Pacific Rim Vol 17 No.1

Transcription

Pacific Rim International
Journal of Nursing Research
Vol.17 No.1 January – March 2013 ISSN 1906-8107
Administrative Advisory Board : Wichit Srisuphan, Dr.P.H.,RN
EDITORS:
Clinton E. Lambert, PhD, RN, CS, FAAN
Vickie A. Lambert, DNSc, RN, FAAN
Somchit Hanucharurnkul, PhD, RN
Aim and Scope: The Pacific Rim International Journal of Nursing Research is an English language, refereed (peer-reviewed),
quarterly publication for nursing research, literature review and conceptual analysis papers.
Assistant Editor: Manee Arpanantikul, PhD, RN
Editorial Board Members: Thailand
Wannee Deoisres, PhD, RN Warunee Fongkaew, PhD, RN
Orasa Punpakdee, PhD, RN Aranya Chaowalit, PhD, RN
Ampaporn Namvongprom, PhD, RN
Ruja Phuphaibul, DNS, RN
Siriporn Chirawatkul, PhD, RN
Sukanya Parisunyakul, PhD, RN
Tipaporn Wonghongkul, PhD, RN
Jiraporn Kespichayawattana, PhD, RN
Saipin Gasemkitvattana, DNS, RN
Sophen Choonuan, PhD, RN
Veena Jirapaet, DNSc, RN
Wanapa Sritanyarat, PhD, RN
Wandee Suttharangsee, PhD, RN
Wipada Kunaviktikul, DSN, RN
Wongchan Petpichetchian, PhD, RN
Yajai Sithimongkol, PhD, RN
Other countries
Dorothy Brooten, PhD, RN, FAAN, USA
John Daly, PhD, RN, Australia
Karin Olson, PhD, RN, Canada
Marilyn Parker, PhD, RN, FAAN, USA
Rebecca Sloan, PhD, RN, USA
Yu-Mei Yu Chao, PhD, RN, Taiwan
Administrative Manager: Chulepon Chawmathagit, MS, RN
Advertising Manager: Pensri Rabieb, MS, RN
Ownership:
Thailand Nursing and Midwifery Council
Nagarindrasri Building, Ministry of Public Health,
Tiwanon Rd., Amphur Muang, Nonthaburi 11000
Telephone: (02) 596-7500
Website:www.cabells.com, http://thailand.digitaljournals.org/index.php/PIJNR, http://thailand.digitaljournals.org/index.php/
TJNR, http://www.tnc.or.th/e-journal/e-journal-list.html, http://www.tci-thaijo.org/index.php/PRIJNR
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Disclaimer: The Thailand Nursing and Midwifery Council and the Editors of the Pacific Rim International 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.
Pacific Rim International
Journal of Nursing Research
Vol. 17 No. 1
January - March 2013 ISSN 1906-8107
Content
1
Editorial: Building a Program of Research
3
The Effect of a Parent Training Program, In Conjunction with a Life Skills Training Program
for School-age Children, on Children’s Life Skills, and Parents’ Child-rearing Skills and
Perceptions of Support for Child Life Skills Development
28
39
56
Vickie A. Lambert, Clinton E. Lambert
Jeeraporn Kummabutr, Rutja Phuphaibul, Nantawon Suwonnaroop, Antonia M. Villarruel, Dechavudh Nityasuddhi
Relationships among Health Promoting Behaviors and Maternal and Infant Birth Outcomes in
Older Pregnant Thais
Supawadee Thaewpia, Lois Chandler Howland, Mary Jo Clark, Kathy Shadle James
Comparison of Outcomes of Patients with Diabetes Receiving Care by Way of Three Primary
Care Practice Models
Chatsiri Mekwiwatanawong, Somchit Hanucharurnkul, Noppawan Piaseu, DechavudhNityasuddhi,
Effect of the Prince of Songkla University Birthing Bed on Duration, Pain, and Comfort Level
during Second-Stage Labor in Primiparous Thais
Sasitorn Phumdoung, Boonrueing Manasurakarn, Kitti Rattanasombat, Sukit Mahattanan, Kalaya Maneechot,
Benjamach Chanudom, Somboon Kaewnak
68
Predicting Factors of Relapse among Persons with a Major Depressive Disorder
83
Menopausal Transition with a Yogic Lifestyle: Experiences of Thai Yogi Masters
96
Instructions to Authors
Khwanjit Mahakittikun, Darawan Thapinta, Hunsa Sethabouppha, Phunnapa Kittirattanapaiboon
Thaparat Rakpanusit, Urai Hatthakit, Umaporn Boonyasopun, Amrita Bagga
Editorial:
Building a Program of Research
In order for nursing to continue to advance as a profession, a continual development of research is needed.
However, many nurses who are required, as part of their professional performance, to be involved in conducting
research projects are at a loss regarding how to develop an ongoing program of research. This creates a problem
for the continual development of nursing science. Thus, the purpose of this editorial is to provide some basic
guidelines that nurse researchers need to consider as they journey along their paths of research interest.
A program of research can be defined as an area of concern that addresses an important health issue that
is relevant to the public. As one selects and develops a program of research it must be: a topic to which the
researcher has passion and commitment; designed to build on prior knowledge; related to the improvement of
health care outcomes; grounded in theory; and, linked to appropriate and rigorous research methods.
A program of nursing research may be generated from several sources, such as one’s: review of the
literature; clinical practice; life experiences; and/or belief system. Any one or a combination of these sources can
prove helpful in creating a program of research. However, one needs to examine what is truly of interest, to him/
her, so that interest can and will be sustained over time. Creating a program of research is not a linear process,
but one that involves repetition. A researcher may see new knowledge being created in small increments or quantum
leaps. Whatever the process, the outcomes of each component of a program of research may be somewhat
unpredictable. However, a nurse researcher sustains his/her program of research by building on his/her prior
research, as well as generating new knowledge for nursing science.
According to Hulley and colleagues,1 there are five aspects of a program of research that must exist, which
include: feasibility, interest, innovation, ethics, and relevance. Regarding feasibility, a researcher needs to ask:
“Is the research program feasible?” and “Can the research program be accomplished?” Questions to ask, regarding
interest and innovation, would be: “Is the program of research of interest to me and others?” and “Is the program
of research innovative/novel?” Questions related to ethics and relevance, that a researcher should ask himself/
herself include: “Is the research ethical and do the risks outweigh the benefits for participants?” and ”Is the
research program relevant to nursing, health care in general, patient outcomes, cost, and other relevant variables?”
If one’s program of research is to be sustainable, the answers to each of these questions need to be a resounding
“yes.”
Finally, there are general approaches2 that a nurse researcher needs to take into consideration when
developing a program of research, including:
1.Having a passion for the area of research interest. In other words, a researcher must understand, in detail,
all aspects of the area in which he/she intends to have a program of research, as well as have a passion for
the work involved. Otherwise, the program of research will not be sustained and the researcher will find
the work unpleasant and laborious.
Vol. 17 No. 1
1
2.Ensuring a high public health significance of the area of interest. This means that a researcher’s area of
interest must have significance to the public that will be served by the findings. If the area of interest has
little significance to the health of the public, the researcher may find difficulty in obtaining funding.
3.Knowing the literature related to the area of interest. This involves an in-depth, continuous, and up-todate understanding of the literature published on the researcher’s area of interest. A good researcher always
will read the most current publications related to his/her program of study.
4. Understanding clinical practice in the area of interest. This means the nurse researcher must be up-to-date
on all aspects of health care delivery related to his/her program of research. As new research findings are
published, a scholarly researcher will be aware of how these findings may or may not relate to his/her
program of research.
5.Understanding the potential outcomes of the program of research. Understanding the potential outcomes
of one’s program of research can help to strengthen each study that is developed in the research program.
Outcomes can have a direct effect on research funding, as well as how well the research findings are
received by other scholars in the area of interest.
6.Building the program of research from study to study. Each study needs to build, in some way, on
previous work the researcher has done. Most studies open up new questions and avenues for examination.
These questions and avenues can assist in developing a researcher’s next study.
7. Working with interdisciplinary colleagues. Working with colleagues in other fields can assist in strengthening
one’s program of research. Using colleagues from other disciplines can help to broaden the various aspects
of interest that can be addressed in a single research study. In addition, scholars from various disciplines
may look at an area of interest in slightly different ways.
8. Publishing research findings. A researcher always must publish, as soon as possible, the findings of a study.
No researcher should wait months or years to begin to prepare a manuscript for submission to a journal.
Timeliness is of essence! No one will be interested in old, dated information. In addition, if the research
findings are not published, no one will be able to apply the outcomes of the research.
Developing a program of research is not an easy task, especially for the novice researcher. However, it is a
necessary task for nurses to undertake. A program of research allows for the creation of knowledge that has depth
and breadth. In addition, developing a program of research prevents one from continually trying to re-invent him/
herself or an area of research interest.
Vickie A. Lambert, DNSc, RN, FAAN
Clinton E. Lambert, PhD, RN, CS, FAAN
Editors: Pacific Rim International Journal of Nursing Research
1. Hulley S, Cummings S, Browner W, Grady D, Newman T. Designing clinical research.3rd ed. Philadelphia (PA): Lippincott
Williams & Wilkins; 2001.
2. Holzemer W. Building a program of research. Jpn J Nurs Sci. 2009; 6:1-5.
2
Pacific Rim Int J Nurs Res • January - March 2013
Jeeraporn Kummabutr et al.
The Effect of a Parent Training Program, In Conjunction with a Life
Skills Training Program for School-age Children, on Children’s
Life Skills, and Parents’ Child-rearing Skills and Perceptions of
Support for Child Life Skills Development
Jeeraporn Kummabutr, Rutja Phuphaibul, Nantawon Suwonnaroop, Antonia M. Villarruel, Dechavudh Nityasuddhi
Abstract: This quasi-experimental study sought to examine the effect of a parent training program, in
conjunction with a life skills training program for school-aged children, on children’s life skills, and
parents’ child-rearing skills and perceptions of support for child life skills development. One school was
purposively selected, from which two 5th grade classes were randomly assigned to either the experimental
group or the comparison group. The parent and student study participants, who met the inclusion criteria
and consented/assented to take part in the study, included 26 student/parent dyads in the experimental
group and 27 student/parent dyads in the comparison group. All students were recruited into the life
skills training program, while only parents of the students assigned to the experimental group were
recruited into the parent training program. The principle investigator based these programs on the Theory
of Planned Behavior and interactive group techniques. Instruments for data collection included: a Life
Skills Questionnaire for School-aged Children; and, the researcher-developed Child Life Skills Development Questionnaire for Parents. Data were collected on all participants prior to implementation of both
programs, immediately following each program’s completion, and one month and three months after each
program’s completion. Analysis of covariance (ANCOVA) and repeated measures ANOVA were used to
test the effect of the parent training program.
The results demonstrated no significant effect of the parent training program on the children’s life
skills, the parents’ attitudes, and their subjective norms regarding child life skills development. Positive
effects, however, were seen on the parents’ child-rearing skills that supported child life skills development,
self-efficacy toward child life skills development, and intention to engage in child-rearing skills that
supported child life development. These findings suggest this intervention may require a longer duration
of implementation, so as to improve child life skills. Recommendations for further research include a
larger sample size and a longer period for outcome measurements.
Pacific Rim Int J Nurs Res 2013 ; 17(1) 3-27
Key words: Children’s life skills; Training program; School-age children; Parents’ perceptions;
Parental child-rearing skills
Introduction
The proportion of child behavioral problems
and risk behaviors has increased throughout the 21st
century. 1, 2 Data indicate a number of interrelated
social problems have their roots in childhood
behavioral problems, including aggressive behavior,
delinquency, smoking, and drug and alcohol abuse.1,
2, 3
The lack of competencies in adapting to and dealing
Vol. 17 No. 1
Correspondence to: Jeeraporn Kummabutr, RN, PhD (Candidate)
Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi
Hospital, Mahidol University, 270 Rama 6 Road, Phayathai, Bangkok
10400, Thailand E-mail: [email protected]
Rutja Phuphaibul, RN, DNS. Professor, Ramathibodi School of
Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University,
Bangkok, Thailand.
Nantawon Suwonnaroop, RN, PhD. Assistant Professor, Faculty of
Nursing, Mahidol University, Bangkok, Thailand.
Antonia M. Villarruel, RN, PhD. Professor, School of Nursing,
University of Michigan, Ann Arbor, MI, USA.
Dechavudh Nityasuddhi, PhD. Associate Professor, Department of
Biostatistics, Faculty of Public Health, Mahidol University, Bangkok,
Thailand
3
The Effect of a Parent Training Program
with situations and problems is a frequently-cited
cause of negative behavior among children and
adolescents.1 Thailand is encountering emotional and
behavioral problems in children and adolescents similar
to those of other countries.4 As a result, child
behavioral problems have been dominant in the public
mind for several years. Consequently, dealing with
these problems is an urgent issue facing Thai society.
Literature reviews have indicated the major
causes of child behavioral problems are a lack of
interpersonal skills in a child and the parents’ lack of
child-rearing skills.5, 6 Deficits in interpersonal skills
and social skills have long-term effects on child
competency and make children vulnerable to engaging
in risky behaviors.1, 7 In addition, lack of appropriate
child-rearing skills impacts a child’s beliefs and
behavior, especially during the school-age period that
is characterized by progressive changes in a child’s
biology, emotions, and thought processes.1, 8 Thus,
school-aged children are at an increased risk of
engaging in risky behaviors, although full-scale
problems, typically, do not tend to emerge during this
period.1 This suggests, before children encounter
various risk factors in society, their school years are
an important window of time for interventions that
promote and maintain child health, particularly
regarding skills development.1,6
Life skills training has been one of the strategies
used to promote child and adolescent development,
whereas parent training programs are new in behavioral
science in terms of child care. Life skills training
focuses on child development in social competencies,
self-management skills, drug abuse prevention, and
general health promotion. Often, this type of program
produces positive changes in children’s decisionmaking, critical thinking ability, empathy, positive
coping, and management of life in a healthy and
productive manner.1, 3
Likewise, literature reviews have indicated
training parents in child-rearing skills reduces child
behavioral problems.9, 10, 11 Improvement in parenting
4
practices is viewed as having a mediating effect on life
skills resources and reducing child behavioral
problems.10, 11, 12 The effectiveness of child preventive
programs that combine parent training programs, along
with child life skills training programs, is an acceptable
and appropriate practice that is supported by scientific
findings.2, 11
The Theory of Planned Behavior (TPB) has
been used as an organizing framework for familybased interventions related to life skills development.
This theory provides insight into the mechanisms of
parent-child attachment and the influence of the
family.14, 15 The TPB addresses the relationship
between parents’ attitudes, beliefs, intentions, and
behaviors and the effect they have on their child’s
attitudes, beliefs, intentions, and behaviors. This is
most noticeable in the strong mediating effects parental
behavior and intention (i.e., approval or disapproval)
have on a child’s behavior.14, 15, 16 It is believed that
changes in parental intention and behavior, related to
supervising and monitoring a child, are transferable to
a child’s behavior.14, 16
Literature Review
Child life skills development: In order to face
risk factors in society, children need adequate life skills
development. 18, 19 Life skills are viewed as an
individual’s ability to: exhibit adaptive and positive
behavior in protecting him/herself from health risks;
promote health; and, deal effectively with the demands
and challenges of life.1 Life skills training in children’s
competencies has become of increasing interest to the
public and is needed in order to reform traditional
educational systems throughout Thailand.1, 18, 19
Life skills training programs: Over the past
thirty years, life skills training (LST) has been found
to produce positive behavioral changes and better
skills, especially regarding taking responsibility for
making healthy choices, resisting negative pressures,
and avoiding risky behaviors.1, 3 The World Health
Organization (WHO) has recommended that LST
programs, for children, include content addressing:
decision making; problem solving; critical and creative
thinking; interpersonal relationship skills; selfawareness; empathy; coping with emotions and stress;
and, effective communication.1 However, several
training programs have added the additional skills of
negotiation and refusal, for the purpose of facilitating
children’s ability to handle their decisions,1, 3, 20 while
others have added content related to moral skills.17, 21,
22
It is believed moral skills support the development
of children’s practices of problem solving, decision
making, and organization of emotions, particularly in
regards to conflict and stress.21
Prior research, consistently, has shown that
LST programs have a positive effect on prevention of
risky health practices (i.e., drinking, smoking, abusing
drugs, and engaging in unprotected sex).20 With regard
to the statistical effectiveness of LST programs, the
results of meta-analyses has shown effect sizes ranging
from 0.28 to 0.32.6, 20, 21 In addition, prior research
has found the effectiveness of LST programs, for
children, to be positively influenced when parents are
included. When a family-focused approach is used in
a LST program, child behavioral problems are reduced,
on average, nine times more than when solely childfocused approaches are used.9, 24 Thus, in order to
increase the effectiveness of developing and changing
child behaviors, most LST program developers are
combining parent training with child skills training.
Parent training programs: Over the past two
decades, when parent training has been included as
part of risk prevention programs for children, the
training has addressed parents’ ability to practice sound
child-rearing skills (i.e., parent-child communication,
support, modeling, monitoring, supervising, and stress
and coping management), as well as consciously think
about their children’s development. 14, 25, 26
Unfortunately, few studies, conducted in Asian
countries have included parent participation in their
child life skills development programs, particularly
Vol. 17 No. 1
those in Thailand.17, 27 Preventive interventions that
emphasize parent participation have not been widely
utilized because of the widespread belief that it is
impossible to get parents to participate. Unfortunately,
little is known about family-based prevention
programs in Thailand, and sizeable gaps appear to exist
in the effectiveness of parent participation in child life
skills development programs. Thus, in order to address
this gap in knowledge, it seemed reasonable to examine
the effectiveness of intervention programs, especially
designed to develop child life skills, by combining
parent training with child life skills training. Therefore,
the purpose of this study was to examine the effect of
a parent training program, in conjunction with a life
skills training program for school-aged children, on
children’s life skills, and parents’ child-rearing skills
and perceptions of support for child life skills
development.
Conceptual Framework
The organizing framework for the intervention
employed in this study was the Theory of Planned
Behavior (TPB).13 The TPB suggests a person’s
behavior is directly determined by his/her intention to
perform a behavior (i.e., immediate antecedent) and
this intention is, in turn, a function of the person’s:
attitude toward the behavior (positive or negative
expressions about the behavior in question); subjective
norm (beliefs about how others, of importance to the
person, will view the behavior in question); and,
perceived behavioral control (one’s perception of his/
her ability to perform the behavior in question). As a
general rule, the more favorable one’s attitude,
subjective norm, and perceived behavioral control, the
stronger the person’s intention to perform a given
behavior. Thus, the TPB purports individuals will
intend to perform a behavior when they: evaluate it
positively (attitude); believe significant others want
them to participate in the behavior (subjective norms);
and, perceive the behavior to be under their control
(perceived behavioral control).
5
Generally, the TPB looks specifically at the
relationship between individuals’ beliefs, based on
perception or sense on favorable attitudes, and
subjective norms toward the behavior to predict
perceived behavioral control and form intentions and
beliefs concerning the consequences of behavior of
interest. 13 In this study, the parents’ attitudes,
subjective norms, self-efficacy (perceived behavioral
control), and intentions that involved the support for
their children’s life skills development were referred
to as parents’ perceptions of support for their children’s
life skills development.
The TPB also states that the relationship
between intention and behavior may be influenced by
the congruence of the measurement of intention and
behavior, and the stability of intention at the time of
behavior measurement. Thus, measurement of
behavior should include four elements: action, target,
context, and time. However, intention can: alter over
time; be taken prior to the observation of a behavior;
and, differ from the intention at the time the behavior
was observed. Therefore, the longer the timeframe
between measurement of intention and observation of
behavior, the less accurate the prediction of behavior.
