Thai Journal of Nursing Research Vol 13 No 3 Jul 92974

Vol.13No.3•July-September2009ISSN0859-7685

EDITORS: Clinton E. Lambert, PhD, RN, CS, FAAN Vickie A. Lambert, DNSc, RN, FAAN Somchit Hanucharurnkul, PhD, RN Aim and Scope: The Thai Journal of Nursing Research is an English language, refereed (peer-reviewed), quarterly publication for nursing research, literature review and conceptual analysis papers. AssistantEditor: Manee Arpanantikul, PhD, RN EditorialBoardMembers: Thailand Ampaporn Puavilai, PhD, RN Aranya Chaowalit, PhD, RN Jintana Yunibhand, PhD, RN Jiraporn Kespichayawattana, PhD, RN Linchong Pothiban, DSN, RN Orasa Punpakdee, PhD, RN Rutja Phuphaibul, DNS, RN Saipin Gasemkitvattana, DNS, RN Siriporn Chirawatkul, PhD, RN Sophen Choonuan, PhD, RN Sukunya Parisunyakul, PhD, RN Susanha Yimyam, PhD, RN Tipaporn Wonghongkul, PhD, RN Veena Jirapaet, DNSc, RN Wanapa Sritanyarat, PhD, RN Wandee Suttharangsee, PhD, RN Wantana Maneesriwongul, DNSc, RN Warunee Fongkaew, PhD, RN Wongchan Petpichetchian, PhD, RN Yajai Sithimongkol, PhD, RN USA Carol Loveland-Cherry, PhD, RN, FAAN Gail D’ Dramo Melkus, PhD, RN Marjorie Meuke, PhD, RN Karin Olson, PhD, RN Marilyn E. Parker, PhD, RN, FAAN AdministrativeManager: Kanniga Punyaarmonwat, MA, RN AdvertisingManager: Suchin Vichitkran, MS, RN Ownership: Thailand Nursing and Midwifery Council Nagarindrasri Building, Ministry of Public Health, Tiwanon Rd., Amphur Muang, Nonthaburi 11000 Telephone: (02) 9510145-51 SubscriptionRates: The subscription rates for the journal are: Members of Thai Nursing and Midwifery Council: 300 Baht Non-members: In Thailand: 400 Baht Outside Thailand: 50 USD Students: 200 Baht Individual issue: 100 Baht Disclaimer: The Thailand Nursing and Midwifery Council and the Editors of the Thai Journal of Nursing Research are not to be held liable for errors or any consequences arising from use of information contained herein. The views and opinions expressed, as well as the advertisements do not necessarily reflect those of the Editors or the Thailand Nursing and Midwifery Council, and are not to be considered an endorsement by the Editors, the Publisher or the Thailand Nursing and Midwifery Council.

Thai Journal of Nursing Research

Vol.13No.3 July-September2009ISSN0859-7685

Content

159 Environment for Scholarship and Journal Impact Factor in Thailand

Shaké Ketef ian, Somchit Hanucharurnkul

167 Quality of Diabetes Care in PCUs in Central Thailand

Rukchanok Koshakri, Nantawon Suwonnaroop, Kobkul Phancharoenworakul, Chanvit Tharathep,

Noel Chrisman

181 Relationship among Maternal Depressive Symptoms, Gender Differences

and Depressive Symptoms in Thai Adolescents

Nopporn Vongsirimas, Yajai Sitthimongkol, Linda S. Beeber, Nonglak Wiratchai, Sopin Sangon

199 Cognitive Performance after a Transient Ischemic Attack: Attention, Working Memory,

and Learning and Memory

Vishuda Charoenkitkarn, Saipin Kasemkitwattana, Barbara Therrien, Orapan Thosingha,

Thavatchai Vorapongsathorn

216 Participative Model of Child Protection in Northern Thailand

Naruemon Auemaneekul, Wilawan Senaratana, Yuwayong Juntarawijit, Kasara Sripichyakan,

Barbara J. Ensign

227 Buddhist Mothers’ Experience of Suffering and Healing After

the Accidental Death of a Child

Kallaya Wiriya, Urai Hatthakit, Wantanee Wiroonpanich, Lee Smith-Battle


Editorial : Writing an Appropriate Methods Section for a Research Article: Design, Ethical Considerations and Sample

Over the years, while editing numerous manuscripts, we have noted a consistent problem exists regarding the manner in which the method section, of research articles, is written. All too often crucial content is missing and, thus, the reader is unable to truly understand what the researcher did. If the method section of the article is poorly written, not only will the reader not understand what was done, but no one can replicate the researcher’s work, since no one will know what actually had been done. In general, the method section, of a research article, needs to contain the following elements: design, ethical considerations, sample, procedure, instruments or measurements, and data analysis. Each of these elements will be discussed, over the next two issues of the Thai Journal of Nursing Research. In this issue, we will focus on what needs to be included in the: design, ethical consid-erations and sample components of the method section of a research article. Design: The design component of the method section needs to briefly indicate what type of design was used in the study. For example, if the study was qualitative in nature, the author needs to indicate the approach used (i.e. phenomenology, grounded theory, historical, ethnography or participative action research.). Since several of these qualitative approaches have varying ways of implementing the analysis of the data, the author needs to indicate clearly the specific approach used. For example:

If phenomenology was used, was the analytical approach Heideggerian or Gadamerian? If grounded theory was used, was the analytical approach based on the work of Glaser and Strauss, or on the work of Corbin and Strauss?

If a quantitative research project was conducted, the author needs to explicate the type of design used. For example, was the research design: descriptive; correlational; quasi-experimental; experimental; or, non-traditional? • If the design was descriptive, was it a typical descriptive, comparative descriptive or time dimensional design? • If the design was correlational, was it descriptive correlational, predictive correlational or model-testing? • If the design was quasi-experimental, was it a type of a non-equivalent group design, or an interrupted time-series design?


• For an experimental design, was it a: classic experimental design; post-test only control group design; randomized block design; factorial design; nested design; cross-over or counterbalanced design; or, randomized clinical trial design? • Finally, if the research design was non-traditional, was it a: primary prevention and health promotion study; secondary analysis; meta-analysis; or, methodological design? It is possible for a researcher to use a mixed design, and utilize both a quantitative and a qualitative approach. If this occurs, the author must indicate that a mixed design was used and explain what type of quantitative and qualitative approaches were implemented. For example, the researcher may have implemented a predictive correlational design, using specific survey instruments, but also interviewed the participants, using a grounded theory approach. It is essential for the author to clearly identify what research design was used, in his/her study. This is necessary so the reader will be prepared for what to expect in the procedure component of the method section of the research article. Ethical considerations: Whenever human or animal subjects are used, in a study, ethical considerations are required. Since most nursing studies use human subjects, rather than animal subjects, we will address only ethical considerations related to human subjects. The author must indicate that consent to engage in a study was obtained from his/her institution (i.e. university, hospital, or clinic). In most situations this means that the author has obtained approval, to gather data, from the institution’s Human Assurance Committee. In addition, depending upon the research sites (hospital, clinic, school, etc.) used in the study, approval also may be required from these organizations’ Human Assurance Committees or from the organizations’ appropriate administrative officers. It is essential that the author indicate that approval to gather data was granted, both by the researcher’s institution and by each research site, prior to any form of data gathering. In addition to indicating approval was obtained from the researcher’s institution and each of the data gathering sites, the author is required to indicate that consent, either verbal or written, was obtained from each research subject, prior to his/her involvement. In addition, the author must state that each subject was informed of the following: the purpose of the study; what would be involved, if the subject agreed to become part of the study; how much of the subject’s time would be required in order to participate in the study; his/her confidentiality and anonymity would be maintained; and, that he/she could withdraw, from the study, at any time, without negative repercussions. If survey questionnaires were used, for data gathering, the completion of the questionnaires serves as the subject’s consent to participate, as long as the questionnaires cannot be identified with any specific subject. When questionnaires are used, the author needs to indicate whether code numbers, instead of the respective subjects’ names, were placed on the completed questionnaires for the purpose of identification.

If an interview of a subject was part of the research procedure, the author needs to indicate if it was done in private, and how the subject’s confidentiality and anonymity was maintained. Additionally, anytime a subject has been tape recorded, as part of the research, the author must indicate whether the subject gave verbal or written consent to be recorded. When children have been part of a research project, the author must reveal whether their respective parents signed a consent form granting approval for their children to participate. In addition, it must be clearly indicated that each child, if he/she is old enough to understand, received an explanation, just as is done with adult subjects, regarding what will be involved in the study and what rights he/she has regarding the study. Even though a parent may grant approval for his/her child to participate, in a study, the child may not want to be involved. Thus, the author must indicate whether children, who are old enough to understand, signed an assent form, in addition to their respective parents signing a consent form. Sample: In all research articles, the author needs to provide a comprehensive description of the study’s sample, so when readers examine the research findings, they have a thorough understanding of what type of individuals generated the data that were obtained. Knowing what a study’s subjects were like assists other researchers and readers of the research article to determine how applicable the findings are to their research, or to their particular work situation. Information about the sample that must be addressed includes: who was studied; how the subjects were identified and contacted; the location of the subjects; the subjects’ inclusion criteria; how many subjects were involved in the study; how many subjects either dropped out of the study or were excluded from the study; information about why subjects dropped out or were excluded; the characteristics of the subjects (age, education, income, gender, information specific to the study, etc.); and how many (number and percentage) subjects were in each characteristic category. The sample’s characteristics may vary greatly depending upon the nature and focus of the study. The sample characteristics can be put either into a table format or described in the narrative of the article. However, the narrative and the table should not repeat the same information, since doing so is redundant. Summary: The design, ethical considerations and sample components of the method section of a research article are only some of the important content that is required. Having well developed design, ethical considerations and sample components in the method section of a research article greatly enhances the possibility of having one’s article accepted for publication, in an English language journal. If these components, of a research article, have been poorly developed, a reviewer will question the author’s ability to adequately explain exactly what was done during the research process. In the next issue of the Thai Journal for Nursing Research, the editors will discuss what needs to be addressed in the procedure, instruments or measurements, and data analysis components

of the method section of a research article. Authors need to recognize that the likelihood of having their manuscript accepted for publication is enhanced if ALL parts of the research article are well written and thoroughly developed. We, as editors of the Thai Journal of Nursing Research, look forward to you submitting your research manuscripts for consideration for publication in the Thai Journal of Nursing Research. Vickie A. Lambert, DNSc, RN, FAAN Clinton E. Lambert, PhD, RN, CS, FAAN

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Shaké Ketefian and Somchit Hanucharurnkul

Vol. 13 No. 3

Environment for Scholarship and Journal Impact Factor in Thailand Shaké Ketefian, Somchit Hanucharurnkul

Abstract: An increasing number of institutions, internationally, are requiring their faculties publish in journals with high impact factors (IF), and providing various types of rewards to motivate scholars to do so. The literature describes appropriate and inappropriate uses of such policies. Thus, this study, as part of a five country study, aimed to explore, in Thailand: (a) the extent to which institutions are requiring faculty to publish in high impact journals, and (b) how the pressure of publishing in high impact journals influences a nurse scientist’s choice of topic for investigation, and the development of nursing science. The design was qualitative, using a questionnaire designed to obtain respondent views. One senior faculty member, from each of the seven nursing doctoral programs in the country, was invited to participate; five did so. Objective responses were summarized and descriptively presented. Content analysis was used for narrative responses. Results indicate that faculties were expected to publish in high IF journals. The faculties stated this led to: competition instead of cooperation; and, authors wanting to publish in journals of other countries, so as to bring prestige to their institutions. However, they felt this does not contribute to resolving health problems of the country, and further enumerated the hurdles and positive outcomes of the policy. They said Thai scholars study health problems of the country, and frame the practical applications of their work, in terms that might be of interest to their country, as well as to other countries. Results were discussed and interpreted in view of current realities in Thailand.

Thai J Nurs Res 2009; 13(3) 159 - 166

Keywords: Impact factor uses; Nursing science; Publications; Scholarship, Thailand

Background Information

Institutions of higher learning, throughout the world, are seeking to improve their offerings, research, and standing nationally and internationally. This has led to competition and search for objective measures to assess quality of various aspects of their educational programs, especially as it relates to the output of faculty, in the form of their publications. The development of bibliometric measures, such as the impact factor (IF), which is

Correspondence to: Shaké ketefian, EdD, RN, FAAN Professor and Director of International Affairs University of Michigan, School of Nursing, 400 North Ingalls, Ann Arbor, MI 48109, USA. E-mail: [email protected] Somchit Hanucharurnkul, PhD, RN, Professor, Department of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

intended as a measure of a journal’s impact; and citation analysis, which is the number of times a scientific article is cited by others,1 have spurred the interest of academicians, and are being used for a variety of purposes.

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Some universities are requiring faculty members to publish in high IF journals; using rewards, such as cash bonuses, to spur faculty members in this regard; and are using bibliometric measures in faculty hiring and promotion decisions.2 Despite caution having been expressed about unintended uses of such measures, institutions of higher learning are using them in making individual faculty decisions, such as in: hiring and promotion; institutional rankings; determination of research funding to individuals and/or institutions/departments; and, national priority setting.3 Some authors have decried this tendency.2, 3

Professionals often have complained that the peer review process does not take into account the social utility of published papers, while those who practice, and provide services to the public, recognize that social relevance is a major concern.4 In addition, the way a journal’s IF is used, as a measure of the quality of an individual’s article, or of a scholar’s body of work, has raised concern among some scholars. For example, an investigation of the predictive validity of journals’ IF scores, in the hiring and promotion decisions of social work faculty, was found to have a low effect, and led the researchers to conclude their findings did not justify using journal IF scores in hiring and promotion decisions.5

The relationship between the quality elements of journal articles, and the frequency of citations of articles in four psychiatric journals, was found to have an IF of 0.88 - 11.2, over a 9-year period.6 Quality features, such as: statistical errors; reporting of sample size; poorly reported research questions; and, the primary outcome of the study, were found not to be related to the citation counts. However, some of the quality features were related to the visibility and prestige of the journal (in this case, two of the four journals with high IF scores). The investigators concluded the latter findings were due to detailed author guidelines and rigorous peer

reviews, which are characteristic of high IF journals.6

The Thai Journal Citation Index Centre created a national system for evaluating journals published within the country.7 This evaluation is conducted yearly, with national and international journals being ranked according to established criteria. The Thai Commission of Higher Education provides funding for journals which are highly ranked, as well as national journals which are determined to have the potential to improve their quality to meet the criteria to become international journals. In order for a journal, published in Thailand, to be classified as an international journal, it must: be published in English; be listed in an international data base; have at least 25% of its editorial board comprised of scholars from other countries; have at least 25% of the authors of papers published in the journal be from outside Thailand; and, have 25% of its reviewers for each issue be experts from outside Thailand. On the other hand, in order to be classified as a national journal: 25% of a journal’s editorial board members must have the academic rank of professor or have a doctoral degree; 25% of the published papers, in each issue of the journal, must be from outside the institution that publishes the journal; and, 50% of the reviewers for each issue must be from outside the institution that publishes the journal. At present one Thai nursing journal is classified, based on the established criteria, as an international journal.7

Thailand was selected as one of the countries for this study, due to the emphasis it places, as a result of governmental and institutional policies, on academicians having articles published in a high IF journal. It is important to study the effects such policies have on the work of scholars who conduct research, as well as to address the broader question of how such policies influence the production and direction of nursing science.

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Research Questions

Many countries face similar situations as Thailand, yet there have been no studies in nursing that address how the behavior of scholars is affected, or more importantly, how constraints imposed by national or institutional policies affect the development of nursing science. This investigation, as part of a five country study, aimed to address this vacuum in our understanding. Thus, the research questions investigated were:

1. To what extent are selected institutions in Thailand requiring their faculties to publish in high impact factor journals?

2. How do the pressures to publish in high impact factor journals, influence the behavior of individual nurse scientists, choice of topic for investigation and development of nursing science?

Method

A descriptive inquiry, using a qualitative survey design, was conducted regarding: the extent to which journals’ impact factors are used in Thailand as the venue for faculty publications; the purposes for which such information is used; how selected nurse scholars perceive the consequences of prevailing practices; and, how their perceptions regarding the consequences of prevailing practices influence various decisions.

Study subjects. Five senior academic nurses, one from five of the seven institutions of higher learning which offer doctoral degrees in nursing in Thailand, participated. A key informant provided country-specific information regarding the institutional ratings, or rankings, as well as identified senior faculty to be solicited to participate. The key informant was a senior academic, holding the rank of professor in a major university, who has held offices in professional organizations over many

years, and had overall familiarity with nursing programs in the country, as well as being familiar with nurse leaders. The respondents held the rank of professor or associate professor and, due to their faculty rank, were familiar with their respective institution’s policies and the state of nursing science in Thailand, had taught in doctoral programs, and had published in international journals. To obtain the respondents, one potential participant, who met the selection criteria, from each of the seven nursing doctoral programs, in Thailand, was invited to participate.

Procedure. Institutional Review Board (IRB) approval was obtained from the institution of the first author. Due to the low risk posed by the study, the IRB required that a letter, with the elements of informed consent, for information only, instead of a signed consent form, be provided to all potential respondents. Seven identified individuals, one from each doctoral program, were invited to participate through an approved letter, which provided relevant information about the study and included all elements of informed consent. Once individuals agreed to participate, they received the questionnaire and were asked to return it within three weeks. All communication occurred electronically. Several reminder letters were sent over an eight week period, which resulted in five responses being received.

Study instrument. A survey questionnaire, containing 21 items, was developed by the investigators, based on review of the literature, for use in the collection of data regarding the extent and purposes for which institutions and systems in Thailand make use of the impact factor of journals in which faculty members have published. The questionnaire further sought to explore the ramifications and effects the use of the impact factor of journals have on individual scholars and the development of nursing science.

A draft of the questionnaire was reviewed

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by four individuals from five countries, for clarity and relevance of the items to the study questions. These individuals were senior faculty in research universities, who also served as journal editors in their countries. Revisions of items were made, based upon the reviewers’ comments; thus, the questionnaire had content validity. Eleven questions presented a list of statements as options, five asked for yes/no responses to be checked, followed by a request for comments. The “comments” section was provided to enable respondents to explain and shed light on their choices. Five questions required narrative responses. It was estimated that it would take 30-40 minutes to complete the questionnaire.

Data Analysis. Data were analyzed via content analysis and descriptive statistics, through the use of frequencies. The participants’ objective responses were summarized and described. For comments and narrative responses, content analysis, established by Wilson,8 was used to elicit meaning from the text and identify categories that emerged.

Wilson8 established three basic elements of content analysis: (1) deciding on the unit of analysis; (2) borrowing or developing the set of categories; and, (3) developing rationale and illustrations to guide coding of data into categories. Deciding on the unit of analysis means a decision needs to be made whether the whole response, or a breakdown of responses into separate words, phrases, or sentences, will be used. Borrowing the set of categories means a set of categories can be developed before data collection, if the concepts are borrowed from existing theory; data can be coded using the pre-identified categories. In this study, the set of categories, for the content analysis, were “borrowed,” as they were primarily derived from the questions asked in the questionnaire. Developing rationale and illustrations to guide coding of data into categories means in order to code data into categories, the investigator has to “make a judgment on the right category for every response or unit of

analysis.” 8(p470)

The analysis process was done manually. Many respondents provided the same answers to questions pertaining to citation counts as they did for impact factor. To avoid redundancy, the authors have not focused on citation counts.

Results

Results were described and organized around categories relevant to the study’s questions. The bracketed numbers refer to the number of respondents who checked each respective statement.

Context: All respondents agreed that the concept of journal metrics, in the form of expectation that faculty publish in high impact factor (IF) journals and achieve high citation counts for their publications (citation counts are the basis for computation of IF), was in use in Thailand. Further, the respondents indicated these practices were promulgated and used by the Ministry of Education and university administrators. Other government agencies also were mentioned as using such information, especially those concerned with research funding and quality assurance of universities. However, respondents did not indicate nursing schools required their faculties to publish in high IF journals. The five respondents indicated several uses of information on publication in high IF journals, including: assurance of the institution’s high ranking in national/international surveys [5]; measurement of individual faculty productivity [5]; measurement of collective faculty productivity [4]; measurement of a journal’s quality [4]; and, measurement of overall quality of a department or school [3]. In addition, faculty publication in journals with a high IF served as the basis for obtaining funding for a faculty member’s doctoral students.

How scholars’ behavior is influenced by the existing policy: Respondents were queried on their views regarding the extent to which the policy, on

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requiring publication in high IF journals, influenced the behavior and decisions of scholars. The respondents stated there was strong competition, among colleges, to be published in high IF journals [4]. Such pressure leads most scholars to publish in journals from other countries, rather than their own [4], and to publish in high quality journals, regardless of a journal’s IF [2].

The respondents were queried further on their perspective of publishing in national versus international journals. They indicated that those who publish: nationally are addressing domestic health problems [4]; internationally add prestige to their institutions and country [4]; internationally are not providing the country the benefit of the researchers’ findings [3]; and, in high IF journals focus on problems of interest to those journals, rather than on the interest of the country [3].

The effects of the existing policy and perceived hurdles: Respondents were asked to provide their views on the effects of the existing policy to publish in high IF journals, and seemed to agreed: graduate schools have improved research training overall [5]; there is greater methodological rigor seen in research [4]; and, published works have become stronger in their theoretical grounding [3]. Hurdles mentioned were: insufficient English language skills [5]; topics that interest scientists are not of interest to some journals [5]; and, those who attended graduate school overseas are more successful in publishing internationally [5]. Also mentioned were that: English-speaking authors and English language journals, as well as authors from disciplines outside of nursing, do not cite Thai nursing authors’ work; computation of IF does not take into account various forms of scientific publications; the emphasis on the IF can have the effect of suppressing the pursuit of innovative research directions that could be culturally relevant; and, there are too many ways to raise a journal’s IF, making it an artificial measure.

Perceptions of nursing science in Thailand: Respondents were asked to assess the current published works in Thailand. They stated that they: are responsive to health needs of the country [5]; frame the practical application of their work in terms of the health problems of the country [5]; involve replication of work done elsewhere to determine the relevance and applicability to local needs [5]; present research that is of interest to the investigators, but not of value to the local population [4]; and, frame the practical application of their work, in terms of health problems of interest, to other regions of the world [3].

Efforts to internationalize Thai journals: Respondents provided information that Thailand has clear criteria that must be met prior to a journal being considered to be national or international. They stated: international members have been appointed to Thai journal manuscript review panels [5]; scholars in Thailand have accepted positions as assistant/associate editors, or members of review panels, for journals in other countries [4]; and, these steps have changed the profile of Thai journals, by strengthening their quality.

Discussion and Recommendations

Respondents generally had a good understanding of what was being asked. They were able to describe advantages and disadvantages regarding the use of IF. However, they identified more disadvantages regarding the use of IF to them, and to nursing, than they did advantages. All indicated that no Thai journals currently were listed in the Web of Science (WoS), or had an IF assigned. At present only one Thai journal, the Thai Journal of Nursing Research, is considered “international” by the criteria established by the Thai Journal Citation Index Centre.

The respondents stated IF computations are biased heavily toward English language journals.

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This criticism appears justified when one reads the publications of various disciplines in the country.

All agreed Thai university administrators place a high degree of emphasis on faculty publications for academic rank, prestige and funding decisions. However, it is puzzling that they did not feel that nursing schools placed the same degree of emphasis on faculty publications, compared to government and university administrators. While faculty members, from the basic sciences and medicine, have international publications, the respondents stated that Thai nursing faculty do not have international publications and are unfamiliar with the requirements of international journals. These statements are puzzling since many Thai nurse scientists have studied, at the graduate level, in English-speaking countries, and have been socialized in the matter of publishing internationally. Given the availability of electronic websites, where author guidelines are available for the various journals, it is a puzzle as to why nurse faculty would not familiarize themselves with manuscript requirements of international journals.

The constraints faculty members face, in their efforts to conduct research and achieve publication, need to be recognized. The first constraint is the fact that faculty do not have support systems to facilitate their scholarship, and must do their own secretarial work. The second constraint is the nursing shortage, in Thailand, has lead to the enrollment of larger numbers of students, which has increased the faculty workload. Finally, the teaching of some master’s level specialties are offered only on weekends, leaving faculty little time for scholarly activities.

A number of other findings were similar to those found in the literature.4, 9, 10 For example, respondents indicated there are important disciplinary variations that are not accounted for in the computation of IF. They felt these computations needed to be standardized, so that meaningful

comparisons can be made. Respondents also pointed out that the IF does not measure the quality of individual articles, but simply indicates journal status. Therefore, to make a generalization about an individual article from the overall journal status, is a misuse of the IF score, and can lead to erroneous conclusions about a specific article. The respondents also noted that the IF does not address the value of the research for patient care and application to real world problem solutions, a critical consideration in nursing.

Respondents noted the trend toward publication in high IF journals can lead to research that is more responsive to models, paradigms and themes valued in other countries. Such a research focus may or may not contribute to solutions of local health care problems; whereas those who publish locally contribute to solving health problems of the country. However, we do not know to what extent this is the case, as no examples were provided.

Thailand currently does not have any journals listed in the WoS, nor with an IF assignment. All of the respondents were in favor of international efforts, now under way, to increase the listing of Thai journals in the WoS, but it is not clear whether the respective editors of the journals are submitting applications to have their journal so listed. The respondents felt such listing would bring about a wider dissemination of Thai research to those in other countries, as well as to members of other disciplines.

Anecdotally obtained information revealed that many schools of nursing, in Thailand, publish their own journals, typically with local or national circulation. Some of them do not meet the criteria to be considered a national journal, and none meet the established criteria for international journals. However, there are eight journals, in Thailand, that meet national standards, and one that meets international standards, although it is not listed in the WoS, nor has an IF assignment.

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From the reported data, it can be concluded a great deal of nursing research is being carried out, but only is published locally. Local publications do not have international visibility, and, thus, have limited impact beyond the country. Respondents mentioned that nurse and non-nurse scholars in other countries do not cite Thai nurses’ published works. One of the reasons for this is that scholars outside of Thailand often do not have access to local or national Thai publications. It is suggested, therefore, that schools of nursing, in Thailand, consolidate their energies and resources, and jointly publish fewer journals of high quality, with a view to establishing international reputations for the journals.

Thai universities have, for a long time, emphasized the importance of having graduate students, especially those enrolled in doctoral programs, attain competence in the English language, regardless of whether the students are studying within the country or overseas. The reason is that much of the advanced literature students need to access, for their work, is published in English. The fact that some researchers’ lack of sufficient English language skills, gets in the way of publishing in international journals, remains unclear. This factor requires future examination.

Limitations

This study has several limitations. The first is that the questionnaire presented options to check, and, thus, was a “recognition” task, rather than a “generation” task, with ideas derived from the literature. It is possible the respondents’ task was made easier, in that they could check an item if it appealed to them, whether or not they knew it to be true. In addition, it is not clear whether the same ideas would have emerged had the participants been asked to generate the ideas, rather than recognize them.

Two other limitations were the qualitative/descriptive design and the small sample size. Neither of these factors enabled the use of statistical procedures or provided a basis for generalizations. Therefore, if deans and faculties wish to better understand the phenomenon examined in this study, it will be necessary to design a study that has a national scope.

References

1. Meho LI. The rise and rise of citation analysis. Physics World. 2007; 20: 32-6.

2. Monastersky R. The number that’s devouring science. Chron High Educ. 2005; 52(8): A12.

3. Campanario JM, Gonzales L, Rodriguez C. Structure of impact factor of academic journals in the field of education and educational psychology: Citations from editorial board members. Scientometrics. 2006; 69(1): 37-56.

4. Freshwater D. Impact factors and relevance of research outputs: One step forward, two back? J Psychiat Ment Health Nurs. 2006; 13: 473-4.

5. Holden G, Rosenberg G, Barker K, Onghena P. An assessment of the predictive validity of impact factor scores: Implications for academic employment decisions in social work. Res Soc Work Pract. 2006; 16(6): 613-24.

6. Nieminen P, Carpenter J, Rucker G, Schumacher M. The relationship between quality of research and citation frequency. BMC Med Res Methodol. 2006; 6: 42-9.

7. Thai Journal Citation Index Centre [updated 2008 November 10; cited 2009 April 28]. Available from: http://www.kmutt.ac.th/jif/publichtmcriteria.htm. (in Thai).

