. For children, parenting stress wasshown to
moderate

the

relationship

depressivesymptoms

in

youth

between

perceived

with

diabetes(Mullins

vulnerability
et.

al.,

and
2004),

rheumatoidarthritis(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 childrenwith sickle cell disease was associated with greater diseaseseverity and
more frequent health care utilization 1 yearlater.
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For parents, studies on children with different chronic conditions showed that
greater general and disease-related parenting stress was associatedwith
psychological distress (e.g., depression and anxiety) in caregivers of children with
arthritis(Manuel, 2001), cystic fibrosis (Driscoll et. al., 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 et. al., 2008).
Kazak and Barakat(1997)reported positive associations between general parenting
stress and parenting state anxiety and posttraumaticstress disorder symptoms in
caregivers of children withcancer.
The most frequently used coping strategy to coping with 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. Parental stress and asthma
2.2.3.1. The impacts of parental stress on children with asthma
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Numerous studies demonstrate that parental stress may influence theonset and
course of a child’s asthma. Parenting stress is associated withan increased riskof
asthma or wheeze in childhood(Kozyrskyj et. al., 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 et. al., 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 et. al.,
2002). Furthermore, few studies (Bartlett et. al., 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 et. al., 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
21

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 (2011b) 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.(2011b) 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
22


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 parentingstress
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(Abidin, 1990, 1995).

Table 1. Some popular assessment tools of parenting stress
Tool
Parenting

Author
stress (Abidin, 1997)

Advantages
Disadvantages
• Assess the impact that the • Too much items

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index

•

Parenting
scale

stress (Berry & Jones,
1995)

•
•

Cleminshaw(Guidubaldi
Guidubaldi parent Cleminshaw,
satisfaction scale
1985)

&

Global Inventory (Sheridan
&
of Stress
Radmacher, 1998)

Perceived
scale

stress (Cohen, Kamarck,
&
Mermelstein,
1983)

Family inventory

of life events and
changes
Coping Resources
Inventory
for
Stress

Pediatric
Inventory
Parents

•

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.
Identify
attitudes
and
emotions
affecting
parenting behaviors

• Examination

of coping
resources, environmental
stressors,
and
the
perception of stress
• The reliability and validity
has
been
demonstratedwidely
• Assess the respondent's
beliefs about stressors

(McCubbin
&
Patterson, 1991)

• Assess the presence of

(Matheny
&
Curlette, 1998)

• Measure coping resources

(Cousino
for Hazen, 2013)

&

stressors

in dealing with parenting
stress

• Indicate the frequency at
which
disease-related
parenting stressor occurs,
and the difficulty-level of
each stressor

2.2.4.1. Parenting stress index

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(120)

• Need more studies
on
evaluating
reliability
and
validity

• Further information
concerning
validity

reliability

its
and

• Further information
concerning
validity
reliability
• Too much
(71)

its
and
items

• Too much items
(45-60)

• Further information
concerning
validity
reliability

its
and


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

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