Finally, the literature points out, in regards to
measurement, the terms, perceived behavior control
and self-efficacy, often are used interchangeably,
particularly in family-based interventions.14, 15, 16
Therefore, in this study, perceived behavioral control
(i.e., controllability in parenting skills) was labeled
and measured as parenting self-efficacy.
Method
Design: A quasi-experimental design, using
an experimental group (child training and parent
training) and a comparison group (child training only),
was implemented in this study.
Ethical Considerations: Prior to commencing
the study, the Committee on Human Rights Related to
Research Involving Human Subjects at the principle
6
investigator’s (PI) academic institution approved the
study. In addition, the Administrative Committee and
Parent-Teachers Association, at the school used as a
data gathering site, granted approval for access to
potential participants.
Potential participants were informed about: the
nature of the study; the study’s purpose; what study
involvement would entail; voluntary involvement;
confidentiality and anonymity issues; the right to refuse
to answer any specific questions; and, the ability to
withdraw, at any time, without repercussions. Consent
of parent and child participation was obtained from the
parents, and assent was obtained from the children.
Sample and Setting: The sample consisted of
53, fifth-grade students and their parents, who were
selected from catchment schools under the Human
Potential Development in Thai People Project of the
PI’s academic institution. The students were selected
via purposive sampling. Two classrooms of 5th grade
students, in the selected school, were randomly
assigned to either the experimental or comparison
group. All students from the two classrooms were
recruited into the life skills training program, while
only the parents of the students assigned to the
experimental group were recruited into the parent
training program. Inclusion criteria, for both the
students and their parents, were: able to read and write
Thai; willing to participate and give consent/assent to
be in the study; and, living together in one household.
Exclusion criteria involved the: students being
involved, previously, in a formal life skills development
program; students being unable to attend at least 8 out
of 10 sessions of the life skills development program
sessions; and, parents being unable to attend at least
2 out of 3 sessions of the parent training program.
The sample size was determined, for a single
group repeated measures design, based on a statistical
power analysis, at a significance level of 0.05, a
desired power of 0.80, and the average correlation of
the subjects’ responses to the number of repeated
measures. 28 In accord with previous findings,
the average effect size was 0.62.29 Therefore, a
minimum of 17 subjects per group was determined to
be needed. Since the attrition rate of a prior study that
was based on a Thai family context was 20%,30 in
order to prevent missing cases and data, four subject
dyads (student and his/her parents) were added. Thus,
the minimum number of student/parent dyads needed
in each group was 21.
Initially, a total of 58 students and their parents
met the inclusion criteria and consented to participate
with 28 students and their parents, in the experimental
group, and 30 students and their parents in the
comparison group. During the study, two of the
experimental group student/parent dyads and three of
the comparison group dyads dropped out because of
illness and relocation to another school (13.33%
attrition rate). As a result, 26 students and their
parents, in the experimental group, and 27 students
and their parents, in the comparison group, completed
the study.
The majority of students, in the experimental
and comparison groups, respectively: were of similar
ages (mean age = 10.50; SD = 0.510 vs. mean age
= 10.37; SD = 0.491); were boys (n = 14; 53.8%
vs. n = 14; 51.9%); were the last-born child
(n = 12; 46.1% vs. n = 9; 33.3%); had siblings
(n = 20; 76.9% vs. n = 20; 74.1%); and, lived with
both parents (n =16; 61.5% vs. n = 17; 63.0%).
Thus, no significant difference, in demographic
characteristics, existed between the two groups
( >0.05). With regard to the parents, who were all
Buddhist, the majority, in the experimental and
comparison groups, respectively: were of similar ages
(mean age = 42.31; SD = 4.523 vs. mean age =
42.74; SD = 3.879); were female (n = 22; 84.6%
vs. n = 20; 74.1%); lived with their spouse (n = 23;
88.5% vs. n = 26; 96.3%); had two children
(n = 17; 65.4% vs. n = 13; 48.1%); had other family
members living with them (n=17; 65.4% vs. n=18;
66.7%); held a bachelor’s degree (n = 17; 65.4%
Vol. 17 No. 1
vs. n = 14; 51.9%); and, were government officers
(n = 14; 53.8% vs. n = 11; 40.7%). Both groups
indicated their family incomes to be approximately
40,000 baht per month (31 baht = 1 USD). Thus,
no significant differences, in demographic
characteristics, existed between the two groups
( >0.05).
Interventions: Two interventions were used in
this study. These interventions included a: Life Skills
Training Program for School-aged Children
(LSTPSAC), for both the experimental group and
comparison group children; and, Parent Training
Program (PTP), for the parents of the children assigned
to the experimental group.
The Life Skills Training Program for Schoolaged Children (LSTPSAC), based on key constructs
from the TPB and developed by the PI,13 focused on
providing information about and promoting the
development of child life skills. The content validity
of the program was examined by three experts (i.e.,
one nursing faculty member with experience and skills
in child cognitive behavioral strategies, using the TPB;
and, one educator and one school health nurse, both
experts in conducting life skills training interventions
in school). The experts recommended the sequence of
each session be adjusted, and changes be made in the
learning activities so as to be more easily understood
and to fit within a one-hour timeframe. Once revisions
were made in the program, it was administered, for
the purpose of pilot testing, to 35 fifth-graders (one
classroom) who were similar to the study participants.
As a result of the pilot test, games and group activities
were added to the program so as to foster the children’s
attitudes toward life skills and development of
self-efficacy.
The final program (see Table 1) consisted of
eleven, 60 minute, sessions that introduced the
program and presented ten child life skills: selfesteem; critical thinking; decision-making and
problem-solving; coping with emotions; honesty;
7
generosity; sufficiency; self-responsibility; familyresponsibility; and, social-responsibility.31 Session
one of the program involved the PI and two trained
research assistants (RAs) introducing the program and
gathering baseline data. The other ten sessions,
presented by the RAs, involved activities focused on
the development of each of the child life skills. A new
life skill was presented each week. All program
sessions were presented, in a school classroom at the
end of the school day, over a period of 11 weeks. The
children in the experimental group and the children in
the comparison group were presented the program in
separate sessions.
Each session was sequentially organized into
three major components: a) promoting a positive
attitude toward each skill by way of giving information
about the advantage of and need for the skill; b)
increasing subjective norms by focusing on peer and
parental norms related to each skill; and, c) developing
self-efficacy and promoting intention to carry out each
skill by practicing the methods for developing each
skill. The strategies used for teaching the life skills
involved: skill demonstration; practice of the skill;
games; group activities; and, extended practice of a
skill through homework assignments. The homework
assignments were used as a means of facilitated parents
and children to participate, together, in child life skills
development while at home. The homework assignments
were designed for parents and children to know and
understand each other regarding: attitudes, norm
perceptions, self-efficacy, and intentions regarding child
life skills development. The homework assignments were
provided to the children, every week after each life skills
session, and brought back to the RAs the next week.
The Parent Training Program (PTP), based on
the TPB and developed by the PI, focused on promoting
and providing information on child-rearing skills, and
addressing the beliefs, attitudes, subjective norms, and
child-rearing self-efficacy needed for supporting a
8
child’s life skills development. To further facilitate
parents’ knowledge and abilities related to the program
content, the PI developed a parent handbook. The
purpose of the handbook was to provide parents with
printed information, regarding the same content
presented in the PTP sessions, which could be used as
a reference for self-study. Both the PTP and the
handbook were reviewed for content validity by three
experts (i.e., two nursing faculty with clinical
experience and skills in family-child nursing care and
a pediatrician with expertise in family counseling).
Based on the experts’ reviews, refinements were made
in the handbook and program which included additional
examples of child-rearing strategies and keywords for
the role playing session.
Following the refinements, the program and
handbook was pilot tested on five parents who were
similar to the parents participating in the study. As a
result of the pilot testing, examples of parent-child
communication, and parental monitoring and
supervision were added to the program sessions and
handbook.
The final PTP (see Table 1) consisted of three,
3-hour training sessions, as well as weekly involvement
in the children’s life skills homework assignments.
Each of the three sessions was offered, by the PI, in a
classroom at the school, on the first Friday and
Saturday of the month. Each of the Friday and Saturday
sessions involved 15 to 20 parents. The three sessions
addressed ways to develop each of the life skills being
presented in the LSTPSAC as well as essential childrearing skills (i.e., parent-child relationship, parentchild communication, parental monitoring and
supervision, parental modeling, and mentoring).
Strategies used in the three sessions included:
coaching; role playing; group discussion and
reinforcement; and, follow-up telephone calls, from
the PI, between sessions, as well as four weeks after
program completion. The three sessions were
organized around two major components: a) cognitive
restructuring related to knowledge about child life skills
development (CLSD) and parents’ child rearing skills
(PCRS) involved with child life skills of interest; and,
b) developing and practicing, at home, support for
CLSD. Finally, the parents were required to work with
their children, each week, on the child skills homework
they were given to complete and return.
Instruments: Three instruments were used in
the study: a researcher-developed Demographic Data
Questionnaire (DDQ); the Life Skills Questionnaire
for School-age Children (LSQSAC);31, 32 and, a
researcher-developed Child Life Skills Development
Questionnaire for Parents(CLSDQP).
The researcher-developed Demographic Data
Questionnaire (DDQ) sought information about the
children. The information obtained, by the PI, from
the school’s registry, included each child’s: age;
gender; birth order; presence of siblings; and, persons
residing within the household.
The Life Skills Development Questionnaire for
School-age Children (LSQSAC), originally developed
by Kaewpatima32 and modified by Phuphaibul,31
consisted of 46 items that assessed ten life-skills (i.e.,
self-esteem, critical thinking, decision-making and
problem solving, coping with emotions, honesty,
generosity, sufficiency, self-responsibility, familyresponsibility, and social-responsibility).
The questionnaire contained scenarios addressing:
substance abuse (3 items); violence (3 items);
sexual-risk (3 items); relationships (7 items); mass
media (7 items); usual daily life (12 items); and,
moral issues (11 items). Examples of questions were:
“Your uncle encourages you to drink beer, but you do
not (decision-making and problem solving skills with
substance abuse);” “You want to reward yourself with
a new toy because you earned a good score on the last
examination (sufficiency skill with usual daily life);”
and, “You see your friends quarreling and fighting in
school, but you decide not to take part in the activity
(social-responsibility skill regarding violence).”
Vol. 17 No. 1
Possible responses to the items were: 1 = “inappropriate
behavior that has negative effect on me and others”;
2 = “inappropriate behavior that has benefit to me, but
not to others”; 3 = “appropriate behavior that has
benefit to me, but not to others”; and, 4 = “appropriate
behavior that has positive effects on me and others.”
A total score was obtained by summing the response
values across all items. A high score indicated a high
level of life skills, while a low score suggested a low
level of life skills. In this study, the Cronbach’s alpha
for this instrument was 0.87.
The Child Life Skills Development
Questionnaire for Parents (CLSDQP) consisted of two
major sections: demographic characteristics; and,
levels of PCRS and perceptions of support for CLSD.
The demographic characteristic section of the CLSDQP
requested information on each subject’s: age; gender;
living with or without the spouse; number of children;
others residing in the household; educational level;
occupation; monthly family income; and, sufficiency
of the family income.
The second major section of the CLSDQP,
which measured the level of parents’ child-rearing
skills and perceptions of support for CLSD, consisted
of five parts. The five parts addressed the level of:
involvement in child-rearing skills for CLSD; attitude
toward child-rearing skills that support CLSD;
subjective norm regarding CLSD; child-rearing selfefficacy that supports CLSD; and, intention to engage
in child-rearing skills for CLSD.
The first part of the second major portion of the
CLSDQP, involvement in child-rearing skills for
CLSD, consisted of 30 items. Involvement in childrearing skills was measured in terms of performance
(i.e., teaching, modeling, and monitoring/
supervision). Each item was developed in terms of the
TPB’s beliefs about target, action, context, and time.
Examples of items were: “Over the last three months,
up to now: I have taught my child to have self-esteem
in daily life;” and, “I have monitored and supervised
9
my child regarding critical thinking in daily life.”
Parents were asked to rate their performance on each
of the 30 items, using the following responses: 1 =
“definitely false”; 2 = “false”; 3 = “uncertain”; 4=
“true”; and, 5 = “definitely true”. A total score was
obtained by summing the response values across all
items A high score indicated more positive involvement
in child life skills development. In this study, the
Cronbach’s alpha, for this portion of the instrument,
was 0.94.
Attitude toward child-rearing skills for CLSD,
the second component of the second major portion of
the CLSDQP, consisted of 12 items. Attitude was
measured by way of parents’ beliefs about specific
child-rearing skills that support CLSD. Examples of
items were: “During the last three months, up to now:
I believe I have taught my child that having life skills
is extremely valuable;” and, “I believe I have found
monitoring and supervising my child, based on life
skills, to be extremely pleasant.” Parents were asked
to indicate their level of belief about the child-rearing
skill described in each item, using the following
responses: 1 = “strongly disagree”; 2 = “disagree”;
3 = “uncertain”; 4 = “agree”; and, 5 = “strongly
agree”. A total score for this portion of the questionnaire
was obtained by summing the numerical values of the
responses across all items. A high score indicated a
more positive attitude toward CLSD. In this study, this
portion of the questionnaire had a Cronbach’s alpha
of 0.84.
Subjective norm regarding CLSD, the third
component of the second major portion of the
CLSDQP, consisted of six items. These items assessed
the parents’ level of perception regarding what they
believed people of significance to them would think
regarding their participation in CLSD. Examples of
items were: “Over the last 3 months, up to now: People
who are important to me (i.e., my parents and family
members) want me to develop my child’s life skills,
therefore, I have taught life skills to my child;” and,
10
“Most people whose opinions I value would approve
of my child’s life skills development.” Possible
responses to each item were: 1 = “strongly disagree”;
2 = “disagree”; 3 = “uncertain”; 4 = “agree”; and,
5 = “strongly agree”. A total score for this portion of
the CLSDQP was obtained by summing the numerical
values of the responses across all items. A high score
suggested the parents had a more positive perception
about how others would view their participation in
CLSD. In this study, the Cronbach’s alpha, for this
portion of the questionnaire, was 0.84.
The fourth portion of the second major
component of the CLSDQP, child-rearing selfefficacy that supports CLSD, consisted of 12 items.
Six of the items addressed perceptions of self-efficacy,
while the other six dealt with perception of being able
to control three specific child-rearing skills (teaching,
role modeling, and monitoring and supervising). An
example of a self-efficacy item was: “Over the last
three months, up to now: I have not found it difficult
to support my child regarding his/her life skills
development.” An example of a child-rearing (role
modeling) item was: “Over the last 3 months, up to
now: the decision to be a good role model for my child,
in order for him/her to develop life skills, was under
my control.” Each item had possible responses of: 1
= “strongly disagree”; 2 = “disagree”; 3 = “uncertain”;
4 = “agree”; and, 5 = “strongly agree.” A total score
for this portion of the CLSDQP was obtained by
summing the numerical values for responses across all
items. A high score suggested a high level of perception
of child-rearing self-efficacy. Cronbach’s alpha for
this portion of the CLSDQP, in this study, was 0.83.
The fifth and final portion of the second major
component of the CLSDQP, intention to engage in
child-rearing skills that support CLSD contained six
items. The items measured the extent to which parents
perceived they needed to engage in activities that
developed their children’s life skills. Examples of items
were: “Over the past three months, up to now: I have
taught my child about life skills;” and, “I have served
as a good role model for my child regarding his/her
life skills development.” Possible responses to the
items were: 1 = “strongly disagree”; 2 = “disagree”;
3 = “uncertain”; 4 = “agree”; and, 5 = “strongly
agree”. A total score for this portion of the CLSDQP
was obtained by summing the numerical values of
responses across all items. A high score suggested a
high perception of intention to engage in child-rearing
skills that support CLSD. Cronbach’s alpha for this
portion of the questionnaire, for this study, was 0.87.
Prior to the use, in this study, of the LSQSAC
and CLSDQP, their content validity was verified by
five experts (one educator, one school health nurse
and three nursing faculty members with experience
and skills in child cognitive behavioral strategies, using
the TPB). The item-content validity index (I-CVI)
for the LSQSAC was found to range from 0.90 - 0.96
and the scale-content validity index (S-CVI), using
the averaging approach, was found to be 0.94. The
I-CVI of the CLSDQP was found to range from 0.90
- 0.96, while the S-CVI, using the averaging
approach, was found to be 0.93. Based upon
suggestions from the experts and a pilot testing of both
instruments (five 5th grade children for LSQSAC and
five parents for the CLSDQP), minor linguistic
changes were made to a few items to improve their
understandability.
Procedure: Prior to commencement of the
research process, two RAs were trained, by the PI, in
the protocol of the LSTPSAC. After all the student/
Vol. 17 No. 1
parent dyads consented to participate and were
randomly assigned either to the experimental or
comparison group, the students were administered the
LSQSAC, at the school. It took approximately one
hour for the children to complete the questionnaire.
One week after administration of the questionnaire,
the LSTPSAC was implemented (see Table 1). The
program was offered to all children (both the
experimental group children and the comparison group
children) on the same day. Each group was in a separate
classroom with each group being directed by one of
the two RAs. To assure the RAs were complying with
the intervention protocol, the PI randomly observed,
on three occasions, what was taking place during
implementation of the intervention.
Once a parent/dyad, in both the experimental
group and comparison group, consented to be in the
study, the CLSDQP was sent home, with the respective
child, for his/her parents to complete and send back,
with the child, to the school. It took parents 45 to 60
minutes to complete the questionnaire. Then, one week
before the LSTPSAC started, the PTP began for the
parents assigned to the experimental group (see Table 1).
The PTP was implemented solely by the PI. The
rationale for starting the training program for parents,
prior to the start of the training program for the
children, was so the parents would be able to begin
learning about and practicing their child-rearing skills
related to their children’s life skills development. The
parents in the comparison group did not receive the
training program.
11
Table 1 Schedule and Content of Child Life Skills Training Program and Parent Training Program
Child Life Skills Training Program
Session/Content
Time Schedule
Parent Training Program
Session/Content
Preparing child training program
- Setting up the program schedule with the school.
- Preparing the children by introducing the program
and conducting an “ice-breaking” activity between
the trainers (RAs) and children.
Doing baseline (pre-test) datacollection.
1st Week
Session I: Developing Self-esteem Skill:
- Class training: Conducted to develop the children’s
abilities to recognize their personal worth/strengths
and identify their self-efficacy for promoting selfesteem.
- Homework assignment 1: Children and their parents
recorded, in separate columns on one sheet of paper,
their perceptions, feelings, values, and needs regarding
self-esteem, and ways to develop and maintain the skill.
2nd Week
- Complete homework assignments on selfesteem with children.
Session II: Developing Critical Thinking Skill
- Class training: Conducted to develop children’s
abilities to think critically, and analyze beliefs,
attitudes, values, and relevant information from
the mass media and other sources, based on
reasonable evidence or facts.
- Homework assignment 2: Children and their
parents recorded, in separate columns, on one
sheet of paper, their perceptions, feelings, values,
and needs regarding the skill of critical thinking,
and ways to develop and maintain the skill.
3rd Week
- Complete homework assignments on critical
thinking skill with children.
12
Session I: The content consisted of presenting how
to support the development of five child life skill: a)
self-esteem; b) critical thinking; c) decision-making
and problem solving; d) coping with emotions; and, e)
honesty. In addition, the program presented guidelines
for appropriate parental child-rearing skills for
promoting and supporting children’s: a) attitudes
toward life skills; b) subjective norms; c) self-efficacy;
and, d) intention to develop those five life skills.