8. Wilson HS. Research in nursing. 2nd ed. New York (NY): Addison-Wesley Publishing Co.; 1989.

9. Smith, R. Measuring the social impact of research; difficult but necessary. BMJ. 2001, 323: 328.

10. Smith, R. Commentary: The power of the unrelenting impact factor – is it a force for good or harm? Int J Epidemiol. 2006, 35: 1129-30.

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สงแวดลอมเชงวชาการ และอมแพคแฟคเตอรของวารสารในประเทศไทย

Shaké Ketefian, สมจต หนเจรญกล

บทคดยอ: มจำนวนสถาบนเพมขนหลายแหงในประเทศตางๆ ทตองการใหนกวชาการตพมพผลงานในวารสารทมอมแพคแฟคเตอร (Impack facter) สง โดยการสรางระบบการใหรางวลและแรงจงใจตางๆ มบทความตางๆ ทไดกลาวถงความเหมาะสมและไมเหมาะสมของการใชนโยบายเหลาน ดงนนรายงานการศกษานเปนการศกษาในประเทศไทย ชงเปนสวนหนงในการศกษาจาก 5 ประเทศ มวตถประสงค เพอสำรวจ 1) สถาบนตองการใหอาจารยตพมพผลงานในวารสารทมอมแพคแฟคเตอร สงมากนอยเพยงใด 2) จากแรงกดดนใหตพมพผลงานในวารสารทมอมแพคแฟคเตอรสง มผลใหนกวชาการพยาบาลเลอกเรองทจะทำวจย และการพฒนาองคความรของศาสตรทางการพยาบาลอยางไร วธการศกษาใชวธการวจยเชงคณภาพ ใชแบบ สอบถามเกบขอมลเกยวกบความคดเหนของอาจารยพยาบาลทเปนผอาวโสทางวชาการและสอนในระดบปรญญาเอกสาขาพยาบาลศาสตรจาก 7 สถาบนๆ ละ 1 คน มอาจารยยนดใหขอมล จำนวน 5 คน วเคราะหขอมลโดยการวเคราะหเนอหาสรป และเสนอเชงพรรณาความ ผลการวจยพบวา ผใหขอมลทงหมดบอกวา มหาวทยาลยคาดหวงใหอาจารยตพมพในวารสารทมอมแพคแฟคเตอรสง ดวยเหตนทำใหเกดการแขงขนแทนทจะรวมมอกน อาจารยทตพมพในวารสารตางประเทศทมอมแพคแฟคเตอรสง ถอวาเปนผมสวนทำใหมหาวทยาลยมชอเสยง แตปญหาการวจยอาจไมสอดคลองกบปญหาสขภาพของประเทศอยางแทจรง อาจารยทใหขอมลเหลานกลาวถงความยากลำบากและประโยชนของนโยบายนคอ อาจารยจะตองศกษาปญหาสขภาพของประเทศ แตจะตองวางกรอบการนำผลการวจยไปใชททำใหผอานทงในและตางประเทศสนใจ ผวจยไดอภปรายและแปลผลตามขอเทจจรงของประเทศไทย

วาร ารวจยทางการพยาบาล 2009; 13(3) 159 - 166

คำ ำคญ: อมแพคแฟคเตอร ศาสตรทางการพยาบาล การตพมพ สงแวดลอมเชงวชาการ

ประเทศไทย

ตดตอท: Shaké ketefian, EdD, RN, FAAN Professor and Director of International Affairs University of Michigan, School of Nursing, 400 North ingalls, Ann Arbor, MI 48109, USA. E-mail: [email protected] สมจต หนเจรญกล, RN, PhD, ศาสตราจารย ภาควชาพยาบาลศาสตร คณะแพทยศาสตรโรงพยาบาลรามาธบด มหาวทยาลยมหดล ประเทศไทย

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Rukchanok Koshakri et al.

Vol. 13 No. 3

Quality of Diabetes Care in PCUs in Central Thailand Rukchanok Koshakri, Nantawon Suwonnaroop, Kobkul Phancharoenworakul, Chanvit Tharathep, Noel Chrisman

Abstract: This descriptive study, using a mixed method design, sought to describe, within Central Thailand, the quality of diabetes care in terms of the structure of Primary Care Units (PCUs), care processes for diabetics and outcomes of diabetic care; and the relationships among these factors. Three hundred health care providers from 300 PCUs completed a researcher-designed questionnaire which sought information regarding the structure and care processes, used in the PCUs, with diabetics. Outcomes of diabetic care were assessed using fasting plasma glucose reports obtained from the PCUs. In addition, 9 care providers, who completed the questionnaire, served as key informants, for in-depth interviews, which validated and further explained the quantitative data. Quantitative data were analyzed using descriptive statistics and Pearson’s product moment correlation, while qualitative data were examined by way of content analysis. Almost one-quarter of the PCUs met all components of structure, based upon PCU standards. Results revealed the structure of most PCUs were sufficient in terms of facility, financing and networking. Although the majority of staff consisted of nurses, the PCUs were considered insufficiently staffed, and 825 demonstrated improper preventive care. However, 43% of the diabetics, being cared for in the PCUs, showed sound glycemic control. Good PCU structure suggested an increase in the likelihood of appropriate care processes and corresponding positive outcomes. In addition, the presence of well- trained health volunteers provided assistance to the PCU staff, particularly when professional staffing levels were low. Thus, a need for an increase in the number of professional staff in PCUs, enhanced training for health care volunteers and revision of the standards of diabetic care was evident.

Thai J Nurs Res 2009; 13(3) 167 - 180

Key words: quality of diabetes care, primary care units, Thailand

Background and Significance of

the Problem

Diabetes mellitus represents a significant public health problem in Thailand, with a prevalence rate ranking three times higher than the global average.1 In 2000, the prevalence of diabetes, among Thai adults, was reported to be

Correspondence to: Rukchanok Koshakri, RN, PhD Candidate, Faculty of Nursing, Mahidol University, Thailand. E-mail: rukchanok. koshakri@ gmail.com Nantawon Suwonnaroop, RN, PhD, Assistant Professor, Faculty of Nursing, Mahidol University, Thailand. Kobkul Phancharoenworakul, RN, PhD, Associate Professor, Faculty of Nursing, Mahidol University, Thailand. Chanvit Tharathep, MD, FRCST, Bureau of Health Service System Development, Ministry of Public Health, Nonthaburi, Thailand. Noel Chrisman, PhD, Professor, School of Nursing, University of Washington, USA.

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Quality of Diabetes Care in PCUs in Central Thailand


9.6% of the population. Furthermore, reports from recent health status surveys reveal that only 40% of Thai people with diabetes are able to maintain appropriate glycemic control.2 However, control of glycemic rates in patients’ cared for in one of Thailand’s Primary Care Units (PCUs), which were set up to address primary care under the Universal Coverage Insurance Plan, have been found to be worse than the national average.3 While evidence suggests 38% of diabetics attending PCUs have glycemic control,3 the glycemic control rates at PCUs, in Central Thailand, were found to be 29.5 %.4

In addition to enhancing significant factors that improve diabetic health, the organizational structure of the health care system has been found to be a major contributing factor in good diabetes management.3 As a result of the reform of Thailand’s health care system, emphasis has been placed on the quality of primary health care delivery, including the care of diabetics. Using the guidelines established by the Thai National Health Plan of 2008, the PCUs have focused on quality of care.5 Nurses play a major role in providing individuals with diabetes quality health care, including: service delivery, health promotion, health prevention, and coordination and continuity of care. All these factors serve as indicators of the delivery of quality care.

Factors that reflect the quality of care for diabetics can be grouped into the categories of: organizational structure; processes of care; and, care outcomes. Previous studies, regarding organizational structure, have found that finance,6, 7 human resources,8, 9 equipment10 and networks11, 12 positively influence the process of care. Adherence to guidelines for diabetes management, in terms of processes of care, also has been found to improve the outcome of care,13, 14 while continuity of care has been shown to be associated with higher glycemic control rates.15, 16 In addition, evidence suggests

that coordination, such as referrals, is positively associated with care outcomes of individuals with diabetes.17

Organizational structure, processes of care and care outcomes also have been identified as key factors in quality of care.18, 19 Since most studies have been conducted in Western countries, the quality and outcome of the care, in response to these standards, remains unclear in Central Thailand. Thus, the purpose of this study was to describe the quality of diabetes care in terms of the structure of PCUs, care processes for diabetics and outcomes of diabetic care, as well as to determine the relationships among these factors, in Central Thailand.

Method

Design: The study was descriptive in nature, using both quantitative and qualitative methods, undertaken within two phases. In Phase I, the quantitative portion of the study, the primary researcher obtained data by way of a structured questionnaire, regarding the PCUs’ structure, diabetes care processes and diabetes care outcomes. In addition, 6-month fasting plasma glucose (FPG) reports of patients receiving care in the participating PCUs were obtained. Phase II, the qualitative portion of the study, involved in-depth interviews of 9 health care providers, each from a different PCU, who were selected from the survey sample and represented varying degrees of experience. The interviews were conducted in an effort to extend an understanding of the diabetes care phenomena.

Instruments: The quality of diabetes care was assessed by way of a, 85 item, researcher-designed questionnaire based on the: standards set forth for Primary Care Units;20 Standards and Indicators for Setting up PCUs;21 and, Diabetes Care Guidelines for Practitioners in PCUs.22 The 3 part questionnaire sought information regarding the PCUs: (a) staff demographics and reports on

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participating patients’ FPG; (b) structure; and, (c) diabetes care processes. Part one of the questionnaire consisted of 15 items, which sought general information about the demographics of participating PCUs, as well as their monthly reports of patient FPGs. Examples of questions were: “What kind of PCU is this?” and, “How many diabetics visit the clinic daily?”

Part two of the questionnaire consisted of 30 items, which requested information about the structure of the facilities, as well as the financial, staffing and networking aspects of the PCUs. Examples of questions included: “Does your PCU have a glucose test machine?” and, “Have you received up to date diabetes mellitus training?

Forty items, in part three of the questionnaire, sought data regarding the PCUs diabetes care process, specifically service delivery, continuity of care and coordination. Examples of questions were: “How many times did you visit people with diabetes at their home last year?” and, “Does the PCU have a counseling system?”

Consideration was given to the format of the questionnaire to ensure that it was user-friendly and easy to complete. A check list was used in Parts I and II. The items which represented the standard level of performance were rated as 1, while items failing to met the standard were rated as 0. A Likert-like scale was used in Part III. Items which were positively stated were rated as 1 for ‘strongly agree’ and 5 for ‘strongly disagree.’ Items which were negatively stated were rated as 5 for ‘strongly agree’ and 1 for ‘strongly disagree.’

The researcher developed an interview guide, after the quantitative data were gathered, to obtain in-depth qualitative information about: how health care providers administered diabetes care; provision of services: continuity of diabetes care in the past year: and, what things were needed to provide quality care. The interview guide consisted of five open-ended questions, including: “How do

you provide care for a diabetes patient?”; “What are the barriers to providing good diabetes care?”; “How do you manage such problems;?” and, “If you could change everything, what would you want to change in order to improve the quality of diabetes care?”

Seven experts in PCUs diabetes care and research were asked to review the questionnaire and interview guidelines for validity, understanding and practicality. Sixty-eight of the 85 items were considered valid; however, some wording was refined to make the questions more practical. Seventeen of the 85 items were deleted.

Once the questionnaire was finalized, a pilot study was conducted, using 20 health care providers working in a PCU, for the purpose of testing the questionnaire’s reliability and face validity. Participants were selected from health care providers who had a main responsibility in diabetes care in PCUs, in Central Thailand, which were not part of the study sample. Subjects, in the pilot study, were asked to assess comprehensibility of the wording of each item and determine which aspect of diabetes care quality was being measured by each item. Based upon the results, item wording was adjusted and similar items were placed under the specific factors being measured, in each of the three parts of the questionnaire.

The refined questionnaire consisted of 68 items. Part I consisted of 13 items regarding general information; while Part II consisted of 22 items regarding finance, facility, staffing and networking. The 33 items that made up Part III assessed service delivery, continuity of care and coordination. All items in the interview guidelines were justified as being valid. The content validity index (S-CVI) of the questionnaire was found to be 0.97, while the reliability, using Cronbach’s alpha, was 0.86. Interpretation of the content, from the in-depth interviews, was validated with individuals who took part in the interview process.

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Sample: The sample consisted of employees of PCUs in Central Thailand. The PCUs were randomly selected, using two stage cluster sampling. Inclusion criterion were: being an employee who worked in a PCU, managed by the Minister of Public Health (MOPH), and providing care to individuals with diabetes. Since the National Health Security Office divided the area of Central Thailand into 6 zones,23 the steps of the two-stage sampling involved the following: 1) randomly selecting a province from each zone; 2) randomly selecting 50 PCUs from each selected province; and, 3) identifying employees, at each selected PCU, to serve as respondents, to the questionnaire, for their respective PCU.

Using Yamane’s formula,24 a sample size of 295 participants was considered adequate for completing the questionnaire. However, to assure an adequate return rate, 325 questionnaires were distributed. Three hundred, usable, questionnaires were return, for a return rate of 92.3%.

The majority (n = 251, 83.7%) were female with an average age of 36 years. Nearly all (n = 245, 81.7%) had a bachelor’s degree in nursing or public health. Most (n = 289, 96.3%) reported the structure of their PCU had been developed from the health posts to meet MOPH standards, while only 3.7% (n = 11) of the PCUs were newly established within a hospital. An average of 64 diabetics were registered in each of the PCUs, with a range of 2 to 575 (SD =75.20) individuals with diabetes per PCU.

In addition, a total of 9 employees served as key informants for the in-depth interviews. The informants were interviewed until no new categories, concepts, dimensions or incidents emerged23 from the data. They represented 9 PCUs, had a broad range of experiences24 and were identified from the completed and returned questionnaires. Five key informants were selected from PCUs that provided the best diabetes care (i.e. highest glycemic control

rates among all PCUs in the study). Four key informants also were selected from PCUs with the lowest glycemic control rates among all of the PCUs in the study. The key informants were purposely chosen to reflect the gender, average age, average level of education and average work experience characteristics of the 300 questionnaire respondents.

Ethical considerations: Approval to conduct the study was granted by the Committee on Human Rights Related to Human Experimentation at the primary researcher’s university. Each participant was informed about: the study’s purpose; what was involved in participating in the study; maintenance of participants’ anonymity and confidentiality; and, the right to withdraw, at any time, without negative repercussions. Informed consent was obtained from all participants and key informants. All participants were asked to sign a consent form before they completed the questionnaire or were interviewed. Anonymity was maintained by placing code numbers on the completed questionnaires after they were returned to the primary investigator. Confidentiality was addressed by keeping the completed questionnaires in a locked file and viewed only by members of the research team.

Procedure: Survey data were obtained from October 2007 through February 2008, while interview data were obtained between April and June 2008. The procedure for obtaining data consisted of two parts.

Part I: The primary researcher requested permission, by way of a formal letter to the Director of the Provincial Health Office, to collect data. After approval was granted, the Coordinator of each provincial public health office was called so as to build a relationship, explain objectives of the study and request assistance in collecting data. The researcher and each Coordinator then created a timetable for collecting data together.

Data were collected the days the monthly provincial meetings with healthcare providers,

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working in each PCU, were held. After the meeting, at the provincial health office, the researcher and/or the coordinators explained the objectives of the study and requested the healthcare workers informed consent. Those who gave consent to participate were given the questionnaire and asked to complete and return it that day. It took an average of forty-five minutes to complete the questionnaire. The participants also were asked to save, on a researcher provided CD, their FPG data or to copy the FPG data and send it, via mail or e-mail, to the researchers.

Part II: After the quantitative information were analyzed, appointments were made, telephonically, with the participants working in the PCU with the lowest, as well as the PCU with the highest glycemic control rates, as compared with the sample value, to conduct in-depth interviews. Seven participants were interviewed, in private, at his/her respective PCU. Two participants were interviewed, by phone, to reduce interviewer effect, since one interviewee was a former student of the primary researcher and one was the researcher’s classmate. An interview guide was employed, as needed, during the interviews. Each interview was audio-taped, and lasted approximately one-half hour. During the interviews, changes sometimes were made changes in data collection techniques, i.e. re-wording questions, changing the sequence of questions, and/or modifying the interview locations. Field notes were written regarding interactions, observations and occurring events, as soon as possible, after each interview.

The researcher performed member checks, after each interview, so as to provide the respective participant an opportunity to confirm and/or clarify the researcher’s interpretation of the interview data. Sometimes, new data emerged and was recorded.

Data analysis: Descriptive statistics were used to analyze contents of the questionnaire, while Pearson’s product moment correlation was

carried out to examine correlations among the structure of PCUs, care processes for diabetics and outcomes of diabetic care. Each interview was recorded and transcribed, wherein, content were analyzed, via descriptive categories, naming substantial phenomena and coding.25

Findings

PCU Structure: Over two-thirds of the PCUs had sufficient financial support for delivery of services for diabetics, and three-fifths o f them had sufficient financial support for coordination and continuity of care (Table 1). The major source of support was drawn from Contracting Units for Primary Care (CUP). PCUs with insufficient financial support searched for other financial support sources, i.e. donation boxes, local administrative organizations, national health security offices and other local organizations. However, information from the survey showed that over half (56.7 %; n =170) were unable to find additional financial support sources; wherein, the key informants explained that this was because they did not have good connections with other organizations. One key informant commented:

“I didn’t obtain funds from other financial support sources because I didn’t know the sub-district administrator. I got my only budgetary funds from the hospital and it was not enough to visit patients at home”

Some 59.7 % (n = 179) of the PCUs had sufficient facilities for diabetes care in terms of both general office supplies and medical supplies. The PCUs could draw supplies from CUP and share supplies with other PCUs. All of them had blood glucose testing machines, and the vast majority had a sufficient amount of diabetic drugs

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to prescribe in their clinic (Table 1). Those that needed additional facility supplies also could share supplies with other organizations. One key informant explained obtaining secondary supply needs as follows:

“We used to have more glucose test

strips, needles, and weight scales of

our own. Sometimes, we can borrow

things from other PCUs.”

Sufficient staff were available in only 19 % (n = 57) of the PCUs, with only 9.7% (n = 29) having full-time physicians and 81% (n = 243)

having full-time registered nurses. The standards, provided by the MOPH, regarding total number of staff members, was met only by 2.7% (n = 8) of the PCUs, with an average of 2-3 full-time staffs per PCU, including one to two nurses. Some CUPs supported the PCUs by rotating staff, at least once a month, from the CUP to work in one of the PCUs. However, only 57% (n = 171) of the participants reported their PCU received such staff support. Almost one-fourth (n = 71; 23.7%) of the PCUs reported that, even though they had support, they continued to experience staff shortages (See Table 1).

PCU Financing Budget for diabetes service delivery 208 69.3 Structure Budget for coordination and continuity of care 184 61.3 Other sources of budget 130 43.3

Facilities Glucose test machine 300 100.0 Family folder 282 94.0 Safety & privacy clinic 267 89.0 Diabetes mellitus drugs 250 83.3 Computer databases 202 67.3 Mission and goal 109 36.3

Staffing Staffs supported by the CUP 171 57.0 Continuity of diabetes mellitus training 242 80.7 Physician: Population1:≤10,000 22 7.3 Nurse: Population1:≤1250 110 36.7

Networking CUP and other PCUs 300 100.0 Community participation 235 78.3 Local organizations 152 50.6 Local people in community 300 100.0

CUP = Contracting Units for Primary Care PCU = Primary Care Units

Table 1 Structure of primary care units (n = 300)

Quality of Factors Standard PCU met the Care standard N %

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The key informants explained that, due to staff insufficiency, the PCUs could not provide quality care, nor provide certain procedures, i.e. home visits and/or health education. The PCUs managed this problem by training health volunteers to help nurses take blood pressures and weights, while managing their outpatient department (OPD) cards. One described the insufficiency of staff and quality of care as:

“We had a lot of work, but we had only 3 staff members…This insufficiency of staff caused us to provide low quality care, as we could not perform everything that we were supposed to.”

The key informants also explained that the major network, for sharing staff, knowledge and supplies, was the CUP. However, 23% (n = 69) of the participants indicated they had networks with local administrative organizations, and all reported having connections with health volunteers. Some of them stated health volunteers were able to help with home visits, referrals from the community and community-based disease surveillance.

Diabetes Care Process: The diabetes care process was explained in terms of service delivery, continuity of care and coordination. Only 35% (n = 103) of the PCUs provided proper service delivery, i.e. medical treatment, health prevention and health promotion, while 84.3% (n = 253) regularly provided proper diabetes treatment.

As shown in Table 2, 90.3% of the time, nurses in the PCUs administered, to those with a normal range blood-glucose level, the prescribed dosage of diabetic medication. This was done in accord with the clinical practice guidelines and under the physician’s orders, without need for consultation with, or another order from, each individual’s physician. However, for those unable to control their blood-glucose level, the nurses, 32%

of the time, adjusted their medications according to the clinical practice guidelines or referred them, 47 .3% of the time, to the CUP, in accord with the clinical practice guidelines. One key informant’s description of the medical treatment process was:

“… If patients had high blood glucose levels, we would adjust drugs or refer patients to the CUP. Nurses could adjust diabetes drugs under the physician’s permission or clinical practice guidelines….”

Although only 18.3 % (n = 55) of the participants indicated their PCU regularly provided preventive care, which met the clinical standards, 58% reported receiving annual triglyceride and cholesterol blood tests. Less than one-third (30%, n = 90) of the PCUs provided annual foot and eye examinations, while 19.0% provided HbA1Cc examinations at least once yearly, and 11.0% provided neuro-examinations, at every visit, in order to meet MOPH standards (See Table 2).

With respect to health promotion, all PCUs provided education to each diabetic, while only 35.3% reported providing diabetic care education to the families of the diabetics. Furthermore, 85% of PCUs provided proper continuity of care, and 82.0% had an appointment system and made appointments every 4-6 weeks for both poor and well glycemic controlled individuals. Health volunteers followed-up with those who missed appointments, by visiting them in their homes. One key informant described the follow-up system in this manner:

“We had appointment registration in paper form. If patients missed their appointments for more than 1 month, we would follow-up on the patients by making calls or visiting the patients at home.”

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Some 69.3% of PCUs provided proper coordination services regarding referral and consultation. The PCUs referred those with poorly controlled glycemia (100%), new cases of diabetes (100.0%), emergency cases (66.0%), laboratory tests (56.7%) and diabetic patients with complications (78.0%). Key informants explained that full-time nurses consulted the respective physician and/or pharmacist regarding FPG levels between 100-126mg%, while managing those with complications and drug-related side effects.

Care Outcomes: As shown in Table 2, the

outcome of care (See Table 2) was measured from the average six-month FPG level, of 19,141 diabetics who were seen in one of the 300 PCUs, with approximately two-fifths demonstrating good glycemic control (FPG = 100-126 mg%). The average FPG level was 147.10 mg% (min = 109.96 mg%; max = 190.71 mg%; SD = 16.27 mg%). A significant relationship was found between each of the components of the PCUs’ structure and care processes, and the service delivery component of the process of diabetes care and outcome (See Figure I).

Quality of Factors Standard PCUs met Care standard n %

Table 2 Process and outcome of diabetes care in primary care units (n = 300)

Care Service Medical treatment Process Delivery Distribution of the correct diabetes mellitus drugs 253 84.3 No long waiting for services 173 57.7 Adjusted drugs under the monitoring of a physician 142 47.3 Adjusted drugs using clinical practice guidelines 96 32.0

Preventive care

Blood pressure examinations at least 4 times/yr 271 90.3 Fasting blood sugar examinations at least 4 times/yr 246 82.0 Triglyceride and cholesterol testing once a year 174 58.0 Foot examination at least once a year 91 30.3 Eye annual check-ups 90 30.0 HbA1Cc examination at least once a year 57 19.0 Neuro- examinations at every visit 33 11.0

Health promotion

Individual health education 217 72.3 Family education 106 35.3

Continuity of Out-patient department cards and report system 262 87.3 Care Appointment system 246 82.0 Continuity of health history to physicians 204 68.0 Follow-up system 141 47.0 Home visits 4 times a year 109 36.3

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Discussion

The management of diabetes care failed to meet most of the required standards set forth for good diabetes management in PCUs, although care-giving standards have been recommended to assure individuals with diabetes receive quality care.22, 28 One-third of those with diabetes had foot examinations once a year, while 11% had neurological

examinations every visit, in accord with the standards. These results are similar to previous studies, in Thailand, wherein low rates of preventive care have been found among diabetics.29 The findings, of this study, are similar to those of Dunn and Pickering,30 Chin and colleagues,31 Grant32 and Saaddine and colleagues,33 who found few creatinine and cholesterol tests, as well as foot and eye examinations, were performed in primary care.

Figure 1 Relationships among the structure of primary care units, diabetes care process and diabetes outcomes

Table 2 (continued)

Quality of Factors Standard PCUs met Care standard n %

Coordination A referral system for emergency cases 198 66.0 A counseling system 180 60.0 Patient information was referred 176 58.7 Less than 60 minutes in transportation to refer 167 55.7

Care Glycemic Fasting plasma glucose < 126 mg% 8,227 42.98 Outcome Control (n= 19,141)

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The lack of suggested preventive care practice may be due to the shortage of available staffs in the PCUs. Since health care reform was instituted, the number of PCU staff positions has not increased; however, diabetes care has been extended to the PCUs. Thus, nurses have had to provide care, in the PCUs, be proactive in their communities and perform tasks beyond the role of nursing (i.e. general management and coordination with the community). This, in turn, has lead to nurses experiencing increased workloads.

Although an average of 64 diabetics/per day comes to the PCUs for care, there only are one to two health care providers available to deliver care. Thus, the nurses often are unable to provide preventive care for all with diabetes. These findings are congruent with those of previous studies, in Thailand, which have found the lack of staffs in the PCUs leads to a work overload for the nurses.34, 35 The findings also are consistent with those of Davidson, Ansari and Karlan,36 and Render and colleagues,37 who revealed staff shortages to be associated with poor diabetes control.

In Thailand, an individual with diabetes, whether it is controlled or not, is scheduled to visit a PCU every four to six weeks. The frequency of the visits is slightly higher than recommended by the American Diabetes Association (ADA).22, 28

However, the guidelines for quality practice recommends diabetics, with poor metabolic control, visit a PCU every one to two weeks.22, 28

Unfortunately, in this study, this action was not being carried out. It appears the standards for diabetes care were not being done, due to the lack of adequate staff and the presence of a local organizational network.

Findings, of this study, reveal the staff shortages resulted in inadequate service delivery, especially in terms of improper preventive care (see Figure 1). However, given those limitations, it appears the health care providers provided proper

health promotion and continuity of care, and achieved good care outcomes. This may have been due to the available network, wherein the health care providers had good relationships with health volunteers who helped them connect with the community.

The health volunteers also helped the health care providers with home visits and communication, which facilitated continuity of care, as well as the transfer of those with diabetes from the community to the PCUs. The findings demonstrated the increased role of volunteers, within the health care system, was the result of the primary health care project38 launched in the late 20th century, wherein local people were encouraged to become involved in the health care system within their community. Finding that the involvement of the volunteers had a positive impact on the health care being delivered is congruent with Chuengsatiansup’s39 research, which suggested that health volunteers are an extremely valuable health resource.

Similar to Chuang’s40 findings, almost half of the diabetics utilizing the PCUs reached the desired level of glycemic control. When compared with the glycemic control rates found in studies conducted in Western countries,33-35 the glycemic control rate found, in this study, was slightly higher. However, compared to the glycemic control rate found by Nitiyanant and colleagues,29 the glycemic control rate, found in this study, was considerable higher. The fact the glycemic control rate, found in this study, was higher than that in other studies,41 conducted in Thailand, may have been due to differences in the setting, as well as to the condition of those utilizing the specific health care institution. For example, in Thailand, those attending tertiary care facilities usually have more severe cases of diabetes than do those receiving care at a PCU.

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The fact that a high glycemic control rate was found, in this study, may reflect the efficiency and effectiveness of the system and the staff members in the PCUs. The majority of health care providers were nurses and able to provide, within the primary care concept, diabetes care in the PCUs. Even though the existing work overload brought about improper service delivery, the glycemic control rate was compatible with rates found in Western countries. This suggests the primary care provided, by nurses, reduced costs, increased access to appropriate medical services for the population being served and did not reduce the quality of care being delivered.

The findings were consistent with those of prior studies which have suggest the structure of an organization has an important affect on health care performance and outcome.29-31 These results also support Donabedian’s19 model, a well accepted method for setting standards in hospitals, which proposes that structures affect care processes, which in turn, affect care outcomes. The relationships among PCU structure, diabetes care processes and care outcomes, in this study, support the application of Donabedian’s framework within the primary care settings in Thailand.

Limitations

One cannot apply the findings of this study without examining its limitations. Data were obtained exclusively from providers working within PCUs and did not address information from individuals with diabetes or their families. Furthermore, quality of care was assessed in terms of technical quality and did not include amenities or the interpersonal domain.

Implications

Based upon the study’s findings, the following recommendations are suggested:

(1) The shortage of nurses working in PCUs, as well as nurses’ current work overload need to be addressed.

(2) Nurses need to enhance the assistance of health care volunteers by providing them appropriate training. In addition, nurses continually need to foster relationships with key community leaders for the purpose of strengthening the organizational network.

(3) The standards of diabetes care, practiced in PCUs, should be refined to better address the level of quality care.

Acknowledgements

The primary investigator expresses gratitude, for support of this study, to the Commission of Higher Education, the Thai Ministry of Education; and, the Thai Council of Nursing and Midwifery.

References

1. Aekplakorn W, Stolk R, Neal B, Suriyawongpaisal P, Chongsuvivatwong V, Cheepudomwit S, et al. The prevalence and management of diabetes in Thai adults. Diabetes Care. 2003; 26: 2758-63.

2. Health status survey of Thai people, 2003-2004. Nonthaburi: Public Health System Research Institute; 2004.

3. Suggestions for development of primary care units underinternational health insurance. [Database on the Internet]. Health care system reform project office, 2008 [cited 2008 April 7]. Available from : http:// www.moph.go.th/ops/hcrp/download/ucsupatra.pdf.

4. Porrapakkham Y, Boonyaratpun P, Lim S, Hogan M, Chaiyapornsupaisarn W, Kornputsa P. The report of Thailand’s population health examination S\survey III Nonthaburi: Ministry Of Public Health; 2006.

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5. Kheawcharoen O. Evaluation of the medical services under the Universal Health Coverage Scheme: A case study of Phitsanulok province. [Online] 2002 [cited 2008 April 7]. Available from : http://www.moph. go.th/ngo/oddh/r&d30b2.htm.

6. Chaix-Couturier C, Durand-Zaleski I, Jolly D, Durieux P. Effects of financial incentives on medical practice: Results from a systematic review of the literature and methodological issues. Int J Qual Health Care. 2000; 12: 133-42.

7. Khunti K, Ganguli S, Lowy A. Inequalities in provision of systematic care for patients with diabetes. Fam Pract. 2001; 18(1): 27-32.

8. Barbara AM, David WH, Michael M, Yihua X. A longitudinal examination of hospital registered nurse staffing and quality of care. Health Serv Res. 2004; 39(2): 279-301.

9. Akkadechanunt T, Scalzi C, Jawad A. The relationship between nurse staffing and patient outcomes. J Nurs Adm. 2003; 33(9): 478-85.

10. Jackson GL, Edelman D, Ibrahim MA, Lee SD, Dudley TK. Veterans affairs primary care organizational characteristics associated with better diabetes control. Am J Manag Care. 2005; 11(4): 225-37.

11. Kim C, Williamson DF, Mangione CM, Safford MM, Selby JV, Marrero DG, et al. Managed care organization and the quality of diabetes care: Translating research into action for diabetes (TRIAD) study. Diabetes Care. 2004; 27(7): 1529-34.

12. Ackermann E, Mitchell G. An audit of structured diabetes care in a rural general practice. Med J Aust. 2006; 185(2): 69-72.

13. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. J Am Med Assoc. 2005; 294(6):716-24.

14. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. J Am Med Assoc. 2005; 293(2): 217-28.

15. Van Servellen G, Fongwa M, Mockus D’Errico E. Continuity of care and quality care outcomes for people experiencing chronic conditions: A literature review. Nurs Health Sci. 2006; 8(3): 185-95.

16. Parchman M, Pugh J, Hitchcock P, Larme A. Continuity of care, self-management behaviors, and glucose control in patients with type 2 diabetes. Med Care. 2002; 40(2): 137-44.

17. Mondry A, Zhu A-L, Loh M, Vo T, Hahn K. Active collaboration with primary care providers’ increases specialist referral in chronic renal disease. BMC Nephrol. 2004; 5(1)16.

18. ADA. Summary of revisions for the 2006: Clinical practice recommendations. Diabetes Care. 2006; 29 (suppl.1) : S3.

19. Donabedian A. Exploration in quality Assessment and monitoring: The definition of quality and approaches to its assessment. Ann Arbor: Health Administration Press; 1980.

20. Standard for establishing the Primary Care Units. Nonthaburi: Office of Health Care Reform, Ministry of Public Health; 2002.

21. Manual of primary health care unit standard evaluation and quality assurance. Nonthaburi: Ministry of Public Health; 2005.

22. Poawilai K, Ungsusin K, Wannasaeng S, Junprasert S, Oungpheepattanakul B, Deerojjanawong C. Diabetes guidelines for practitioners in Primary Care Units in Thailand. Bangkok: Thai Endocrine Society and Ministry of Public Health; 2004.

23. Bureau of Health Service System Development. The evaluation of community health center report. Nonthaburi: Ministry of Public Health; 2008.

24. Yamane, T. Statistics, An introductory analysis. New York: Harper and Row; 1967.

25. Sirauss, Corbin. Basic of qualitative research: grounded theory procedure and technique. Newbury Park (CA): Sage; 1998.

26. Sandelowski M. Focus on qualitative methods sample size in qualitative research. Res Nurs Health. 1995; 18: 179-83.

27. Weber R. Basic content analysis. 2nd ed. Newbury Park (CA); 1990.

28. ADA. Standards of medical care in diabetes, 2008. Diabetes Care. 2008; 31(1): S12-54.

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29. Nitiyanant W, Chetthakul T, Sang-A-kad P, Therakiatkumjorn C, Kunsuikmengrai K, Jing Ping Y. A survey study on diabetes management and complication status in primary care settings in Thailand. J Med Assoc Thai. 2007; 90(1):65-71.

30. Dunn N, Pickering R. Does good practice organization improve the outcome of care for diabetic patients? Br J Gen Pract. 1998; 48: 1237-40.

31. Chin MH, Auerbach SB, Cook S, Harrison JF, Koppert J, Jin L, et al. Am J Public Health. 2000; 90(3): 431–34.

32. Grant RW, Buse JB, Meigs JB. Quality of diabetes care in U.S. academic medical centers: Low rates of medical regimen change. Diabetes Care. 2005; 28(2 : 337-442.

33. Saaddine JB, Cadwell B, Gregg EW, Engelgau MM, Vinicor F, Imperatore G, et al. Improvements in diabetes processes of care and intermediate outcomes: United States, 1988-2002. Ann Intern Med. 2006; 144(7): 525-7.

34. Pengpara U, Jongjirasiri N, Hongumphai P. The assessment of the universal health care coverage project in Pattani province. J. Health Sci. 2003; 12(3): 407-19.

35. Leesawad S. Evaluation of working readiness in a community health center, Lampang province. Chiang Mai: Chiang Mai University; 2002.

36. Davidson MB, Ansari A, Karlan VJ. Effect of a nurse-directed diabetes disease management program on urgent care/emergency room visits and hospitalizations in a minority population. Diabetes Care. 2007; 30(2): 224-7.

37. Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk Van JT, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: A systematic review. Diabetes Care. 2001; 24(10): 1821-33.

38. Wibulpolprasert S. Thailand Health Profile, 2005-2008. Nonthaburi: Veteran Press; 2008.

39. Chuengsatiansup K. Health Volunteers in the context of changes: Potentials and development strategies. Nonthaburi: Health Systems Research Institute; 2006.

40. Chuang S, Huang B, Tai T. The status of diabetes control in Asia: A cross-sectional survey of 317 patients with diabetes mellitus in 1998. Diabet Med. 2002; 19(12): 978-85.

41. Rawdaree P, Ngarmukos C, Deerochanawong C, Suwanwalaikorn S, Chetthakul T, Krittiyawong. Thailand Diabetes Registry (TDR) Project: Clinical status and long term vascular complications in diabetic patients. J Med Assoc Thai. 2006; 89 (Suppl 1):S1-9.

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คณภาพของการดแลผปวยเบาหวานในระบบบรการปฐมภม เขตภาคกลาง ประเทศไทย

รกชนก คชไกร, นนทวน สวรรณรป, กอบกล พนธเจรญวรกล, ชาญวทย ทระเทพ, Noel Chrisman

บทคดยอ: วตถประสงคของการวจยเชงบรรยายน เพออธบายคณภาพของระบบบรการดแลผปวยเบาหวานในปฐมภม ประกอบดวยโครงสรางของสถานบรการปฐมภม กระบวนการดแลผปวยเบาหวาน ผลของการดแล รวมทงความสมพนธของปจจยดงกลาว การศกษานเปนการวจยเชงผสมผสาน โดยทำการสำรวจผใหบรการในสถานบรการปฐมภมจำนวน 300 แหง และบนทกผลระดบนำตาลในเลอดยอนหลง 6 เดอนของผรบบรการจำนวน 19,141 ราย และสมภาษณเชงลกผใหบรการในสถานบรการปฐมภมจำนวน 9 คน วเคราะหขอมล โดยหาคาความสมพนธเพยรสน และการวเคราะหเนอหา ผลการศกษาพบวารอยละ 24 ของสถานบรการปฐมภมมโครงสรางเหมาะสมในการใหการดแลผปวยเบาหวาน สถานบรการปฐมภมสวนใหญมสงอำนวยความสะดวก งบประมาณ และเครอขายอยางเพยงพอ แตขาดแคลนดานกำลงคน นอกจากนนยงพบวารอยละ 82 ใหการบรการในการปองกนภาวะแทรกซอนจากโรคเบาหวานยงไมตรงตามมาตรฐาน และพบวาผปวยเบาหวานรอยละ 43 สามารถควบคมระดบนำตาลในเลอดได ผลการศกษายงพบวา โครงสรางของสถานบรการปฐมภมทดชวยสงเสรมใหเกดกระบวนการการดแลผปวยเบาหวานทเหมาะสม (r = 0.337) และทำใหมอตราผปวยเบาหวานทควบคมระดบนำตาลไดสงขน (r = 0.116) ทงนอาสาสมครสาธารณสขมสวนสำคญในการเชอมตอของสถานบรการปฐมภมและชมชน ซงทำใหสามารถใหการดแลผปวยเบาหวานอยางตอเนองไดด จากผลการวจยครงนมขอเสนอแนะใหผกำหนดนโยบาย ไดเพมอตรากำลงพยาบาลในสถานบรการปฐมภม และผใหบรการในสถานบรการปฐมภม ควรเพมศกยภาพของ อสม โดยการจดใหมการอบรมเพมพนความร ทงนเพอเปนการพฒนาคณภาพการใหบรการผปวยเบาหวานในสถานบรการปฐมภมตอไป


คำ ำคญ: คณภาพการดแลผปวยเบาหวาน ระบบบรการปฐมภม ประเทศไทย

ตดตอท: รกชนก คชไกร, RN, PhD Candidate, คณะพยาบาลศาสตร มหาวทยาลยมหดล ประเทศไทย E-mail: rukchanok.koshakri @gmail.com นนทวน สวรรณรป, RN, PhD, ผชวยศาสตราจารย คณะพยาบาลศาสตร มหาวทยาลยมหดล ประเทศไทย กอบกล พนธเจรญวรกล, RN, PhD, รองศาสตราจารย คณะพยาบาลศาสตร มหาวทยาลยมหดล ประเทศไทย ชาญวทย ทระเทพ, MD, FRCST, ผอำนวยการสำนกพฒนาระบบบรการสขภาพ กระทรวงสาธารณสข จงหวดนนทบร ประเทศไทย Noel Chrisman, PhD, Professor, School of Nursing, University of Washington, USA.

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Nopporn Vongsirimas et al.

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Relationship among Maternal Depressive Symptoms, Gender Differences and Depressive Symptoms in Thai Adolescents

Nopporn Vongsirimas, Yajai Sitthimongkol, Linda S. Beeber, Nonglak Wiratchai, Sopin Sangon

Abstract: To examine the pattern of relationships among factors related to depressive symptoms in adolescents of mothers with depressive symptoms, the structural equation model of adolescent depressive symptoms was tested. The conceptual framework, for this study, drew on the Interpersonal Theory of Depression. Through use of stratified sampling, 460 Thai adolescents, and respective mother, were selected for participation. All adolescents completed the: Demographic Data Questionnaire; Center for Epidemiologic Studies Depression Scale; Rosenberg’s Self-esteem Scale; Multidimensional Scale of Perceived Social Support; Maternal Supportive Behaviors Questionnaire; Negative Event Scale; and, Parental Bonding Instrument. Each mother completed the: Demographic Data Questionnaire; and, Center for Epidemiologic Studies Depression Scale. Data were analyzed using LISREL. A goodness of fit was obtained with the model. The adolescents’ depressive symptoms accounted for over 60% of the variance. A strong effect of maternal depressive symptoms on depressive symptoms among Thai adolescents, as well as on mediation by intervening variables, was found. The results also enhanced understanding of how to develop and target nursing interventions to prevent development of depressive symptoms, and optimize mental health, among Thai adolescents, when their mother suffers from depressive symptoms.

Thai J Nurs Res 2009; 13(3) 181 - 198

Key words: adolescent depressive symptoms, social support, self-esteem

Introduction

The World Health Organization (WHO) has estimated that 121 million people suffer from depression, a major cause (60%) of suicide.1 In addition, depression has been projected to comprise, by 2020, the largest disease burden, of all health conditions among women, and to rank second in the total yearly disability-adjusted life expectation.1

Depression and depressive symptoms, historically,

Correspondence to: Nopporn Vongsirimas, RN, PhD. Candidate, Faculty of Nursing, Mahidol University, Bangkok, Thailand. E-mail: [email protected] Yajai Sitthimongkol, RN, PhD. Associate Professor, Faculty of Nursing, Mahidol University, Bangkok, Thailand. Linda S. Beeber, RN, PhD, FAAN. Professor, School of Nursing University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Nonglak Wiratchai, PhD. Professor Emeritus, Chulalongkorn University, Bangkok, Thailand. Sopin Sangon, PhD, Assistant Professor, Department of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

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Relationship among Maternal Depressive Symptoms, Gender Differences and Depressive Symptoms


have been considered disorders that afflict middle-aged and older persons.2 Depression refers to a diagnostic term that meets set criteria in the Diagnostic and Statistic Manual of Mental Disorder (DSM-IV),3 while depressive symptoms are defined as “a spectrum of cognitive, affective, behavioral and somatic phenomena that accompany an unremitting sad mood (p. 154).”4 Adolescents and young adults, however, have been noted to be increasingly depressed and to seek treatment.2 Prior studies have found an increase in the onset of depressive symptoms among individuals 15 to 19 years of age.2 In the United States of America (USA), the prevalence rate of adolescent major depressive disorder (MDD) is estimated to range from 15% to 20%,5 while the prevalence rate of depressive symptoms is known to be close to 30%.5 In Thailand, the incidence rate of MDD, among Thai adolescents, ranges from 5% to 8%,6 while the prevalence rate of depressive symptoms ranges from 20% to 67%.7-9

Review of Literature

Depressive symptoms are known to be predictors of depression, with 25% of adolescents experiencing a MDD within one year of developing depressive symptoms.10 A diagnosis of depression during adolescence has been shown to be a predictor of a recurrence of depression during adulthood.10 In addition, the occurrence of a MDD during adolescence, when compared to that on childhood-onset MDD, has been found to indicate a poorer prognosis.6

Review of the literature reveals a number of factors, which increase adolescents’ risks of developing depressive symptoms, have been investigated, including whether their mother has depressive symptoms.10, 11 In particular, adolescent offspring of mothers with depressive symptoms have been found to be twice as likely to develop a major

depression, or dysthymic disorder, compared to adolescents of mothers who never have been depressed.12

Not surprisingly, mothers with depressive symptoms have been recognized to experience difficulties carrying out parental responsibilities, lack maternal confidence and present with hostility,11, 13 as well as have difficulty dealing with interpersonal relations with their adolescent child.13 Mothers who suffer from depression, also may appear unavailable, or insensitive, to their adolescent11 and be less able, compared to mothers who are not depressed, to provide appropriate guidance and rule enforcement.12 Adolescents living in such an environment have expressed being resentful of their poorly functioning mother.13

Yet adolescents who receive sufficient maternal warmth and support, from their symptomatic mothers, appear less likely to develop depressive symptoms.13, 14 This may be due to the fact that, when their mothers are impaired and unable to provide needed warmth and support, their fathers, grandparents, or concerned friends or relatives step in and provide for them. Thus, it appears the power of warm and supportive parenting is a critical factor in decreasing the likelihood of development of depressive symptoms among adolescents of mothers who are depressed.13

Self-esteem also appears to be a protective factor in decreasing the likelihood of adolescents developing depressive symptoms. Those with a high level, compared to those with a low level, of self-esteem have been found to suffer fewer depressive symptoms when facing similar stressful situations.15 However, in order to optimize resistance to depressive symptoms, one’s self-esteem has been shown to need mediation by social support.15, 16

Although a number of studies, in Thailand, have examined the relationship of life stress, social support, self-esteem and depressive symptoms among adolescents, none could be located which

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have predicted any pattern of associations among the various factors.8 Furthermore, no studies could be located, in English language or Thai language publications, which have investigating depressive symptoms among Thai adolescents, in relation to their mothers having depressive symptoms.

Therefore, this study sought to: 1) explore the relationships and factors associated with depressive symptoms among Thai adolescents of mothers with depressive symptoms; and, 2) test, in at-risk adolescents, the meditational roles of life stress, social support and self-esteem associated with maternal depressive symptoms and adolescent depressive symptoms.

Conceptual Framework

The conceptual framework, for this study, drew on the Interpersonal Theory of Depression.16, 17 The assumptions underlying the theory, proposed by Sullivan,18 are there are two basic human needs: biological and psychological. Both of these needs are met by having an “interpersonal relation” with a “significant other.” Such interaction is dynamic and acknowledges both individuals’ biological and psychological needs.

According to Sullivan, without having interpersonal relations with a significant other, one may not be able to satisfy his/her basic human needs.18 In the Interpersonal Theory of Depression,16, 17 “anxiety” refers to an insecure feeling, or emotional discomfort, that derives from the person not satisfying his/her basic needs. “Self-esteem” refers to a feeling that emerges from one having a positive self-evaluation, which is obtained from having an interpersonal relation with a significant other and perceiving a positive evaluation from his/her significant other. The “positive evaluation” one receives from a “significant other” constitutes “emotional support,” which is an important support that can be gained by having an “interpersonal relation,” or role relation, with one’s “significant other.”19

Thus, from this perspective, the interpersonal relation process, or interaction, between a mother and her children, might influence the children’s anxiety and self-esteem. In other words, the mental health of the mother may have an impact on the mental health of her children.

Methods

This study used a cross-sectional, correlational research design. Causal effects were examined via investigation of adolescents’ experiences of living, based on lifetime retrospective ratings, with their depressed mothers.

Setting and Participants: Fifteen high schools were randomly selected from 103 high schools in Bangkok, Thailand. A stratified sampling technique was used to obtain 460 adolescents who were 15 to 19 years of age, able to read and write in Thai and residing with their biological mother, who could read, write and score 16 or higher on the CES-D scale.

In this study, the term “adolescents” refers to late adolescence, which is classified from a psychosocial perspective as one 15-19 years of age and enrolled in a high school, including a Mathayom 4-6 (level of high school which includes grades 10 to 12). The study’s sample size was based upon Hair and colleagues20 suggestion that a ratio of 10 respondents per each estimated parameter be considered appropriate for calculation of a structural equation procedure. Therefore, the minimum sample size was set at 460, since the study included 46 estimated parameters.

The adolescent subjects ranged in age from 15 to 19 years, with an average age of 16.53 (SD = 1.00). Almost three-fourths (74%) of them had a daily allowance of 51-100 baht/day (mean = 86.63; SD = 31.55).

More than half (53.9%) of the mothers were in the age range of 41 to 50 years, with a mean

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age of 43.55 (SD = 5.38). Almost one-third of them had a family income of 5,001to10,000 baht/month (mean = 17,782.19; SD = 41,107.68). Most (79%) were married, but had an insufficient family income (55.2%). Almost half (44.8%) of the mothers only had a primary education.

Procedure and Ethical Considerations: Permission to conduct this study was obtained from the Human Rights Related to Human Experimentation and Ethics Committee, of the primary researcher’s university, and the School Board Committee of each of the 15 schools, where data were collected from November 2007 to March 2008. Once approval to conduct the study was obtained, the primary researcher approached the teachers, who served as counselors, within each of the schools. These teachers were responsible for non-academic issues (i.e. social support) and able to provide practical suggestions and assistance prior to and during data gathering. In addition, the teachers facilitated the researcher’s access to the students for the purpose of data gathering.

A total of 4, 261 adolescents were approached, in their respective classrooms, and told about the: study’s purpose and procedure; issues of confidentiality and anonymity; and, their right to withdraw at any time without repercussions. Each was given a packet, to take home to their mother, which contained a letter (explaining the study, issues of confidentiality and anonymity, and the right to withdraw, at any time, without negative repercussions), along with a consent form to sign, and the Demographic Data Questionnaire for Mothers and the Center for Epidemiologic Studies Depression Scale (CES-D) to complete. The letter requested each mother to complete the enclosed instruments, sign the consent form, place all completed documents back into the packet envelope and return the packet, with the enclosed documents, to the primary investigator the next day, via their adolescent. A total of 1,758 completed packets were returned, for a 41.26% return rate.

Upon receipt of the mothers’ signed consent forms and their completed CES-D, code numbers were placed on the CES-Ds. Each student then was administered, in a class room, the: Demographic Data Questionnaire for Adolescents; Center for Epidemiologic Studies Depression Scale (CES-D); Negative Event Scale (NES); Parental Bonding Instrument (PBI); Multidimensional Scale of Perceived Social Support (MSPSS); Maternal Supportive Behaviors Questionnaire (MSBQ) and Rosenberg Self-Esteem Scale (RSE).

Directions for completion of the questionnaires were provided, as well as responses to questions that arose during the administration process. Prior to administration of the questionnaires, the students were informed their respective mother had given written approval for them to participate. However, they were asked to sign an assent form if they desired to take part in the study, and reminded they had the right to withdraw, at any time, without negative repercussions. None withdrew from the study.

Code numbers were placed on each adolescent’s completed questionnaires to facilitate matching with their respective mother’s completed CES-D. Only questionnaires of those, whose mother obtained a CES-D score of 16 or greater, were placed into the analysis process. All code numbers were removed from the questionnaires immediately after completion of the CES-D screening process.

Four hundred ninety-four of the CES-D Scales indicated the responder had depressive symptoms (CES-D≥16). However, 32 respondents did not live in the same household as their biological adolescent and two made errors answering the questionnaires. Thus, 34 questionnaires were excluded, leaving a total of 460 viable questionnaires.

Instruments: Eight instruments were used to collect data from each adolescent and mother. They included the: Demographic Data Questionnaire for Mothers; Demographic Data Questionnaire for Adolescents; Center for Epidemiologic Studies

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Depression scale (CES-D); Negative Event Scale (NES); Parental Bonding Instrument (PBI); Multidimensional Scale of Perceived Social Support (MSPSS); Maternal Supportive Behaviors Questionnaire (MSBQ); and, Rosenberg’s Self-esteem Scale(RSE).

With the exception of the Demographic Data Questionnaires and the MSBQ, both of which were constructed, in Thai, by the primary investigator, the instruments were translated from English into Thai, by prior researchers,9, 21 and then back-translated into English. The back-translated English version was compared with the original English version of each instrument for the purpose of assuring no change in meaning occurred in the content. Each instrument was reviewed by five experts (two psychiatrists, two psychologists and a nursing instructor) and pilot-tested to determine the instruments’ internal reliability, clarity and comprehensiveness.

The pilot-test was accomplished through use of 31 Thai adolescents and their respective mother with depressive symptoms, whose characteristics were similar to the study sample and independent of the intended study sample. The procedure used to conduct the pilot study was identical to the intended study. The pilot study internal reliabilities, for adolescents, were: CES-D (0.87) NES (0.94), PBI (0.89), MSBQ (0.86), MSPSS (0.79) and RSE (0.88). The reliability of the CES-D, for mothers, was 0.74.

The Center for Epidemiologic Studies Depression Scale (CES-D)22 is a self-administered 20 item questionnaire designed to measure depressive symptoms by ascertaining the level of depressive symptoms a subject has experienced over the previous week, including the current day. The scale consists of four major depressive symptoms: 7 items for depressed affect (items 3, 6, 9, 10, 14, 17, 18); 4 items for positive affect (items 4, 8, 12, 16); 7 items for somatic and retarded activity (items 1, 2, 5, 7, 11, 13, 20); and, 2 items for interpersonal relationships (items 15, 19). The

possible responses, for each of the 20 items, ranges from 0 = rarely or none of the time to 3 = most or all of the time. The score from each of the 20 items is summed to produce an overall total score, which can range from 0 to 60. Higher scores indicate greater depressive symptom severity. A score between 0 and 15 suggests that “no depression” is present, while scores at or above 16 are indicative of clinically significant symptomatology. There is a linear relationship between increasing score values and the likelihood of a diagnosis of major depressive disorder.22 In population screening, the cut-off score of 16 has shown high sensitivity ranging from 86% to 100%, and determined to be the best cut-off score in detecting depressive symptoms among a variety of populations across cultures.23 In addition, a longitudinal study found that adolescents, with an initial CES-D score of 16, developed moderate/severe depressive symptoms at follow-up. This finding confirmed a high sensitivity of the CES-D scale at the score of 16.24 A cut-off score of 16 for the CES-D has been used among researchers in the area of depressive symptoms in adolescences of depressed mothers.25 The CES-D also has been shown to be a valid instrument across racial and culturally diverse groups.23 It takes approximately 10 to 15 minutes to complete. The alpha reliability coefficient of the instrument, for this study, was 0.87 for adolescents and 0.74 for mothers.

The Negative Event Scale (NES)26 is a self-administered questionnaire that measures perceived life stressors commonly experienced by adolescents. The 42 item scale consists of 10 subscales addressing problems with: 1) friends; 2) boy/girl friend; 3) money; 4) courses; 5) teacher; 6) parents or parents-in-law; 7) other students; 8) relatives; 9) health; and, 10) academic limitations and course interest. The respondent is asked, “Last month, how much hassle did you experience?” for each of the 42 negative life events. Each event is

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scored using a 6-point Likert-like scale: 0 = did not occur; 1 = event occurred but there was no hassle; 2 = event occurred along with a little hassle; 3 = event occurred along with somewhat of a hassle; 4 = event occurred along with a lot of hassle; and, 5 = event occurred along with extreme hassle. A total score is obtained by summing across all 42 items, which can produce a range of scores from 0 to 210. It takes approximately 10 minutes to complete the scale. The NES has demonstrated excellent construct validity and reliability with Thai adolescents (r = 0.98).9 The reliability of the instrument, for this study, was 0.94.

The Parental Bonding Instrument (PBI)27 is a 25-item self-rating scale designed to measure perceived relationships and experiences, with parents, based upon the child’s memory of his/her parents during the first 16 years of life. For this study only maternal bonding was measured. The PBI is composed of 2 subscales: evaluating care (12 items) and evaluating overprotection (13 items). Each item, which assesses the parent in question, is rated by the respondent on a four-point Likert-type scale (0 = very unlike to 3 = very like). The total score for each of the two dimensions (care and overprotection) is created by summing items that address the respective dimension. The possible range of scores for the care dimension is 0 to 36, while the range of scores for the overprotection dimension is 0 to 39. High scores on the care dimension represent the adolescent’s perception of caring and affectionate parenting, while high scores on the overprotection dimension represents the adolescents’ perception of overprotective parenting.27 Low scores on the care dimension and high scores on the overprotection dimension are considered to be suggestive of a risk for depressive symptoms.28 The PBI shows excellent construct and convergent validity, as well as reliability with a range from .91 to .99.1 In addition, it has demonstrated stability over a 20-year period.28

Charoensuk9 translated the PBI from English into Thai, but added 5 items, in order to increase the instruments’ reliability in a Thai adolescent population. Two items were added to caring (#26 and #27), while three items were added to the overprotection dimension (#28, #29 and #30). Thus, the Thai version of the PBI consists of 14 items for parental care and 16 items for parental overprotection. Like the original English version of the PBI, items are scored on the same four-point Likert-like scale (0 = very unlikely to 3 = very likely), and total scores for each dimension are obtained by summing the score for items in each respective dimension. Scores for the care dimension can range from 0 to 42, while scores for the overprotection dimension can range from 0 to 48. Interpretation of the scores is the same as the original English version of the PBI. Alpha coefficients found, by Charoensuk,9 for the Thai version of the PBI were .88 for caring and .78 for overprotection.