Table 1 Schedule and Content of Child Life Skills Training Program and Parent Training Program (Continued)
Session/Content
Time Schedule
Session/Content
Session III: Developing Decision-making & Problem
Solving Skills
- Class training: Conducted to develop the children’s
abilities to evaluate information from various
sources, make informed decisions based upon
advantages/disadvantages, determine the results
of decisions made, find constructive solutions to
problems, and determine alternative solutions.
- Homework assignment 3: Children and their parents
recorded, in separate columns, on one sheet of
paper, their perceptions, feelings, values, and
needs regarding decision-making and problem
solving skills, and ways to develop and maintain
both skills.
4th Week
- Complete homework assignments on decisionmaking & problem-solving skills with children.
Session IV: Developing Coping with Emotions Skill
-Class training: Conducted to develop children’s
abilities to handle emotions (i.e., violence and
anger) that can negatively influence health.
-Homework assignment 4: Children and their parents
paper, their perceptions, feelings, values, and needs
regarding coping with emotions, skills, and ways to
develop and maintain the skill.
5th Week
- Complete homework assignment on coping
with emotions skill with children, and receive
follow-up telephone calls from the PI.
Session V: Developing Honesty Skill
abilities to be honest and truthful based on integrity.
regarding the honesty skill, and ways to develop and
maintain the skill.
6th Week
Session II: The content consisted of presenting
how to support the development of five child life
skill: a) generosity; b) sufficiency; c) selfresponsibility; d) family responsibility; and, e)
social responsibility. In addition, the program
presented guidelines for appropriate child-rearing
skills for promoting the children’s: a) attitudes
toward life skills; b) subjective norms; c) self-efficacy;
and, d) intention to develop those five life skills.
- Complete homework assignment on coping with
honesty skill with children.
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13
Session/Content
Session VI: Developing Generosity Skill
abilities to perform personal behaviors regarding
helping others and showing kindness in one’s
attitudes about and treatment of others.
regarding the generosity skill, and ways to develop
and maintain the skill.
Time Schedule
7th Week
14
Session/Content
- Complete homework assignments on
generosity skill with children.
8th Week
Session VII: Developing Sufficiency Skill
abilities to perform personal behaviors regarding
moderation, reasonableness, and self-immunity
for sufficient protection from impacts arising from
internal and external changes.
regarding the sufficiency skill and ways to develop
Session VIII: Developing Self-responsibility Skil
abilities to respond to personal basic needs and duties
in daily life. l
regarding the sufficiency skill and ways to develop
- Complete homework assignments on sufficiency
skill with children.
9th Week
- Complete homework assignment on selfresponsibility skill with children, and receive
follow-up telephone calls from the PI.
Session/Content
Time Schedule
Session/Content
Session IX: Developing Family Responsibility Skill
abilities to show concern for, respond positively to,
and cooperate with family members, in order to meet
the needs of the family.
recorded, in separate columns, on one sheet of paper,
their perceptions, feelings, values, and needs
regarding the family responsibility skill, and ways
to develop and maintain the skill.
10th Week
Session X: Developing Social Responsibility Skill
abilities to show concern for and respond positively
to the needs of one’s community and social
environment.
-Homework assignment 10: Children and their
parents recorded, in separate columns, on one sheet
of paper, their perceptions, feelings, values, and
needs regarding social responsibility skill, and ways
to develop and maintain the skill.
11th Week
- Complete homework assignments on social
responsibility skill with children.
15th Week
- Receive follow-up telephone calls from the PI.
- Complete homework assignments on family
responsibility skill with children.
Immediately following completion of the
LSTPSAC, and one month and three months after
program completion, the children, assigned to the
experimental group, were administered, at the school,
the LSQSAC. In addition, immediately following
completion of the PTP, and one month and three
months after program completion, the parents,
assigned to the experimental group, were sent, via their
children, the CLSDQP to complete and return to the
school via their children.
Data analysis: Descriptive statistics were used
to analyze the participants’ demographic characteristics.
Chi-square and independent t-test were used to
evaluate differences, between the experimental and
comparison groups, in regards to: demographic
characteristics; CLSD; parents’ involvement in
Vol. 17 No. 1
Session III: This session was conducted for overall
reflections and discussions regarding child-life skills
and parental child-rearing skills development.
child-rearing skills that support CLSD; parents’
attitude toward child-rearing skills that support CLSD;
parents’ subjective norm regarding CLSD; parents’
child-rearing self-efficacy toward CLSD; and,
parents’ intention to engage in child-rearing skills that
support CLSD. Analysis of covariance and repeated
measures ANOVA were employed to test change, over
time, in each group, and the difference between groups
regarding all of the variables, with the exception of the
demographic variables. Additionally, the standardized
difference between means was calculated to determine
the effect size of treatment or the magnitude of the
treatment effect. A small effect size was defined as
0.20, a moderate effect size as 0.50, and a large effect
size as 0.80.32
15
Results
Child life skills: As shown in Table 2, after
controlling for the covariate (scores at baseline), the two
groups did not differ significantly in mean scores at
the third month after the intervention. Moreover, there
was no significant difference, between groups, in the
children’s life skills, over time, and no significant
interaction between types of parent training and the
children’s life skills development over time (see Table
3). However, the mean scores of the life skills of the
experimental group children continuously tended to
increase and were significantly higher than those of
the comparison group at the third month after the
intervention (see Table 4 and Figure 1).
Table 2 Analyses of Covariance of Children’s Life Skills and Parents’ Child-rearing Skills and Perceptions of
Support for Child Life Skills Development
Source of Variation
Children’s Life Skills
Group
Error
Parents’ Child-rearing Skills
Group
Error
Parents’ Attitude
Group
Error
Parents’ Subjective Norm
Group
Error
Parents’ Child-rearing selfefficacy
Group
Error
Parents’ Intention
Group
Error
SS
df
MS
Fc
p
24.063
1719.342
1
50
24.063
34.387
0.700
NS
668.567
3906.432
1
50
668.567
78.129
0.700
0.005
1.607
524.280
1
50
1.607
10.486
0.153
NS
.030
105.800
1
50
.030
2.116
0.014
NS
112.584
1131.069
1
50
112.584
22.621
4.977
0.030
28.841
293.587
1
50
28.841
5.872
4.912
0.031
Note: c = Analysis of covariance; NS = P > 0.05
16
Table 3 Mean Score Differences, Across Time, for Children’s Life Skills and Parents’ Child-rearing Skills and
Perceptions of Support for Child Life Skills Development
Source of Variation
Children’s Life Skills
Between subjects
Groups
Error
Within subjects
Time
Group × Time
Error
Parents’ Child-rearing
Skills
Between subjects
Groups
Error
Within subjects
Time
Group × Time
Error
Parents’ Attitude
Between subjects
Groups
Error
Within subjects
Time
Group × Time
Error
Between subjects
Groups
Error
Within subjects
Time
Group × Time
Error
Vol. 17 No. 1
SS
df
MS
Fr
p
1.491
9434.830
1
51
1.491
184.997
0.008
NS
608.162
37.445
7118.083
2.64
2.64
134.51
230.596
14.198
52.921
4.357
0.268
0.008
NS
9.057
16672.971
1
51
9.057
326.921
0.028
NS
1026.037
804.528
13267.406
2.798
2.798
142.687
366.733
287.559
92.983
3.944
3.093
0.011
0.032
9.968
1257.513
1
51
9.057
24.657
0.404
NS
65.049
10.558
1006.074
3
3
153
21.683
3.519
6.576
3.297
0.535
0.022
NS
0.000
544.323
1
51
0.000
10.673
0.000
NS
23.690
23.576
660.884
3
3
153
14.321
10.846
5.606
2.555
1.935
NS
NS
17
Table 3 Mean Score Differences, Across Time, for Children’s Life Skills and Parents’ Child-rearing Skills and
Perceptions of Support for Child Life Skills Development (Continued)
Source of Variation
SS
df
Parents’ Child-rearing
Self-efficacy
Between subjects
Groups
121.026
1
Error
4382.172
51
Within subjects
Time
26.600
3
Group × Time
98.411
3
Error
3050.768
153
Between subjects
Groups
51.297
1
Error
684.779
51
Within subjects
Time
93.883
3
Group × Time
40.921
3
Error
859.607
153
Note: r = Two-way repeated measure ANOVA; NS = p > 0.05
Fr
p
121.026
85.925
1.409
NS
8.867
32.804
19.940
0.445
1.645
NS
NS
51.297
13.427
3.820
NS
3.174
20.620
6.084
5.570
2.428
0.001
NS
MS
Table 4 Comparison of Effect Size and Mean Scores, Across Time, for Children’s Life Skills and Parents’
Child-rearing Skills and Perceptions of Support for Child Life Skills Development
Groups
Children’s Life
Skills
Experimental group
Comparison group
Parents’ Childrearing Skills
Experimental group
Comparison group
Parents’ Attitude
Experimental group
Comparison group
18
Mean Scores
Post-test 1st month
3rd month
157.654
157.704
156.885
157.889
160.615
160.222
125.692
129.704
130.577
131.370
55.808
56.037
56.731
55.704
baseline
Effect
Size
Fr
p
161.961
160.629
3.005
1.464
0.036
NS
0.24
132.962
133.185
136.423
129.741
5.782
0.895
0.001
NS
1.22
56.692
56.185
57.615
57.185
1.932
0.696
NS
NS
0.17
Table 4 Comparison of Effect Size and Mean Scores, Across Time, for Children’s Life Skills and Parents’
Child-rearing Skills and Perceptions of Support for Child Life Skills Development (Continued)
Groups
baseline
Mean Scores
Post-test 1st month
3 month
rd
Fr
Parents’ Subjective
Norm
Experimental group 24.500
25.077
25.154
24.423 1.390
Comparison group
25.296
24.037
25.407
24.407 2.070
Parents’ Childrearing
Self-Efficacy
Experimental group 46.885
47.269
48.962
49.115 1.521
Comparison group
47.296
46.407
46.148
46.333 0.403
Experimental group 26.077 27.923
27.423
28.846 9.290
Comparison group
26.481 25.963
26.481
27.407 1.314
Note: r = One-way repeated measure ANOVA, NS = p > 0.05
Post-test = data were collected immediately after completion of the interventions.
1st month = data were collected one month after completion of the interventions.
3rd month = data were collected three months after completion of the interventions.
p
Effect
Size
NS
NS
0.02
NS
NS
0.65
0.000
NS
0.46
Figure 1 Mean Scores for Children’s Life Skills
Vol. 17 No. 1
19
Child-rearing skills and perceptions of
support for child life development skills: As shown
in Table 2, after controlling for the covariate (scores at
baseline), the results showed significant differences,
between the groups, in the scores for parents’ childrearing skills, child-rearing self-efficacy, and intention
to engage in child-rearing skills that support CLSD.
On the other hand, there was no significant difference,
between the groups, regarding the parents’ attitude and
subjective norm at the third month after the intervention.
Consistent with the results in Table 3, significant
changes, over time, in parents’ child-rearing skills,
attitude, and intention to engage in child-rearing skills
that support CLSD were found between the two groups
(see Table 3). There was significant interaction
between the two types of parent training and PCRS
scores, but only over time (see Table 3 and Figure
2). However, there was no significant difference,
between the two groups over time, in PCRS, attitude,
and intention to engage in child-rearing skills that
support CLSD. On the other hand, the parents’ attitude
increased significantly at each assessment, just as with
the parents’ intention to engage in child-rearing skills
that support CLSD (see Table 4 and Figures 3 & 6).
There were no significant changes, over time, between
the two groups, regarding parents’ subjective norm
and child-rearing self-efficacy (see Table 3),
although the mean scores of the experimental group
tended to increase and were higher, over time, than
those of the comparison group (see Table 4 and
Figures 4 & 5).
Figure 2 Mean Scores for Children’s Life Skills
20
Figure 3 Mean Scores for Parents’ Attitude toward Child-rearing Skills for Child Life Skills Development
Figure 4 Mean Scores for Parents’ Subjective Norm Regarding Child Life Skills Development
Vol. 17 No. 1
21
Figure 5 Mean Scores for Parents’ Child-rearing Self-Efficacy that Supports Child Life Skills Development
Figure 6 Mean Scores for Parents’ Intention to Engage in Child-rearing Skills that Support Child Life Skills Development
22
As shown in the figures, the trend for the mean
scores of the last measurement of the variables (three
months after the intervention), for the experimental
group, tended to be higher than those for the
comparison group, with the exception of the parents’
subjective norm. In addition, a comparison of the slope
of the mean scores, between the third (one month after
the intervention) and last measurement (three months
after the intervention), was greater for the experimental
group than the comparison group, with the exception
of the parents’ subjective norm. Such findings suggest
the intervention influenced the experimental group
parents’ child-rearing skills and perceptions of support
for CLSD.
Additional analyses on effect size: The effect
size of the intervention was calculated, based on the
outcome measurements three months after the
intervention. The results revealed the effect size was
large for the PCRS (1.22), medium for the children’s
life skills, and the parents’ child-rearing self-efficacy
and intention to engage in child-rearing skills (0.24,
0.65, and 0.46, respectively), and small for the
parents’ attitude and subjective norm (0.17 and 0.02,
respectively) (see Table 4).
Discussion
Effect on the Life Skills of School-Age
Children: The results demonstrated no effect of the
PTP on the life skills of the children in the experimental
group compared to the life skills of the children in the
comparison group. However, the results did suggest
an increasing trend toward positive effects of the
program for children in the experimental group. This
study, however, was consistent with other findings
that indicated no improvement in child life skills after
completion of similar training programs.34, 35 Three
possible explanations exist for explaining the lack of
significance.
First, it is possible the interventions, which
involved ten child life skills, were carried out over too
Vol. 17 No. 1
short a time frame. Therefore, the opportunities for
both the children to work on developing and applying
the ten life skills were insufficient. In addition, as
pointed out in the literature, the intervention effects
may have been constrained by less than optimal
participation of both parents and children in their
respective intervention programs.36
Second, the absence of a significant finding
may have reflected an insufficient period of time from
the end of the intervention to measurement of the
outcomes. The detected sleeper effects highlight the
importance of measuring long-term effects of
preventive interventions, such as the program used
with the children in this study. A longer period of time
(i.e., 6 months to one year) may have been necessary
to adequately assess whether gains had been made and
maintained in terms of the program effects.10, 24, 37, 38
Third, the fact the children involved in the study
were of school age may have been a factor. Several
literature reviews have concluded that the school-age
period tends to be a time when children engage in health
risk behaviors and, thus, are receptive to the positive
effects of prevention programs.1, 39 However, other
studies have suggested that the school-age period is a
latent time for prevention program implementation and
measurement of outcomes.20, 40 Such studies have
demonstrated moderate effect sizes for preventive
interventions for school-age children, but large effect
sizes for preventive interventions for pre-school
children and adolescents.19
Effects on the Parents’ Child-rearing Skills
and Perceptions of Support for Child Life Skills
Development: There were no statistically significant
results regarding the outcome of the PTP on parents’
attitude, subjective norm, and child-rearing efficacy.
However, there were positive effects of the program
on the parents’ child-rearing skills, parents’ childrearing self-efficacy, and intention to engage in childrearing skills that support CLSD. A large effect size
for the intervention was noted regarding parents’
child-rearing skills, while a medium effect size was
23
noted regarding the parents’ intention to engage in
child-rearing skills that support child life skills and
parents’ child-rearing self-efficacy. In addition, small
effect sizes of the intervention were noted for the
parents’ attitude and subjective norm. These findings
were congruent with prior research that noted parents
in an intervention program, similar to the one used in
this study, demonstrated a significant effect size (i.e.,
large) for positive parenting behaviors,29, 36 as well as
medium to small effect sizes in parenting self-efficacy,
and parents’ attitude, norms, and intention to engage
in child-rearing skills that support CLSD.30, 34
Two possible explanations exist for explaining
why the outcomes of the PTP were limited. First, like
the children in the experimental group, parents in the
experimental group may have needed a longer period
of time to assimilate what they had learned in their
training program so they could appropriately assist
their children in implementing what they had learned
in their training program. As recommended, in the
literature, a time frame, from intervention completion
to measurement of program outcomes, may need to be
6 months to one year. 10, 37, 41 Second, parents in the
comparison group may have experienced the Hawthorne
effect. In other words, they were given attention and
gained information during the data collection process,
from the PI, which may have led to them examining
and improving their parenting behaviors. This
explanation is consistent with prior research.29, 30, 36,
37
Limitations and Recommendations
When examining and applying the findings of
this study, several limitations need to be taken into
consideration. First, the sample size was small. Thus,
future research needs to consider increasing the sample
size used. Second, the demographic characteristics of
the children and their parents were representative of
middle class families living in urban areas. Thus, the
findings may not be generalizable to children and their
24
parents who have differing demographic characteristics.
Future researchers need to consider obtaining a more
diverse demographic sample. Third, as previously
pointed out, the length of time the two interventions
were implemented was limited (11 weeks for children
and 15 weeks for parents), as well as the time frames
in which outcome measures were taken. As a result,
these time limitations, most likely, had an effect on
the outcomes of the two interventions. Studies, in the
future, may need to consider developing interventions
that are longer in length, with outcomes measures
occurring at least 6 months to one year after completion
of the intervention. Fourth, only questionnaires were
used to measure intervention outcomes. As a result,
some subtle changes in the children’s behavior may
have occurred, but was not detected by the instruments
used. Thus, future studies need to consider use of
additional sources of data (i.e., observations of
children, and interviews of teachers and parents) for
determining outcomes of the interventions used.
Acknowledgement
The authors gratefully acknowledge the
financial support received from Thammasat University
for implementation of this study.