In this study, prior to data analysis, the scoring method for the “caring component” was reverse, so that high numerical values of the caring dimension of the instrument conceptually fit with high numerical values of the overprotection dimension (a negative concept). As a result, high scores indicated low levels of caring and affectionate parenting, rather than high levels of caring and affectionate parenting. The scoring for the overprotection dimension of the scale remained the same and was not reversed. The scale can be completed in approximately 5 to 10 minutes. The alpha coefficient for the instrument, for this study, was 0.87.

The Maternal Supportive Behaviors Questionnaire (MSBQ) was a modification, by the primary researcher, of the Inventory Social Supportive Behaviors (ISSB)29 instrument. The purpose of both the ISSB and the MSBQ is to measure the quantity of support adolescents received over the

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past four weeks from a significant person, with whom they have had a personal relationship. For the MSBQ, the significant person is the mother. Permission to modify the MSBQ was obtained from Dr. Manual Berrera (personal communication, May 23, 2007), an author of the ISSB. Although the ISSB has been modified, translated into Thai and used on a Thai adolescent population,22 based upon the evaluation, by the primary researcher’s instrument evaluators, of the Thai version of the ISSB, it was determined best to modify the original ISSB and, thereby, create the MSBQ. The instrument evaluators indicated the contexts and conditions given in many items, of the Thai version of the ISSB, did not fit the Thai culture.

In the ISSB, received support is defined as assistance received in three forms: 1) being there (physically, emotionally and spiritually); 2) giving help; and, 3) giving information and advice.29

Moreover, the framework of question asking was developed for use in adolescents who also were target subjects in this study. To create the MSBQ, via modification of the ISSB, seven items were deleted from the ISSB (i.e., items 1, 3, 13, 17, 22, 34, 38, and 40) and the content/conditions stated in the remaining items were changed to more accurately reflect the Thai culture. However, the conceptual framework for the ISSB’s three support forms and their related questions were maintained in the MSBQ. Since the required responses for the ISSB questions were based upon the frequency of occurrence of support, which cannot be appropriately applied in the Thai culture, the MSBQ item responses were changed to an agree/disagree format.

The created, self-administered MSBQ, contains 33 items that were answered on a 4-point rating scale (1 = definitely disagree; 2 = somewhat disagree; 3 = somewhat agree; and, 4 = definitely agree). Higher scores indicate higher support received from mothers. It takes about 15- 20 minutes to complete the instrument. After content

validation by the experts, the scale was considered acceptable for use with adolescents having a mother with depressive symptoms, with a scale-level CVI of 0.85. The alphas coefficient for the instrument, in this study, was .96.

The Multidimensional Scale of Perceived Social Support (MSPSS)30 is a 12-item instrument designed to measure the perceived amount of social support one receives from three separate sources: family, friends and significant others. Each of the three sources of social support is assessed using four respective questions. Examples of two questions are: “There is a special person who is around when I am in need;” and, “My family really tries to help me.” The instrument utilizes a 7-point Likert-like response format (1 = very strongly disagree to 7 = very strongly agree). A score for each of the three subscales is obtained by summing across the respective items. A total score is obtained by summing across all 12 items.30 Scores for each subscale range from 4 to 28, with higher scores indicating a higher level of perceived social support received from the respective subscale (i.e., family, friends and significant other), whereas low scores suggest decreased levels of perceived social support. It takes approximately 3 minutes to complete. The MSPSS has been used extensively and has demonstrated sound psychometric properties.31 It has been used in Thailand to measure perceived social support in adolescents, with a reliability of 0.89.7 In this study, the reliability for the MSPSS was 0.89.

The Rosenberg Self-Esteem Scale (RSE)32 is a 10-item, self-administered instrument developed for the purpose of measuring adolescent’s global feelings of self-worth or self-acceptance. The scale consists of 2 dimensions: a feeling of self-worth and self-respect; and, a feeling of competence and ability. Feelings of self-worth and self-acceptance are measured using eight items, while competence and ability are assessed using two items. Examples

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of one question from each of the two dimensions of the scale are: “I feel that I am a person of worth at least on an equal plane with others;” and, “I am able to do things as well as most other people.” For each of the 10 items, a participant rates how much he/she has valued himself/herself in the last month on a scale of 1 = strongly disagree to 4 = strongly agree. The higher the score, the higher one’s self-assessed self-esteem. It takes approximately 5 minutes to complete. Reliability of the scale has been found to range from .77 to .88.32 The reliability of the RSE, for this study, was .78.

Results

Data analysis, using structural equation modeling (SEM), validated the causal model of adolescent depressive symptoms, while employing LISREL revealed a significant fit with chi-square = 251.462; df = 217; p-value = 0.054; RMSEA = .019, GFI = .964; AGFI = .927, as displayed in Figure 1. The correlation matrix of latent variables is shown in Table 1. The paths in the model consisted of factor loadings and effects between variables in the model (see Table 2 & 3). Every factor loading of indicators, measuring the seven latent variables, were significant at 0.01 (see Table 3).

Findings from structural equation modeling showed maternal depressive symptoms had a significant, positive, indirect effect on adolescent depressive symptoms (.095; p <.01), via perceived life stress, perceived maternal parenting, maternal support, support from others and self-esteem. Gender had a significant, positive, indirect effect on adolescent depressive symptoms (.086; p <.05), via perceived life stress, perceived maternal

parenting, maternal support, support from others and self-esteem.

Perceived life stress had a significant, positive, total effect on adolescent depressive symptoms (.281; p <.01), which was both a significant, positive, direct effect (.161; p <.01) and an indirect effect (.120, p <.01), via maternal support, support from others and self-esteem. Perceived maternal parenting had a significant positive total effect on adolescent depressive symptoms (.471; p <.01), which was both a significant, positive, direct effect (.163, p <.05) and an indirect effect (.308, p <.01), via maternal support, support from others and self-esteem. Maternal support had a significant, negative, total effect on adolescent depressive symptoms (-.096; p <.01), which was decomposed into a negative, non-significant, direct effect and a significant, negative, indirect effect (-.032; p <.01), via self-esteem, indicating that maternal support had the mediating effect through self-esteem on adolescent depressive symptoms. Support from others had a significant, negative, total effect on adolescent depressive symptoms (-.187; p <.01), which was decomposed into a negative, non-significant, direct effect and a significant, negative, indirect effect (-.138, p <.05), via self-esteem, indicating that support from others had the mediating effect through self-esteem on adolescent depressive symptoms. Self-esteem not only had a significant, negative, direct effect on adolescent depressive symptoms (-.601; p <.01), but also had the greatest effect on adolescent depressive symptoms in the model. The LISREL model fit very well to the empirical data and explained 61.5% of variance of depressive symptoms in adolescents of mothers with depressive symptoms.

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Table 1 Correlation matrix of the study variables (n=460)

MoDe Gen PLS Ppar Msup Osup Selfest AdoDe

MoDe 1.000 Gen 0.006 1.000 PLS 0.166** 0.109* 1.000 Ppar 0.186** 0.089 0.317** 1.000 Msup -0.061 -0.067 -0.212** -0.541** 1.000 Osup -0.068 0.042 -0.173** -0.370** 0.548** 1.000 Selfest -0.090 -0.025 -0.298** -0.321** 0.308** 0.360** 1.000 AdoDe 0.194** 0.087 0.462** 0.410** -0.341** -0.397** -0.506** 1.000

* p<.05; ** p<.01

MoDe = Maternal Depressive Symptoms Gen = Gender PLS = Perceived Life Stress PPar = Perceived Maternal Parenting Msup = Maternal Support Osup = Support from Others Selfest = Self-esteem AdoDe = Adolescent Depressive Symptoms

Observed b SE t SC R2

variables Maternal Depressive Symptoms (MDS) mds 1 0.320 0.017 18.808 0.787 0.619 mds 2 0.387 0.021 18.375 0.776 0.602 mds 3 0.406 0.021 18.931 0.789 0.623 mds 4 0.492 0.026 18.735 0.786 0.617

Gender female 0.361 0.020 18.378 0.778 0.606

Perceived Life Stress (LS) ls1 0.747 - - 0.780 0.608 ls2 0.900 0.066 13.679 0.772 0.597 ls3 0.907 0.066 13.838 0.777 0.603 ls4 0.934 0.067 14.012 0.778 0.605 ls5 0.760 0.055 13.891 0.781 0.610 ls6 0.796 0.064 12.508 0.694 0.620 ls7 0.643 0.044 14.586 0.778 0.605 ls8 0.688 0.049 14.003 0.782 0.612 ls9 0.738 0.053 13.998 0.776 0.602 ls10 0.842 0.057 14.785 0.779 0.607

Table 2 validation results of the causal model of adolescent depressive symptoms

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Perceived Maternal Parenting par-nc 0.358 - - 0.750 0.562 par-o 0.348 0.026 13.358 0.780 0.609

Maternal Support (MS) ms1 0.287 0.045 6.361 0.798 0.636 ms2 0.254 0.040 6.297 0.776 0.603 ms3 0.252 0.040 6.300 0.784 0.614

Support from Others (OS) os1 1.019 - - 0.784 0.615 os2 0.957 0.060 15.963 0.790 0.625 os3 0.920 0.060 15.280 0.779 0.606

Self-esteem (SE) se1 0.312 - - 0.784 0.615 se2 0.414 0.023 18.405 0.795 0.623

Adolescent Depressive Symptoms (ADS) ads1 0.260 - - 0.600 0.360 ads2 0.335 0.024 14.205 0.655 0.429 ads3 0.308 0.032 9.595 0.623 0.388 ads4 0.378 0.036 10.626 0.699 0.488

χ2 =251.462, df = 217, p-value = .0542, RMSEA = .019, GFI = 0.964, AGFI = 0.927

Note: b = Estimated Parameter; SD = Standard Error; t = t-value; R2 = Construct Reliability; SC = Completely Standardized Value of Factor Loading

mds1 = somatic and retard activity par-nc = perceived not caring mds2 = depressed affect par-o = perceived overprotection mds3 = positive affect ms1 = emotional and physical support mds4 = interpersonal relationship ms2 = giving help Fem = female ms3 = giving information and guidance ls = problems with friends os1 = significant others ls2 = problems with boy/girl friends os2 = family ls3 = problems with money os3 = friends ls4 = problems with courses se1 = feeling of self value and self respect ls5 = problems with teacher se2 = feeling of competence and ability ls6 = problems with parents ads1 = somatic and retard activity ls7 = problems with other students ads2 = depressed affect ls8 = problems with relative/s ads3 = positive affect ls9 = health problems ads4 = interpersonal relationship ls10 = academic limitations & course interest

Table 2 (continued) Observed b SE t SC R2

variables

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Causal Effected Variables Variables PLS PPar DE IE TE DE IE TE MoDe 0.116** - 0.116** 0.132** - 0.132** (0.029) (0.029) (-0.036) (-0.036) Gen 0.098* - 0.098* 0.123* - 0.123* (0.045) (0.045) (0.057) (0.057)

Structural Equation Fit R2 =.021 R2 =.030 Causal Effected Variables Variables Msup Osup DE IE TE DE IE TE

MoDe -0.006 -0.107* -0.113* - -0.074** -0.074** (-) (0.062) (0.062) (0.021) (0.021) Gen - -0.099* -0.099* - -0.068* -0.068* (-0.082) (-0.082) (0.031) (0.031) PLS -0.013 - -0.013 -0.025 - -0.025 (0.049) (0.049) (0.032) (0.032) PPar -0.798** - -0.798** -0.536** - -0.536** (0.311) (0.311) (0.071) (0.071)

Structural Equation Fit R2 = .638 R2 =.288 Causal Effected Variables Variabales Selfest AdoDe DE IE TE DE IE TE

MoDe - -0.074** -0.074** - 0.095** 0.095** (0.018) (0.018) (0.022) (0.022) Gen - -0.066* -0.066* - 0.086* 0.086* (0.025) (0.025) (0.031) (0.031) PLS -0.190** -0.006 -0.196** 0.161** 0.120** 0.281** (0.039) (0.008) (0.040) (0.040) (0.030) (0.044) PPar -0.218** -0.165** -0.384** 0.163* 0.308** 0.471** (0.067) (0.035) (0.060) (0.082) (0.059) (0.070)

Table 3 Standardized direct effect, indirect effect, total effect of latent variables in the model (n = 460)

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Msup 0.053 - 0.053 -0.064 -0.032** -0.096** (-) (-) (-) (0.003) (0.003) Osup 0.229** - 0.229** -0.050 -0.138** -0.187* (0.060) (0.060) (0.072) (0.042) (0.073) Selfest - - - -0.601** - -0.601** (0.087) (0.087) Structural Equation Fit R2 = .228 R2 = .615 *p < .05; **p <.01 Note: The values in the table are Standardized Values. The values in the parenthesis are Standard Error. DE=Direct Effect PLS = Perceived Life Stress IE=Indirect Effect PPar= Perceived Maternal Parenting TE=Total Effect Msup= Maternal Support MoDe = Maternal Depressive Symptoms Osup= Support from Others Gen = Gender Selfest= Self-esteem

Table 3 (continued)

Causal Effected Variables Variabales Selfest AdoDe DE IE TE DE IE TE

Figure 1 Validation results of the adolescent depressive symptoms model

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Discussion

The interpersonal theory of depression framework was used to predict relationships among the factors related to depressive symptoms in Thai adolescents of mothers with depressive symptoms. The findings identified the effect of maternal depressive symptoms on depressive symptoms in Thai adolescents. This relationship was mediated by intervening variables, including: perceived life stress; perceived maternal parenting; maternal support; support from others; and, self-esteem. The results are congruent with previous findings which have shown maternal depressive symptoms do not directly impact adolescents’ depressive symptoms, but are influenced by mediating variables.2

The effect of maternal depressive symptoms on adolescents’ depressive symptoms was shown to be mediated through: life stress (perceived life stress and perceived maternal parenting); social support (maternal support and support from others); and, self-esteem. In addition, social support (maternal support and support from others) was found to have a mediating effect on adolescents’

depressive symptoms through self-esteem. These findings are congruent with prior research, which has revealed interpersonal relationships with significant others, in providing support and protecting self-esteem, are significant protective factors in the development of depressive symptoms.15, 16 In addition, self-esteem has been shown to mediate the relationship of social support and depression, and social support has been found to be an important resistance factor, regarding depressive symptoms, but only in combination with self-esteem.15,16 However, providing social support, without self-esteem enhancement, has not been found to be effective and might even place one at risk for diminished self-esteem.16 Thus, the test model for Thai adolescents, in this study, supports previous findings which show cultural and racial differences are not strong enough to make a difference in the way self-esteem mediates depressive symptoms.15

The findings reveal depressive symptoms in their respective mother, not only led to increasing perceived life stress among adolescents, but also lead to increasing perceived impaired parenting behaviors (not caring and overprotective) from

Figure 1 (continued)

mds1 = somatic and retard activity par-nc = perceived not caring mds2 = depressed affect par-o = perceived overprotection mds3 = positive affect ms1 = emotional and physical support mds4 = interpersonal relationship ms2 = giving help Fem = female ms3 = giving information and guidance ls1 = problems with friends os1 = significant others ls2 = problems with boy/girl friends os2 = family ls3 = problems with money os3 = friends ls4 = problems with courses se1 = feeling of self value and self respect ls5 = problems with teacher se2 = feeling of competence and ability ls6 = problems with parents ads1 = somatic and retard activity ls7 = problems with other students ads2 = depressed affect ls8 = problems with relative/s ads3 = positive affect ls9 = health problems ads4 = interpersonal relationship ls10 = academic limitations & course interest

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them. In other words, Thai adolescents of depressed mothers were found to encounter stressful parenting, from their depressed mother, as well as experience stressful events in their own lives. These findings are congruent with prior studies, wherein life stress for adolescents of depressed mothers has been shown to consist of two domains: 1) stress from being parented by the depressed mothers; and, 2) stress from the stressful events in their own live.11

Moreover, this study found that gender had a mediating effect through perceived life stress and perceived maternal parenting on the adolescents’ depressive symptoms, indicating the girls were more sensitive to this effect than the boys. Perceived life stress and perceived maternal parenting were found to be associated with depressive symptoms in the boys and the girls, but was slightly stronger in the girls than in the boys. This finding is congruent with recent research which has documented Thai culture plays an important role on parental rearing practices and a child’s gender.33 In addition, Thai parents are known to exercise more control over their daughters than their sons.33 Differences in child rearing practices has been shown to have a significant impact on the perceived life stress and mental health of Thai children.34 These findings also are congruent with prior findings which have revealed adolescent girls experience higher levels of interpersonal stress than do adolescent boys.35 The higher levels of interpersonal stress, in turn, helps explain the higher rates of depressive symptoms in adolescent girls, in that exposure to episodic interpersonal stressors is an important factor regarding the development of depressive symptoms in adolescents.35, 36

The findings also suggest that perceived life stress has both a significant, positive, direct and indirect effect on adolescents’ depressive symptoms. Those who had high levels of perceived life stress, directly and indirectly, also had an increase in their depressive symptoms. This finding is congruent with previous research, which has indicated that adolescents

who are exposed to high levels of stress, particularly interpersonal stressors, are more likely to develop depressive symptoms than adolescents who are exposed to high levels of stress, but not in an interpersonal context.35

In addition, impaired parenting (not caring and over protection) from one’s mother could, directly and indirectly, increase an adolescent’s depressive symptoms. Adolescents, in this study, who received impaired parenting (not caring and over protection) from their respective mother, were less likely to receive support from their mother and others. The lack of perceived support may have decreased the adolescents’ self-esteem and precipitated their depressive symptoms. However, impaired parenting from their respective mother also was found to directly decrease the adolescents’ self-esteem and increase their depressive symptoms. The findings, of this study, are congruent with prior findings, which imply perceived lack of maternal care is associated with a diagnosis of depression among adolescents,37 and support previous findings which suggest deficits in parental support can predict future increases in depressive symptoms, and the onset of major depression, among adolescents.37

These findings also suggest that the combination of having a depressed mother and a high level of life stress (perceived life stress and perceived maternal parenting) may lead an adolescent to perceive less social support, and, thus, a decreased self-esteem. In other words, adolescents of depressed mothers, who have high levels of life stress, may not perceive support from either their respective mother, or others, and be unable to develop their own self-esteem. On the other hand, if such adolescents perceive receive social support, their self-esteem may not be affected when experiencing stress. These findings are supported by the interpersonal theory of depression that purposes adolescents need support provided by their significant other, so that they can gain self-esteem. This theoretical foundation also is supported by prior

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research which reveals the emotional support a Thai student receives from a significant other, specifically a parent, is the significant factor in the prediction of the development of the adolescent’s self-esteem.38 These findings also are congruent with previous findings which show peer and parental support has an effect on adolescents’ self-esteem, but do so independently. In addition, peer support has been found to have more effect when maternal support is low, but minimal effect when maternal support is high.39

The applicability of the interpersonal theory of depression to Thai maternal-adolescent depressed populations (a theory in which self-esteem mediates the intimate relationship quality with a significant person having depressive symptoms) appears to be validated by the findings of this study. Having a poor, interpersonal, relationship with a mother could cause chronic anxiety and be conceptualized as a stressor.

This study also extends the understanding of social support in the context of adolescents of mothers with depressive symptoms. Prior research regarding social support has not distinguished maternal support from the support of others. In this study, besides others’ social support, maternal support was explicitly identified. The results revealed that maternal support and support from others were key factors influencing adolescents’ self-esteem. Thus, either support from one’s respective mother, who has depressive symptoms, or from others, could attenuate the impact of maternal depressive symptoms on an adolescent’s self-esteem.

Study Limitations and Recommendations

for Future Research

All studies have limitation and this study is no exception. Firstly, the sample was limited to high school adolescents in Bangkok. Therefore, the findings are not generalizable to the entire Thai adolescent population, or to adolescents whose

respective mother does not have depressive symptoms. Secondly, the sample consisted entirely of adolescence. It is possible that the relationship between maternal depressive symptoms and the course of depressive symptoms, in adolescents, might differ between individuals with pre-pubertal versus post-pubertal depressive symptoms onset.40

Based on the causal model, developed in this study, a potential future direction for research could be to test the causal model in other samples, i.e. Thai vocational and college students. Given the susceptibility of girls to impaired mothering, a study regarding the development, implementation and evaluation of mental health programs focusing on adolescent females might be in order.

Implications for Nursing Practice

The results reveal that having a mother with depressive symptoms is a sign of risk for depressive symptoms in an adolescent. Nurses, both in hospital and community settings, need to detect early depressive symptoms in adolescents, and provide appropriate preventive interventions. Mothers diagnosed with depression should be immediately assessed for their ability to take care of their children, and their interpersonal relationships with family members, which might create stress. Children of depressed women need regular monitoring for risk of developing problematic behaviors and depressive symptoms. They need to be provided with age appropriate information regarding stress management options. In the community, specifically in the schools, effective screening for at-risk adolescents is needed.

Psychiatric-mental health nurses need to assist teachers in developing the ability to assess and identify adolescents of mothers with depressive symptoms, and those at risk for impaired educational, social, and emotional functioning. School-based interventions, designed to improve maternal parenting and enhance social support, as well as protect self-

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esteem in adolescents of mothers with depressive symptoms, need to be initiated. Such interventions would strengthen the family-school relationship, whereby schools could become more involved in the well-being of their students, and parents could gain social support and greater involvement within the multiple contexts and needs of their children.

Currently all high schools, in Bangkok, are run by the Ministry of Education and have instituted the ‘student caring system’. Teachers are in the best place to identify and screen students who may be at risk. However, questionnaires, currently being used, are not designed to screen for depressive symptoms, or to screen adolescents for the signs of risk for depressive symptoms. Thus, effective screening instruments and interventions for adolescents with symptomatic parents are needed in Thailand.

Acknowledgements

This research was financial supported by: the Commission of Higher Education, Ministry of Education, Thailand; the Thai Council of Nursing and Midwifery; and, the Faculty of Graduate Studies, Mahidol University. The authors also thank Professor Eleanor Holroyd and Associate Professor Jarruwat Charoensuk for their suggestions in the preparation and editing of the initial submission of this manuscript.

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12. Hammen C, Brennan P. Severity, chronicity, and timing of maternal depression and risk for adolescent offspring diagnosis in a community sample. Arch Gen Psychiatry. 2003; 60: 253-8.

13. Beardslee WR. When a parent is depressed. New York (NY): Little, Brown and Company; 2002.

14. Brennan P, Le Brocque R, Hammen C. Maternal depression, parent-child relationships, and resilient outcomes in adolescence. J Am Acad Child Adolesc Psychiatry. 2003; 42(12): 1469-77.

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15. Beeber LS. Social support, self-esteem, and depressive symptoms in young American women. Image (IN). 1998; 30(1): 91-2.

16. Beeber LS. Testing an explanatory model of the development of depressive symptoms in young women during a life transition. J Am Coll Health. 1999; 47(5): 227-34.

17. Coyne JC. Toward an interactional description of depression. Psychiatry. 1976; 39: 28-40.

18. Sullivan HS. The interpersonal theory of psychiatry. New York (NY): Norton; 1953.

19. Thoits PA. Social support and psychological well-being: Theoretical possibilities. In: Sarason I, Sarason B, editors. Social support: Theory, research and applications. Boston (MA): Martinus Nijhoff Publishers; 1985.

20. Hair JF, Anderson R, Tatham R, Black W. Multivariate data analysis. Englewood Cliffs (NJ): Prentice-Hall; 2005.

21. Srisang P. Self-esteem, stressful life events, social support, and postpartum depression in adolescent mothers in Thailand. [dissertation]. Cleveland (OH): Case Western Reserve Univ.; 2003.

22. Radloff LS. The CES-D Scale: A self-report depression scale for research in the general population. Appl Psychol Measure. 1977; 1: 385-401.

23. Radloff LS. The use of the Center for Epidemiological Studies Depression Scale in adolescents and young adults. J Youth Adolesc. 1991; 20: 149-66.

24. Rushton J, Forcier M, Schectman R. Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health. J Am Acad Child Adolesc Psychiatry. 2002; 41(2): 199-205.

25. Fergusson D, Horwood J, Lynskey M. Maternal depressive symptoms and depressive symptoms in adolescents in adolescents. J Child Psychol Psychiatry. 1995; 36: 1161-78.

26. Maybery DJ. Including interpersonal events on hassle and uplift scales: Verification employing global and molecular events. Stress Health. 2003; 19(5): 289-96.

27. Parker G, Tupling H, Brown LB. A parenting bonding instrument. Br J Med Psychol. 1979; 52:1-10.

28. Wilhelm K, Niven H, Parker G, Hadzi-Pavlovic D. The stability of the Parental Bonding Instrument over a 20-year period. Psychol Med. 2004; 35: 387-93.

29. Barrera MJ, Sandler IN, Ramsay TB. Preliminary development of a scale of social support: Studies on college students. Am J Community Psychol. 1981; 9: 435-47.

30. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The Multidimensional Scale of Perceived Social Support. J Pers Assess. 1988; 52(1): 30-41.

31. Clara IP, Cox BJ, Enns MW, Murray LT, Torgrude LJ. Confirmatory factor analysis of the Multidimensional Scale of Perceived Social Support in clinically distressed and student sample. J Pers Assess. 2003; 81(3): 265-70.

32. Rosenberg M. Society and the adolescent self-image. Middletown (CT): Wesleyan University Press; 1989.

33. Rucharoenpornpanit O, Jumratrithirong A. Thai culture of child rearing: Gender difference and “gender status” of the child. Population and society. 2008: 114-27.

34. Boonprakob W. Child rearing and mental health. J Psychiatr Assoc Thai. 2001; 46(1): 55-68.

35. Shih JH, Eberhart NK, Hammen CL, Brennan PA. Differential exposure and reactivity to interpersonal stress predict sex differences in adolescent depression. J Clin Child Adolesc Psychol. 2006; 35(1): 103-15.

36. Bouma E, Ormel J, Verhulst FC, Oldehinkel AJ. Stressful life events and depressive problems in early adolescent boys and girls: The influence of parental depression, temperament and family environment. J Affect Disord. 2008; 105: 185-93.

37. Stice E, Ragan J, Randall P. Prospective relational between social support and depression: Differential direction of effects for parent and peer support? J Abnorm Psychol. 2004; 113(1): 155-9.

38. Ross R, Zeller R, Srisaeng P, Yimmee S, Sawatphanit W, Somchid S. Self-esteem, parent-child interaction, emotional support, and self-perception among Thai undergraduate nursing students. Int J Nurs Educ Scholarsh. 2006; 3(1): Article 21. Available from: http://www.bepress.com/ijnes/vol123/iss21/art21

39. Hoffman MA, Ushpiz V, Levy-Shiff R. Social support and self-esteem in adolescence. J Youth Adolesc. 1988; 17(4): 307-16.

40. Harrington R, Rutter M, Weissman M, Fudge H, Groothues C, Brendenkamp D. et al. Psychiatric disorders in the relatives of depressed probands I: Comparison of prepubertal, adolescent and early adult onset cases. J Affect Disord. 1997; 42(1): 9-22.

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ตดตอท: นพพร วองสรมาศ, RN, Ph.D. Candidate คณะพยาบาลศาสตร มหาวทยาลยมหดล กรงเทพฯ ประเทศไทย E-mail: [email protected] ยาใจ สทธมงคล, RN, PhD. รองศาสตราจารย ภาควชาสขภาพจตและการพยาบาลจตเวชศาสตร คณะพยาบาลศาสตร มหาวทยาลยมหดล กรงเทพฯ ประเทศไทย Linda S. Beeber, RN, PhD, FAAN. Professor, School of Nursing University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. นงลกษณ วรชชย, PhD. ศาสตราจารยเกยรตคณ ภาควชาวจยการศกษาและจตวทยา จฬาลงกรณมหาวทยาลย กรงเทพฯ ประเทศไทย โสภณ แสงออน, RN, PhD. ผชวยศาสตราจารย ภาควชาพยาบาลศาสตรคณะแพทยศาสตรโรงพยาบาลรามาธบด มหาวทยาลยมหดล กรงเทพฯ ประเทศไทย

ความสมพนธระหวางภาวะซมเศราในมารดา เพศ และ ภาวะซมเศราในวยรนไทย

นพพร วองสรมาศ, ยาใจ สทธมงคล, Linda S. Beeber, นงลกษณ วรชชย, โสภณ แสงออน

บทคดยอ: งานวจยนมวตถประสงคเพอทดสอบรปแบบความสมพนธของกลมตวแปรทมความสมพนธกบภาวะซมเศราในวยรนทมมารดาซมเศรา โดยทำการทดสอบโมเดลสมการโครงสรางของภาวะซมเศราในวยรน กรอบทฤษฎทใชในงานวจยนคอ Interpersonal Theory of Depression กลมตวอยางไดมาโดยการสมไดวยรนจำนวน 460 คนและมารดาของวยรนแตละคน เครองมอทใชในการวจยทวยรนเปนผตอบ ไดแก แบบสอบถามขอมลสวนบคคล ภาวะซมเศรา การเหนคณคาในตนเอง การสนบสนนทางสงคมจากบคคลอน การสนบสนนทางสงคมจากมารดา เหตการณทสรางความยงยากใจ และ การเลยงดของมารดา สวนเครองมอวจยทมารดาเปนผตอบ ไดแก แบบสอบถามขอมลสวนบคคลและภาวะซมเศรา ผลการศกษาพบวา โมเดลสมการโครงสรางมความสอดคลองกบขอมลเชงประจกษ และสามารถอธบายความแปรปรวนของภาวะซมเศราในวยรนไทยทมมารดาซมเศราไดมากกวา 60 % ผลการวจยนแสดงใหเหนถงอทธพลของภาวะซมเศราในมารดาและบทบาทของตวแปรสงผานทมอทธพลตอการเกดภาวะซมเศราในวยรน ผลการศกษาครงนทำใหเกดความเขาใจในการพฒนาโปรแกรมการปองกนการเกดภาวะซมเศราในวยรนทมมารดาซมเศราและการสงเสรมภาวะสขภาพจตในเดกไทยทมมารดามภาวะซมเศรา


คำ ำคญ: ภาวะซมเศราในวยรน การสนบสนนทางสงคม ความรสกมคณคาในตนเอง

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Vishuda Charoenkitkarn et al.

Cognitive Performance after a Transient Ischemic Attack: Attention, Working Memory, and Learning and Memory Vishuda Charoenkitkarn, Saipin Kasemkitwattana, Barbara Therrien, Orapan Thosingha, Thavatchai Vorapongsathorn

Abstract: This prospective study aimed to explore the three main areas of cognitive function (attention; working memory; and, learning and memory) among individuals who had experienced a transient ischemic attack (TIA). Convenience sampling was used to recruit 52 individuals, who had experienced a TIA, from outpatient and emergency departments in three tertiary hospitals, in Bangkok, and one tertiary hospital in Ayutthaya province, Thailand; as well as 52 persons, who had experienced minor surgery and served as matched control subjects, from the outpatient department at a tertiary hospital in Thailand. Subjects were assessed, 3, 10 and 30 days after experiencing a TIA or having minor surgery, using the Necker Cube Pattern Control Test, Trial Making A Test, Digit Span Forward and Backward Test, Barratt Impulsiveness Scale, Irritability Assessment Scale, Digit Symbol Substitution Test, and Hopkins Verbal Learning Test. A repeated-measures-within-and-across-subjects design was used to analyze the results. Findings indicate that those who had a TIA continued to experience attention, working memory, and learning and memory changes, but not irritability changes, for over 30 days after symptom occurrence. Three days after symptom occurrence, those who had a TIA showed less ability in the 3 main cognitive performances than did the control group. Their performance ability became worse at day 10, but improved at day 30. All performances among those with a TIA were lower than the control group, at all three time points. Thus, nurses should be concerned about the cognitive ability of those who have had a TIA, as well as their respective families, and provide information to both about the effects of a TIA, particularly 10 days after symptom occurrence.

Thai J Nurs Res 2009; 13(3) 199 - 215

Key Words: attention, cognitive performance, learning and memory, transient ischemic attack, working memory.

Introduction

Individuals who have experienced a transient ischemic attack (TIA) are at risk of a future stroke.1,2 One of the most common causes of TIA, or ischemic stroke, is atherosclerosis, which usually occurs in one of the internal carotid arteries.3 Prior studies have suggested that blockage of the internal carotid arteries may be a major risk factor for

Correspondence: Vishuda Charoenkitkarn, RN, PhD candidate, Faculty of Nursing, Mahidol University, Bangkok, Thailand. E-mail [email protected] Saipin Kasemkitwattana, RN, DNSc. Associate Professor, School of Nursing, Mae Fah Luang University, Chiang Rai, Thailand. Barbara Therrien, RN, PhD, FAAN. Associate Professor, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA. Orapan Thosingha, RN, DNSc. Assistant Professor, Faculty of Nursing, Mahidol University, Bangkok, Thailand. Thavatchai Vorapongsathorn, Ph.D. (Research Design & Statistics in Education), Associate Professor, Faculty of Public Health, Mahidol University, Bangkok, Thailand.

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Cognitive Performance after a Transient Ischemic Attack: Attention, Working Memory


cognitive impairment.2,4 The carotid arteries supply blood to the anterior two-thirds of the brain (prefrontal cortex, and lateral and temporal lobes).3 These areas control not only motor and sensory function, but also are associated with higher brain functions, such as thoughts and actions. Humans are able to attend to and analyze sensory data, perform memory functions, learn new information, form thoughts, solve problem and make decisions. Therefore, a TIA may produce changes in cognitive functions, which are more difficult to characterize than motor or sensory loss.

Clearly, cognitive difficulties may negatively impact one’s learning, understanding, and adoption of new health behaviors. However, previous investigations of cognitive function, among individuals who have experienced a TIA, have found conflicting results.5-10 Thus, before developing and implementing presumed effective health education programs to prevent strokes, it is important to identify one’s level of cognitive function, including attention, working memory, and learning and memory. Programs may need to be tailored to account for the person’s existing cognitive abilities or disabilities. For example, if a person cannot pay attention to the information being transmitted, he/she will not learn and remember.11, 12 In other words, if people cannot use the information they receive, they cannot change their behavior.

Literature Review

Despite the short duration of TIA symptoms, and absence of residual disability, those who have experienced a TIA require an active approach, because the risk of future events remains high. The highest risk is within the first 30 days.1,2 A study of patients presenting to an emergency department, within 24 hours after a TIA, reported a 5.3% risk of stroke at two days,13 a 8 % risk at seven days, and a 12 % risk at one-month.1 In an attempt to

prevent a recurrent stroke, national stroke guidelines recommend symptom management within the first 48 hours, after the onset of symptoms, and referral to a neurological specialist within 7 to 10 days.13,14 Treatment should include 300 mgs of aspirin, along with a 4-week intake of all other medications prescribed by the neurological specialist.14 In addition, health information needs to be provided each time the patient interfaces with a health care provider.

Nurses usually provide a psychosocial supportive role to individuals who have experienced a TIA. The main aspects of providing support include directing patients to key services, and giving appropriate and accurate information regarding treatment and lifestyle changes for the purpose of preventing future strokes.14 Therefore, effective communication between patients and nurses is essential, especially within the first month post-TIA. Nurses are aware, from practical experience, that non-adherence to health care regimens is a major factor in the recurrence of strokes.15,16 One seldom explored, yet potentially powerful explanation for why patients encounter difficulties in making lifestyle changes and adhering to treatment regimes, could be subtle or overlooked changes in patients’ cognition, or actual cognitive impairment. Problems within the brain of a person who has had a TIA may affect his/her ability to select, attend to, learn and/or remember information. Some cerebrovascular lesions are clinically silent or cause disorders in function so mild that the effect is hardly noticeable to the patient.17

Regarding the pathology of TIAs, one of the most common causes is atherosclerosis, which usually occurs in the internal carotid arteries.3 These two arteries supply blood to the prefrontal cortex (the anterior part of the frontal lobes of the brain) and the hippocampus (a structure located inside the medial temporal lobe of the cerebral cortex).3 When blood flow through one, or both, of the internal carotid arteries is impeded, cerebral ischemia occurs.

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Animal models have provided clues to the nature of cognitive function impairment secondary to a cerebral ischemia. Cerebral ischemia, lasting at least 5 minutes in rats, has been found to be related directly to the extent of damage in the hippocampus.18 The pyramid CA1 cells, in the hippocampus, are known to be very susceptible to ischemia.18 The hippocampus area of the brain plays an important role in both learning and memory processing. Research has shown that an ischemic event in the rodent brain leads to selective loss of pyramidal CA1 cells of the hippocampus, which slowly occurs over a two to three day period, with almost total destruction of the cells after four days.6 The cellular damage has been found to be present after a recovery period of one week.19 Tanaka and colleagues7 found, in Wistra rats, that cholinergic activity (an index of transmitter activity associated with learning and memory) in the frontal cortex markedly decreased 3 weeks after an ischemic event, but was restored six weeks later. The prefrontal cortex is another area significantly impacted by a TIA.2,3 This area of the brain is associated with cognitive functions, such as attention, working memory and executive attention (the main component of both attention and working memory).20,21 The findings of the aforementioned studies suggest that, in animal models, cognitive function may change, anywhere from a few days to nine weeks, after TIA symptoms occur.

Evidence suggests that cognitive problems are experienced, among humans, after a TIA occurs. Attention, working memory, and learning and memory are three main cognitive functions associated with the prefrontal cortex and hippocampus.5 Prior studies have confirmed that attention, working memory, and learning and memory impairment occur after one experiences TIA symptoms.8,9 In contrast, Sinatra and colleagues10 found individuals who had experienced TIA symptoms did not have

poorer performance in all verbal tests, than did those who had not experienced a TIA. However, the tests were administered one to three months after the occurrence of the last ischemic event.

Frontal lobe dysfunction, accompanying carotid stenosis, has been found to be associated with potential attention and working memory difficulties. For example, Rao and colleagues22 found two measures of frontal lobe function (verbal fluency and behavioral control) to be independent predictors of global cognitive impairment among individuals who have experienced a TIA. Moreover, Sachdev and colleagues23 found cognitive deficits among individuals who had experienced a TIA to be characterized by disturbances of frontal functioning, but with less verbal memory impairment. As a whole, prior investigations have revealed conflicting findings regarding cognitive functioning among individuals who have experienced a TIA. Cognitive function may be affected by the time of measurement and the various tests administered. However, they indicate cognitive function changes, within a month, after a TIA event occurs. Clearly cognitive difficulties would impact negatively the learning, understanding and adoption of new health behaviors.

Thus, based upon the need to prevent a recurrent stroke, during the first month after a TIA event, and due to the conflicting findings regarding cognitive function, the aim of this study was to explore the three main areas of cognitive performance (attention, working memory, and learning and memory) 3, 10, and 30 days after TIA symptom occurrence.

Method

Design: A repeated measures, within-and-across subjects, design, using case-control technique, was utilized to exam the pattern of cognitive performance of individuals, who had experienced a TIA, 3, 10, and 30 days after TIA symptom

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occurrence. Matched control subjects, after experiencing minor surgery, also were tested at the same intervals. Cognitive function has been studied primarily in Western cultures and, thus, norms may not be representative of Eastern cultures. The case-control study approach was used to obtain an index of normal cognitive function in a different culture.

Sample size

Sample size was calculated using the formula for ANOVA,24 yielding 52 subjects, who had experienced a TIA, and 52 control participants, who had experienced minor surgery, with a statistical power of 0.80, an effect size of 0.25 and a significance level of 0.05. The total sample size was 104 persons.

Sample

After institutional ethics committee approval was granted, from the main author’s academic institution and from all hospital settings involved in the study, subjects for both the TIA group and the minor surgery group were recruited. A convenience sample of 52 individuals who had experienced a TIA was drawn from the list of patients’ who were admitted through the outpatient and emergency departments of three tertiary hospitals in Bangkok and one tertiary hospital in Ayutthaya province, Thailand. Selection criteria, included individuals who had experienced a TIA and were: (a) at least 24 years old; (b) able to read and write Thai; (c) able to take and respond to tests and questions; (d) without hearing loss, eye problems, history of substance abuse or dependency, diagnosis of cancer, HIV/AIDS, head injury, attention deficit hyperactivity disorder or any known neurological disorder other than a TIA; (d) not currently on prescription medications known to alter cognitive processing; (e) not depressed; and, (f) willing to participate in

the study. A volunteer registered nurse, from each outpatient and emergency department, was asked to assist the primary investigator in recruiting potential subjects for the TIA group. This was accomplished by the volunteer nurse identifying potential subjects, via their chief complaint, and then confirming, with a neurologist, their diagnosis of TIA and adherence to the selection criteria. Once potential subjects were identified, the volunteer nurses explained: the objective of the study; what the subjects’ involvement would entail; that anonymity and confidentiality would be maintained; and, that the subject had the right to withdraw at any time, without negative repercussions. Potential subjects consenting to take part in the study were asked to sign a consent form and to provide their telephone number so that they could be contacted by the primary investigator. After receiving a subject’s consent to participate, the researcher called the subjects for the purpose of setting up an appointment to introduce herself and to arrange for the three administrations of the research instruments.

Fifty-two individuals, who had undergone minor surgery (i.e. any surgical procedure that did not involve anesthesia or respiratory assistance, such as excision of a scar or suturing of a minor wound), but had no known hypertension, diabetes, vascular disease or history of a TIA or stroke, were recruited for the control group. Potential subjects were identified by way of their patient record, while they were being seen in an outpatient department of one of the selected hospitals. Each potential subject was demographically (age, gender and educational level) matched with a subject in the TIA group. Once potential control subjects were identified, the primary investigator provided them the same information subjects in the TIA group received. Those consenting to participate were asked to sign a consent form and appointments were made with them for the purpose of administering the three rounds of the research instruments.

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Four subjects, who had experienced a TIA, had a stroke within 30 days of their initial symptoms. They and their four matching control subjects were removed from the study. As a result, four more individuals, who had experienced a TIA, as well as four matching control subjects, who had experienced minor surgery, were recruited and participated in the study. Thus, the attrition rate for the study was 7.69%

Instruments

A Demographic Data Questionnaire was used to obtain subjects’ demographic characteristics, while their cognitive performance (attention, working memory, and learning and memory) was evaluated via eight different measures. Their cognitive performance assessment included the: Necker Cube Pattern Control Test (NCPCT); Digit Span Forward Test (DSFT ; Trail Making A Test (TMAT); Barratt Impulsiveness Scale (BIS); Visual Analogue Scale (VAS); Digit Symbol Substitution Test (DSST); Digit Span Backward Test (DSBT) and, Hopkins Verbal Learning Test-revised (HVLT-R).

The researcher developed Demographic Data Questionnaire obtained information on all subjects regarding their gender, age and educational level. Data obtained on those who had experienced a TIA, included their TIA symptoms, length of symptoms and illness history.

Attention, the first component of cognitive performance, was assessed via five tests that measured distractibility, impulsivity and irritability. Distractibility was measured using the NCPCT, DSFT and TMAT. Impulsivity was assessed using the BIS, while irritability was measured by way of the VAS. The NCPCT was developed as a direct test of one’s “attentional capacity” (ability to inhibit a competing pattern stimulus) by using a cube with a width and length of 2 centimeters each and a depth of 1 centimeter.25, 26 Subjects may see the cube pattern in two different views, one when

looking at the foreground and the other when reversing to the background of the cube. To maintain one pattern, subjects have to mentally inhibit the alternative pattern. There are two assessment components to the NCPCT, for: 1) establishing a baseline of passive attention; and, 2) measurement of controlling, or effortful, attention.

In the first component, the subject is tested in two 30-second sessions (T1 and T2). The subject is asked to passively look at the cube. Each time the cube reverses or flips, the subject taps the researcher’s hand. The researcher counts the number of flips that occur.

In the second component, the subject is tested in the two more 30-second sessions (T3 and T4). The subject is asked to try to keep the cube from flipping. Whenever, the cube reverses or flips, the subject also taps the researcher’s hand. The numbers of flips that occur are counted. The values obtained from session T1 and session T4 are discarded. The value obtained in session T2 is subtracted from the value obtained in session T3, with the results being divided by the value obtained in session T2. This results is then multiplied by 100 for a percentage score [(T3-T2)/T2 x100]. The result was defined as the person’s attentional capacity. TIA subjects who had a significantly higher mean NCPCT score than their matched control were determined to have distractibility

The DSFT examines verbal recall; attention capacity and working memory by having subjects retain a verbally stated series of numbers, and then repeated back in the correct order.27 The number of digits in the sequence increases, with each successful repetition, until 9 digits are successfully repeated, or until the person fails, at a given sequence, after two attempts. The score is the highest number of digits successfully completed. Scoring is expressed in the form of a digit. Each item is scored 0, 1, or 2, with: 2 = passes both trials; 1 = passes only one trial; and, 0 = fails both trials. TIA subjects who

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had significantly lower mean scores than their matched control were considered to have attention impairment and distraction.28

Attention and concentration abilities, including visual-motor, conceptual tracking and sequencing skills, were measured by the TMAT.29 This instrument is a timed (minutes) paper and pencil test, which consists of 25 encircled numbers randomly scattered over an 8x11 paper. Subjects are instructed to connect, in order, the series of numbers without lifting his/her pencil from the paper. TIA subjects, who spent significantly more time to complete the

test than their matched control, were determined to have poorer attention and concentration abilities.

Impulsivity was measured by the Barratt Impulsiveness Scale (BIS) short form,30 which consists of 15 items with a 3 factor structure: poor-planning (5 items), motor impulsivity (5 items) and attention impulsivity (5 items). Since it originally was used with students, slight modifications of the situation in the questionnaire were made for this study. Each of two original questions on attention impulsivity was replaced by a more relevant question, as follows:

The scores of the items of the BIS were rated on a 4-point Likert-type scale (1= rarely/never to 4=almost always). TIA subjects who had significantly higher scores, than their matched control, were considered to have high impulsivity.

Irritability was measured, using a Visual-Analogue Scale (VAS).25 Subjects were asked to respond to two mood state items (patience and annoyance), which assess how they usually feel and how they currently feel. The four questions asked were:

1. How patient am I with others usually? 2. How patient am I with others right now? 3. How easily annoyed or irritated am I

usually? 4. How easily annoyed or irritated am I

with others right now? For each of the four questions, subjects are

asked to place a mark on a 100 mm line which has, at one end, “not at all,” and, “extremely so,” at the other end. For each of the two mood states, the placement of the mark on the 100 mm line, for the “usually” response, was compared to the placement of the mark, for the “right now” response. The distance,

in millimeters, was measured between the two marks. The larger the distance between the two marks, the greater the presence of irritability. TIA subjects who had significantly higher scores, on the difference between the “usual” and “right now” responses for the two mood states (patience and annoyance), than their matched controls, were considered to have higher irritability.

Working memory, the second component of cognitive performance, was assessed by way of the Digit Symbol Substitution Test (DSST) and Digit Span Backward Test (DSBT). The DSST is used to identify cognitive and cerebral dysfunction. This tool requires complex visual scanning and tracking perception, motor speed, and memory.31 The test consists of rows containing small blank squares, each paired with a randomly assigned number from one to nine. Above the rows is a printed key that pairs each number with a different symbol. The subject is required to scan the numbers and fill in the blank space with the symbols corresponding to each number, as rapidly as possible, within 90 seconds. The number of correctly matched symbols and numbers that are recorded, within

Original: I am restless at lectures and talks. New: I am restless when listening to long talks.

Original: I squirm at plays or lectures New: I squirm when listening to long talks.

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90 seconds, are counted. TIA subjects who had a significantly lower score, than their matched control, were considered to have a working memory deficit.

The Digit Span Backward Test (DSBT) measures working memory, which involves both the storage and manipulation of information.27 Subjects are asked to repeat digits backwards after they are verbally stated by the researcher. The number of digits, in a sequence, increase, with each successful repetition, until 9 digits are successfully repeated, or until the subject fails at a given sequence, after two attempts. The score is the highest number of digits completed. Scoring is expressed in the form of a digit. Each item is scored 0, 1, or 2, with: 2 = passes both trials; 1 = one trial is passed; and, 0 points = both trials are failed. TIA subjects who had significantly lower mean scores, than their matched control subject, were considered to have working memory impairment.

Learning and Memory, the third component of cognitive performance, was assessed using the Hopkins Verbal Learning Test-R (HVLT-R).32 This tests examines three aspects of learning and memory: total recall, retention and recognition. The HVLT-R tasks include three learning trials (T1, T2 & T3), one 20-25 minute delayed recall trial (T4), and one yes/no delayed recognition trial (T5). The latter trial (T5) consists of a randomized list that includes the 12 target words and 12 non-target words, six of which are drawn from the same semantic categories as the target words. Raw scores are derived for total recall, delayed recall, retention (% retained), and a recognition discrimination index. The scores are measured as follow: 1) Total Recall = Trial 1 + Trial 2 + Trial 3; 2) Percent retained = (Trial 4 / Trial 3) x 100; and 3) Recognition = number of

hits of the T5 recognition trail / 12. TIA subjects who had significantly lower scores, than their matched control, were considered to have learning and memory deficits.

Since all instruments, except the Demographic Data Questionnaire, were written in English, they required translation into Thai and then back translation into English. The back translated English version of each instrument was compared to its original English version to make certain that no changes in meaning occurred. Permission to use and translate each of the copyrighted instruments was obtained prior to them being translated and used.

Instruments’ validity and reliability: The primary researcher was trained in the use of the instruments by Dr. Barbara Therrien, School of Nursing, University of Michigan and Dr. Bruno Giordani, Director, Neuropsychology Section, Department of Psychiatry, University of Michigan, USA. Content validity of all instruments in Thai version was tested by four experts who were two psychologists, one medical doctor, and one neurologist. Face validity was assessed by administering the instruments to ten Thai elderly, who were not part of the study, for the purpose of evaluating cultural appropriateness, language, level of readability and clarity of instructions. Instrument items and instructions were revised accordingly, based upon feedback from the ten Thai elders. All instruments were pilot tested on 20 individuals, who met the study’s inclusion criteria, but would not be part of the study. Based upon the pilot study data, test-retest reliability was assessed on the: NCPT, DSFT, DSBT, TMAT, DSST and HVLT-R. The BIS and VAS were tested by way of Cronbach’s alpha. The reliabilities for all instruments were acceptable (r = .812 to .985).

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Procedure

Each subject in both groups (TIA and matched control) was administered the battery of tests, by the primary researcher, in his/her respective home, on three separate occasions. Test administration occurred for those in the TIA group 3, 10 and 30 days after experiencing symptoms, while his/her matched control was administered the tests 3, 10 and 30 days after having minor surgery. The test environment was free of distractions (music, noise, people, or outside view) during the testing process. It took subjects approximately 50 minutes to complete all tests.

Results

No significant differences were found among the demographics between those who had experienced a TIA and those who had experienced minor surgery. The majority were middle-aged males, with a low level of education (see Table 1). Among those who had experienced a TIA, it was their first TIA episode. All of them had a history of hypertension and most (n =52; 100%) encountered physical weakness and difficulty speaking (n = 29; 55.70%) after experiencing their TIA. Their symptom duration ranged from 5 to 120 minutes, with a mean of 20 minutes (see Table 2).

Gender - Male 31 59.60 31 59.60 - Female 21 40.40 21 40.40 Age (years) < 40 2 3.80 2 3.80 40-49 19 36.50 19 36.50 50-59 21 40.40 21 40.40 60-70 10 19.20 10 19.20

Average Mean=52.52 ( SD=7.97), Mean=52.52 (SD=8.00), Min-max = 37-69 years Min-max=37-68 years

Education - Illiterate 7 13.46 7 13.46 - < Elementary school 7 13.46 7 13.46 - Elementary school 12 23.08 12 23.08 - Secondary school 8 15.38 8 15.38 - High school / Vocational school 6 11.54 6 11.54 - Diploma Degree / Vocational school 6 11.54 6 11.54 - Bachelors or Higher Degree 6 11.54 6 11.54

Table 1 Demographic characteristics of the sample

Demographics TIA Control n % N %

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Symptoms

- weakness on left side 4 7.70 - weakness on right side 11 21.20 - speech difficulty 8 15.40 - weakness on left side & speech difficulty 2 3.80 - weakness on right side & speech difficulty 27 51.90

Duration of Symptoms (minutes)

<10 1 1.90 10-59 48 92.30 >59 3 5.80 Average Mean=20 SD=20.627 Min=5; Max=120 Personal Illness History

- Hypertension 26 50.00 - Hypertension & diabetes mellitus 12 23.10 - Hypertension & hyperlipidemia 6 11.50 - Hypertension, diabetes mellitus & hyperlipidemia 8 15.40

Table 2 Characteristics Related to Health Status (n = 52)

TIA Demographics N %

All variables met the assumptions underlying statistical testing for two-way analysis of variance (ANOVA) repeated with one factor. Results of the Necker Cube Pattern Control Test (NCPCT), Trail Making A Test (TMAT), Digit Span Forward Test (DSFT), Barrett’s Impulsiveness Scale (BIS), Digit Span Backward Test (DSBT), Digit Symbol Substitution Test (DSST) and Hopkins Verbal Learning Test-revised (HVLT-R) showed a similar pattern. The main effect of time points and group, as well as the interaction effect of group by time points, were significant (p<.05; .01; .001). These findings imply that those who had experienced a TIA, as well as those who had minor surgery, had a different degree of attention, working memory, and learning and memory at each of the three time points (see Table 3).

Comparing mean scores of all tests performed revealed that those who had experienced a TIA displayed poorer performance than did those who had minor surgery, with respect to attention, working memory, and learning and memory at each of the three time points. Individuals who experienced a TIA also were found to have a similar pattern of impairment, which indicated some degree of impairment three days after TIA symptom occurrence. The mean scores of all tests showed increased impairment, among those who experienced a TIA, 10 days after they had TIA symptom occurrence. In contrast, the battery of test scores showed a change towards improvement 10 to 30 days after TIA symptoms occurred. However, those who experienced a TIA still exhibited poorer performance in cognitive performance than did those who had minor surgery (see Figure 1).

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Attention

NCPCT TIA -52.23±15.03 -48.74±12.80 -55.97±12.36 13.09*** 10.90*** 12.02*** Control -59.99±12.01 -60.84±10.75 -60.73±11.06

Trail Making a Test TIA 59.83±1.92 63.06±2.05 57.35±2.02 12.77** 45.90*** 52.66*** Control 51.50±1.39 51.50±1.40 51.54±1.39

DSFT TIA 11.88±1.82 10.96±1.77 12.46±1.82 11.45** 47.319*** 30.90*** Control 12.82±0.24 12.81±0.24 12.98±1.82

Barrett’s Impulsivity TIA 27.10±0.50 27.35±0.48 26.76±0.52 27.65*** 13.19*** 4.37* Control 23.27±0.50 24.75±0.48 22.98±0.52

Irritability TIA 5.38±0.57 5.19±0.57 4.81±0.55 5.35* 1.06ns 1.13ns

Control 3.65±0.57 3.07±0.52 3.56±0.55

Irritability TIA 5.48±0.50 4.71±0.50 4.33±0.47 4.43* 2.85 ns 0.56 ns

Control 3.65±0.62 3.46±0.61 3.17±0.59

Working Memory

DSBT TIA 6.92±0.25 5.83±0.24 7.13±0.27 15.74*** 32.61*** 55.22*** Control 7.98±0.24 8.06±0.25 7.85±0.25 DSSTa

TIA 34.58±1.36 32.52±1.34 35.40±1.34 16.97*** 92.91*** 59.43*** Control 41.50±1.13 41.23±1.13 41.54±1.15

Learning & Memory

HVLT -R - Total Recall TIA 20.54±0.71 19.10±0.40 22.06±0.64 11.27** 32.30*** 30.30*** Control 23.17±0.53 23.37±0.52 23.40±0.52 - Retained

TIA 104.69±2.39 96.55±2.62 114.20±1.38 60.55*** 12.98*** 10.76*** Control 122.64±1.53 117.13±1.53 118.38±1.39 - Recognition

TIA 1.71±0.02 1.63±0.02 1.74±0.02 22.33*** 58.53*** 41.04*** Control 1.78±0.02 1.77±0.02 1.80±0.02

*p<.05,; **p<.01; ***p<.001

Table 3 Repeated measures ANOVA for TIA group and matched control group

3 days 10 days 30 days Group Time Group x Time Mean±SD Mean±SD Mean±SD F F F

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Figure1 Comparison of the mean scores of the NCPCT, DSFT, TMAT, DSBT, DSST, and HVLT-R

The irritability score of those who experienced a TIA did not show, over the 30 day period, the same pattern of change as the other test scores. However, the mean irritability scores of those who had experienced a TIA suggested they were more irritable, at all three time points, than were those who had experienced minor surgery.