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ผลของโปรแกรมอบรมพ่อแม่เพื่อพัฒนาทักษะชีวิตในเด็กวัยเรียนร่วมกับ
โปรแกรมอบรมทักษะชีวิตในเด็กวัยเรียนต่อทักษะชีวิตของเด็กวัยเรียน
จีราภรณ์ กรรมบุตร, รุจา ภู่ไพบูลย์, นันทวัน สุวรรณรูป, Antonia M. Villarruel, เดชาวุธ นิตยสุทธิ
บทคัดย่อ: การศึกษาเชิงทดลองครั้งนี้มีวัตถุประสงค์ เพื่อศึกษาผลของโปรแกรมอบรมพ่อแม่เพื่อพัฒนา
ทักษะชีวิตร่วมกับโปรแกรมอบรมทักษะชีวิตในเด็กวัยเรียนต่อทักษะชีวิตของเด็กวัยเรียน ทักษะพ่อแม่ และ
การรับรูต้ อ่ การพัฒนาทักษะชีวติ ในบุตรวัยเรียน โดยศึกษาในกลุม่ เด็กวัยเรียนชัน้ ประถมศึกษาปีที่ 5 และพ่อแม่
ซึ่งอาศัยในกรุงเทพมหานคร กลุ่มตัวอย่างถูกเลือกโดยวิธีการสุ่มอย่างเฉพาะเจาะจงทั้งในระดับโรงเรียนและ
ชั้นเรียน นักเรียนชั้นประถมศึกษาปีที่ 5 พร้อมทั้งพ่อแม่ที่มีคุณสมบัติตรงกับปัจจัยการคัดเข้าและยินยอม เข้าร่วมโปรแกรม ถูกสุ่มเข้ากลุ่มทดลองซึ่งประกอบด้วยนักเรียน 26 คนและพ่อแม่ และกลุ่มเปรียบเทียบ
จ�ำนวน 27 คนและพ่อแม่ ในระดับห้องเรียน นักเรียนทั้ง 2 กลุ่ม ได้รับการอบรมทักษะชีวิตในขณะที่เฉพาะ
กลุ่มพ่อแม่ในกลุ่มทดลองเท่านั้นที่ได้รับการอบรมพ่อแม่เพื่อพัฒนาทักษะชีวิตในบุตรวัยเรียน โปรแกรมอบรม
พ่อแม่เพื่อพัฒนาทักษะชีวิตในบุตรวัยเรียน และโปรแกรมอบรมทักษะชีวิตในเด็กวัยเรียนถูกสร้างขึ้นบนกรอบ
แนวคิดของทฤษฎีพฤติกรรมตามแผน และการอบรมให้ความรู้ ฝึกทักษะการปฏิบัติ และการแลกเปลี่ยน
ประสบการณ์ โดยท�ำการเก็บข้อมูลในนักเรียนทั้ง 2 กลุ่ม ด้วยแบบสอบถามทักษะชีวิต และในกลุ่มพ่อแม่ทั้ง
สองกลุ่มด้วยแบบสอบถามการพัฒนาทักษะชีวิตในเด็ก ซึ่งท�ำการเก็บข้อมูล ก่อนได้รับโปรแกรมและภายหลัง
โปรแกรมสิ้นสุดแล้วที่ 1 สัปดาห์ 1 เดือน และ 3 เดือน และการวิเคราะห์ข้อมูลส่วนบุคคลด้วยสถิติเชิง
พรรณนา และวิเคราะห์ผลของโปรแกรมด้วยสถิติการวิเคราะห์ความแปรปรวนร่วม ความแปรแปรนทางเดียว
และสองทางแบบวัดซ�้ำ
ผลการวิจัยพบว่า ภายหลังสิ้นสุดการทดลอง คะแนนทักษะชีวิตในนักเรียนทั้งสองกลุ่มไม่แตกต่างกัน
ในขณะที่คะแนนทักษะพ่อแม่ (ES=1.22) ความสามารถของพ่อแม่ (ES=0.65) และความตั้งใจในการพัฒนา
ทักษะชีวิตในบุตรวัยเรียนของพ่อแม่ (ES=0.46) ในกลุ่มทดลองสูงกว่ากลุ่มเปรียบเทียบในการวัดผลเมื่อ 3 เดือนภายหลังโปรแกรมสิ้นสุด ถึงแม้ว่าคะแนนการรับรู้อื่นๆของพ่อแม่รวมถึงคะแนนทักษะชีวิตของนักเรียน
จะไม่แตกต่างกันอย่างมีนัยส�ำคัญระหว่างสองกลุ่มและตลอดเวลา จากผลการศึกษาแสดงให้เห็นว่า โปรแกรม
การพัฒนาทักษะชีวิตที่ผนวกรวมโปรมแกรมการอบรมพ่อแม่และโปรแกรมการพัฒนาทักษะชีวิตในเด็กวัย
เรียนนี้อาจจะต้องการเวลาที่ยาวนานขึ้นในการปรับพัฒนาทักษะชีวิตในเด็กวัยดังกล่าว ข้อเสนอแนะในการ
ศึกษาครั้งต่อไปคือการใช้จ�ำนวนกลุ่มตัวอย่างที่มากขึ้นและใช้การวัดผลในระยะยาว
ค�ำส�ำคัญ: ทักษะชีวิต/ โปรแกรมอบรม/ เด็กวัยเรียน/ ทักษะการเลี้ยงดูบุตร
ติดต่อที่: จีราภรณ์ กรรมบุตร, RN, PhD (Candidate)
นั ก ศึ ก ษาปริ ญ ญาเอก โรงเรี ย นพยาบาลรามาธิ บ ดี คณะแพทยศาสตร์
โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล กรุงเทพมหานคร ประเทศไทย
E-mail: [email protected]
รุจา ภู่ไพบูลย์, RN, DNS. ศาสตราจารย์ โรงเรียนพยาบาลรามาธิบดี
คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล กรุงเทพมหานคร
ประเทศไทย
นันทวัน สุวรรณรูป, RN, PhD. ผู้ช่วยศาสตราจารย์ คณะพยาบาลศาสตร์
มหาวิทยาลัยมหิดล กรุงเทพมหานคร ประเทศไทย
Antonia M. Villarruel, RN, PhD. Professor, School of Nursing,
University of Michigan, Ann Arbor, MI, USA.
เดชาวุธ นิตยสุทธิ, PhD. รองศาสตราจารย์ ภาควิชาชีวถิติ คณะสาธารณสุข
ศาสตร์ มหาวิทยาลัยมหิดล กรุงเทพมหานคร ประเทศไทย
Vol. 17 No. 1
27
Relationships among Health Promoting Behaviors and Maternal and Infant Birth Outcomes in Older Pregnant Thais
Relationships among Health Promoting Behaviors and Maternal
and Infant Birth Outcomes in Older Pregnant Thais
Supawadee Thaewpia, Lois Chandler Howland, Mary Jo Clark, Kathy Shadle James
Abstract: Given that approximately 36% of all Thai births are by women 35 years of
age and older, advanced maternal aged women experience poor perinatal outcomes,
and limited data exists regarding factors associated with negative maternal and infant
outcomes among older pregnant Thais, this prospective correlational research sought to
describe the relationships among health promoting behaviors, and maternal and infant
outcomes in older pregnant Thais. The sample consisted of 142 pregnant Thais who
were 35 years of age or older and receiving antenatal care in one of four public hospitals
in northeastern Thailand. Data were collected via a Personal Characteristics Questionnaire,
the Health Promotion Lifestyle Profile II Scale, and each subject’s medical record.
The results revealed that gestational diabetes mellitus, premature labor, breech
presentation, pregnancy-induced hypertension, premature rupture of membrane, and
antepartum hemorrhage were the most frequently reported maternal outcomes. The infants’
complications included fetal distress, preterm delivery, and low birth weight. Although
the subjects reported a high level of health promoting behavior, a significant negative
correlation was found between their health promoting behavior scores and antepartum
hemorrhage. On the other hand, no significant relationships were found among the
mothers’ health promoting behaviors and the infants’ outcomes. Thus, interventions that
enhance health promoting behaviors may help to prevent some of the poor maternal
outcomes that can occur in this at-risk population.
Keywords:Advanced maternal age; Health promotion; High risk pregnancy; Maternal
outcomes; Pregnancy outcomes
Introduction
Global concern about the prevalence of
maternal and infant complications among older women
is on the increase.1, 2 Older pregnant women often
experience gestational diabetes mellitus and pregnancy
induced-hypertension, 3, 4 while their newborns most
commonly experience pre-term birth and low birth
weight.5, 6 According to the World Health Organization
(WHO), the average age at pregnancy, worldwide, is
20 to 30 years of age.7 In response to the fact that
28
Correspondence to: Supawadee Thaewpia, PhD, RN. Instructor,
Srimahasarakham Nursing College, Mahasarakham Province, Thailand.
Lois Chandler Howland, DrPH, MSN, RN. Associate Professor Hahn School
of Nursing and Health Science University of San Diego, San Diego,
CA 92110, USA.
Mary Jo Clark, PhD, RN. Professor, Hahn School of Nursing and Health
Science University of San Diego, San Diego, CA 92110, USA.
Kathy Shadle James, DNSc, APRN, FAAN. Associate Professor, Hahn School
of Nursing and Health Science University of San Diego, San Diego,
CA 92110, USA.
Supawadee Thaewpia et al.
women who become pregnant after age 35 have been
categorized as members of a high-risk group8 the
WHO has set a goal to decrease infant, perinatal, and
maternal mortality rates, worldwide, by 2020. 7
However, given the increasing age of women becoming
pregnant and the greater risk of complications, much
work needs to be done to meet this goal.
Fifty years ago the Thailand Ministry of Public
Health recognized the need to improve maternal,
infant, and child health outcomes and, thus, initiated
health promotion activities to promote improved
health-related pregnancy behaviors. Although the
maternal and infant mortality rates have steadily
decreased, health problems continue to exist among
pregnant women, especially among older primigravidas
and their infants. Between 1996 and 2006, the
proportion of first births to Thais over 35 years of age
increased almost two-fold (1.0% to 1.9%) and
continues to increase.9 Thus, in an attempt to identify
and solve the problems that exit within this group,
numerous studies have been undertaken regarding
pregnancies among older Thais.2, 10-12 However,
examination of health promoting behaviors, among
older pregnant Thais, with respect to maternal and birth
outcomes has been limited.
Review of Literature
Societal changes, globally, have led individuals
to marry later in life, resulting in an increase in the
number of pregnancies to women 35 years of age and
older. This phenomenon has been noted especially in
the United States of America (USA), Australia,
Canada, Taiwan, and Thailand.2, 13-16 In the USA,
the number of older primigravidas increased 36%
between 1991 and 2001, 3 while one in four
pregnancies in the United Kingdom (UK) occurred
in women 35 to 39 years of age.17
In Thailand, 13.69% of the married women
who had a child one year of age or less were noted to
be 35 to 49 years of age. 9 In addition, the number
Vol. 17 No. 1
of deliveries at the Prince of Songkla University
Hospital in Hat Yai, Thailand, among women 40
years of age or older increased 30% between1997
and 2006.2 Moreover, 9% of pregnant Thais, at
Kalasin Hospital, Thailand, experienced their
pregnancy at an older age (i.e. 35 years and older)
between 2006 and 2007,12 and the percentage of
older pregnant women (i.e., 35 to 42 years), at
the Khon Kaen Hospital, Thailand, increased from
15.03% (2006) to 21.75% (2009).18
Older pregnant women, especially those with
first-time pregnancies, are known to be confronted by
both physiological and psychological perinatal
complications, with many of the complications
resulting in long-term consequences that affect both
the individual and society at-large. For example,
pre-eclampsia has been found to be more common in
older primiparas3 and gestational diabetes mellitus
(GDM) has been found to be associated with increased
maternal age.4, 19 In addition, older pregnant women’s
increased obstetrical risks include, but are not limited
to: antepartum hemorrhage; miscarriage; and, the need
for a caesarean section (C-section), vaginal operative
delivery, and induction and augmentation of labor.19
In Thailand, the number of unnecessary
C-sections remains high (42.85%), due to pregnant
Thais, 30 to 45 years of age, believing their age makes
them and their babies particularly vulnerable during
labor, and/or that a C-section results in experiencing
less lost work time from one’s job than does a vaginal
birth.10 In addition, older pregnant Thais have been
found to have significantly increased risks for
gestational diabetes mellitus, chronic hypertension,
malpresentation, pregnancy induced hypertension,
placenta previa, multiple pregnancies, preterm labor,
fetal distress, postpartum hemorrhage, and
endometritis.2, 11, 12 Furthermore, older mothers, who
have a history of pre-eclampsia and/or chronic
hypertension in previous pregnancies, have been found
to be at risk of pre-eclampsia.20
29
Prior studies have revealed that having children
in later life can result in the occurrence of fetal
and neonatal problems, including: fetal death;
preterm delivery; low birth weight; intrauterine growth
retardation; Down syndrome; and newborn
complications.5-6, 13, 21, 22 Moreover, older women have
been found to be at greater risk for having a stillbirth
or preterm birth, and for their infants to require
admission to a neonatal intensive care unit.23
In Thailand, the birth rate of low birth weight
infants to mothers 35 years of age and older is about
12% higher than among mothers 20 to 34 years
of age.9 In addition, infants of older pregnant Thais
have been found to experience more adverse fetal
outcomes (i.e., low birth weight, low Apgar scores,
and congenital anomalies) compared to infants of
younger Thai mothers.2, 13, 24
Although older mothers often are expected to
be well informed and have greater knowledge about
pregnancy than younger mothers, having a delayed
pregnancy may be harmful for the woman or her fetus,
especially when associated with inappropriate
behaviors.25 A number of studies have suggested that
women differ in terms of their willingness to engage
in healthful behaviors during their pregnancies. For
example, 69% of married pregnant Thais, who admitted
to consuming alcohol during pregnancy, were 35 years
of age or older, while only 31% of married pregnant
Thais, who admitted to consuming alcohol during
pregnancy, were less than 35 years of age. 26
Although the Thailand Ministry of Public
Health has initiated efforts to decrease the number of
married pregnant Thais who do not receive prenatal
care, 7.66% of them are 35 years of age or older. 9, 12
Furthermore, 43.65% of married pregnant Thais, 35
years of age and older, reportedly gave birth at home,
with the assistance of a trained midwife.9 In light of
the fact that the place of delivery and the personnel
assisting during delivery are variables related to maternal
and infant outcomes, giving birth at a hospital, with
30
professional health care providers in attendance,
reduces the risks of poor maternal and infant outcomes.8
Despite an increased interest in problems
related to older women giving birth, a limited amount
of research, throughout Thailand, has been conducted
to identify factors associated with good maternal and
infant outcomes among this group.2, 11, 12 In addition,
limited information is available, throughout Thailand,
regarding health promoting behaviors and their
impact on pregnancies among older women. Previous
research on maternal care has emphasized normal
pregnancies and the care of other groups of women
with high-risk pregnancies, from the point of view of
physicians and treatments, rather than in regards to
nursing care.11, 12 However, it is important to identify
ways to optimize health promoting behaviors among
the at-risk (i.e., 35 years of age and older) female
pregnant population. While a number of factors have
been identified as influencing maternal and infant
outcomes, the presence of health promotion practices
in pregnancy has been recognized as one of the most
significant factors.27 Thus, the purposes of this study
were to: describe the relationships among health
promoting behaviors, and maternal and infant birth
outcomes; and, identify health promoting behaviors
that predict maternal and infant birth outcomes.
Method
Design: A prospective correlational design
was used to study the relationships among health
promoting behaviors and maternal and infant birth
outcomes in older pregnant Thais. The health promoting
behaviors identified in the Health Promotion Model
were examined. The concept of health promoting
behaviors involves a positive action life-style directed
toward sustaining or increasing the individual’s level
of well-being, self-actualization, and personal
fulfillment.27 Thus, older pregnant women need to
establish healthy behaviors in order to be healthy
mothers. Healthful physical and psychological
conditions during pregnancy can allow them to achieve
good health, as well as normal fetal development.25
The independent variables were health promoting
behaviors. The dependent variables were maternal
outcomes (gestational diabetes mellitus, pregnancy
induced hypertension, antepartum hemorrhage,
preterm labor, and type of delivery) and infant birth
outcomes (birth weight, gestational age, 5-minute
APGAR scores, and congenital anomalies).
Ethical considerations: Approval to conduct
the study was obtained from the Institutional Review
Board of the primary investigator’s (PI) academic
institution, as well as from the Directors of the four
hospitals used as study sites. All potential subjects
were informed about: the purpose of the study; what
being in the study would entail; anonymity and
confidentiality issues; and, the right to withdraw from
the study at any time without repercussions. Women
agreeing to take part in the study were asked to sign a
consent form.
Sample: A sample size of 121 subjects was
determined via Cohen’s power analysis. 28 The level
of statistical significance was set at an alpha of 0.05,
a power of .80, and a medium effect size (0.13).
One hundred fifty-eight potential subjects were
purposively recruited from the antenatal clinics of
four public hospitals in northeastern Thailand. The
hospitals were selected because of the large number
of pregnant women they served each year. Of these
158 women, two refused to take part in the study
Vol. 17 No. 1
because of lack of time and one did not have her
glasses with her so she was unable to read the
questionnaires, leaving 155 potential subjects. Thirteen
of the 155 recruited subjects were excluded from the
study because they did not deliver at one of the four
selected hospitals, leaving a total of 142 subjects
participating in the study.
The study’s inclusion criteria consisted of
being a pregnant Thai who: was at least 35 years of
age; had a gestational age of 25 to 36 weeks; was able
to read and understand Thai; and, did not have a
psychiatric diagnosis, as reflected in the medical
record. The majority of the sample had: an elementary
school education (n = 74; 52.5%); a monthly
income of 5,001-15,000 Baht [30 baht = 1 USD]
(n = 60; 42.3%); and, a vaginal delivery (n = 74;
52.5%). Most of them were: married (n = 136;
97.2%); multiparous (n = 120; 84.5%); nonsmokers (n = 138; 97.9%); and alcohol consumption
free during pregnancy (n = 134; 97.8%).
As shown in Table I, the subjects’ most
frequent complication, during their pregnancy, was
gestational diabetes mellitus, while cephalopelvic
disproportion was their most frequent birth
complication and postpartum hemorrhage was their
most frequent postpartum complication. In addition,
approximately 6% of subjects’ infants experienced
fetal distress and/or prematurity, while about 5% of
their infants experienced low birth weight or mild
meconium stain, which indicated some fetal distress
(see Table 2).
31
Table 1 Frequency Distribution for Maternal Outcomes (n=142)
Variables
n
Complications During Pregnancy
Gestational diabetes mellitus
Premature labor
Breech presentation
Pregnancy-induced hypertension
Premature rupture of membrane
Ante-partum hemorrhage
Complications During Delivery
Cephalopelvic disproportion
Poor maternal effort
Postpartum Complications
Postpartum hemorrhage
Yes
No
%
n
%
24
10
9
8
6
5
16.9
7.0
6.3
5.6
4.2
3.5
118
132
133
134
136
137
83.1
93.0
93.7
94.4
95.8
96.5
18
5
12.7
3.5
124
137
87.3
96.5
8
5.6
134
94.4
Table 2 Frequency Distribution for Infant Outcomes (n=142)
Variables
Fetal distress
Preterm baby
Infant low birth weight
Mild meconium stain
Instruments: Data were collected via use of
two instruments, including a researcher developed
Personal Characteristics Questionnaire (PCQ) and
Modified Health Promotion Lifestyle Profile II
(MHPLP II). The PCQ was used to collect demographic
information regarding each subject’s level of education;
monthly income; parity; marital status; smoking
history; and alcohol consumption during pregnancy.
Information from each subject’s medical records was
obtained regarding her and her infant’s: maternal
complications; birth weight; gestational age; 5-minute
APGAR scores; and congenital anomalies. It took
about one minute to complete the PCQ
32
n
9
8
7
7
Yes
%
6.3
5.6
4.9
4.9
n
133
134
136
136
No
%
93.7
94.4
95.1
95.1
Each subject’s health promoting behaviors
were measured via the 52-item MHPLP II, which
was adapted, by the PI, from the Health Promotion
Lifestyle Profile II Scale (HPLP II), 29 based on
Pender’s Health Promotion Model,27 to measure the
health promoting behaviors of older pregnant Thais.
Items on the MHPLP II included: asking the doctor or
nurse about preventing complications during
pregnancy for women 35 years of age and older; and,
discussing with the doctor or nurse the possibility of
delivering a baby with problems because of being
pregnant at an older age. Three items (i.e., those
asking about eating habits and exercise activities)
were adapted so as to be appropriate for use in the
Thai culture.
An example of an item on the MHPLP II was:
“I report unusual signs or symptoms to the doctor or
nurse whenever I notice them.” The items had
possible responses that ranged from 1 = “never do
this behavior” to 4 = “always do this behavior.” A
total score, which could range from 52 to 208, was
calculated by summing response values across items,
with higher scores indicating better health promoting
behaviors. The internal consistency reliability for the
MPHLP was found to be 0.932. It took about 10 to
15 minutes to complete the MHPLP II.
The HPLP II questionnaire was translated
from English to Thai and then the Thai translated
version of the HPLP II was modified for use, as the
MHPLP II, with the older pregnant Thais in this
study. The Thai version of the HPLP II was translated
back to English by an experienced translator proficient
in Thai and English, who had not seen the English
version of the HPLP II. Then the English version,
derived from back translation of the Thai version of
the HPLP II, was compared to the original English
version of the HPLP II, by two Thai nursing educators
proficient in English and Thai.