Discussion

The results provided evidence that compromised cognitive performance (attention, working memory, learning and memory) occur after a TIA. Most subjects presented with weakness and speech difficulties, which may have occurred secondary to a disturbance in their frontal lobe, and the lateral surfaces of their temporal and parietal lobes, due to ischemia.3,34 Thus, their symptoms may have contributed to their brain function.

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Furthermore, the mean duration of TIA symptoms was 20 minutes, providing an indication of the extent of possible CA1 cell damage, in the hippocampus, and deficits in spatial learning. Confirmation of CA1 cell loss has been conducted, in rats, when ischemia has occurred for 5 and 10 minutes.17 The fact that those who had experienced a TIA had ischemia for approximately 20 minute helps explain why their cognitive performance was worse than those who had minor surgery. In addition, results of this study are supported by prior findings,35, 36 which show that persons with an obstructed carotid artery, who have experienced a TIA, can have lasting cognitive impairment, which affects their attention, memory and learning, despite recovery of their focal neurological deficits, such as weakness or speech difficulties.

Attention: Anatomical studies on attention impairment have cited findings regarding prefrontal and parietal lobe damage.20 This study found impaired performance, at all three time points, when using measures of distractibility and impulsivity, two of the indicators of attention impairment. Attention is essential for effective functioning, since it is necessary for learning needed information.

Distraction manifests as failure to inhibit competing demands or loss of focus, while impulsivity is related to the loss of inhibition in the behavioral dimension. In this study, results from the BIS showed the same pattern as those of the distractibility tests (NCPCT, DSFT, TMAT). These results corroborate other studies, which concluded there are real attention deficits among individuals who have experienced a TIA.22, 23 In contrast, individuals who have experienced a TIA have been found to not necessarily show worse performance than those who have not experienced a TIA.10 However, this was found through the use of dissimilar tests from this study and without matched controls, based on gender and education.

In this study, an increase in distractibility and

impulsivity was found between days 3 and 10, and beginning improvement of cognitive function was noted between days 10 to 30. This may be related to the fact that body weakness is present when prefrontal and parietal lobes are damaged.20 In addition, brain cells are known to remain damaged one week post-TIA symptoms.18 Another explanation for the worsening of attention capacity, at day 10, is that environmental and life demands may be increasing at that time, since subjects were trying to return to their normal life activities. It is likely that these demands overwhelmed their attention capacity, since their brain cells still were compromised. Beginning improvement of cognitive function may have been noted between days 10 to 30, since neurological recovery is known to generally occur during the first few weeks to months, post attack.37 The fact that attention deficit was still found at day 30, among those who had experienced a TIA, most likely is related to the fact that, in Wistar rats, an increase in choline acetyltransferase activity in the frontal cortex and hippocampus, caused by hypofusion of cerebral blood flow in the forebrain, results in behavior deficits.7

Although the results of the irritability testing (VAS) did not show the same pattern as found with distraction or impulsivity, those who had experienced a TIA showed more irritability than did the controls at all three times of measurement. This may be because the irritability test was not sensitive enough, or the irritability change was too small, to detect the change. It is possible, also, the irritability test failed to adequately capture irritability, due to no specific situation being provided, or the subjects could not feel a change in their irritability.

Working memory: Results suggest those who had experienced a TIA had working memory impairment, as measured by the DSBT and the DSST. A consistent pattern of change in their working memory was found, over the three time periods, similar to the distraction and impulsivity

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testing. One component of the working memory model is the central executive function, which is an attentional control system in the attention model. Executive function has been shown to be responsible for directing attention to relevant information, suppressing irrelevant information and inappropriate actions, and coordinating cognitive processes, when there is more than one task to be done at the same time.21 In this study, those who had experienced a TIA were found to have attention deficit. Thus, they had deficiencies in their working memory and were not able to manipulate all the information they received.

Another possible explanation of the finding is there is a relationship between the frontal lobes and working memory. Prior studies have shown the frontal lobes play an important role in working memory.38 Electrophysiological recordings have demonstrated that some neurons, in the frontal lobes, fire only during the delay period of a working memory task.39 Impairment of working memory means that information cannot be acquired, manipulated or used in a normal manner, significantly impacting what and how much one can learn and remember.

Learning and Memory: Learning and memory performance (assessed by the HVLT-R) of those who had experienced a TIA were lower than that of their matched controls. Thus, the pattern of learning and memory of those who had experienced a TIA appeared to be similar to the pattern of attention and working memory.

Impaired learning is known to be associated with ischemic damage to the temporal lobe, especially the hippocampus, which is supplied with blood by the internal carotid arteries. It has been found that CA1 cells, in the hippocampus of animals, are sensitive to ischemia and related to learning and memory.18 In addition, attention is needed to focus on the target of information before manipulating it by working memory. The working memory then manipulates the information and

transfers it to long term memory. These three main concepts appear to work together as a network. Thus, either attention or working memory deficits could influence one’s ability to learn and remember, and have an indirect relationship with other cognitive impairments on learning. It is likely that the explanation, regarding the learning and memory deficits of those who have experienced a TIA, involves a combination of the above.

The pattern of change also may be explained by the delayed death of CA1 cells, after a carotid occlusion, in the hippocampus. Animal studies have revealed that after an ischemic event of at least 5 minutes, the cells change very slowly after two days; but are almost totally destroyed within four days.18 Therefore, those who have experience at TIA, at day three, may show less ability in learning and memory than they had pre-TIA, due to the decreased number of functioning CA1 cells. It also is possible that the destruction of CA1 cells continued, which may account for the worsening of learning and memory at day ten post-TIA.

In contrast, test scores, of those who had experienced a TIA, showed improvement, between day 10 and day 30. This may be related to the fact that the activity of the enzyme, choline acetyltransferase, has been found to be restored, in sham-operated rats, six weeks after a carotid ligation.7 In addition, choline acetyltransferase dysfunction has been shown to be correlated with discrimination learning disabilities in hypoperfused rats.7 Even though improvement was noted, among those who had experienced a TIA, at day ten, such an explanation may explain why their HVLT-R means scores, at day 30, were poorer than the HVLT-R means scores of their matched control. Prior research also found that individuals who had experienced a TIA subjects showed significant differences in their cognitive impairment, when compared to persons who had not experienced a TIA. 23

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Conclusions, Recommendations and

Limitations

This study found that impairment of attention, working memory, and learning and memory, but not irritability, occurred in the first few days after the presentation of TIA symptoms. The impairments were found to worsen, by day ten, but improved between day 10 and 30. However, it is not clear if there was continual regression before recovery, or if recovery had begun earlier than the tenth day. Regardless, nurses need to assess the ability of those who have experienced a TIA to receive information, particularly 10 days after their initial symptom occurrence. Further research is needed to measure cognitive performance at different times, i.e. at days 3, 5, 10, 15, 20 and 30 to help clarify the impairment pattern.

Moreover, the findings show that those who experienced a TIA may have had cognitive impairment before testing. Their cognitive impairment may have occurred before the presentation of their TIA symptoms. Since to demonstrate the effect of cognitive impairment, the relationship between cognitive impairment and an individual’s ability to learn and remember are required, comparison of cognitive performance, among those who have TIA symptoms and individuals who do not have TIA symptoms should be explored.

Although irritability among those who had experienced a TIA did not change within 30 days of their occurrence of symptoms, they were found to have more irritability than their matched controls, at all three times of measurement. Even though the instrument used to measure irritability had a high reliability, the individual items used within the instrument need to be further examined, since it is possible they were not sufficiently

sensitive to detect changes in the subjects’ irritability. In addition, the use of qualitative questions, in future studies, may be needed to enhance measurement and interpretation of irritability.

Finally, the primary researcher, who had been trained to administer all the tools used, as well as to score and measure the results, did so solely by herself. Therefore, unintentional biases in the measurement and reporting of data may have occurred.

Implications for Nursing Practice

The findings may stimulate nurses and other health care providers to consider patients’ ability to think, receive information, and learn, particularly 10 days after having experienced the occurrence of TIA symptoms. If any information is to be given, during this time, families or relatives probably are the key persons to help those who have experienced a TIA receive suggestions and instructions from nurses and other health care providers. Moreover, individuals who have experienced a TIA should be cautioned to think before they act, especially since impulsivity often leads to falls, accidents and mistakes.

Furthermore, nurses should implement therapies to help those who have experienced a TIA deal with their cognitive changes. Examples of restorative techniques, which may assist to improve learning and memory, include: using vivid pictures to capture attention; limiting competing stimuli (TV); doing one task at a time; speaking slowly; using short sentences during instructions to facilitate working memory; putting important pieces of information first and last during short instruction periods; and, building in repetition and demonstration of tasks.25, 40

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Acknowledgements

The lead author wishes to thank the Faculty of Nursing, Mahidol University and the Commission of Higher Education for their scholarship, as well as the Thailand Nursing Council for Nursing and Midwifery for the grant which supported this study.

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ตดตอท: วชชดา เจรญกจการ, RN, PhD candidate, คณะพยาบาลศาสตร มหาวทยาลยมหดล ประเทศไทย E-mail [email protected] สายพณ เกษมกจวฒนา, RN, DNSc. รองศาสตราจารย คณะพยาบาลศาสตร มหาวทยาลยแมฟาหลวง จงหวดเชยงราย ประเทศไทย Barbara Therrien, RN, PhD, FAAN. Associate Professor, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA. อรพรรณ โตสงห, RN, DNSc. ผชวยศาสตราจารย คณะพยาบาลศาสตร มหาวทยาลยมหดล ประเทศไทย ธวชชย วรพงศธร, Ph.D. รองศาสตราจารย คณะสาธารณสขศาสตร มหาวทยาลยมหดล ประเทศไทย

ประสทธภาพในการเรยนรจดจำของผทเคยมอาการสมองขาดเลอดชวคราว: สมาธ กระบวนการจำ การเรยนรและความจำ วชชดา เจรญกจการ, สายพณ เกษมกจวฒนา, Barbara Therrien, อรพรรณ โตสงห, ธวชชย วรพงศธร

บทคดยอ: การศกษาไปขางหนา (prospective study) นมวตถประสงคเพอ ประเมนประสทธภาพ การเรยนรจดจำ 3 ดานหลก ไดแก สมาธ (attention) กระบวนการจำ (working memory) และการเรยนรและความจำ (learning and memory) ของผทมอาการสมองขาดเลอดชวคราว (TIA) คดเลอกกลมตวอยางแบบสะดวก (convenient sampling) จากผทเคยมอาการสมองขาดเลอดชวคราว 52 คน ทมารบการรกษาทหอผปวยนอกและหนวยฉกเฉน จากโรงพยาบาลระดบตตยภม 4 แหง ในประเทศไทย และผทเคยไดรบการผาตดเลก (กลมควบคม) 52 คน จากผทมารบการรกษาทหอผปวยนอก จากโรงพยาบาลระดบตตยภม 1 แหงในประเทศไทย เครองมอทใชไดแก แบบทดสอบ Necker Cube Pattern Control, Trial A, Digit Span Forward, Barratt Impulsiveness Scale, Irritability Assessment Scale, Digit Symbol Substitution, Digit Span Backward, และ Hopkins Verbal Learning เกบรวบรวมขอมลโดยการทดสอบและสมภาษณ 3 ครง ในวนท 3,10 และ 30 หลงจากมอาการสมองขาดเลอดชวคราว วเคราะหขอมลดวยสถตการวเคราะหความแปรปรวนแบบวดซำ ผลการวจยพบวา ผทเคยมอาการสมองขาดเลอดชวคราว มสมาธ กระบวนการจำและการเรยนรและความจำ เปลยนแปลงในชวง 30 วนหลงจากมอาการสมองขาดเลอดชวคราว โดยประสทธภาพการเรยนรจดจำทง 3 ดานหลก ตำกวากลมควบคมในวนท 3 หลงเกดอาการสมองขาดเลอดชวคราว ยกเวนเรองอารมณหงดหงด(Irritability) และมประสทธภาพตำลงอกในวนท 10 แตประสทธภาพนนกลบดขนในวนท 30 อยางไรกตามประสทธภาพการเรยนรจดจำทง 3 ดานของกลม TIA ตำกวากลมควบคมทกชวงของการประเมน ขอเสนอแนะจากผลการศกษา พยาบาลและบคลากรทางดานสาธารณสขควรตระหนกถงความสามารถในการรบขอมลขาวสารของผทเคยมอาการสมองขาดเลอดชวคราว โดยเฉพาะวนท 10 หลงเกดอาการ ผปวยอาจขาดสมาธ ตดสนใจเรว และความสามารถในการเรยนรและความจำลดลง ญาตควรมสวนชวยในการรบฟงคำแนะนำจากทมสขภาพเพอชวยดแลผปวยใหปฏบตตามแผนการรกษาตอทบานไดอยางถกตอง


คำ ำคญ: ประสทธภาพในการเรยนรจดจำ ผทเคยมอาการสมองขาดเลอดชวคราว สมาธ

กระบวนการจำ การเรยนรและความจำ

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Participative Model of Child Protection in Northern Thailand


Participative Model of Child Protection in Northern Thailand Naruemon Auemaneekul, Wilawan Senaratana, Yuwayong Juntarawijit, Kasara Sripichyakan, Barbara J. Ensign

Abstract: This community-based, participatory research was undertaken with the aim to develop a model for promoting child protection in Northern Thailand. Semi-structured interviews, focus group discussions, participant activities and observations, group meetings and brainstorming were conducted among children, parents, villagers and key community leaders of one rural community in Chiang Mai province, Thailand. Content analysis was utilized for analyzing qualitative data. The model demonstrated three levels of protective factors for child protection. At the individual level, both children and parents needed to be equipped with the skills and knowledge of child protection. At the family level, the focus was on promoting family warmth and applying sufficient economy. At the community level, the emphasis was on promoting public awareness, encouraging a child protection network, and developing a community child protection master plan. Community mobilization supported the sense of belonging and sustainability of the project. The participation evaluation indicated change outcomes in terms of more network interest, raising public awareness, improving capacity, disseminating knowledge, and committing and implementing community child protection policy. The study outlines implications for nursing research, education and practice regarding child protection. Culturally appropriate activities and programs also were encouraged.

Thai J Nurs Res 2009; 13(3) 216 - 226

Key words: child protection, participative model, Northern Thailand

Background and Significance

Children have rights to special protection because of their powerlessness against maltreatment. The United Nations (UN) Convention on the Rights of the Child (CRC), to which Thailand became a signatory, addresses survival, protection, development and participation rights.1 Child protection refers to protecting children from violence, exploitation, abuse and neglect.1, 2 Violations of children’s rights to protection are massive, under-recognized and underreported obstacles to child survival and development. According to the World Health Organization’s (WHO) Global Burden of

Correspondence to: Naruemon Auemaneekul, RN, PhD Candidate Faculty of Nursing, Chiang Mai University, Thailand. E-mail: [email protected] Wilawan Senaratana, RN, MPH. Associate Professor, Department of Public Health Nursing, Faculty of Nursing, Chiang Mai University, Thailand. Yuwayong Juntarawijit, RN, DrPH. Assistant Professor, Department of Public Health Nursing, Faculty of Nursing, Chiang Mai University, Thailand. Kasara Sripichyakan, RN, PhD. Associate Professor, Department of Pediatric Nursing, Faculty of Nursing, Chiang Mai University, Thailand. Barbara J. Ensign, RN, DrPH. Associate Professor, Department of Psychosocial & Community Health, School of Nursing, University of Washington, Seattle, WA, USA.

Disease, some 875,000 children and adolescents, under the age of 18 years, died as result of an injury or violence in 2002.3 Most child victims are abused by their parents.4

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In Thailand, the available statistics of child victims who need help has been increasing almost every year.5, 6 The statistics from the Health Care Service Development Office, Ministry of Public Health,7 revealed, in 2007, there were 19,068 cases of abuse, which involved women and children, for an average of approximately 52 cases of abuse daily. Of the child abuse cases reported between 2004 and 2007, the majority involved sexual abuse (60-70%), followed by physical abuse (20-30%), mental abuse (3-7%) and neglect (2-4%).

Review of the literature, regarding Western culture and Thai research, reveals child abuse prevention research has focused on improving a protective environment, parenting and children’s life skills. Most of the studies have used a quasi-experimental design, when examining families at risk.8, 9, 10, 11, 12 Although positive changes have been reported in most of the studies, limitations in design, including: small sample sizes, few common characteristics being evaluated among the studies, the use of similar methodology, and inadequate formal and rigorous evaluations have been noted. Therefore, the design of new studies should take these limitations into account.11, 13 In addition, the impact of the findings from previous studies, on children’s life skills and knowledge, remains unknown.14

Prevention is the priority, which also supports and advocates for mitigating the effects of abuse. The quasi-experiments and randomized control trials, which were examined, can neither be used to confirm nor refute questions about one’s values or beliefs. The content of the studies also does not indicate how children and parents retained skills, learned during the studies, or maintain modified behaviors, if they were not supported within their own homes or communities. Additionally, child abuse is a problem, which is influenced by the norms, customs, values and beliefs of the people in a specific geographical area. Therefore, taking cultural and ecological context into account,

encouraging participation from individuals within a specific community, encouraging general respect for the rights of the children and raising awareness that all forms of violence against children are taboo is needed.

Community Based Participatory Research (CBPR) increasingly has been applied in violence related fields, especially in child abuse prevention efforts.15, 16 All reviewed studies confirmed the CBPR approach engaged local knowledge, and encouraged the enhancement of cultural relevance, on the respective issue under examination.15, 16, 17, 18 In order to protect children from being abused, it would be helpful when trying to understand the perception of people, in a specific geographical area, regarding their cultural beliefs on child physical abuse and corporal punishment, to have accomplished a community based participatory assessment. This is significant since the concerns, beliefs, and cultural values and norms, mentioned by the community members, need to contribute to the development of proper child protection programs and activities that fit within the local culture.

Therefore, the purpose of this study was to develop a child protection model based on the participation of community members. The following questions were posed: How does the community participate in developing a culturally appropriate model of child protection? What is a culturally appropriate model of child protection in Northern Thailand?

Method

Community Based Participatory Research (CBPR) was employed as the research method in this study. Motivation for this research arose from expressions of interest and concern regarding the issue by stakeholders in the Northern Thailand rural community used as the research setting.

Sample: Participants were: community leaders (Chief Executive of the Sub-district Administration Organization [SAO]; Community Abbot; Sub-district and Village Headman; Assistant Village Headman;

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Chair of the Public Health Center; and, Director of the primary school in the community); community members, including a group of 10-13 year old children (both low and high risk) and their parents; local organization personnel, both formal and informal community leaders; and, other interested villagers. Also contributing to the study were volunteers of the Community Network on Child Protection committee (CNCP); child protection experts; and, two local research assistants.

Research Instruments: The primary instruments for data collection were personal interviews conducted by the primary researcher. In addition, the primary researcher provided interview guidelines for focus group discussions, semi-structured interviews and an observation guide. Tools included tape cassettes and tape-recorders. Two research assistants were trained regarding the data collection procedures, and provided assistance as note takers, facilitators and co-coordinators for the research activities, as well as interviews transcribers.

Research Procedure: The research procedure for model development was based on the concepts of Community Based Participatory Research (CBPR). The strategies used involved people, capacity building, taking culture into account, working partnerships, power sharing and community change. The free participation in the model development process, among the participants, generally, began with community preparation, problem identification, capacity building, planning, collaborative community assessment, and reflection and sharing of the findings. The desired child protection model was tailored via validation and review of child protection experts, and reflection and consensus among community members. This was followed with planning for implementation of a policy driven model, including participative evaluation for project monitoring and further improvement.

Data Collection: Data were collected via focus group discussions, semi-structured interviews,

group and public meetings, brainstorming, participative activities, participative observation and field notes. The interviews lasted one and a half to two hours each. During each interview, note taking, clarification of questions and eliciting of elaboration of responses was accomplished by the primary researcher and research assistants. The primary researcher played the role of facilitator, consultant and participant observer when conducting group and public meetings, including group brainstorming sessions. Upon completion of data collection, the researcher reflected on the observations, interactions and discussions, impressions from the field notes, as well as transcribed the interviews verbatim from the audio tape-recordings.

Trustworthiness: To ensure trustworthiness of the study, criteria for developing an effective evaluation of qualitative research was employed.19, 20, 21 Credibility of the study was established by prolonged engagement with the participants, triangulation of information from the multiple data sources, member checking and use of peer debriefing processes. Transferability of the study to other contexts was established by providing a data base with sufficient information and detailed descriptions of the means utilized. Dependability and conformability, in this study, were established by providing enough information and an audit trail.

Data Analysis: Data analysis of statements and opinions voiced by the target groups during the focus groups and semi-structured interviews was based on content analysis.22 This process allowed the researcher to analyze and classify words and/or statements. Data then were interpreted for the induction analysis, so as to answer the research questions.

Human Subjects Protection: Prior to implementation, the study was approved by the Human Subjects Review Board of the Faculty of Nursing of the researcher’s university. Informed consent was obtained from all participants. Data collection procedures were designed to cover all aspects of protecting the human subjects. Participants’

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names were not disclosed, and all other information was kept confidential. The audio-tapes, from the interviews, were erased, and written transcripts were destroyed upon completion of the study.

Results

Team building: The study began with introduction of child abuse issues to the community, and community discussion was encouraged regarding the situation, causes and consequences of child abuse. As a result, community awareness was raised and a community child protection team, comprised of volunteers, was established. They later were named the “Community Network on Child Protection committee” (CNCP). A team building activity then was conducted, to facilitate community members in getting to know each other and in learning to work together as a team.

Need identification: The model development process began with need identification from the CNCP and other community members. There was community concern that child abuse causes long-term negative consequences, both for individual children and society, as a whole. The CNCP and other community members, therefore, decided to instill prevention measures, rather than wait for serious cases to occur in the community. They equated protection measures to vaccines for communicable diseases, and expressed the belief the proverb ‘spare the rod, spoil the child’ should be adjusted and carefully applied for more appropriate child rearing practices. The participants stated:

“Waiting for a case to happen is just like shutting the stable-door after the cow has been stolen” “Voey haey leaw loom koo (ววหายแลวลอมคอก)”

“Protection is the vaccine” “Kan pong kan preab sa muan kan ceet vaccine” (การปองกนเปรยบเสมอนการฉดวคซน)

Problem Identification: The child abuse situation analysis was suggested and the data collection methods were raised from individual observations or what is called “detective inquiry activity.” Information was collected from the CNCP and focus groups, composed of children, parents and villagers. In addition, semi-structure interviews were conducted with key informants. Information for the situation analysis was gathered, by the researcher, research assistants and volunteers, from the CNCP.

Risk factors, suggesting the need for child abuse action in the community, included community conflict, social isolation, communication problems, pilfering, presence of gangs, broken families, family violence, alcohol abuse, stress, gambling, economic problems and materialism. It was determined that this was an at risk community (see Figure 1). Despite the presence of these risk factors, no indication of serious child abuse cases was found in the community.

Model development: The child protection concepts, gained during focus group discussions and semi-structured interviews, were used as the first draft for the community child protection model. This was then presented, to the community members during a public meeting, in order to get feedback and suggestions. The CNCP was given the responsibility of revising the model to more comprehensively reflect the community concerns. The model then was reviewed by external child protection experts, and presented to the community group for consensus. This resulted in the final draft of the primary prevention model for child protection in the community.

The child protection model emphasized participation among local organizations and community members, in order to protect children from all kinds of abuse. This included improved surveillance of children and families at risk. Details of the community child protection strategies are portrayed in Figure 2.

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Figure 1 Problem identification

Figure 2 Primary prevention model for child protection

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1. Child protection at the individual level: Protection at the individual level included children as victims and adults as perpetrators. Protection for children focused on promotion of protective factors, in order to reduce ‘triggers’ and the chance of a child becoming a victim. This included promoting the child’s social immunity by: increasing awareness of children’s rights violations; promoting desired behavior and self-discipline; promotion of their morals and virtue; and, increasing life skills. Developing children’s life skills, included: teaching critical thinking, refusing, avoiding, protecting oneself from harm and asking for help; and, providing instructions on how to be safe in risky situations.

For protection from adults being a child abuser, focus was on placed on helping adults reduce the chance of their becoming a perpetrator. This involved adult education about child rights, child protection laws and the minimum standard treatment of a child, as stipulated in the ministerial regulations. In addition, the adults’ education involved promoting knowledge, attitudes and skills on non-violence; positive child discipline; and, rearing practices. Thus, the promotion of good relationships, love and bonding between parents and children was emphasized.

2. Child protection at the family level: Protection at the family level focused on promoting happiness and a good environment within the family, in order to reduce the chance of a child becoming a victim, due to stress within the family. Strategies included promoting: warm and healthy relationships among family members; non-violence in the family; and, economization, by applying the sufficiency economy concept initiated by His Majesty the King.

3. Child protection at the community level: Protection at the community level focused on promoting awareness among community leaders and public education for community members, in order to continue promotion of child protection as a system. Creating a protective community environment

for children involved: promoting safe areas and non-violence; development of a security system; and, discouraging gambling, and drug and alcohol use. Additional activities focused on providing growth opportunities for children, such as sports and alternative recreation for children and youth. Finally, a committee was established to develop a community network on child protection. The committee organized protection surveillance and coordinated assistance when required. The development of the community network involved: arranging continuous child protection activities; developing sincere involvement among local organizations; integrating child protection into local activities; and, promoting social cohesion and unity in the community. Promoting participation of a variety of community groups served to build community strength, and raised consciousness among community leaders, to be good role models for non-violent problem-solving.

4. Key leaders on community child protection: The key leaders on community child protection were composed of two main sectors, the: SAO and CNCP. The SAO was the main local organization to provide budgetary support and integrate other local resources. The SAO also was set as the key leader in academic and education support, including educating community members about child protection laws. The CNCP was set as the key leader in coordinating and running child protection activities. The CNCP’s responsibilities included: conducting child protection surveillance and case reporting service; running public hearings and consensus; and, developing and proposing the child protection plans to the SAO. The proposal to the SAO was necessary in order to put the plan into local policy and integrate it with local budgets and other resources. In addition, this allowed the two groups to search for and write grant proposals, and run and evaluate projects together.

5. The community network: The community child protection network was comprised

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of local organizations and resources; temple, village administration team, school, and public health center. The temple was set as the key leader in applying dharma doctrine and teaching for family life during weekends. The village administration team was the network leader in promoting community awareness and also serving as a role model for non-violence. As the school was the community network closest to the children and their families, it was set as the leader for surveillance and home visits. The public health center was considered the leader in mental health promotion, and promoted stress management for families and community members and performed home visits to families considered at risk. The purpose of the home visits was to reduce the risk factor of adults becoming perpetrators, by visiting those who were more likely to abuse children.

6. Collaborative child protection activities: Some of the activities required the cooperation and involvement of key leader groups, community network groups and community members, in order to proceed and integrate child protection activities with existing local programs. In addition, some of the programs offered overlapping services and activities, i.e. reducing alcohol assumption in the community; parent education; children and youth education; local risk area surveillance; promoting positive recreation activities for children (sports, family activities); and, promoting sufficiency economy.

Impact of model development: The model development process brought about change to promote the protective environment for children in the community. The community meeting for both assessment and model reflection showed increasing community concern and awareness on child abuse as a public issue. This could be seen with the presence of interested parties from adjacent communities and provincial organizations, as well as from community suggestions, feedback, and questions posed, by community members, to the project coordinator. The sub-district’s quarterly

journal was utilized to educate community members on child protection activities. Outreach discussion regarding networking and policy implementation at higher levels were supported. The child protection master plan, to be implemented, was another evidence of change in the community. The community members also came up with the vision, mission, strategies and priority setting for each year.

Discussion

The results showed an acceptance of corporal punishment, the embed belief of the Thai proverb of “Spare the rod and spoil the child,” and a view of children as a possession among community members. This supports the findings of Bhikkhu,23, 26 and Natamongkonchai et al.24 who mentioned that corporal punishment is likely to be acceptable as a normative belief regarding appropriate parenting behaviors. It also supports the studies of Wechayachai,25 Amornvivat et al.,26 Phuphabul et al.,27 and Natamongkonchai et al.24 who indicated Thai parents use verbal aggression, along with physical punishment by spanking, hitting and pinching, to discipline their child.