Procedure: Following approval to conduct the
study, potential subjects, who met the inclusion
criteria, were identified and recruited by the respective
antenatal clinic nurses on a day each pregnant woman
received care in the clinic. After informing each
potential subject about the study, the nurses gave each
interested woman the primary investigator’s (PI)
contact information, in the event she had questions or
concerns about being in the study. Once a subject
consented to take part in the study and signed a
consent form, she was given, by the antenatal clinic
nurses, the PCQ and MHPLP II to personally
complete, while sitting in a private area of her respective
Vol. 17 No. 1
antenatal clinic. In addition, the day after each woman
gave birth, the PI collected information regarding the
maternal and infant outcomes (maternal complications,
infant birth weight, gestational age, 5-minute APGAR
scores, and congenital abnormality) from each
subject’s hospital record. As a token of appreciation
for her involvement in the study, each subject was
given a baby gift set after completing the questionnaires.
to describe the sample characteristics. Pearson
product-moment correlations were used to compare
the continuous variables, while point-biserial
correlation coefficient was used to compare the
discrete dichotomous variables and continuous
variables.30 In addition, regression analyses were
planned to determine the extent of the contribution of
health promoting behaviors to variance in maternal
and infant outcomes variables. However, since the
health promoting behaviors variable was significantly
related to only one of five dependent variables of
maternal outcomes, no regression analyses were
conducted.
Results
As shown in Table 3, the subjects had relatively
high health promoting behaviors scores (range = 98
to 201; mean = 157). However, the findings indicated
they had a moderate level of stress management and
less than optimal physical activity. In addition, as
shown in Table 4, a significant negative correlation
was found between their health promoting behavior
scores and antepartum hemorrhage (r = -.185; p < .05).
However, as reflected in Table 4, those with higher
health promoting behavior scores may have a lower
risk for antepartum hemorrhage. As noted in Table 5,
no significant correlations were found among health
promoting behavior scores and infant outcomes.
33
Table 3 Descriptive Statistics for Health Promoting Behaviors (n=142)
Health Promoting Behaviors
Total
Subscales
Health responsibility
Physical activity
Nutrition
Spiritual growth
Interpersonal relationship
Stress management
Mean (S.D.)
157.08 (21.43)
Range
98-204
28.16 (4.49)
20.63 (3.80)
27.38 (4.09)
28.75 (4.40)
28.28 (4.45)
23.87 (4.03)
17-36
13-29
14-36
17-36
16-36
13-32
Table 4 Correlations for Health Promoting Behaviors and Maternal Outcomes (n = 142)
Variables
1
1. Gestational diabetes mellitus
2. Pregnancy induced hypertension
3. Ante partum hemorrhage
4. Premature labor
5. Type of delivery
* p<.05
-
2
3
-.029
-
4
-.086
-.047
-
.037
-.064
.107
-
5
Health Promoting
Behaviors
.136
-.049
.202*
.074
-
-.018
.108
-.185*
-.051
.028
Table 5 Correlations for Health Promoting Behaviors and Infant Outcomes (n = 142)
Variables
1. Birth weight
2. Gestational age at birth
3. 5-minute APGAR
4. Congenital anomalies
** p<.01
34
1
2
3
4
-
.461**
-
.269**
.567**
-
.020
.101
.335**
-
Health Promoting
Behaviors
.025
.013
-.037
-.146
Discussion
Regarding the frequency of maternal and
infant outcomes, this study found three out of four
participating women (n = 94; 65.5%) had complications
during pregnancy or during the perinatal period.
Moreover, one quarter of them experienced adverse
infant outcomes, such as fetal distress, preterm birth,
low infant birth weight, and mild meconium stain.
These findings are similar to those reported in
previous studies.2, 12
The fact subjects had high scores for health
promoting behaviors suggest that they usually had
good health promoting behaviors during their pregnancy.
These findings are consistent with many quantitative
and qualitative studies in the literature.25, 31 A possible
explanation could be that women who chose to get
pregnant later in life are more likely to have a higher
education level and higher family income making
them more likely to be knowledgeable about and able
to participate in health promoting behaviors. 31
Furthermore, they may have planned well for their
pregnancies by preparing themselves both physically
and psychologically.32 However, some of the subjects
did have poor health promoting behaviors during
pregnancy, including low physical activity levels and
low levels of stress management. These findings are
similar to those that have been previously reported.32, 33
Antepartum hemorrhage had a significant
inverse relationship with health promoting behaviors
suggesting that women with higher health promoting
behaviors may have a lower risk of antepartum
hemorrhage. However, it must be recognized that
very few women experienced antepartum hemorrhage
in this study. Contrary to previous findings among
pregnant African-American women,33 no significant
relationships were found, in this study, among the
subjects’ health promoting behaviors and other
pregnancy outcomes. It is possible that other variables,
(i.e., biological factors, psychosocial factors, and
Vol. 17 No. 1
situational influences) had more effect on adverse
maternal outcomes in older pregnant Thai women
than health promoting behaviors. Furthermore, health
services provided by the Royal Thai Government
permit older pregnant women easy access to health care.
Thus, the pregnant women, in this study, were in a
position to take good care of themselves.
Finally, no significantly correlations were
found among the women’s health promoting behaviors
and their infants’ birth outcomes. These results are
similar to those of Neggers and asssociates33 who
concluded, in African-American pregnant women,
health practice scores are not associated with any
pregnancy outcomes. However, other factors, such as
maternal stress, family income, and social support
have been noted to influence infant birth outcomes in
pregnant women.34-36 This suggests that variables,
not associated with health promoting behaviors, may
have more influence on infant outcomes in older
pregnant Thai women than actual health promoting
behaviors.
Although the researchers were able to recruit a
sample that exceeded the original estimate needed to
address the purpose of the study, the purposively
obtained sample was comprised of older pregnant
Thais who attended specific public hospital antenatal
clinics. Thus, it is possible that the women were not
generally representative of older pregnant Thais. The
recruitment of a more diverse sample from other
geographic areas of Thailand is needed to validate and
enhance the generalizability of the findings. In
addition, not all of the women who received care in
the selected antenatal clinics participated in the study.
Thus, those who did volunteer to participate in the
study may have provided different responses and
experienced different perinatal outcomes from the
women who declined to participate. Furthermore, the
35
self-report measurement of the women’s behaviors
and attitudes relied on their recall. In addition,
personal biases also may have affected the reliability
of the women’s reported health behaviors. Thus,
future research needs to include means of data
collection that involve more than just self-report
instruments (i.e. observations, personal journals, and
interviews of family members, as well as study
subjects).
Conclusions
This study described the relationships among
health promoting behaviors and maternal and infant
outcomes in older pregnant Thai women. These
women have distinct concerns, opportunities, and
health risks during their prenatal period, labor, and
delivery. Early identification of health promoting
behaviors may offer a unique opportunity for nurses
to provide effective teaching and counseling to assist
pregnant women to engage in more optimal health
behaviors. Older pregnant women, in particular,
should be made aware of the benefits of preconception
and early prenatal care and encouraged to obtain first
trimester screening and early healthcare interventions
as needed.
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37
ความสัมพันธ์ระหว่างพฤติกรรมส่งเสริมสุขภาพที่มีผลต่อภาวะสุขภาพ
ของมารดาและทารกในหญิงตั้งครรภ์อายุ 35 ปีขึ้นไป
ศุภวดี แถวเพีย, Lois Chandler Howland, Mary Jo Clark, Kathy Shadle James
บทคัดย่อ: จำ�นวนหญิ ง ตั้ ง ครรภ์ อ ายุ ม ากกว่ า 35 ปี ขึ้ น ไปในประเทศไทยมี จำ�นวนเพิ่ ม มากขึ้ น
ประมาณร้อยละ 36 ของหญิงตั้งครรภ์เป็นมารดาที่มีอายุมาก ซึ่งหญิงตั้งครรภ์กลุ่มนี้เผชิญกับภาวะ
แทรกซ้อนทั้งในมารดาและทารก การศึกษาถึงปัจจัยที่มีผลกระทบต่อภาวะสุขภาพของมารดาและ
ทารกในหญิงตั้งครรภ์อายุ 35 ปีขึ้นไปยังมีจำ�กัด ดังนั้นการวิจัยครั้งนี้เป็นการวิจัยเชิงบรรยายมี
วัตถุประสงค์เพื่อศึกษาความสัมพันธ์ระหว่างพฤติกรรมส่งเสริมสุขภาพและภาวะสุขภาพของมารดา
และทารกในหญิงตั้งครรภ์อายุมากกว่า 35 ปี
กลุ่มตัวอย่างถูกเลือกโดยการเจาะจงคุณสมบัติตามที่ระบุไว้จำ�นวน 142 ราย เป็นหญิงตั้งครรภ์
อายุ 35 ปีขึ้นไปที่มารับการฝากครรภ์ โรงพยาบาลรัฐบาลในภาคตะวันออกเฉียงเหนือจำ�นวน 4 แห่ง
เก็บรวบรวมข้อมูลโดยใช้แบบสอบถาม ปัจจัยส่วนบุคคล และพฤติกรรมส่งเสริมสุขภาพ ส่วนข้อมูล
ภาวะสุขภาพของมารดาและทารกรวบรวมจากแบบบันทึกทางการแพทย์และการพยาบาลของกลุ่ม
ตัวอย่างแต่ละราย
ผลการศึกษาพบว่าภาวะแทรกซ้อนในหญิงตั้งครรภ์อายุมากที่พบบ่อยได้แก่ เบาหวานจาก
การตั้งครรภ์ การเจ็บครรภ์คลอดก่อนกำ�หนด การตั้งครรภ์ทารกท่าก้น ภาวะความดันโลหิตสูง
เนื่องจากการตั้งครรภ์ ถุงนํ้าครํ่าแตกก่อนกำ�หนดคลอด และภาวะตกเลือดก่อนคลอด ส่วนภาวะ
แทรกซ้อนของทารกได้แก่ ภาวะพร่องออกซิเจน ทารกคลอดก่อนกำ�หนด และนํ้าหนักตัวแรกคลอด
น้อย กลุ่มตัวอย่างมีพฤติกรรมส่งเสริมสุขภาพอนู่ในระดับสูง และยังพบว่าพฤติกรรมส่งเสริมสุขภาพมี
ความสัมพันธ์ทางลบกับภาวะตกเลือดก่อนคลอดอีกด้วย ดังนั้น พยาบาลควรจัดกิจกรรมส่งเสริมให้
หญิงตั้งครรภ์มีพฤติกรรมส่งเสริมสุขภาพที่ดีต่อไป เพื่อป้องกันภาวะแทรกซ้อนและดำ�รงไว้ซึ่งภาวะ
สุขภาพที่ดีของมารดาในหญิงตั้งครรภ์กลุ่มนี้
ค�ำส�ำคัญ: หญิงตั้งครรภ์อายุมาก การส่งเสริมสุขภาพ การตั้งครรภ์เสี่ยง การดูแลในระยะตั้งครรภ์
ผลของการตั้งครรภ์
ติดต่อที่ : ศุภวดี แถวเพีย, PhD, RN. อาจารย์ วิทยาลัยพยาบาลบรมราชชนนีศรีมหาสารคาม
จังหวัดมหาสารคาม ประเทศไทย E-mail: [email protected]
Lois Chandler Howland, DrPH, MSN, RN. Associate Professor
Hahn School of Nursing and Health Science University of San Diego, San Diego, CA 92110, USA.
Lois Chandler Howland, DrPH, MSN, RN. Associate Professor
Hahn School of Nursing and Health Science University of San Diego, San Diego, CA 92110, USA.
Mary Jo Clark, PhD, RN. Professor, Hahn School of Nursing and Health Science University of
San Diego, San Diego, CA 92110, USA.
Kathy Shadle James, DNSc, APRN, FAAN. Associate Professor, Hahn School of Nursing and
Health Science University of San Diego, San Diego, CA 92110, USA.
38
Chatsiri Mekwiwatanawong et al.
Comparison of Outcomes of Patients with Diabetes Receiving
Care by Way of Three Primary Care Practice Models
Chatsiri Mekwiwatanawong, Somchit Hanucharurnkul, Noppawan Piaseu, DechavudhNityasuddhi,
Abstract : The study’s purpose was to compare outcomes of care among patients, with type-2
diabetes, who were receiving care via three primary care practice models: a nurse practitionerphysician full-time model (NP-MDf); a nurse practitioner-physician part-time model (NP-MDp);
and, an NP without a physician model (NP). Outcomes of diabetes care included glycemic
control, self-care ability, satisfaction with care, and quality of life. Six primary care settings, in
a province in central Thailand, were used as study sites, with each model implemented in two
of the settings. A convenience sample of 300 participants, with type-2 diabetes,who were receiving
care at the selected study sites, was recruited (100 for each model). Data were collected via
the; Demographic Information Questionnaire (DIQ); Diabetic Self-Care Ability Questionnaire
(DSCAQ); Patient’s Satisfaction with Care Questionnaire (PSCQ); and, Diabetes Quality of Life
Questionnaire (DQOLQ). Descriptive statistics and MANOVA, with Tukey’s HSD, were used to
analyzethe data.
Results indicated no significant difference, in the mean score of the fasting blood glucose
level, was found among the subjects who received care via the three models. The mean scores
of the DSCAA and DQOL of participants, receiving care via the NP-MDf and NP models,
were significantly higher than those receiving care via the NP-MDp model. In addition, the
mean scores of the PSA of participants, receiving care via the NP and the NP-MDp models,
were significantly higher than those receiving care via the NP-MDf model.
The findings suggested that NP model can, provide care to individuals with type-2 diabetes
of the same quality as NP-MDF and NP-MDP model. In addition, the results revealed the NP model
was likely to achieve better psycho-social-behavioral outcomes than the NP-MDf and NP-MDp
models.
Keywords: Outcomes; Patients with diabetes; Primary care practice models; Nurse practitioner
Introduction
Healthcare reform, throughout Thailand, was
initiated in 2001, with the goal of ensuring universal
health care coverage for the all residents.1Achieving
this goal involved improvement in the quality of
services provided at the primary healthcare level, with
recognition that primary care can be expected to lower
the cost of care, improve health through access to more
appropriate services, and reduce inequities in a
population’s health. 2 Having a regular primary
Vol. 17 No. 1
Correspondence to: Chatsiri Mekwiwatanawong, RN, PhD (Candidate),
Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi
Hospital, Mahidol University, 270 Rama 6 Road, Phayathai, Bangkok
10400, Thailand.
Somchit Hanucharurnkul, RN, PhD. Professor Emeritus, Ramathibodi
School of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Bangkok, Thailand.
Noppawan Piaseu, RN, PhD. Associate Professor, Ramathibodi School
of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Bangkok, Thailand.
Dechavudh Nityasuddhi, PhD. Associate Professor, Department of
Biostatistics, Faculty of Public Health, Mahidol University, Bangkok,
Thailand.
39
Comparison of Outcomes of Patients with Diabetes Receiving Care by Way of Three Primary Care Practice Models
healthcare provider is one of the best indicators that a
person will receive appropriate comprehensive care,
including: health promotion; disease prevention; early
detection of illness; management of common health
problems; management of chronic illness/conditions;
and, rehabilitation.3
The Thailand Nursing and Midwifery Council
(TNMC) envisioned that nurses should be at the
forefront in providing primary healthcare. A review of
studies, in Thailand and developed countries, has
revealed that nurses are the major providers of primary
healthcare services, particularly in remote
areas.3Furthermore, there is strong evidence that
appropriately-trained nurses and/or nurse practitioners
have the ability to provide primary healthcare even in
high-income countries (i.e., the United States of
America4 and the United Kingdom5).
In the midst of a severe physician shortage in
Thailand, and while healthcare reform to ensure
universal coverage was being initiated, the TNMC
responded by building a nursing workforce, especially
community health nurses, to expand the scope of
nurses’ primary care practice. This led to a formallydeveloped, post-basic, nurse practitioner (NP)
program that consists of four months of training, after
two years of clinical experience as a registered nurse
(RN). The NPs are expected to work in primary care
units to provide integrated services to those who live
and work nearby.3 The integrated services provided
include: health promotion; disease prevention; disease
detection; diagnose and treatment of common health
problems; management of chronic illnesses/conditions;
and, care of terminally-ill patients at home and in the
community.
Currently, primary care practice models within
Thailand are divided into three categories: 6
•Health centers without physicians: This model
is a small community health center (CHC)
serving the population at the sub-district and
village level, with coverage of fewer than
40
5,000 people. One NP or one RN, and one to
two community health workers are present.
•Health centers with physicians on rotation:
This model is a large CHC, with coverage of
5,000-10,000 people. One to two NPs and
two to four community health workers (CHW),
including a dental assistant ordental hygienist,
are present.
•Upgraded health centers with a “non-rotating”
family medicine (FM) or general practice
physician (GP): This model is referred to as
a “Community Medical Unit” (CMU), with
coverage to 10,000-15,000 people in the
catchment area. At least one physician, two to
three NPs, four to six CHWs, and a part-time
or full-time dentist and dental hygienist are
present. Very few CMUs are in large urban
areas.
As chronic illnesses, especially diabetes
mellitus, have increased,worldwide, almost 50% of
Thais who have diabetes receive care via a variety of
primary care practice models:6 the Nurse PractitionerPhysician full time (NP-MDf) model; the Nurse
Practitioner-Physician part-time (NP-MDp) model;
and the Nurse Practitioner (NP) model. However, no
data is available for comparison, between the three
models, of the outcomes of care of persons with
diabetes.
Literature Review
The NP’s role, in Thailand, continues to
develop in response to changing societal and healthcare
needs, in all settings, to ensure universal healthcare
coverage of the population. At present, NPshave an
opportunity to perform primary care service,
particularly in the rural and underserved communities.
In clarifying their role in primary care, members of the
profession are responsible for advancing the role of
the NP and ensuring that the standards of the profession
are maintained. Outcomes research on their practice
will allow NPs to improve health outcomes and quality
of care. A number of NP-sensitive outcome measures
have been identified, including clinical outcomes (i.e.,
health status, complications, and symptom reduction;
knowledge of disease and its treatment;7, 8 self-care
abilities;4, 7, 8 patient satisfaction and quality of life;4, 9
and, cost of care.4, 8, 9)
Prior studies have consistently supported the
quality and cost-effectiveness of NP practice in a
variety of practice areas (i.e. acute, chronic, and
ambulatory care). A meta-analyses of NP outcomes7,
8
and a review of NP effectiveness,9comparing the
quality of care provided by NPs and MDs, revealed
that NP outcomes and management of care were at
least as good as that of physicians. A longitudinal
study, in a primary care setting, among patients with
diabetes, hypertension, and asthma,found no
difference, at a two-year follow up, between patients
followed by NPs or MDs,with respect to health status,
physiological indicators, satisfaction with care,
hospitalization, or utilization of health services.10
A number of studies have compared NP
outcomes and those of physicians regarding patients
with diabetes. One such study11 showed that NPs and
MDs had similar patient outcomes with respect to
patients’: blood pressure, blood glucose and creatinine
testing, foot examination, and ophthalmologist
referrals. However, the NPs were found to be more
likely than the MDs to document general diabetes
education and education regarding nutrition, weight
and height, exercise, HbA1c, and medications.
Additionally, positive NP-diabetic outcomes were
demonstrated in an experimental study that compared
patient outcomes of care between an experimental
group of a MD-NP team and a control group receiving
the usual MD-directed care.12 The experimental group
had a significantly shorter stay and, after adjustment
for the cost of the team intervention, a significant net
cost savings was associated with the use of the team.
Vol. 17 No. 1
In addition, there were no differences in readmission
rates, mortality, or patient satisfaction. The author
implied, but did not specify, that the NPs employed in
the study were acute care NPs. The NPs’ role was to
perform continuity of care to supplement physician
care. However, they did not function fully as NPs, as
they did not admit patients or prescribe medications.12
Within the primary care setting, the practice of
NPs providing care to diabetics, compared to the care
provided by physicians, showed the NPs’ interventions
lowered HbA1c and glucose to a greater degree than
his or her physician colleagues.13 Blood pressure of the
patients cared for by the NPs and MDs remained equal.
Diabetes patient education was initiated, documented,
and offered throughout the continuum of care more
consistently by the NPs than the MDs. The findings
suggested the NPs were capable of performing a high
level of expertise in clinical management and were
dependent upon the clinical practice guidelines to
achieve optimized outcomes (i.e. improving metabolic
control and saving health care costs).
An evidence-based project 14 investigated
whether the consistent care provided by NPs, in a free
diabetic clinic, would match or exceed the voluntary
but inconsistent care provided by MDs, in achieving
the American Diabetes Association (ADA) guidelines
for 2004-2009.14 The results demonstrated that the
NP visits and the volunteer MD visits did not differ
statistically, regarding the patients’ HbA1c, HDL, or
LDL goal attainment. However, the ophthalmology
and podiatry referrals, and microfilament testing were
more frequently performed by the NPs than by the
MDs.
Although the literature demonstrates that NPs
perform a comprehensive range of practice, including
expanded medical care practice (i.e. physical
assessment and diagnosis, ordering laboratory tests,
prescribing treatments), that is comparable to that of
physicians, the need for outcome evaluation studies
that provide reliable data to verify the impact of NP
care still are desired. Such NP outcome research
41
hopefully would: make the results of Thai NP practices
more visible to the healthcare system; lead to better
understanding of NP contributions; and, provide
rationale for development and expansion of an
integrated NP role.
In addition, previous studies have revealed that
the characteristics of NPs, such as clinical competency
and provider performance, affect healthcare
outcomes.15 These characteristics are related to the
NPs’ experience and educational preparation. It must
be kept in mind, however, that the referenced NPs
were trained at the masters or doctoral level, and
underwent rigorous assessment via a certificated
examination to become an advanced practice nurse.15
On the other hand, the NPs, throughout Thailand, are
trained only for four months after a minimum of two
years of clinical experience as an RN. Thus, evaluation
of NP utilization, in various primary care practice
models, throughout Thailand, is needed. Therefore the
purpose of this study was to compare the differences
in outcomes (i.e., glycemic control, self-care ability,
satisfaction with care, and quality of life) among
persons with diabetes receiving care at primary care
settings, based on the NP-MDf, NP-MDp, and NP
models.
Method
Design: A descriptive comparative study design
was used.
Ethical considerations: The study was approved
by the Institutional Review Board (IRB) of the Primary
Investigator’s (PI) academic institution and the
primary care units (PCUs) used as study sites.
Potential participants were informed about: the purpose
of the study;what study involvement entailed;
voluntary participation; anonymity and confidentiality
issues; and theright to withdraw, at any time, without
repercussion. Those willing to participate were asked
to sign a consent form before taking part in the study.
42
Settings: Since one province, near Bangkok,
Thailand, contained all three types of the primary care
models (NP-MDf, NP-MDp, and NP), it was selected
as the study site. Out of the 16 districts, in the selected
province, six were chosen for inclusion because they
meet the pre-determined criterion of having more than
100 registered patients with diabetes.
All three primary care practice models used the
medical practice guideline for diabetes (B.E. 2551)
set forth by the Thai National Health Security Office
(NHSO).16 In addition, they all provided five specific
aspects of diabetic healthcare: screening and diagnosis
of diabetes; treatment for glycemic control; follow-up
and evaluation of treatment outcomes; complication
screening; and, diabetic education for self-care and
lifestyle adjustment.
In the NP-MD f model, a physician was
responsible for the diagnosis, prescribing treatment,
complication screening, and follow-up/evaluation of
treatment outcomes for the patients with diabetes. The
NP was mainly responsible for the patients’ education
for self-care and lifestyle adjustment, as well as
assisting the physician in all other aspects of care.
In the NP-MDp model, both the NPs and the
physicians provided medical care to the patients. The
physicians routinely worked only two days a week,
while the NPs examined and treated patients the other
three days of the PCUs’ weekly schedule. The
physicians solely examined patients and prescribed
treatments the two days they were present, while the
NPs switched from providing total care to providing
health education and screening for complications.
In the NP model, the NPs provided all five
aspects of primary diabetic care in accord with the
NHSO’s diabetes’ care guidelines.16 The NPs referred
the patients whose blood sugar could not be controlled
to a higher level of care.
Sample: A sample size of 315 (105 participants
for each model), with a 5% attrition rate,was
calculated through use of the Guilford and Fruchter’s
Table17 (alpha = 0.05, p = 0.70, d = 0.5, c = 0.25,
q2 = 0.125, and group = 3, variable = 4). Thus,
325 persons with type-2 diabetes mellitus were
approached and invited to take part in the study.
Twenty-five of them (7.69%) refused, mainly
because of inconvenience to participate, leaving 300
participants (100 for each model). The inclusion
criteria for participants included: being a Thai
diagnosed with type-2 diabetes; being 18 years of age
or older; receiving care at one of the selected PCUs
for at least one year prior to data collection; and, having
no known impairment in cognition or hearing.
The participants, who ranged in age from 27
to 82 years ( x = 60.70), primarily were: female
(n = 219; 73.0%); Buddhists (n = 271; 90.3%);
primary school graduates (n = 262; 87.6%); married
(n = 198; 66%);working (n = 171; 57.0%);
receiving an income of less than 5,000 baht per month
(n = 207; 69%); receiving the Universal Healthcare
Coverage Scheme (n = 258; 86%); and, overweight
(n = 174; 58%).
The average duration of being diagnosed with
diabetes was 7.17 years (SD = 5.26), with 97.7%
(n = 293) having no diabetic wounds and being
controlled through use of oral diabetic medications
(n = 277; 92.3%). Regarding risk behaviors, 9.3%
(n = 28) smoked cigarettes and 8.3% (n = 25)
consumed alcohol. Most had one or more comorbidities, including hypertension (n = 206;
68.6%) and dyslipidemia (n = 169; 56.3%). None
of the participants’ characteristics were significantly
different (p> .05).
Instruments: Data were collected via testing
capillary fasting blood glucose levels and administration
of four questionnaires (Demographic Information
Questionnaire (DIQ); Diabetes Self-Care Ability
Questionnaire (DSCAQ;20 Patient’s Satisfaction with
Care Questionnaire (PSCQ);22and Diabetic Quality of
Life Questionnaire (DQOLQ).23, 24 Fasting capillary
blood glucose (FCBG) was measured through a
glucometer because of its convenience and cost
effectiveness. A prior study demonstrated that the FCBG
test had an acceptable accuracy, with 94.2% sensitivity
Vol. 17 No. 1
and 90.2% specificity, when compared to results from
standard plasma glucose testing.18 Hence, the average
of the last three months of each subject’s FCBG was
used in this study. However, the FCBG test is known
to likely value the blood glucose level more than the
peripheral venous blood glucose measurement because
the glucose in capillary blood is not fully delivered to
the cells. 19 Interpretation of the FCBG values
wereclassified, according to the NHSO’s diabetes’
care guidelines,16 as: good (70-129.99 mg/dl); fair
(130-149.99 mg/dl); or, poor (≥ 150 mg/dl).
The researcher-developed Demographic
Information Questionnaire (DIQ)consisted of 14
items, including each subject’s: age, gender, marital
status, religion, education, occupation, income,
healthcare financing, BMI; current risk behaviors
(smoking and alcohol consumption); duration of
diabetes; treatment regimen; co-morbidities; presence
of diabetic wounds; and fasting capillary blood glucose.
The Diabetes Self-Care Ability Questionnaire
(DSCAQ) was developed, based on the self-care
needs of individuals with diabetes that were
recommended by the Thai Association of Diabetes
Educators,20 as part ofthe Advanced Practice Nurse
Outcomes Research Task Force of the Thailand
Nursing and Midwifery Council. 21The DSCAQ
consisted of 36 items that addressed six dimensions:
diet (14-items); exercise and activity (2-items);
self-monitoring (4-items); information and followup (4-items); hygiene and foot care (9- items);
and,medication taking routine (3-items). The
participants were asked to respond, using the following
rating scale, according to how often they performed
each behavior: 0 = “never to rarely done (0 days per
week or once in a while)”; 1 = “sometimes (1-3 days
per week)”; 2 = “frequently (4-5 days per week)”;
and, 3 = “always (6-7 days per week)”. Examples
of the questions were:“How often do you eat desserts
between meals?” and “How often do you examine
your feet?” Twenty-nine of the items were positively
stated, while seven were negatively stated. Prior to
43
calculating the six dimension scores and total score,
the negatively stated items were reverse scored.
Dimension scores were calculated by summing the
response values across all relevant items, while the
total score, which could range from 0 to 108, was
calculated by summing the response values across all
items. A high total score meant having a higher ability
to perform diabetes self-care. Interpretation of the
total score was: high (score of 72-108); moderate
(score of 36-71.99); or, low (score of 0-35.99).
The content validity (CVI) of the DSCAQ was
reviewed by five experts (two faculty members with
expertise in diabetes care; one diabetic nurse educator;
and, two advanced practice nurses in diabetic care).
The CVI was found to be 0.83. Prior to use, the
DSCAQ was pilot-tested on 30 patients with diabetes.
Its reliability was found to be 0.83. For the actual
study, the reliability was 0.87.
The Patient’s Satisfaction with Care
Questionnaire (PSCQ),22 consisted of 15 items that
measured patients’ satisfaction with their providers’
care in terms of the sub-dimensions of humanization
(6 items), competency (2 items), and accessibility
to diabetes care (7 items). Examples of the items were:
“I got explicit explanations regarding health through
the health care provider (physician or nurse)” and
“The health care provider (physician or nurse)
performed mindful and attentive care for me.” The
participants were asked to respond to the items on a
5-point Likert-like scale (1 = “very strongly
disagree”; 2 = “somewhat disagree”; 3 = “neutral”;
4 = “somewhat disagree”; and, 5 = “very strongly
agree”). Sub-dimension scores were obtained by
summing the response values across all relevant items,
while a total score, which could range from 15 to 75,
was determined bysumming across all items. High
scores meant better patient satisfaction with the
healthcare received. Interpretation of the total PSCQ
score was classified as: high (55-75); moderate
(35-54.99); or, low (15-34.99). The reliability,in
pilot-testing the PSCQ on 30 patients with diabetes,
was 0.92. For this study, the reliability was 0.95.
44
The original version of the Diabetes Quality of
Life Questionnaire (DQOLQ),23 was published and
available for public use. The DQOLQ was translated
into Thai by Keeratiyutawong24 and permission for
usage was obtained. The questionnaire was divided in
two sub-dimensions: satisfaction with life (15 items
i.e., “How satisfied are you spending time to perform
diabetes self-care?”) and, life impact (10 items i.e.,
“How often do you have to stop working because of
diabetes?”). Possible responses for the satisfaction
with life items ranged from 5 = “very satisfied” to 1
= “very unsatisfied.” Possible responses for the life
impact items ranged from 5 = “disappeared” to 1 =
always present.” Eight of the life impact items required
reverse scoring before calculating the total score. Subdimension scores were obtained by summing the
response values across relevant items, while a total
score was obtained by summing the numerical values
of the responses across all items. Scores then
weretransformed into a 100 point scale where zero
represented the lowest possible quality of life and 100
represented the highest possible quality of life.
This was accomplished by using the following formula:
Transformed scale =
[(raw score – lowest possible score)] x 100
raw score range
A high score on each component of the DQOLQ
suggested a positive quality of life. Interpretation of
scores on the DQOLQ were classified as: high (75100); moderate (50-74.99); and, 3) low (2049.99).The reliability, in pilot-testing the DQOLQ
on 30 persons with diabetes, was: 0.75 (life
satisfaction = .77; life impact = .72). For the actual
study,the reliabilities were 0.78 (life satisfaction =
.79; life impact = .75).
Procedure: After approval to conduct the study
was granted, data were collected at each of the study
sites. The PI introduced herself to the directors of the
PCUs, the health care providers, and patients with
diabetes, as well as explained the purposes and benefits
of the study to all of them. The PI reviewed the patient
medical records on the days potential participants
attended the diabetic clinic. Those who met the
inclusion criteria were approached and invited to
participate in the study. After an individual agreed to
participate, the PI read theitems in each questionnaire
to him/her. He/she would, in turn, verbally respond
with the responses being recorded on the respective
questionnaire. The questionnaires were administered
in the following order: DIQ, DSCAQ, PSCQ, and
DQOLQ. It took 45 to 50 minutes to complete all four
questionnaires. The medical information for the DIQ
(i.e., FCBG, presence of diabetic wounds, comorbidities, type of treatment regimen, and duration
of diabetes) was obtained from each subject’s medical
record.
Data Analysis: The demographic data were
analyzed using descriptive statistics. Differences on
characteristics among the participants were tested using:
2
for data on a nominal scale; Kruskal-Wallis for the
interval and ratio scale with non-normal distribution;
and, ANOVA for normal distribution. MANOVA was
used to test the differences in the subjects’FCBG,
DSCAQ, PSCQ, and DQOQL. If a significant difference
was detected, a Tukey’s HSD (honestly significant
difference) test was performed to test the difference
between different pairs of the models.
Results
Fasting Capillary Blood Glucose (FCBG):
As shown in Table 1, participants receiving care via
the NP model had the lowest mean for FCBG.
However, the mean was close to the mean scores for
FCBG of those receiving care via the NP-MDf model
and the NP-MDpmodel. MANOVA demonstrated no
significant difference, among the participants receiving
care via the three models, with respect to their mean
FCBG. Upon considering the number of good, fair and
poor controls, about 30% of the participants were
found to be in good control, nearly half exhibited fair
glycemic control, and approximately 20% showed
poor glycemic control. Those receiving care via the
NP-MDf model had the highest percent of good glycemic
control and the lowest percent of poor glycemic control.
On the other hand, those receiving care viathe NP-MDp
model had the highest percentage of poor glycemic
control. Additionally, c 2 showed no significant
differences in glycemic control across the three models.
Table 1 Comparison Fasting Capillary Blood Glucose among Participants Receiving Care via Three Primary
Care Practice
Dimensions of FBG
NP-MDf NP-MDp
NP
Total
n=100 (%) n=100 (%) n=100 (%) N=300
Total FBG
Mean
152.60
154.97
149.20
SD
42.90
40.22
32.44
Min
91.08
91.33
86.00
Max
236.68
242.85
223.33
Glycemic control
n=100
n=100
n=100
1. Good (70-129.99mg/dl) 33(33.0) 31(31.0) 30(30.0)
2. Fair (130-149.99 mg/dl) 48(48.0) 47(47.0) 49(49.0)
3. Poor control(≥ 150 mg/dl) 19(19.0) 22(22.0) 21(21.0)
153.29
38.68
86.00
242.85
F
df
p-value
.262 (2, 297)
NS
.262
.057
.298
NS
NS
NS
(2, 91)
(2,141)
(2, 59)
Note: FCBG = Fasting capillary blood glucose; NP = Nurse practitioner model; NP-MD square = Nurse practitionerPhysician full-time model; NP-MD square = Nurse practitioner-Physician part-time model; NS = Non-significant
(p-value > .05)
Vol. 17 No. 1
45
Diabetes Self-Care Ability (DSCA): As
shown in Table 2, the level of the participants’ diabetic
self-care ability was moderate in all three models.
However, those receiving care viathe NP model had
the highest mean score of total DSCA and the four
sub-dimensions of diet, exercise, follow up, and foot
care. MANOVA showed a significant difference,
among participants receiving care via all three models,
in the mean scores of total DSCAQ, the sub-dimension
of diet; and the sub-dimension of follow-up. Further
analysis, using the Tukey’s HSD test, showed that
participants receiving care via the NP and NP-MDf
models were not significantly different regarding their
mean scores for the total DSCAQ (p> .05), while
those receiving care viaboth models had significantly
higher mean scores for the total DSCAQ than those
receiving care viathe NP-MDp model (p< .05). For
the sub-dimensions, there were significantly higher
mean scores for diet and follow-up for those receiving
care via the NP and NP-MDf models than those
receiving care via the NP-MDp model (p< .05).
However, no significant differences in the diet and
follow-up mean scores were found between participants
receiving care viathe NP and NP-MDf models (p> .05).
Table 2 Comparison of Diabetes Self-Care Abilities among Participants Receiving Care via Three Primary
Care Practice Models
Dimensions of DSCA
Total DSCA
Mean
SD
Min
Max
Possible range
1. Diet
Mean
SD
Min
Max
Possible range
2. Exercise#
Mean
SD
Min
Max
Possible range
3. Self-monitoring
Mean
SD
Min
Max
Possible range
46
NP - MDf
n=100
NP - MDp
n=100
NP
n=100
61.53
8.75
44
83
0-108
58.19
9.27
36
77
61.85
8.95
41
85
28.20
4.31
18
36
0-42
25.54
4.48
14
36
2.35
1.10
0
6
0-6
2.28
1.54
0
6
2.51
1.63
0
6
4.00
2.44
0
10
0-12
4.24
2.31
0
9
3.52
2.76
0
12
28.84
4.09
17
39
F
df1, df2
p-value
5.081
(2, 297)
.007
6.070
(2, 297)
.009
NS
5.206
(2, 297)
NS
Table 2 Comparison of Diabetes Self-Care Abilities among Participants Receiving Care via Three Primary
Care Practice Models (Continued)
Dimensions of DSCA
4. Follow up
Mean
SD
Min
Max
Possible range
5. Foot care#
Mean
SD
Min
Max
Possible range
6. Medication Adherence
Mean
SD
Min
Max
Possible range
NP - MDf
n=100
NP - MDp
n=100
NP
n=100
9.95
1.95
2
12
0-12
7.42
1.90
1
12
11.20
3.48
4
20
9.20
3.48
4
20
0-27
10.70
3.19
3
18
9.55
3.60
2
21
7.83
1.23
5
9
0-9
8.01
1.37
3
9
7.13
1.134
3
9
F
df1, df2
p-value
4.537
(2, 297)
.038
NS
4.320
(2, 297)
NS
Note: DSCA = Diabetes self-care ability; NP = Nurse practitioner model; NP-MDsquare = Nurse practitionerPhysician full-time model; NP-MDsquare = Nurse practitioner-Physician part-time model;
#Kruskal -Wallis test; NS = Non-significant (p-value> .05)
Patient’s Satisfaction with Care (PSC): As
shown in Table 3, participants receiving care from all
three models were highly satisfied with their care.
However, those receiving care via the NP model had
the highest mean score on the PSC and the two subdimensions, humanizationand accessibility to care
services. However, participants receiving care viathe
NP model had the lowest mean score on the subdimension of professional competence. MANOVA
showed significant differences, among those receiving
care via the three models, in the mean scores of the
PSC and the sub-dimension of accessibility. The
Tukey’s HSD test showed there was no significant
Vol. 17 No. 1
difference in the mean satisfaction with care score
between those receiving care via the NP and NP-MDp
models (p> .05), while those receiving care from both
the NP and NP-MDp models had significantly higher
mean satisfaction scores than those receiving care via
the NP-MDf model (p< .05). For the sub-dimension,
satisfaction with accessibility, those receiving care via
the NP and NP-MDp models had significantly higher
mean scores than those receiving care via NP-MDf
model (p< .001). No significant difference in
satisfaction with accessibility was found between
participants receiving care via the NP and NP-MDp
models (p> .05).