When the beliefs mentioned above influenced the consideration of corporal punishment, as the common discipline for child rearing practice among parents, child physical abuse in the community was not considered as abusive. Even though Thailand became a signatory to the Convention on the Rights of the Child (CRC), in 1992, and the Child Protection Act was enacted in 2003, these concepts are relatively new for the Thai culture. In addition, Thais, traditionally, believe that family violence is a private issue and it is better for others to stay out of family issues.28, 29, 30 Thus, others are reluctant to intervene when child abuse takes place in the family. Similarly, this study found that the community viewed spanking or verbal aggression as the parents’ right and not an abusive behavior. Rather, these actions, often, are viewed as way for

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parents to show love to their children. Physical aggression becomes abuse when it is unfair, undeserved, done for no good reason and is excessive.

Abuse was defined in terms of harm done or maliciousness. Therefore, the model proposed increasing child protective factors and decreasing risk or ‘trigger’ factors at all levels. At the individual level, protection was focused on increasing child protection knowledge and skills, in order to decrease the likelihood of the child becoming a victim or being the ‘trigger’ for abusive action. This is in accordance with Belsky’s31 results, wherein children’s own behavior was found to elicit or maintain child abuse action.

At the family level, the model focused on promoting happiness and a good environment within the family. This included promoting career and side jobs, thereby applying the concepts of sufficiency economy. Reducing family stress would, in turn, reduce the chance of a child becoming a victim. This was supported by the studies of Sawyer et al.,32 Wongsamari,33 Krongyuth,34 Katz and Woodin,35 and Thyen,36 who indicated that families, in which child abuse occurs, have poor relationship patterns, more conflict and less cohesion. Straus & Smith37 mentioned that poverty causes the highest rate of child abuse. This was supported by the Transitional Model of Wolfe38 who pointed out that child abuse occurs when parents fail to manage their life stressors.

At the community level, focus was on promoting public awareness activities and education on child rights and child protection law. The expectation was that this would deal with those parents who believed that family violence is a private issue. Creating a protective environment for children in the community and promoting community coherence in the model would be the significant protective factors. This idea is supported by Belsky,31 who discussed ecology of child abuse and mentioned that maltreating parents often lack

significant social connections to others in their neighborhoods and communities. Therefore, community coherence would help family members contact with others in the community. This could provide role models for acceptable parental behavior and influence parents to conform to a better standard of the rearing and treatment of their children. It also might maximize the use of community resources on child abuse protection and child rearing practices.

The collaborative activities among community resources on child protection were composed of two majors sectors: child protection key leaders and a child protection network. This supported the idea of capacity-orientation proposed by Kretzmann and Mcknight39 who mentioned that connecting local resources could multiply their power and effectiveness for the project. This also supported the concept of a community network for child protection response proposed by UNICEF.40

Conclusions and Recommendations

The community child protection model emphasized the participation of local organizations and community members in creating child protective factors from all kinds of abuse. Community health professionals need to play a role in identifying and treating victims, as well as preventing the occurrence of abuse. Prevention should be implemented in a child-focused, family-centered, community-based and culturally adapted manner. Review of the protocol and the role of community and school health nurses on child protection should be promoted.

Acknowledgements

The authors would like to express their thanks to the informants who took time to participate in this study. Gratitude also is extended to the Graduate School, Chiang Mai University and the Thai Nursing Council, for providing funds for this study.

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23. Belsky J. Etiology of child maltreatment: A developmental-Ecological analysis. Psychol Bull. 1993; 114(3): 413-34.

24. Natamongkonchai S, Prateepchaikul L, Chaumpluk R, Isaranurug S, Nieamsup T, Mo-suwan L. Child rearing practices of Thai families: A quantitative and qualitative study. Bangkok (Bangkok): Research Foundation Support Office; 2004.

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25. Wechayachai A. An Evaluation of the Social Welfare Scheme for Abused Children. Nonthaburi (Nonthaburi): Health Systems Research Institute; 2004.

26. Amornvivat S, Khemmanee T, Thirajit W, Kulpijit A. Thai ways of child rearing practices: An ethnographic study. Bangkok (Bangkok): Dept. of Elementary Education, Faculty of Education, Chulalongkorn University; 1990.

27. Phuphabul R, Udomtassanee S, Tachudhong A. Parental expectation, beliefs, childrearing practices and the development of preschoolers. Bangkok (Bangkok): Department of Nursing, Faculty of Medicine Ramathibodi Hospital; 2005.

28. Chinlumprasert N. The Development of Violence Research Database and the Synthesis of Research on Violence Issues in Thai Society. Nontaburee (Nontaburee): HSRI Research Report; 2004.

29. Nawaboonniyom V. Violence against wives: Fact from abused, abuser and community attitudes. [thesis]. Bangkok (Bangkok): Mahidol Univ.; 2001.

30. Srisorrachart S. Domestic violence: Socio-cultural perspective and social intervention in a Thai community. [dissertation]. Bangkok (Bangkok): Mahidol Univ.; 2001.

31. Belsky J. Etiology of child maltreatment: A developmental-Ecological analysis. Psychol Bull. 1993; 114(3): 413-34.

32. Sawyer GK, Di Loreto AR, Flood MF, DiLillo D, Hansen DJ. Parent-child relationship and family variables as predictors of child abuse potential: Implications for assessment and early intervention. Poster presented at the 36th annual meeting of the Association for the Advancement of Behavior Therapy, Reno, NV. [online]. 2002 [cited 2003 Sept 10]. Available from: http://www.Unl.edu/.

33. Wongsamari W. Case study: Interagency child abuse investigation and case pilot project of Thammasat. J Ment Health Thai. 2000; 8(2):82-6.

34. Krongyuth K. Child abuse among students grade 5-6; A situation analysis in Bangkok Metropolis. [thesis]. Bangkok (Bangkok): Mahidol Univ.; 2001.

35. Katz LF, Woodin EM. Hostility, hostile detachment, and conflict engagement in Marriages: Effect on child and family functioning. Child Dev. 2002; 73(2): 636-52.

36. Thyen U. Experiencing violence in childhood-risk and health sequelae. Gesundheitswesen. [online]. 2000 [cited 2005 Aug 6]. Available from: http://www. thieme-connect.com/ejournals/pdf/gesu/doi/10.1055/ s-2005-858349.pdf.

37. Straus MA, Smith C. Family patterns and child abuse. In: Straus MA, Gells RJ, editors. Physical violence in American families: Risk factors and adaptations to violence in 8,145 families. London (UK): Transaction Publishers; 1990. p. 245-61.

38. Wolfe DA. Child abuse: Implications for child development and psychopathology. 2nd ed. Thousand Oaks (CA): Sage; 1999.

39. Kretzmann JP, Mcknight JL. Building communities from the inside out: A path toward finding and mobilizing a community’s assets. Chicago (IL): ACTA; 1993.

40. United Nations Children’s Fund. Convention on the rights of the child. [online]. 2006. [cited 2006 Feb 28]. Available from: http://www.unicef.org/crc/index_ 30177.html.

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ตดตอท: นฤมล เออมณกล, RN, PhD Candidate คณะพยาบาลศาสตร มหาวทยาลยเชยงใหม ประเทศไทย E-mail: phnaruemon@staff2. mahidol.ac.th วลาวณย เสนารตน, RN, MPH. รองศาสตราจารย ภาควชาการพยาบาล- สาธารณสข คณะพยาบาลศาสตร มหาวทยาลยเชยงใหม ประเทศไทย ยวยงค จนทรวจตร, RN, DrPH. ผชวยศาสตราจารย ภาควชาการพยาบาล-สาธารณสข คณะพยาบาลศาสตร มหาวทยาลยเชยงใหม ประเทศไทย เกสรา ศรพชญาการ, RN, PhD. รองศาสตราจารย ภาควชาการพยาบาล-กมารเวชศาสตร คณะพยาบาลศาสตร มหาวทยาลยเชยงใหม ประเทศไทย Barbara J. Ensign, RN, DrPH. Associate Professor, Department of Psychosocial & Community Health, School of Nursing, University of Washington, Seattle, WA, USA.

รปแบบการมสวนรวมเพอสงเสรมการคมครองเดกในประเทศไทยภาคเหนอ

นฤมล เออมณกล, วลาวณย เสนารตน, ยวยงค จนทรวจตร, เกสรา ศรพชญาการ, Barbara J. Ensign

บทคดยอ: การศกษาครงนใชกระบวนการวจยแบบมสวนรวมโดยชมชนเปนฐาน โดยมวตถประสงคเพอพฒนารปแบบเพอสงเสรมการคมครองเดกในประเทศไทยภาคเหนอ การเกบรวบรวมขอมลใชวธการสมภาษณแบบกงมโครงสราง การสนทนากลม กจกรรมการมสวนรวม การสงเกต การประชมกลมและการระดมสมองกบกลมตวอยางในหมบานชนบทแหงหนงในจงหวดเชยงใหม โดยกลมตวอยาง ประกอบดวย กลมเดก กลมผปกครอง กลมประชาชน และกลมผนำชมชน การวเคราะหขอมลเชงคณภาพใชวธการวเคราะหเนอหา รปแบบการคมครองเดกแสดงใหเหนถงปจจยปองกนเดก 3 ระดบ ในระดบบคคลทงเดกและผปกครองตองการการสงเสรมความรและทกษะในการคมครองเดก เพอเพมปจจยปองกนสำหรบเดกและลดความเสยงในการกระทำสำหรบผใหญ ในระดบครอบครว การคมครอง เนนทการสงเสรมความอบอนในครอบครว รวมถงการประยกตใชแนวคดเศรษฐกจพอเพยง สำหรบในระดบชมชนเนนการสรางความตระหนกในปญหา สงเสรมเครอขายคมครองเดก และพฒนาแผนแมบทเพอคมครองเดกในหมบาน การเคลอนไหวของชมชนในการปองกนปญหาการทารณกรรมเดก กอใหเกดความรสกเปนเจาของซงมผลตอความยงยน ของโครงการตอไป ผลการประเมนแบบมสวนรวมพบการเปลยนแปลงคอ มเครอขายเพมขน ตระหนกถงความสำคญของปญหาในชมชนทมากขน มศกยภาพทสงขน มการกระจายขาวขอมล ขาวสารดานการคมครองเดก มขอตกลงรวมกนในการบงคบใช และดำเนนงานตามแผนคมครองเดกชมชน ผลการศกษาไดใหแนวคดในการพฒนางานวจยดานการพยาบาลการศกษาและการปฏบตงานดานการคมครองเดกและสงเสรมใหมการจดกจกรรมหรอโปรแกรมการคมครองเดกทเหมาะสมกบวฒนธรรมตอไป


คำ ำคญ: การคมครองเดก รปแบบการมสวนรวม ภาคเหนอประเทศไทย

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Kallaya Wiriya et al.

Buddhist Mothers’ Experience of Suffering and Healing After the Accidental Death of a Child

Kallaya Wiriya, Urai Hatthakit, Wantanee Wiroonpanich, Lee Smith-Battle

Abstract: Numerous nursing studies have examined suffering, but none have addressed the suffering and healing Buddhist mothers experience after the accidental death of a child. The purpose of this study was to gain understanding of the meaning of suffering and the practices of healing and suffering, among Buddhist mothers after such a loss. Buddhist concepts provided the philosophical framework, and Gadamerian hermeneutic phenomenology provided the methodological framework, for this investigation. Ten Buddhist mothers were recruited from a government hospital in Songkhla province, Thailand. In-depth interviews were conducted and data were analyzed using hermeneutics. Five themes that reflected the meaning of suffering among Buddhist mothers, after the accidental death of a child, were identified. They included: the mother’s heart was torn into pieces; the mother’s body was frozen and she was uncertain she would survive; happiness in the mother’s life was missing; the mother’s anger and rage at self and others; and, the mother worried and wondered about the next life of her deceased child. The mothers were found to heal their suffering by: transforming their relationship with the deceased child; elevating the deceased child to be a very good child capable of going to heaven; making merit in order to pass the benefit to the deceased child; self-healing through understanding and mind cultivation; and, seeking support. The findings promote the understanding of the suffering and coping of Buddhist mothers whose child accidentally died.

Thai J Nurs Res 2009; 13(3) 227 - 241

Key Words: death of child, buddhism, suffering, healing, Gadamerian hermeneutic phenomenology

Introduction

A mother and her child are involved in an intensely close relationship from birth to adulthood.1 The loss of a child, through death, is a unique and particularly intense type of grief or suffering, and may be more severe than other types of bereavement.2 The violent or unexpected death of a child is a traumatic event that can bring

Correspondence to: Kallaya Wiriya, RN, PhD Candidate, Faculty of Nursing, Prince of Songkla University, Hat Yai, Songkhla, Thailand. E-mail: [email protected] Urai Hatthakit, RN, PhD. Assistant Professor, Faculty of Nursing, Prince of Songkla University, Hat Yai, Songkhla, Thailand. Wantanee Wiroonpanich, RN, PhD. Assistant Professor, Faculty of Nursing, Prince of Songkla University, Hat Yai, Songkhla, Thailand. Lee Smith-Battle, RN, DNSc. Professor, School of Nursing, Saint Louis University, St. Louis, MO, USA

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unimaginable suffering for the family, especially, for the mother.

Suffering, a universal human experience, can be described as: feeling pain or distress; sustaining injury or loss; being the object of some action; being observed; or, patiently enduring a situation.3 Prior studies, in Thailand, have examined Buddhists’ suffering regarding: family caregivers of seriously mentally ill patients;4 a palliative model for HIV-infected patients;5 the use of meditation, as a healing mode, for HIV-infected patients;6 factors related to paraplegic patients;7 and, tsunami survivors’ unexpected loss of family member(s), houses, possessions and businesses.8 However, no study could be located that specifically examined Buddhists mothers’ suffering, as a result of the accidental death of a child. This oversight needed to be addressed, since approximately 95% of the Thai population are Buddhists.9 Therefore, the purposes of this study were to investigate, using Gadamerian hermeneutic phenomenology, what suffering means to Buddhists mothers, who have experienced the accidental death of a child, and how they attempt to heal their suffering.

Literature Review

Suffering is a significant human experience, not only in nursing and health care, but also within the Buddhist culture. This literature review explored the meaning of suffering in general and the Buddhist concept of suffering, including what Buddhists view as the causes and alleviation of suffering.10, 11 Morse12, 13 indicated that suffering refers to response to a loss, which involves an extremely distressed state, wherein emotions are released. Kahn and Steeves14, 15 suggest that suffering means extreme discomfort, including displeasure or unpleasant perceptions. In addition, they described suffering as an experience that affects the whole person, and is defined in terms of physical, mental or spiritual pain; loss; and, psychological distress. Smith16

viewed suffering as a spiraling, vicious circle of physical, psychological, social and spiritual distress. The immediate response to suffering, according to Battenfield,17 may be shock, loss of control, or having no expression, at all, until one recognizes what has happened and realizes, in order to get through the situation, one must continue to function.17 These responses also are related to the symptoms of traumatic grief, depression and anxiety.18

In Buddhism, the notion of suffering has been translated to Pali (the ancient scriptural and liturgical language of Theravada Buddhism) as “dukkha,” meaning unsatisfactoriness,10, 11 or being inadequate or unsuitable. Suffering also has been presented as the result of, or caused by, such factors as disease, discomfort, disorder, conflict, difficulties, unfullfillment and/or pain.10

Buddha explained everything about life in terms of causation.19 Causality (conditionality) is addressed in the “Law of Dependent Origination” (Paticcasamuppada), which consists of 12 factors: ignorance (Aviccha); volitional actions or kamma-formations (Sunkhara); consciousness (Vinnana); mental and physical phenomena (Nama-Rupa); the six faculties (five physical organs and mind) (Uttayana); sensorial and mental contact (Phussa); sensation (Vedana); desire; thirst (Tanha); clinging (Ubbatan); the process of becoming (Pope); birth (Chatta); decay or death (Jara-marana); and, associated sorrow, lamentation, pain, suffering, grief and despair.10, 20 These factors are linked in a circle of cause and effect. A cause of suffering may begin at any point of Paticcasamuuppada, but proceeds through the circle. For ex ample, when a wife sees her husband with another woman, the stimuli initially occurs through the woman’s eyes (ayatana and pussa). She feels disappointment (vedana) because she loves her husband very much (tanha). Her attachment (ubbatan) to her husband leads her to attempt to keep him as a refuge (pope). Feelings of jealousy, anger or worry occur (chatta). The woman

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suffers because she does not realize her defilement (aviccha). She may create several negative thoughts, such as the other woman is her husband’s new girl friend (sankhara). Without consciousness (vinnana), or the right understanding, the woman will suffer and her suffering will continue in the circle of Paticcasamuuppada. On the other hand, if the woman has wisdom, she can stop the circle, at any point, and her suffering will be alleviated.21 In other words, suffering refers to individual experiences that are extremely uncomfortable and which may involve physical, mental or spiritual dimensions. Usually the physical, mental and spiritual dimensions are interconnected with each other, depending upon the particular event and the person’s response to it.

When a mother has the right understanding of the nature and occurrence of suffering, she is able to break the circle of Paticcasamuppada and stop the suffering. Healing, or the end of suffering, is a result of right actions based on wisdom or right understanding. Buddhists are encouraged to solve problems according to their true sources of the cause of suffering,10 and heal their suffering using their own wisdom. Healing may be achieved through cognitive, emotive or behavioral reactions.22 Healing is both a process and an outcome. As a process, healing is: a natural process; occurring from within; restoring balance to systems; capable of self-diagnosis and repair, without conscious effort; an individual unique experience; and, an active process in which persons take responsibility for their own health. As an outcome, healing restores balance, wholeness, relaxation and harmony.23, 24, 25, 26

When individuals face suffering, they seek whatever is fitting in their minds, so they can alleviate or eliminate the suffering. Thus, healing is what often is referred to as “the best way we have for dealing with suffering in our lives.”

There are several ways to heal suffering, or deal with discomfort, depending on the problem, i.e. prayer, meditation, therapeutic touch and massage.27

Hence, healing is completely unique and creative in maintaining wellness.27 In Buddhism, more than 2500 years ago, Buddha offered a remedy, or strategy, for healing suffering. This remedy is called the “Middle Way,” and can be applied to the conditions of contemporary life. It is a prescription for a happy, well-adjusted life.27 The Middle Way, or Noble Eightfold Path, comprises all the practical teachings of Buddhism. It is classified into three categories; sila, Samadhi and panna, described as: (a) ethical conduct (Sila), composed of right speech, right action, and right livelihood; (b) mental discipline (Samadhi), including right effort, right mindfulness, and right concentration, with suppression of intellectual activity, development of tranquility and loss of sensations; and, (c) wisdom (Panna), or right thought and right understanding. Commonly, these terms are referred to as the three fundamental exhortations of the Buddha, including: not to do any evil; to cultivate good; and, to purify the mind. As described above, purification of the mind, in order to achieve the final goal of absolute freedom, must be completed by wisdom, as a result of insight, into the Law of Dependent Origination, and the state of anatta, or not-self, or impersonality of all phenomena. Having attained this knowledge, the person lives a good life, overcomes all problems, brings suffering to an end, and enjoys freedom, peace and happiness of the mind, without resorting to any external supernatural power.20, 21

Method

Design and analysis: Gadamerian hermeneutic phenomenology was used to guide the study. Gadamer’s key philosophical concepts include the: hermeneutic circle; dialogue; fusion of horizons; and, prejudice.28, 29 Emphasis is placed on language with the belief that language and history supply the shared sphere, in the hermeneutic circle. In addition, Gadamer addresses understanding and interpreting,

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within the research process. Understanding, like conversation, represents a relationship between the researcher and the participants.30 Interviews and conversations are non-directive, so that participants are able to tell their stories in the way they wish. Interpretation occurs by way of creating a fusion of horizons between the researcher’s original prejudices, in conversation with the participants’ understandings. Prejudice refers to our preconceived understandings that come from past experiences and socialization. Gadamer31 advocates continually striving to identify prejudice, which originate from the researcher’s historical background, as it relates to the topic at hand. In practice, the researcher acknowledges, as much as possible, his/her prejudices, while data are collected and interpreted.16 Based on Gadamer’s32 philosophical hermeneutics, the following was accomplished:

1. Audio-taped interviews were transcribed by the researcher.

2. The researcher read and reread each text, while listening to the recordings, to gain a feel for the data.

3. Themes were extracted by: reading, word by word and line by line; under lining and/or highlighting words; coding words; identifying and naming themes, which emerge from segments of the text; grouping themes; and, naming themes, in relation to parts and the whole.

4. Members of the research team were asked, by the primary researcher, to validate the themes identified.

5. The primary researcher looked for constitutive patterns (themes that unified the text). This involved the creative, linguistic and intuitive process of finding metaphors and images to interpret the experiences of the participants.

6. An interpretive account was generated by writing and rewriting, using the chosen metaphors as a narrative device.

7. Writing and rewriting was done to incorporate

all the interpreted accounts into a synthesized interpretation.

Setting: The setting of the study was Songkhla province, Thailand. The province of Songkhla was selected because of its high incidence of death among children, resulting especially from accidents. In 2000, the province reported the highest number of deaths throughout Southern Thailand (n = 7,575).33 Accidents are a primary cause of disability in Thailand, with traffic accidents, specifically, being the leading cause of death. Data, from the Registration Administration Bureau of Thailand,33 indicates the highest rate of accidental child death occurs among the 15-19 year olds, followed by the 5-9 year olds and the 10-14 year olds, respectively.

Ethical considerations and identification of informants: Approval to conduct the study was obtained from the Research Ethics Committee of the primary researcher’s university. In addition, approval was obtained, from the administrator of hospital where data were collected, for the purpose of accessing names of potential informants who had sustained the accidental death of a child. Inclusion criteria for potential informants consisted of mothers who: (a) had a 16 to 18 year old child, who died, as a result of an accident, within the prior three months to two years; (b) were Buddhist; (c) were from Songkhla province; and, (d) were willing to take part in the study.

Once names of potential informants were obtained, community leaders, and members of the health staff at primary care units (PCU), located in the community where the potential informants lived, were approached and asked for assistance in introducing the primary researcher to the potential informants. In addition, potential participants were recruited through the snow ball technique. Each potential informant was told: the purpose of the study; what was involved; her anonymity and confidentiality would be maintained; and, she could withdraw from the study, at anytime, without

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negative repercussions. Once a potential informant verbally consented to participate, she was asked to sign an informed consent form. A total of 23 potential informant names were obtained; however, only 10 participated in the study. The reasons for not participating included: having no time; moving to another province; unable to be contacted by telephone, due to an incorrect phone number; or, not wanting to talk about the death of her child.

Description of informants and their deceased children: The 10 informants ranged in age from 34 to 54 years, with a mean of 44.2 years. Half (n = 5) had one surviving child, while the others had two (n=3), three (n=1) or six surviving children (n=1). The deceased children had died 4 and 17 months prior to the informants’ enrollment in the study and ranged from 10 to 18 years of age, with an average of 13.9 years. The majority (n = 8) of the deceased children were boys. The children’s deaths were the result from a: motorcycle accident (n = 6); drowning (n = 2); stab wound (n = 1); or, gunshot wound (n = 1).

Data collection: A total of 27 interviews were conducted, with half (n=5) interviewed three times, four interviewed twice and one interviewed four times. Interviews were scheduled, about one month apart, at the mother’s convenience, in each respective home. Demographic data (informant’s age, number of living children, length of time since death of child, age and gender of deceased child, and type of accident deceased child had sustained) were obtained during the first interview. The interview took an average of 1.5 hours to complete.

To develop dialogue with the mothers, regarding their feelings of suffering and healing practices, the following questions/statements, initially, were posed: (a) “Please tell me about the child who died.”; (b) “What was he or she like?”; and, (c) Tell me how you felt and what you did when you were told about the child’s death.” As the informants described the nature of their suffering

and healing processes, the researcher posed probing questions/statements, that focused on the content of the informants’ descriptions, such as: (a) “Please elaborate on the situation and your response to the death of your child”; (b) “How did you deal with the situation?”; and, (c) “How did you heal yourself after the death of your child?” This was done to obtain more in-depth descriptions and, subsequent, understanding of the informants’ verbiage regarding their suffering and healing processes.

During the second interview, which took an average of 1.5 hours, the primary researcher focused on specific points (themes) that emerged from data generated from the first interview. Subsequent interviews took place until no new data were generated, and their descriptions of suffering and healing became repetitive.

Findings

The meaning of suffering: Five themes emerged as descriptors of the meaning of suffering among the bereaved mothers. These themes included the mother’s: (a) heart was torn into pieces; (b) body was frozen and she was uncertain if she would survive; (c) happiness in the life was missing; (d) anger and rage at self and others; and (e) worries and wonders about the next life of the deceased children. Details of each theme are presented with illustrative quotes to support their existence.