47
Table 3 Comparison of Satisfaction with Careamong Participants Receiving Care via Three Primary Care
Practice Models
Dimensions of PSC
Total PSC
Mean
SD
Min
Max
Possible range
1. Accessibility to care
Mean
SD
Min
Max
Possible range
2. Provider’s competency
Mean
SD
Min
Max
Possible range
3. Provider’s humanization
Mean
SD
Min
Max
Possible range
NP - MDf
n=100
NP - MDp
n=100
NP
n=100
61.32
5.077
45
75
15-75
64.12
4.557
53
74
65.69
6.108
50
75
21.18
4.68
17
29
6-30
25.20
3.87
18
30
26.29
4.64
20
30
8.56
2.38
8
10
2-10
8.42
2.95
8
10
7.65
1.89
7
10
31.58
5.17
26
34
7-35
30.50
4.62
28
34
31.65
5.36
28
35
F
df1, df2
p-value
19.411
(2, 297) < .001
11.865
(2, 297)
.018
2.032
(2, 297)
.524
1.598
(2, 297)
.642
Note: PSC = Patients’ satisfaction with care; NP = Nurse practitioner model; NP-MDf = Nurse practitioner
Physician full-time model;NP-MDp = Nurse practitioner-Physician part-time model; NS = Non
significant (p-value> .05)
Diabetes Quality of Life (DQOL): As shown
in Table 4, participant sreceiving care via the three
modelshad a moderate level of total DQOL, with those
receiving care via theNP model having the highest
mean scores for total DQOL and both sub-dimensions,
life satisfaction and life impact. MANOVA showed a
significance difference, among those receiving care
via the three models, in the mean scores for total DQOL
and both sub-dimensions, life satisfaction and life
impact. Participants receiving care from the NP and NP
48
-MDf models had significantly higher mean scores on
the sub-dimension, life satisfaction, than those
receiving care from the NP-MDp model (p< .05). In
addition, those receiving care from the NP and NPMDf models had significantly higher mean scores on
the sub-dimension, life impact, than those receiving
care from the NP-MDp model (p< .001and p< .05
respectively). Significant differences were noted in
the life satisfaction and life impact scores between the
NP and NP-MDf models (p> .05).
Table 4 Comparison of Diabetes Quality of Lifeamong Participants Receiving Care via Three Primary Care
Practice Models
Dimensions of DQOL
Total DQOL
Mean
SD
Min
Max
Possible range
1. Life satisfaction
Mean
SD
Min
Max
Possible range
2. Life impact
Mean
SD
Min
Max
Possible range
NP - MDf
n=100
NP - MDp
n=100
NP
n=100
72.79
7.19
59
86
20-100
69.42
5.98
54
85
73.43
6.83
60
88
71.56
5.308
59
74
20-100
68.89
4.23
56
74
72.25
5.671
57
75
75.02
5.687
64
82
20-100
70.95
5.236
61
80
75.61
5.892
66
83
F
11.584
df1, df2
p-value
(2, 297) < .001
9.693
(2, 297)
.032
12.840
(2, 297)
.008
Note: DQOL = Diabetes quality of life; NP = Nurse practitioner model; NP-MD square = Nurse practitioner
Physicianfull-time model; NP-MD square = Nurse practitioner-Physician part-time model; NS = Non
significant (p-value> .05)
Discussion
Fasting Capillary Blood Glucose (FCBG):
Approximately one third of the participants had good
glycemic control. This is consistent with the findings
of a previous study, 25 wherein 26.3% of patients with
type-2 diabetes who attended a diabetes clinic at a
Thai university hospital had a HbA1C of less than 7%.
About half of the participants, in this study,who were
receiving care via all three models had fair glycemic
control (FBG = 130-149.99 mg/dl), while about
20% had poor glycemic control. The FCBG values,
in this study, tended to be higher among the elderly
Vol. 17 No. 1
participants (M = 60.7 years; SD = 10.07). This
might have been due to the healthcare providers being
particularly concerned about hypoglycemia, which is
a major risk of tight glucose control, among the elderly.
Thus, the clinicians’ approaches to what constituted
acceptable glucose control was individualized. 26
However, the goal for blood glucose control, for the
elderly, probably should have been the same as for
younger patients; namely, near-normal FCBG levels
(< 126 mg/dl) without hypoglycemia.26 Among the
elderly, whose care is complicated by chronic medical
illness, frailty, isolation, and/or a shortened life
expectancy, the reduction of hyperglycemia signs and
49
symptoms,rather than accomplishment of a normal
glucose level, is a preferable goal for clinical
management.27 Maintenance of postprandial glucose
level < 200-250 mg/dl generally is adequate for
achieving these goals, and, in most cases, a FCBG
level of < 145 mg/dl is attainable with few
hypoglycemic episodes.27, 28
No significant differences were found in the
mean values of the FCBG of those receiving care via
the three primary care models. This finding could be
explained by the fact the providers, from all three
primary care models, delivered diabetes care using the
same clinical practice guidelines as those recommended
by the NHSO. Furthermore, this finding supports the
idea that the different models of primary care practice
achieved equivalent outcomes regarding the FCBG
values. In addition, non-significant differences of
co-morbidities and types of regimens among those
receiving care from the three models were seen. One
prior study illustrated that co-morbidity does not
appear to limit achievement of good glycemic control; 29
However, multivariate linear regression showed that
receiving different pharmacological therapy was a
significant contributor to HbA1c levels. The findings
of the current study were consistent with those of a
previous study,30 wherein no difference in the mean
values of the HbA1c between the NP providers and
physician providers were found.
Diabetes Self-Care Ability (DSCA): Most of
the participants receiving care via the three models
manifested a moderate level of DSCA, which might
be explained by the fact that most of them were older
adults ( x = 60.7) with an elementary school
education (88%). In addition, a prior study found
older age to be associated with lower literacy and lower
self-management behaviors.31
The findings, of the present study, indicated
the mean DSCA scores, between those receiving care
from the NP and NP-MDf models, to not be significantly
different (p> .05). However, the mean scores for total
DSCA and the two sub-dimensions, diet and
50
follow-up, among the participants receiving care via
the NP and NP-MDf models,were significantly higher
than the mean scores of those receiving care via the
NP-MDp model (p< .05). This may be because the
physicians, in the PCUsusing the NP-MDp model,
routinely worked only two days a week. As a result, the
NP’s role was used to substitute the physicians’ role.
Thus, the NP’s were more likely to pay attention to
delivery of medical care service than to promoting selfcare education. Furthermore, the primary care services
delivered via the NP-MDp model typically were
scheduled to be open to all patients, including those with
diabetes. Thus, the care services were not specifically
focused onor allotted sufficient time for dealing
exclusively with patients being seen in the diabetes
clinic. As a previous study indicated, self-care education
and self-management programs need sufficient time for
consulting visits that have good relationships among the
healthcare providers and clients.32
Another reason for the significantly lower mean
score on the sub-dimension, follow-up,may have been
due to the fact that five of the participants receiving
care via the NP-MDp model had difficulty with followup visits because no caregivers accompanied them to
the PCU. In addition, some of them had to travel to
another country during the year, which prevented them
from keeping their follow-up visits.
Interestingly, the mean scores on the subdimension, diet, among those receiving care via the
three models, were not high. The nurse practitioners,
community health workers, and physicians, in all three
models, were more likely to perform short-term,
traditional, didactic teaching rather than focusing on
empowering participants regarding diabetes self-care.
Instead, the healthcare providers focused more on
individual needs. This finding was consistent with prior
research that found knowledge is not enough to
improve self-care or self-management among
individuals with diabetes.33 Enhancing values of
experience and understanding about diabetes can lead
to a person’s appreciation about diabetes self-care.32
Thus, self-care education and self-management
programs should be carried out and focused more on
empowering patients.34, 35
Patients’ Satisfaction with Care (PSC): Most
of the participants receiving care via all three models
had a high level of PSC. It is possible that this finding
was the result of the providers and participants having
good relationships. Most of the care providers had
worked in their specific primary care setting for many
years. Bryant and Graham 33 noted that the healthcare
provider’s ability to display empathy and concern
contributes positively to enhancing patient satisfaction.
In addition, primary care settings within dwelling
areas, that support patients’ access to services and
saves time/traveling costs, might lead to a high
satisfaction level. However, one must remain aware
that social desirability bias is a tendency of respondents
to reply in a manner that will be viewed favorably by
others. This generally is in the form of over-reporting
high satisfaction.
The results of this study indicated no significant
difference, among the participants receiving care via
the NP and NP-MDp models, in the mean scores for
total PSC(p> .05). Those receiving care via both the
NP and NP-MDp models had significantly higher mean
scores on total satisfaction and the sub-dimension,
accessibility,than those receiving care via the NP-MDf
model (p< .05 and < .001, respectively). This might
be because many of the participants receiving care via
the NP-MDf model complained they had to wait a long
time (35-50 minutes) to see a physician. Two items
in the PSCQ that focused on these data were: “Health
providers give their hand as soon as you need it” and
“I can access care service easily and conveniently.”
Since, those receiving care via the NP-MDf model did
not score either one of these items very high, this may
help explain their significantly lower mean scores
on both the total PSC and the sub-dimension,
accessibility. In addition, in the NP model, the diabetes
clinic was routinely operated once a month and almost
Vol. 17 No. 1
all of the patients with diabetes could attend the clinic.
Thus, they could meet as a group and share their
experiences, problems, and concerns about having
diabetes. The friendly atmosphere provided an
opportunity for interpersonal interactions among
themand with the healthcare providers. Prior studies
have supported the idea of groups of people with
diabetes meeting together to share experiences and
support each other. Given the right environment, this could
improve their interpersonal relationships and increase
their satisfaction with the care they received. 34,35
Diabetes Quality of Life (DQOL): Overall,
the participants receiving care via all three models
manifested a moderate level of DQOL. This could be
explained by the fact that factors, such as gender,
income, and education, might be associated with one’s
DQOL. Prior studies have shown variability in effects
of type-2 diabetes on one’s DQOL. For instance,
Gafvels 35 found that diabetes among women appears
to make a greater impact on their DQOL and generate
more worries about complications for them than men.
Issa and Baiyewu 37also found that lower income, less
education, no employment, and physical complications
adversely affect one’s DQOL. In the present study,
most of the subjects were female and primary school
graduates (87.6%). About two thirds (69.0%) of
them had an income of less than 5,000 baht per month,
with more than half having at least one co-morbidity
(i.e., hypertension and dyslipidemia). These factors
might have contributed to theparticipants havingonly
a moderate level of DQOL.
No significance differences were found in the
mean scores, among the participants receiving care via
the NP and NP-MDf models (p>.05), regarding their
total DQOL. On the other hand, the mean scores on
total DQOL and the sub-dimensions of life satisfaction
and life impact, among those receiving care via these
two models,were significantly higher than those
receiving care via the NP-MDp model (p< .05).
51
Future Implications for Practice
According to the demographic data, five participants
with diabetic foot ulcers received care via the NP-MDp
model, whereas only one person witha diabetic foot
ulcer was seen among those receiving care via the NP
and NP-MDf models. Prior studies have revealed that
chronic diabetic foot ulcers and amputations to be
associated with a lower quality of life and a high level
of depression.38, 39
In conclusion, the diabetic care outcomes of
the participants receiving care via the NP model were
comparable to the outcomes of those receiving care
from the NP-MDf and NP-MDpmodels. Thus, NPs
with four months of advanced practice training, who
have had at least two years of clinical experience as
RNs, were able to provide diabetic care at the primary
care level with the same degree of quality as the
providers offering healthcare via the other two
models(NPs and full/part time MDs working
together).
Even though the NPs seemed to be as good as
the MDs in providing diabetes care, continuing
education is necessary to improve diabetic outcomes,
especially regarding glycemic control. Knowledge and
skills in empowering patients, families, and
communities to become involved in diabetes care are
needed. Also, self-management and case management
should be focused on continuing education. In the
future, nurses that work independently in a primary
care setting should be prepared as advanced practice
nurses at a master’s or doctoral level. However, in
light of the physician shortages in many developing
countries, a four-month short course for experienced
nurses, with good clinical practice guidelines, can
improve the accessibility and quality of healthcare
services to people in remote and underserved areas.
Limitations and Recommendations for
Future Research
Sincere gratitude is expressed to the Thailand
Nursing and Midwifery Council for financial support
of this research.
When applying the study’s findings, limitations
need to be taken into consideration. First, using FCBG
measurements through a glucometer, in this study,
most likely produced higher glucose levels than
actually existed. Thus, future studies need to consider
use of HbA1c for assessing patients’ blood glucose
levels. Secondly, participants were recruited from only
six primary care settings, in one province, in Thailand.
As a result, generalizability of the findings is limited.
Future studies need to consider the use of a larger
number of primary care settings that are located
throughout the country. Finally, one has to assume the
participants were honest in their responses regarding
items on the questionnaires. It may prove beneficial,
in future studies, to use additional means of data
gathering (i.e., interviews with participants, family
members, and healthcare providers).
References
52
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24. Keeratiyutawong P. Effectiveness of a self-management
program for Thais with type-2 diabetes. Thai J of Nurs
Res. 2007; 9(2): 135-141.
25. Kosachunhanun N, Benjasuratwong Y, Mongkolsomlit S,
Rawdaree P, Plengvidhya N, Leelawatana R, et al. Thailand
diabetes registry project: Glycemic control in Thai type-2
diabetes and its relation to hypoglycemic agent usage. J
Med Assoc Thai. 2006; 89 (Suppl. 1): S66-71.
26. Hasen M. Management of diabetes in the older [dissertation].
Pullman (WA): Washington State Univ.; 2005. Available
from: https://research.wsulibs.wsu.edu/xmlui/
bitstream/handle/ 2376/3778/M_ Hansen_
010338975.pdf?sequence=1.
27. Abrass IB, Schwartz RS.Special presentation of endocrine
disease in the elderly.Curr Med Drugs. 1999; 1(2): 4158.
28. Chau D, Edelman SV. Clinical management of diabetes in
the elderly.ClinDiabetes. 2001; 19 (4): 172-5.
29. Wallace TM, Matthews DR. Poor glyceamic control in
type-2 diabetes: A conspiracy of disease, suboptimal
therapy and attitude. QJM. 2000; 93(6): 369-74.
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30. El-Kebbi IM, Ziemer DC, Musey VC, Gallina DL, Bernard
AM, Phillips LS. Diabetes in urban African-Americans:
Provider adherence to management protocols.Diabetes
Care. 2001; 20(5): 698-703.
31. Lorig KR, Holman H. Self-management education: History,
definition, outcomes, and mechanisms. Ann Behav Med.
2003; 26(1): 1-7.
32. Cyrino AP,Schraiber LB. Teixeira RR. Education for type2 diabetes mellitus self-care: From compliance to
empowerment. Education. 2009; 13(30): 93-106.
33. Bryant DM, Graham MA. Models of service delivery. In:
DM Bryant, MA Graham, editors. Implementing early
intervention: From research to effective practice New York
(NY): Guildford; 2002.p. 183-215.
34. SaultzJW, Albedaiwi W. Interpersonal continuity of care
and patient satisfaction: A critical review. Am
FamPhysician. 2004; 2(5): 445-51.
35. Westaway MS, Rheeder P, Van Zyl DG, Seager JR.
Development and testing of a 25-item patient satisfaction
scale for black South African diabetic outpatients.
Curationis. 2002; 25(3): 68-75.
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36. Gafvels C, Wandell PE. Coping strategies in immigrant men
and women with type-2 diabetes.Diabetes Res
ClinPract.2007; 76(2): 269-78.
37. Issa BA, Baiyewu O. Quality of life of patients with diabetes
mellitus in a Nigerian Teaching Hospital. 2006 [cited
2010 Apr 11]. Available from: http://www.hkjpsych.
com/journal_file/0601_v16n1_27.
38. Ribu L, Hanestad BR, Moum T, Birkeland K, Rustoen T.
A comparison of the health-related quality of life in patients
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2007; 16: 179-89.
39. Willrich A, Pinzur M, McNeil M, Juknelis D, Lavery L.
Health related quality of life, cognitive function, and
depression in diabetic patients with foot ulcer or amputation:
A preliminary study.Foot Ankle Int. 2005; 26(2): 128-34.
เปรียบเทียบผลลัพธ์ของผู้ป่วยเบาหวานที่ได้รับการดูแลในสถานบริการ
สุขภาพปฐมภูมิ 3 รูปแบบ
ฉัตรศิริ เมฆวิวัฒนาวงศ์, สมจิต หนุเจริญกุล, นพวรรณ เปียซื่อ, เดชาวุธ นิตยสุทธิ
บทคัดย่อ: การศึกษานี้มีวัตถุประสงค์เพื่อเปรียบเทียบผลลัพธ์ของการดูแลผู้ป่วยเบาหวานระหว่าง
กลุ่มที่ได้รับการรักษาที่สถานบริการปฐมภูมิใน 3 รูปแบบ คือ รูปแบบการมีพยาบาลเวชปฏิบัติ และ
แพทย์เต็มเวลา (NP-MDf), รูปแบบการมีพยาบาลเวชปฏิบัติเต็มเวลา และแพทย์บางเวลา(NP-MDp)
และรูปแบบการมีพยาบาลเวชปฏิบัติเต็มเวลาโดยไม่มีแพทย์ (NP model)โดยวัดผลลัพธ์การดูแล ผู้ป่วยเบาหวานประกอบด้วยการควบคุมระดับน�้ำตาลในเลือด ความสามารถในการดูแลตนเอง ความ
พึงพอใจในบริการ และคุณภาพชีวิตระหว่างผู้ป่วยเบาหวาน กลุ่มตัวอย่าง คือ ผู้ป่วยเบาหวานทั้งหมด
จ�ำนวน 300 คน แบ่งเป็นรูปแบบของสถานบริการปฐมภูมิ อย่างละ 100 คน ในจังหวัดหนึ่งในภาค
กลางของประเทศไทย คัดเลือกกลุ่มตัวอย่างโดยใช้การเลือกแบบสะดวก เก็บรวบรวมข้อมูลโดยใช้
แบบประเมินความสามารถในการดูแลตนเอง แบบประเมินความพึงพอใจ แบบประเมินคุณภาพชีวิต
ในผู้ป่วยเบาหวาน วิเคราะห์ข้อมูลด้วยสถิติบรรยาย และMANOVA
ผลการศึกษาพบว่า 1) ระดับน�ำ้ ตาลในเลือดขณะอดอาหารของผูป้ ว่ ยเบาหวานในทัง้ 3 รูปแบบ
ไม่แตกต่างกัน (p> .05); 2) คะแนนเฉลี่ยความสามารถในการดูแลตนเอง และคุณภาพชีวิตของ ผู้ป่วยเบาหวานในรูปแบบNP-MDf และ NP สูงกว่ารูปแบบ NP-MDp อย่างมีนัยส�ำคัญทางสถิต ิ
(p< .05); 3) คะแนนเฉลี่ยความพึงพอใจในรูปแบบ NP-MDp และNP สูงกว่ารูปแบบ NP-MDf อย่างมี
นัยส�ำคัญทางสถิติ (p< .05)
ผลการศึกษาชี้ให้เห็นว่าพยาบาลเวชปฏิบัติหลักสูตรระยะสั้น 4 เดือนสามารถให้การดูแล ผู้ป่วยเบาหวานในสถานบริการระดับปฐมภูมิได้คุณภาพเทียบเท่ากับการดูแลโดยแพทย์ และรูปแบบ
NP มีแนวโน้มทีจ่ ะเกิดผลลัพธ์ในเชิงจิตสังคมและพฤติกรรม (ความสามรถในการดูแลตนเอง ความพึงพอใจ
และคุณภาพชีวิตของผู้ป่วย) มากกว่ารูปแบบอื่น
ค�ำส�ำคัญ: ผลลัพธ์ผทู้ เี่ ป็นโรคเบาหวานรูปแบบการดูแลสุขภาพระดับปฐมภูมแิ ละพยาบาลเวชปฏิบตั ิ
ติดต่อที่: ฉัตรศิริ เมฆวิวัฒนาวงศ์, RN, PhD (Candidate), นักศึกษา
ปริญญาเอก โรงเรียนพยาบาลรามาธิบดี คณะแพทยศาสตร์โรงพยาบาล
รามาธิบดี มหาวิทยาลัยมหิดล กรุงเทพมหานคร ประเทศไทย
สมจิต หนุเจริญกุล, RN, PhD. ศาสตราจารย์เกียรติคุณ โรงเรียนพยาบาล
รามาธิ บดี คณะแพทยศาสตร์ โ รงพยาบาลรามาธิ บดี มหาวิ ทยาลั ย มหิ ด ล
กรุงเทพมหานคร ประเทศไทย
นพวรรณ เปียซื่อ, RN, PhD. รองศาสตราจารย์ คณะแพทยศาสตร์
โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล กรุงเทพมหานคร ประเทศไทย
เดชาวุธ นิตยสุทธิ, PhD. รองศาสตราจารย์ ภาควิชาชีวสถิติ คณะสาธารณสุขศาสตร์
มหาวิทยาลัยมหิดล กรุงเทพมหานคร ประเทศไทย
Vol. 17 No. 1
55
Effect of the Prince of Songkla University Birthing Bed
Effect of the Prince of Songkla University Birthing Bed on
Duration, Pain, and Comfort Level during Second-Stage Labor in
Primiparous Thais
Sasitorn Phumdoung, Boonrueing Manasurakarn, Kitti Rattanasombat, Sukit Mahattanan, Kalaya Maneechot,
Benjamach Chanudom, Somboon Kaewnak
Abstract: The aim of this study was to test the effectiveness of the newly created Prince of Songkla
University (PSU) Birthing Bed regarding duration of second-stage labor, sensation and distress of
labor pain, lower back pain, and comfort level during the second-stage of labor of primiparous
Thais. The sample consisted of 240 primiparous Thais, who were block randomized into four
groups and, subsequently, during labor, placed in four different types of beds (60 women per
group), including the: PSU Birthing Bed without a holding bar; PSU Birthing Bed with a holding
bar; usual birthing bed with head elevated 45-60 degrees; and, usual birthing bed with head
elevated 15 degrees. Demographic, obstetrical and infant data were obtained via a researcherdeveloped data sheet. Demographic data were obtained directly from the women, while the
obstetrical and infant data were obtained from the women’s medical records. Information regarding
each subject’s experience of sensation and distress of labor pain, lower back pain and comfort
level were collected via use of 100 mm Visual Analogue Scales.