Theme 1: The mother’s heart was torn into pieces. This theme refers to the extreme pain, distress, brokenness and disconnection the mothers experienced when their child died. No previous life situation appeared to be comparable to their immense sense of loss and intense suffering. Their statements supported this theme:

…I was told that he had passed away. He passed away on the way to the hospital. At that minute, I cried like my heart was torn into pieces. (M2)

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Before this, when it happened to my friend, I saw this thing simply. But when it happened to me, oh! (Deep breath) it hurt me badly. It’s like my heart was broken in pieces. No matter how long it takes...not this life or the next life, the pain and suffering will still be with me. (M3)

Theme 2: Mother’s body was frozen and she was uncertain if she would survive. This theme refers to the mothers’ feelings of immobilization. Their brains did not feel like they were functioning and they indicated feel they did not have power to do anything. The mothers described many elements of physical, emotional and embodied suffering. This theme is supported by their statements:

I was going to faint when I realized he was gone. I was down on the floor and felt like I had no energy left. My brain could not function well. (M5)

I was walking to see what happened, but all my energy suddenly was gone. I couldn’t walk, grabbed the table and stood there. I did not cry. No tears, but was in deep shock. I did not cry, but felt like my body was frozen. I could not accept it, never thought of that day before. I was in bed for 3 months, could not get up. When my body demanded food, I ate very little to survive. (M7)

Theme 3: The mother’s happiness in the life was missing. With the death of their children, the mothers’ happiness seemed impossible and future hopes for their children died. The deaths led to a collapse of meaning in the mothers’ lives. A significant person in their lives had disappeared

and their hopes for the dead children were dashed. When the children died, the mothers’ were faced with great suffering. These mothers grieved the loss of their children who had been great company, and contributing members to their respective families’ everyday routines and hopes for the future. These thoughts were noted from their comments:

I was hoping that he would undergo an ordination to be a monk. Thus, I could gain merit from him. But his age disqualified him; he was just 17. He would be going back to school. The school was opening in a month. His future was going well. He would have a bright future (M2)

In the past, the four of us (parents and two children) had meals together. Now there are only three left. We use to have pleasant meals together, and were very happy. My tears poured down just thinking of his condition on that day. Father, mother, and children living, eating, and watching TV together, this is perfection…I didn’t know what this was when he was alive. When he wasn’t here, I realized that something was missing from my life. (M9)

Theme 4: The mother’s anger and rage at self and others: Anger and rage directed at self and others, referred to the internal feeling that the mothers expressed about themselves and those near them. Because a mother suddenly lost her beloved child, she greatly suffered. The women broke down and could not control their emotions, so they expressed themselves by using unpleasant words towards others. These actions were reflected in their statements:

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My own father passed away a long time ago, I worshiped his picture every day. When I went out I asked him to protect my family. Sometimes I was in front of his picture and complained to him for not helping my son, his grandson; you know… Because my husband took my son for training to ride a motorcycle he was dead. I often blamed my husband for my son’s death. (M3)

I am so mad with the policeman. ‘Why didn’t they pay attention to my dead child’s situation?’ I spoke to them with a big mouth when they came back and asked me some irrelevant questions. (M8)

Theme 5: The mothers worried and wondered about the next life of the deceased children. Mothers spent considerable time thinking and worrying about their deceased children. They wanted to know how their children were faring in the next life. Most mothers dreamt about their deceased children. They commented:

After 100 days, I dreamt he asked me to pick him up. Since I had the same dream, repeatedly, I went to see a monk. The thing was he died on the road and no one invited his soul/spirit in, and he’s still there and cannot go anywhere. I asked the monks to pray at the point where the accident took place, and to help to release his soul/spirit. Because at his death, his dry blood was not cleaned, someone told me to invite monks to release his spirit. After I did the rite for him I felt better. (M2)

My sister took me to see a fortune teller, who has so many people believing in him. He said not to cry, whenever you cry, your daughter’s spirit is crying next to you. You just cannot see her. She is even sadder when she sees you crying. She is sad because she cannot take care of you right now. If I am happy, her spirit is happy too. He said that my daughter’s spirit was like a traveler. Her spirit is traveling in another life. (M4)

The healing of suffering: The mothers, as a result of the accidental death of their children, looked for comfort and healing practices to assuage their intense feelings of loss. Data revealed the existence of four practices the used:

1. Transforming the relationship with the deceased child: Most mothers described developing a relationship and connection with their dead child’s spirits. Since their child was no longer physically present, the mothers yearned for, and developed ways to spiritually connect with their child. They stated:

I feel that she stays with us every day. I place rice, water. I don’t know if she can eat or not, but I prepare for her every day. [She pointed to her daughter’s picture and ashes container, and there was some food in front of it]…. I feel she is still with me in this house. (M1)

My son always went to the temple with me. I recently went to temple and walked with lit candles in hand and I prepared flowers and candles for him. In my mind, I asked him to come with me, so I walked by myself with two sets of flowers, joss sticks and lit candles (laughed softly). (M7)

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2. Elevating the deceased child to be a very good child capable for going to heaven. Every mother believed that her deceased child was a perfect person. In particular, each mother compared the deceased child to their other children. Although the mothers suffered for not being with their deceased children, they gained comfort from the belief that their children were special and had gone to a good place, or heaven. Some stated:

He was a very good boy. Everyone loved him, such as friends, teachers, and neighbors. He was a kind boy helping his father, mother and sisters. He was friendly and smiled at everyone… My son was innocent. He was a good boy. He did not do anything bad. Now he has stopped doing anything in this world. His death has stopped all kamma [the Pali term for karma or actions and deeds] and he will gain merit from previous meritorious deeds. (M3)

The fact that I lost my dad from cancer and my beloved brother, who also passed away from his heart failure, was not comparable with the fact I lost my son. It’s not the same at all. People liked him despite the fact that he was drug addicted. He had good relations with people, and he loved helping them. If he saw an old man or lady walking, he would pick him/her up on his motorcycle and take him/her home. He was good in most things, except for the drugs. (M5)

3. Making merit in order to pass the benefits to the deceased child. Each mother made

merit to benefit her deceased child and enhance her child’s chance for rebirth. All of the mothers poured water and prayed for sending the merit to the deceased children. They believed that if they did not pour water, their dead children could not obtain the merit. The practice of merit was reflected in their comments:

Some said my daughter died from the accident. At the time her spirit left her body, she might not know that she’s dead so she might not have taken the benefits from the merit right away. If we do 49 days, when there was a day that her spirit knew that she’d died, she could take the benefits from the merit. I am not sure if it’s true or not, but it made me feel better to do so. After that, I gave another merit at the 100th day after she passed away. (M4)

I did major merit making like everyone did; during the funeral, at the 100th day and a week after 100 days, just like the Thai tradition. Other than that, takbart (alms giving) in the early morning and pouring water for his benefit…In the past, I gave merit and poured water to my dead ancestors, I did not feel much of this. But now, I specifically gave the benefit to my own son, I feel differently. Like I am suffering, so when I give benefits to my dead son, I feel better. (M6)

4. Self-healing through understanding and mind cultivation. The mothers practiced Buddhist actions to gain comfort, cultivate their minds and relieve their suffering, as reflected in their statements:

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From preaching, life is like a coconut, if it is raw (young) and healthy, it doesn’t fall from the tree, but when it becomes too ripe (old), it does. Although, if it is raw bitten by an animal or insect, it will fall from the tree too. Like us, youth or the aged can pass away anytime. It is uncertain. If we can accept this truth, we can accept its’ consequence. I listen to preaching and I understand it so I am resigned to the result. (M6)

I usually do meditate at home. And, my company arranges monthly group meditation. Monks tell me to let my mind be free and peaceful. I should think that there is nothing in my body. I should not adhere to anything. Then I feel free. If I purify my mind, it is good for me. (M10)

5. Seeking support. Seeking support involved reaching out to others. Some of the mothers sought help from a monk by asking him to perform rites to release their child’s spirits; others turned to a fortune teller to learn about their deceased child. These actions are reflected in their statements:

Someone told me that we have to do something to send my son’s spirit to heaven. So I invited an abbot to pray and perform ritual activities at that place where the accident occurred. I prepared 8 kinds of food including whole fish (composed of head and tail), candles and joss-sticks, or aromatic vapors. You know I have never dreamt about my son. He might go to a good place. (M3)

My friend asked me to see a fortune teller. When I asked him about the illness of my youngest son and how my dead child was, he said that my dead child had not committed any sin so he would be ok. He told me not to worry and take care of myself. (M9)

Discussion

All the participants were Buddhist, as would be expected in Thailand, where 95% of the population is Buddhist. (This needs to be documented.) Thus, to understand suffering and ways to overcome it (healing practices), one must examine these concepts within the context of Buddhist beliefs.

Suffering: Suffering is a universal human experience. The mothers, in this study, certainly were no exception, as they stated they could not eat or sleep, felt shock and angry, wept and worried about the loss of meaning and lacked hope for their future. They experienced extreme physical, mental and spiritual distress the first two to three months after their children’s deaths. Their physical suffering was expressed by way of crying, not sleeping well, not being able to eat, losing weight and feeling powerless, while their mental suffering manifested itself in confusion, anger, sadness, non-acceptance and worry, and their spiritual suffering was reflected in feeling disconnected and torn from a normal life.

These findings are consistent with previous research on suffering, wherein suffering has been presented through sorrow, lamentation, grief and despair.10 Suffering also has been recognized as a universal concept, involving emotional response to a loss,13, 14 and viewed as extreme discomfort, experienced through physical, mental or spiritual responses.14, 15 These concepts are congruent with the physical, psychological and spiritual suffering experienced by tsunami survivors.8

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According to Buddhist beliefs, suffering can be categorized three ways, including: dukkha-vedana (feeling of suffering expressed through unpleasant sensations of pain or numbness); dukkha-laksana (suffering that involves uncertainty; it occurs, keeps going, and disappears); and, dukkha-ariyasacca (suffering as a result of cause and effect).10, 21, 34 The mothers’ expressed feelings that their hearts were torn into pieces, their bodies were frozen and they had no power to survive is related to dukkha-vedana (feelings of suffering). Dukkha-vedana is connected to sense-formation through one’s body and mind, or the five aggregates, or five heaps, of existence: (1) Rūpa- physical form; (2) Vedana-feelings or sensations; (3) Senna-ideations; (4) Sankhara-mental formation or dispositions; and, (5) Vinnana-consciousness. When sensations (vedana) of pain, or unpleasantness (a broken heart or frozen body), arose, their minds could not stop ideations (sanna) related to memories of their dead children, and mental formations (sankhara) arose. Although the mothers might imagine how they could survive without their daughters or sons, without having consciousness (vinnana), or a sense of wisdom, their intense suffering continued.

According to Buddhism, not only does the sensation of pain and unpleasantness (dukkha-vedena) result in suffering, but so does the uncertainty of body and mind. If one does not understand and realize this truth, and remains attached to the body and mind, he/she will suffer when the body and mind change.

The mothers, in this study, could not accept the death of their children, and the loss of shared and meaningful activities, i.e. watching TV, singing karaoke, having dinner and taking their children to school. Their intense desire to have their deceased child with them, so they could continue to love and cling to him/her, lead them to be convinced, due to the death of their child, they had no happiness and never would.

Love is part of desire and a wish to love can

greatly heighten suffering in a human being.35

Thus, a mother’s intense desire to love her child could become an unhealthy longing, particularly when faced with suffering, due to the loss of her child. For example, if one had not experienced intense love of another, when that person has died, intense suffering, most likely, would not occur. On the other hand, if one had intense expectations of love, or happiness, and neither occurred as anticipated, the outcome may be one of suffering. However, happiness and love are uncertainties, since nothing in life is permanent, or stable. All things change with time. This is in accord with the Buddhist belief of dukkha-laksana (suffering and uncertainty).20, 21

In accord with dukkha-ariyasacca (suffering is a result of cause and condition), some of the mothers felt anger, and were enraged with themselves and others, especially during highly emotional situations. Anger, hatred and ill-will (Byapada) are defilements, and often viewed as “bad emotions,” which are related to the cause of suffering.34 Unfortunately, if “bad emotions” are not sufficiently dealt with, they can become barriers to moving on to a productive and happy life.

Similar to the anger expressed by the informants, in this study, tsunami survivors were found to express intense anger, because they did not have sufficient time, as a result of the unexpectedness of the deaths that had occurred, to serve their families.8 However, the causes of the unexpected deaths, in this study, were different. Deaths from the tsunami were the result of a natural disaster, while deaths, in this study, were from: motorcycle accident; drowning; stab wound; and, gunshot wound. Thus, the mothers felt anger with those around them, as well as with themselves, because they associated their children’s deaths, either directly or indirectly, with themselves or others. Those around them, with whom they felt anger, may have been the husbands who took their children to where the deaths occurred, or a

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policeman who could not arrest the person who caused the death of their child.

Furthermore, some mothers worried and wondered about the next life for their deceased children. According to Buddhist teaching, worrying and wondering are part of desire or craving, which are causes of suffering related to dukkha-ariyasacca.20, 21 Desire is related to birth and death, known as the “Cycle of Existence,” or Samsara. Samsara, or the cycle of birth and death, also implies a plurality of different realms of existence, in which rebirth takes place according to the nature of kamma (karma).20,34 The “Law of Kamma” relates to how people act and, thus, good or bad outcomes, in life, are the direct result of one’s actions.34 Kamma is part of the “Law of Dependent Origination,” (Paticcasamuppada) and is divided into three parts, including: (a) defilement (kilesa), which involves the tendency to desire, or crave, something (tanha); (b) kamma, which means expression, both good and bad, in physical actions, wording and mind; and, (c) the result of kamma, which means the outcome of every action.10, 20, 34 Paticcasamuppada describes the process of kamma and how it leads to the result of kamma, which brings about the outcome of what one does by his/her intentional mind.20,34

The mothers’ beliefs in rebirth appeared to have influenced their thoughts and actions, related to dealing with the loss of their children. The mothers’ concerns for the next life depended on the children’s previous kamma. Concern about rebirth caused a great deal of emotional worry for some of the mothers. However, most believed their child had no sin and, therefore, would go to a good place for rebirth.

This study revealed the period of intense suffering differed, on a daily, weekly and monthly basis, among the mothers. During the period of intense suffering, the mothers were immobilized. Thereafter, they were able to resume life, but their intense feelings arose, as a result of their memories

of their children. This may have been due to the attachment between the mothers and their children, the mothers’ backgrounds and their understanding of the truth of life and death, related to the Buddhist concept of wisdom.

Healing from suffering: Each mother worked to transform her relationship, with her deceased child, to bring about healing from her suffering. Often this was done by keeping some of their child’s personal possessions, for the purpose of remembering and connecting with them. Remembrance and connection were done: through dreams; looking at photos; or, speaking to others about their deceased child,. This finding is consistent with those of Gudmundsdottir and Chesla,36 who found, families, in an attempt to preserve memories of their deceased children, would create home memorials displaying personal effects, such as hair.

Most of the mothers regularly engaged in Buddhist practices, such as going to temple, making merit, giving charity, listening to Dhamma (the gradual instruction of truth taught by the Buddha) and preparing food for the monks. These activities were done for the purposes of: giving benefits for rebirth to their deceased children; providing themselves with a peace of mind; and, developing personal wisdom. Such behaviors are related to the three fundamental modes of training: sila, samadhi and panna.11, 21, 37 As previously described, sila, or morality, consists of right speech, right action and right livelihood, while Samadhi, or mental discipline, is composed of right effort, right mindfulness and right concentration. Finally wisdom, or panna, consists of right thought and right understanding.

Two of the participants (M5 and M10) regularly practiced insight meditation, prior to and after their loss, while one (M9) started to meditate after she lost her son. Thus, it appeared that how each mother approached healing her suffering varied. For example, one mother (M5) took mind

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development courses in Soun Mok, Surajtanee province, where the practice of dramma is popular, and continued to meditate on a daily basis. Another mother (M10) practiced insight meditation prior to and after she lost her son. Both of these mothers understood their circumstances and returned, fairly quickly, to a normal routine. However, 4 of the mothers (M1, M6, M7 and M9) experienced prolonged suffering, during the first three months, after the death of their child. They could not work and did not want to do anything, although others returned to work after their child’s body was cremated.

Although the mothers, in this study, contended with their loss, 4 to 17 months, after the event, they all continued to suffer, in some way. They could not eliminate, completely, their suffering. They were sensitive to events that prompted their feelings of suffering, i.e. when they heard news related to a person’s death or saw their children’s belongings. Most mothers did not read newspapers in an attempt to avoid bad news. Similar to Hatthakit and Thaniwathananon findings,8 wherein tsunami survivors were noted to experience emotional suffering one to one and a half years after the catastrophic event, the mothers, in this study, showed, although their physical suffering dissipated, their emotional suffering remained and they required a longer time for recovery.

Interestingly, a sense of hope, for what their deceased child would offer them, appeared to have influenced the mothers’ level of suffering. For example, the mothers of deceased sons hoped to gain merit from their sons’ ordination as a monk, while mothers of deceased daughters hoped their daughter would provide care for them, in their old age. This phenomenon was reflected by one mother (M1), whose first child was raped and second child was disabled. Her hope in life was with her third child, who died in an accident. This mother suffered severely, because she felt, after the death of her third child, that she had little hope in her life. However,

the degree to which each mother suffered appeared to depend upon her character, the hope she had anticipated her deceased child would bring her, and her in-depth Buddhist healing practices.

Implications

The aim of this study was to explore the meaning of Buddhist mothers’ suffering and their healing practices after the accidental death a child occurred. The findings revealed: 1) loss of a child leads a mother to experience suffering; 2) suffering is a process of the mind, which can lead one to a different life; 3) suffering is the embodiment of physical, mental and spiritual aspects; and, (4) feelings of suffering and healing practices are unstable and changeable. The findings can be used to help guide nurses, and other health care providers, providing care to suffering mothers. For example, establishing support groups, focused on the healing practices used by the women, and providing information about various meanings of suffering experienced by such mothers could prove useful, not only mothers after the accidental death of a child, but to their families as well.

Limitations and Recommendations

All studies have limitations and this study was no exception. The study was conducted only with Buddhist mothers, in Thailand, who experienced an accidental death of a child. Thus, the findings may not apply to Thai fathers, to mothers from other religious beliefs or cultures, or to mothers who have lost a child due to an event other than an accident. As with any qualitative study, the researcher had to assume the respondents were truthful, and had established a trusting relationship with the investigator.

Future studies need to address the meaning of suffering and healing practices experienced by

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mothers and fathers of children who have died as a result of an acute illness or a chronic illness. In addition, it would be wise to examine suffering and healing practices among mothers and fathers from various religious beliefs and cultures, so as to compare similarities and differences of responses to the death of a child.

Acknowledgements

The primary author would like to thank the Commission on Higher Education, Ministry of Education, Thailand, for the scholarship support provided.

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ตดตอท: กลยา วรยะ, RN, PhD Candidate, คณะพยาบาลศาสตรมหาวทยาลยสงขลานครนทร ประเทศไทย E-mail : [email protected] อไร หถกจ, RN, PhD. ผชวยศาสตราจารย คณะพยาบาลศาสตร มหาวทยาลยสงขลานครนทร ประเทศไทย วนธณ วรฬหพานช, RN, PhD. ผชวยศาสตราจารย คณะพยาบาลศาสตร มหาวทยาลยสงขลานครนทร ประเทศไทย Lee SmithBattle, RN, D.N.Sc. Professor of Nursing, Faculty of Nursing, Saint Louis University. St. Louis, MO, U.S.A.

ประสบการณความทกขและการเยยวยาของมารดาไทยพทธหลงจากการเสยชวตของบตรเนองจากอบตเหต

กลยา วรยะ, อไร หถกจ, วนธณ วรฬหพานช, Lee SmithBattle

บทคดยอ: มการศกษาทางการพยาบาลมากมาย แตไมมการศกษาเกยวกบประสบการณความทกขและการเยยวยาของมารดาไทยพทธหลงจากการเสยชวตของบตรเนองจากอบตเหต การศกษาครงนมวตถประสงคเพอเขาใจความหมายเชงลกของปรากฏการณความทกขและการเยยวยาของมารดา ไทยพทธทสญเสยบตรเนองจากอบตเหตโดยใชหลกปรชญาทางพทธศาสนา และวธการวจยเชงปรากฏการณ วทยาแบบเฮอรเมนนวตกตามหลกปรชญาของกาดาเมอร มารดาผสญเสยบตรเนองจากอบตเหต10 ราย ซงถกเลอกจากโรงพยาบาลของรฐ ในจงหวดสงขลา รวบรวมขอมลโดยการสมภาษณเจาะลกและวเคราะหขอมลเชงคณภาพโดยใชวธวจยปรากฏการณ วทยาเฮอรเมนนวตก พบวา การใหความหมาย ความทกข ของมารดาไทยพทธทสญเสยบตรเนองจาก อบตเหตม 5 ความหมาย ดงน: หวใจของแมแตกสลายเปนเสยงๆ; รางกายทไรความรสกและหมดพลงในการตอสชวต; ความสขในชวตขาดหายไป; ความโกรธและความแคนทงตอตนเองและบคคลทเกยวของ กบการตายของบตร และ ความเปนหวงและกงวลเกยวกบชวตใหมหลงความตายของบตร มารดาไทยพทธทสญเสยบตรเนองจากอบตเหตสะทอนประสบการณการเยยวยาจากความทกข 5 ประเดนดงน: การปรบเปลยนความสมพนธกบบตรทเสยชวต; การยกยองเชดชบตรทเสยชวตเปนคนดสามารถไปสสรวงสวรรค; การทำบญเพอสงผลบญไปใหบตรคนทเสยชวต; การเยยวยาตนเองโดยการทำความเขาใจตนเองและการพฒนาจต และการเสาะหาแหลงสนบสนนอนๆ ผลการศกษามความสำคญตอพยาบาล และเจาหนาททางดานสขภาพ เพอนำไปประยกตใชในการดแลมารดาไทยพทธทสญเสยบตรเนองจากอบตเหตตอไป


คำ ำคญ: การเสยชวตของบตร ศาสนาพทธ ความทกข การเยยวยา ปรากฏการณวทยาแบบ กาดาเมอรเรยนเฮอรเมนนวตก

Instructions to Authors The Thai Journal of Nursing Research is an English language, refereed (peer-reviewed),quarterlypublicationoftheThaiCouncilofNursingandMidwifery.TheEditorsinvitesubmissionofscholarly manuscripts, as a Microsoft Word document written in English, which present nursingresearch,a literaturerevieworaconceptanalysis.AuthorswhouseEnglishasasecondlanguagearehighlyencouragedtohavetheirmanuscriptseditedforcontent,grammarandpunctuation,priortosubmission.Allsubmittedmanuscriptsmustcomplywiththefollowingguidelines: OrderofPaper: Manuscripts are to be prepared in the followingorder and include:CoverLetter; Title Page; Abstract; Key Words; Text; References; and, as needed, Acknowledgments;Tables;Figures;andAppendices.Eachpageistobenumberedintheupperrightcorner.Arunningtitle(shortenedversionofthetitle)istobeintheleftcornerofeachpage.ThemanuscriptistobewritteninEnglish,usingMicrosoftWord,anddouble-spaced,with12pointtypeandTimesNewRomanfont.TheCoverLetter,TitlePage,AbstractandKeyWords,Acknowledgements,andeachFigure,TableandAppendix,aretobeonindividualpages. WordCount:Theword counts are not to be exceeded for the text regarding the following:Abstract:250words;ConceptAnalysis:4000words;QuantitativeResearch:4500words;QualitativeResearch:5000words;andLiteratureReview:6000words. CoverLetter:TheCoverLettermustindicatethat:themanuscript,oranysignificantpartofit,hasnotpreviouslybeenpublishedandcurrentlyisnotbeingconsideredforpublicationbyanotherjournal;eachauthorhasreadandagreeswiththemanuscript,assubmitted,andhascontributed,inasignificantmanner,tothedevelopmentofthecontenttherein;theresearchprotocolwasapprovedandcompliedwiththeguidelinesoftheinstitution(s)oftheauthor(s)andthedatacollectionsite(s);theparticipantswereinformedoftheirrights,gaveinformedconsentandhadtheiranonymitypreserved;and,whetheranyfinancialsupportorrelationshipsexistthatmayposeaconflictofinterest. Title Page: The Title Page must include the title of the paper, as well as the full name,academicandprofessionalcredentials,institutionalaffiliation(s),fullpostalande-mailaddresses,andFAXandphonenumberofeachauthor.Useanasterisk(*)todesignatethecorrespondingauthor. Abstract:Theabstractshouldfollowtheorderofthepaperandcontainnomorethan250words.Noabbreviations,references,statisticalinformationorheadingsaretobeincluded.Eachmanuscript,writtenbyanativeThai,istohaveaduplicateabstractinThai.Theabstractistobeonaseparatepagewiththetitleofthemanuscriptlisted. KeyWords:Nomorethanfive(5)keywordsaretobelistedinalphabeticalorder,toassistwith indexing,which accurately identify the paper’s subject, purpose,method and focus. Use ofMedical SubjectHeadings (MeSH®) thesaurus orCumulative Index toNursing andAlliedHealth(CINAHL)headingsarepreferred. Text:Forresearchpapers, thefollowingsectionsaretobeincluded:Introduction;ReviewofLiterature; Method; Results; Discussion; Limitations; and, Conclusions. Appropriate headings andsubheadingsshouldbeincludedasneeded.ForConceptAnalysisandReviewofLiteraturepapers,sectionswillvarydependingupononhowtheanalysisandreviewwereconducted.Thefirst time


a synonym is used, all of the words explaining the meaning of the synonym must be stated,followedbythesynonyminparentheses().Thereafter,onlythesynonym,withoutparentheses,canbeused.Allmethodsofanalysisusedinresearchpapersmustbereported.Foranalyticalmethodsthat arenotwidely recognized, anexplanationmustbeprovided.Throughout the textof thepaper,appropriatecitationofreferencesmustbegiven.Citationsinthetextofthepapermustmatchthereferencelist. Acknowledgments: So as to limit word count, list only those who have provided directresearch,financialoreditorialassistance. References:ReferencesforConceptAnalysisandResearchpapersarenottoexceed40references.ForLiteratureReviewpapersthereisnolimitonthenumberofreferencescited.TheVancouverSystemforreferencesandcitationsistobeusedasdescribedonlineathttp://en.wikipedia.org/wik/Vancouver_system and in the following article: The American Medical Association. UniformRequirement for Manuscripts Submitted to Biomedical Journals. JAMA 1997; 277 (11): 927-34.CitationsinthetextshouldbemadeusingsuperscriptArabicnumeralsintheorderinwhichtheyappear. All references are tobe listed as citations in themanuscript, and all citations are tobelistedasreferences.Referencesaretobelistedinorderofappearanceinthetext.Citethenamesofallauthorswhentherearesixorless;whensevenormore,listonlythefirstthreefollowedbyet.al.Referencetounpublisheddataandpersonalcommunicationsshouldappearonlyinthetext.SeeBelowforExamplesofReferencing: Journal Article LambertV,LambertC,PetriniM,LiX,ZhangY.WorkplaceandpersonalfactorsassociatedwithphysicalandmentalhealthinhospitalnursesinChina.NursHealthSci.20079(2):120-26. Journal Articles not in English (Need to be translated into English with a designation of the original language) TaoX,Cui,Y.Theinvestigationonlearningstylesofcollegenursingfreshmen.ChinNursRes.200721:311-12[Chinese]. Edited Book DalyJ,SpeedyS, JacksonD,LambertV,LambertC,editors.Professionalnursing:Conceptsissuesandchallenges.NewYork:SpringerPublishers;2005. Authored Book WalkerL,AvantK.Strategies for theoryconstruction innursing.4th ed.UpperSaddleRiver(NJ):PearsonEducation,Inc.;2005. Book Chapter Lambert V, Lambert C. Professionalism: The role of regulatory bodies and nursingorganizations.In:DalyJ,SpeedyS,JacksonD,LambertV,LambertC,editors.Professionalnursing:Concepts,issuesandchallenges.NewYork:SpringerPublishers;2005.p.245-56. Website Drug-interactions.com[homepageontheInternet].Indianapolis:IndianaUniversityDepartmentofMedicine; c2003 [updated 2006May 17; cited 2007May 30].Available from: http://medicine.iupui.edu/flockhart/.

TablesandFigures:Alltablesandfiguresaretobeself-containedandcomplement,butnotduplicate,informationinthetext.Nomorethanatotaloffive(5)TablesandFigures,eachonaseparatepage,areallowed.NumberTables(i.e.Table1.),andFigures(i.e.Figure1.),consecutively,withArabicnumbers,andtitleeachsoastodescribethecontent.Placealegend,toexplainsymbols,abbreviationsandunitsused,beloweachTableorFigure. Appendices:IfAppendicesareused,numbereachonewithaRomannumeral.Includetheauthor’snameoftheappendixbelowtheappendixtitle,ifthecontentiswrittenbysomeoneotherthantheauthorofthemanuscript.CopyrightlawsarenottobeviolatedwhenincludingmaterialinanAppendix. SubmissionofPaper:Identicalcopiesoftheentirepaper,includingtheCoverLetter,TitlePage,Abstract,KeyWords,Text,Acknowledgments,References,Tables,Figures,andAppendicesaretobesentinasingleelectronicfile(onanew,virus-freediskcontainingonlytherelevantfiles),andinprintedform.ThetypeofwordprocessingpackageusedistobeMicrosoftWord.Specifythecorrespondingauthor’snameandthetitleofthemanuscriptonthedisklabel.Onlyelectronicfiguresare tobesuppliedasseparatefiles.Sendthediskandhardcopyof themanuscript,asaWorddocument,to: Editors,ThaiJournalofNursingResearch NagarindrasiBuilding,MinistryofPublicHealth TiwanonRoad,AmphurMuang,Nonthaburi11000,Thailand ReviewProcess:Authorsarenotifieduponreceiptoftheirmanuscript,aswellasafterblind-reviewbyatleasttwoanonymousmembersoftheEditorialBoard.TheEditorsrevieweachmanuscriptandallreviewer’scommentsbeforenotifyingtheauthor(s)whetherthepaperis:accepted(publishableasis);notacceptable(needsrevisionsand/oreditingbeforebeingreconsideredforpublication);or,rejected(notacceptableforpublication).Initialreviewsusuallyareaccomplishedwithin6to8weeksofdateofreceiptofthemanuscript. Revisions/Editing:Manuscriptsdeterminedtoneedrevisionsand/oreditingbeforebeingreconsideredforpublicationwillbereturnedtothecorrespondingauthor.TheEditorswillinformtheauthorofrecommendedsuggestionsregardingneededrevisionsand/orediting,aswellasof thedeadlineforresubmissionoftherevisedand/oreditedmanuscriptforreconsiderationforpublication.Themajorityofsubmittedmanuscriptsrequiresomerevisionsandeditingpriortoacceptanceforpublication. TransferofCopyright:Authorsarerequiredtosignatransferofcopyrightagreementbeforetheirmanuscriptcanbepublished.ThecopyrighttransferwillbesenttothecorrespondingauthoruponacceptanceofthepaperforcompletionandreturntodenotethattheThaiCouncilofNursing&Midwiferyhastheexclusiverightstoreproduceanddistributethepaperandallcontentstherein. PageProofs:Manuscripts accepted for publication are sent to the publisher in the order inwhichtheyareaccepted.Thepublisherwillsendthepageproofs(theprintedpagespriortobeingpublished)tothecorrespondingauthortocheckandapproveforpublicationbeforepublishing.Itisessentialthattheapprovedproofsbereturnedtotheeditorswithinseven(7)daysofreceiptinorderforthemanuscripttobepublished.Theauthor(s)willbechargedforanyalterations,otherthancorrectionoftypesettingerrors,requiredtothetextorillustrationsattheproofstage. Offprints:Authorsmayorderoffprints(copiesofthearticle)atacostof10offprintsfor200Baht.

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Thai Journal of Nursing Research Vol 13 No 3 Jul 92974

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Transcript of Thai Journal of Nursing Research Vol 13 No 3 Jul 92974