Data were analyzed using descriptive statistics, ANOVA, Kruskal-Wallis test, Mann-Whitney
U test, and Chi-square. Analysis revealed those who used the PSU birthing bed without the holding
bar, and the PSU birthing bed with the holding bar, had a significantly lower duration of secondstage labor, less sensation and distress of labor pain, less lower back pain, and greater comfort
than those who used the usual birthing bed with the head elevated 45-60 degrees and the
usual birthing bed with the head elevated 15 degrees. The results indicated that use of the PSU
birthing bed lowered the duration of second-stage labor, lessened the sensation and distress of
labor pain, decreased lower back pain, and enhanced the comfort level of primiparous Thais
during second-stage labor.
Key words: PSU birthing bed; Labor pain; Duration of second-stage labor; Comfort level; Lower
back pain; Primiparous women
Background
E ven though women receive childbirth
preparation,1 labor pains may be severe, with some
women complaining of feeling like their body is being
split apart during delivery.2 The most intense labor
pains have been found to be experienced, especially
by primiparous women, during the second stage of
labor, when the uterine contractions last 60-90
seconds, every 1.5 - 2 minutes, at an intensity of
56
Correspondence to: Sasitorn Phumdoung, RN, PhD. Department of
Obstetric Gynecological Nursing and Midwifery, Faculty of Nursing,
Prince of Songkla University, Hatyai, Songkhla Province, Thailand.
Boonrueing Manasurakarn, MEng. Department of Industrial
Engineering, Faculty of Engineering, Prince of Songkla University,
Hatyai, Songkhla Province, Thailand.
Kitti Rattanasombat, MD. Obstetrics and Gynecology Unit, Thasala
Hospital, Thasala, Nakorn Si Thammarat Province, Thailand.
Sukit Mahattanan, MD. Obstetrics and Gynecology Unit, Nakorn Si
Thammarat Hospital, Moung, Nakorn Si Thammarat Province, Thailand.
Kalaya Maneechot, RN, MPH. Labor Unit, Nakorn Si Thammarat
Hospital, Moung, Nakorn Si Thammarat Province, Thailand.
Benjamach Chanudom, RN, MSN. Labor Unit, Nakorn Si Thammarat
Hospital, Moung, Nakorn Si Thammarat Province, Thailand.
Somboon Kaewnak, RN. Labor Unit, Thasala Hospital, Thasala, Nakorn
Si Thammarat Province, Thailand.
Sasitorn Phumdoung et al.
70-100 mmHg, for one to two hours.2, 3 Thus, it is
no wonder that some women have felt there would be
no end to the labor pains they were experiencing.4
Pushing during second-stage labor causes
acidosis in the women and their fetuses,5 as well as
prolongs labor for expectant mothers.6, 7 Labor
prolonged of more than one hour often leads to an
increased incidence of cesarean sections and third or
fourth degree birth canal tears.8 In addition, prolonged
second-stage labor has been found to lead to increased
use of instrument-assisted births, birth canal injuries,
acidosis, and low Apgar scores in newborn infants.9
Given that prolonged second-stage labor often causes
adverse effects for expectant mothers and their fetuses,
there appears to be a need to seek means to shorten the
duration of second-stage labor, lower the sensation
and distress of labor, and increase the comfort level of
women in labor.10
Relatively few methods have been used to
shorten the length of labor, including the use of: drugs
for augmentation of labor;11,12, 13 and, use of an upright
delivery position. 14,15, 16 At present, oxytocin is
commonly used to increase uterine contractions as a
means to shorten the length of labor.11,12 The use of
oxytocin and other stimulative uterine contraction
medications may cause child-bearing mothers to
experience: lower cardiac output; 17,18 water
intoxication; 17,18 birth canal injuries; 17,18 limitation
of body movement; 17,18 increased pain and discomfort;
17,18
increased need for analgesic drugs;19 and, tetanic
contractions of the uterus,13,19,20 which often lead to
uterine rupture.19,20,21 In addition, the prolonged use
of oxytocin may lead to the expectant mothers
experiencing headaches, dyspnea, hypotension,
tachycardia, and postpartum hemorrhage.22 The use
of oxytocin also may lead to fetal distress17 and
hyperbilirubinemia in infants.23
With respect to the use of an upright delivery
position, the use of standing and squatting delivery
positions have been found to enhance an increase in
the diameter of a woman’s pelvis, and, thus, facilitate
delivery.14,15 In addition, the Prince of Songkla
Vol. 17 No. 1
University Cat position (PSU Cat position), which
involves alternating the height of the head of the
birthing bed, while listening to music, has been found
to shorten the active phase of the first stage of labor to
3.1 hours (SD = 1.9 hours).16 During the second stage
of labor, the squatting position has been effectively
used to increase expectant mother’s pelvic diameter,
as well as facilitate rotation and fetal descent.24 In
addition, the squatting position has been found to
contribute to elimination of perineal tears and
decreased adverse effects on the Apgar scores of
fetuses.25 A previous study, conducted by the principal
investigator (PI) and colleagues, revealed use of the
Prince of Songkla University Locked-Upright position
(PSU Locked-Upright position), which is similar to
squatting in a lying position, significantly shortened
the duration of the second stage of labor to 24.86
minutes, with legs on the stirrups, and to 28.21
minutes, with knees-to-chest.26
Labor positions that have been found to
facilitate reduction of lower back pain and increased
comfort level, during the first stage of labor, have
included: an upright position;27, 28 and, the PSU Cat
position.16 During the second stage of labor, the PSU
Locked-Upright position has been found to decrease
expectant mothers’ lower back pain (n =24; 31.6%)
and increase their comfort level (n =70; 92.1%).26
However, no significant lowering of sensation and
distress of labor pain has been shown with the PSU
Locked-Upright position, compared to groups of
women in labor who used a high head and supine
position. The lack of significant differences in the
previous study may have been because the women who
used the PSU Locked-Upright position were unable,
throughout labor, to maintain support to their lumbar
area. Thus, it became essential to find an effective
means of enabling women in labor to maintain adequate
lumbar support, while in the PSU Locked–Upright
position. Based upon this need and prior findings that
revealed pulling against a force (i.e. towel secured to
an immovable bar or object) could facilitate effective
pushing, when used in the upright position, by
57
enhancing the abdominal muscles in expulsive
efforts,24, 29 the PSU birthing bed was constructed (with
and without a holding bar present) based upon the body
build of pregnant Thais. The PSU birthing bed has
been considered an innovative bed for laboring women
because: the head of the bed can be elevated to 45-60
degrees or more; the lumbar area of the bed can be
elevated to 30-40 degrees; a holding bar is present
(for use if desired) for promoting a force or power, or
expulsion effort; foot support is present to facilitate
knees-to-chest; and, leg stirrups are available for the
legs when they are aching (see Figure 1).
Figure 1 The PSU Birthing Bed with the Holding Bar
Once the PSU birthing bed was constructed, its
effects on women in labor needed to be tested. Thus,
the purpose of this study was to investigate, in
primiparous women, during the second stage of labor,
the effects of the PSU birthing bed (with and without
a holding bar) on: duration of labor; sensation and
distress of labor pain; level of lower back pain; and,
level of comfort.
Method
Design: A randomized four block design was
used in the study.
Ethical considerations: Prior to implementation,
the study was approved by the Human Ethics
Committee of the PI’s academic institution and the
hospital used as a data gathering site. All potential
58
subjects were informed about: the nature of the study;
involuntary participation; what study participation
would entail; confidentiality and anonymity issues;
and, the right to withdraw at any time without
repercussions. Those consenting to take part in the
study were asked to sign a consent form.
Setting and sample: The hospital selected, as
a study site, was located in southern Thailand and
chosen because more than 5, 500 women give birth,
yearly, at the facility. The criteria for subject inclusion
were Thais who: were primiparous; were between 17
and 35 years of age; were 37 to 42 weeks of gestation;
had a fetal vertex presentation; had an expected fetal
weight of 2,500 to 4,000 grams; and, were able to
read and write Thai. Subject exclusion criteria included
pregnant women who had: anemia; hypertension;
asthma; an infection; a bleeding disorder; a history or
presence of psychological problems; fetal distress;
and, a prolapsed cord.
A total of 332 women consented to participate
in the study and were randomly placed into four groups.
The groups consisted of women who experienced labor
and delivery using the: PSU birthing bed without the
holding bar; PSU birthing bed with the holding bar;
usual birthing bed with the head of the bed elevated
45 to 60 degrees; and, usual birthing bed with the
head of the bed elevated 15 degrees. However 68 of
the women had a cesarean section, either because of
unprogressive labor or fetal distress, before reaching
second-stage labor. Thus, only 264 women were
assessed regarding the effects of the birthing bed during
the second stage of labor. However, 22 of these women
gave birth with vacuum extraction and two had a
cesarean section. Therefore, 240 women actually
completed the study (had a normal labor delivery) in
which 60 of them were in each of the four groups.
When the groups were compared, in regards to subject
drop out, no significant differences were noted among
the four groups.
The subjects had an average age of 23.38 years
(SD = 4.31) and held either a: master’s degree (n =
3; 1.3%); undergraduate college diploma (n = 65;
27.1%);14th grade vocational school diploma (n =
25; 10.4%); 12th grade vocational school diploma (n
= 20; 8.3%); high school diploma (n = 42; 17.5%);
9th grade diploma (n = 57; 23.8%); 6th grade diploma
(n = 26; 10.8%); or failed to report their level of
education (n = 2; 0.8%). In addition, the subjects
were Buddhist (n = 200; 83.3%) or Islamic (n = 40;
16.7%); were either housewives (n = 100; 41.7%)
or working outside of the home (n = 140; 58.3%);
and, had a mean family monthly income of 13,015
Baht (SD = 9,413). The vast majority (n = 224;
93.3%) received oxytocin, but not an analgesic
medication. In addition 92.5% (n = 222) of them had
an episiotomy. Two of the subjects experienced a third
degree perineal tear, while one had a fourth degree
Vol. 17 No. 1
perineal tear.
Regarding the infants, one infant, delivered on
the PSU Birthing bed without the holding bar, had thin
meconium staining at birth, while two delivered on
each of the three other types of birthing beds (total of
6 infants) had thick meconium staining at birth. The
mean birth weight of the infants was 3,060 grams (SD
= 333), with most (n = 220; 91.66%) of them having
an Apgar score of 9 at one minute and 10 at five
minutes (n = 218; 90.83%). None of the infants had
an Apgar score less than 7. When the demographic,
maternal and infant data were compared among the
four groups, no significant differences were found.
Instruments: A researcher-developed
Demographic, Obstetrical and Infant Data Sheet
(DOIDS) was used to record information that was
obtained either by interview or from reading each
subject’s medical record. Demographic data obtained
included each woman’s: age, educational level;
religion; employment status; and monthly family
income. Obstetrical data addressed the use of oxytocin
and analgesic medication, the duration of second-stage
labor, the presence of an episiotomy, and the degree
of perineal tear. The infant data included the degree
of meconium staining, birth weight, and Apgar scores
at one and five minutes.
Sensation and distress of labor pain, lower back
pain, and level of comfort, occurring during secondstage labor, were measured using a 100 mm Visual
Analogue Scale (100 mm VAS). Sensation pain was
defined as the unpleasant feeling of hurt in the abdomen
related to the intensity of uterine contractions during
the second stage of labor. Distress pain was the reported
emotional distress related to the sensation of labor pain,
while lower back pain was defined as the unpleasant
feeling of hurt in the lower back. The level of comfort
was defined as the degree of comfort felt with the body
position during labor and the birthing bed used.
Subjects were asked to mark on a separate 100mm
VAS for each variable measured. At the left end of the
59
scales measuring sensation and distress of labor pain
and lower back pain the anchor words of “no pain or
no distress” were listed, while on the right end of the
scale the anchor words of “very severe pain or very
severe distress” were listed. On the analogue scale
measuring the level of comfort, the anchor word on
the left end of the scale was “extremely uncomfortable,”
while the anchor word on the right end of the scale was
“relatively comfortable.” To obtain a score, the
distance from the left end to the 100mm line to where
the subjects placed a mark, indicating the level of
response, was measured in millimeters. The higher the
numerical value the higher the score. Both sensation
and distress pain, in prior research, has demonstrated
a concurrent validity, with a categorical question in
measuring pain in the active phase of labor, between
0.73 to 0.95,30 while concurrent validity of comfort,
in this study, with a categorical question was shown
to be 0.97. Also, the 100 mm Visual Analogue Scale
has been shown to have a high level of validity and
reliability.31 In this study, test-retest reliability was
found to be as follows: sensation of labor pain = 0.98;
distress of labor pain = 0.88; lower back pain = 0.80;
and, level of comfort = 0.98.
Procedure: Potential subjects meeting the
selection criteria were identified, during the first stage
of labor, by the nurses in the labor unit of the hospital
used as a study site. The potential subjects then were
approached by a research assistant (RA), trained in
the research project protocol, who explained the
purpose of the study, what study involvement would
entail, and all ethical considerations. Once a woman
consented to be in the study and signed a consent form,
60
she was randomly assigned to one of the four types of
beds to be used during delivery.
Once a woman was assigned to one of the four
groups, the demographic portion of the DOIDS was
completed by the RA. Upon completion of the second
stage of labor, each woman was asked to complete the
100mm VASs for each of the variables (sensation and
distress of labor pain, lower back pain, and level of
comfort occurring during the second stage of labor).
Upon completion of the delivery, the RA obtained the
obstetrical and infant information for the DOIDS from
the respective woman’s medical record.
to assess demographic data, duration of second-stage
labor, and scores on the 100 mm VAS, while ANOVA,
Kruskal-Wallis test, Mann-Whitney U test, and chisquare were used to compare differences among
groups, during the second stage of labor, regarding
sensation and distress of labor pain, lower back pain,
and level of comfort.
Results
As shown in Table 1, significantly different
durations of second-stage labor were found, via
ANOVA, among the women using the four different
birthing beds. The Bonferroni test showed subjects
using the PSU birthing bed without the holding bar
and the PSU birthing bed with the holding bar had
significantly shorter durations of second-stage labor
than women who used the usual birthing bed lying with
the head raised to 45-60 degrees and the usual birthing
bed with the head elevated to 15 degrees.
Table 1 Differences in Duration of Second-stage Labor among Women Using Four Different Birthing Beds
1) PSU birthing Bed without holding bar
Duration (min.)
Mean
SD
17.63
9.70
2) PSU birthing Bed with holding bar
16.58
8.47
3) Usual birthing bed with head ↑45-600
24.18
14.20
4) Usual birthing bed with head elevated ↑150
31.63
14.22
Types of Beds
F1
20.343***
Post-hoc
1-2ns
1-3*
1-4***
2-3**
2-4***
3-4**
Note: 1 = effect size of .205 and a power of 1; ns = non significance; * = p < .05; ** = p < .01; *** = p < .001
sensations of pain during the second stage of labor
were found, via ANOVA, among subjects using the
four different birthing beds. The Bonferroni test
showed that those using the PSU Birthing bed without
the holding bar and the PSU Birthing bed with the
holding bar had significantly lower sensation of pain
than the women using the usual birthing bed with the
head elevated to 45-60 degrees and the usual birthing
bed with the head elevated 15 degrees.
Table 2 Differences in Sensation of Pain among Women Using Four Different Birthing Beds
Duration (min.)
Mean
SD
74.48
21.78
75.48
19.09
94.33
9.53
94.66
9.53
Types of Beds
F1
Post-hoc
30.03***
1-2ns
1-3***
1-4***
2-3***
2-4***
3-4ns
Note: 1 = effect size of .267 and a power of 1; ns = non significance; *** = p < .001
levels of distress of pain during the second stage of
labor were found, via ANOVA, among the subjects
using the four different birthing beds. The Bonferroni
test showed that those using the PSU birthing bed
Vol. 17 No. 1
without the holding bar and PSU birthing bed with the
holding bar had significantly lower distress of pain
than the women using the usual birthing bed with the
head elevated to 45-60 degrees and the usual birthing
bed with the head elevated 15 degrees.
61
Table 3 Differences in Distress of Pain among Women Using Four Different Birthing Beds
Duration (min.)
Mean
SD
56.55
28.59
52.43
24.16
80.46
25.62
80.78
26.09
Types of Beds
F1
20.23***
Post-hoc
1-2ns
1-3***
1-4***
2-3***
2-4***
3-4ns
Note: 1 = effect size of .204 and a power of 1; ns = non significance; *** = p < .001
Since the data did not have a normal distribution,
Birthing bed without the holding bar and the PSU
the level of lower back pain was compared via the
birthing bed with the holding bar had mean ranks
Kruskal-Wallis test. There was a significant differences
significantly lower than the women using the usual
in the medians of lower back pain score among the
birthing bed with the head elevated 45-60 degrees
²
four groups, (3, n=240) = 166.74; p <.001. Subsequent
and the usual birthing bed with the head elevated 15
testing of each pair of the four groups, using a Manndegrees (p < .001). Figure 2 shows the median of
Whitney U test, indicated that subjects using the PSU
lower back pain of each group using a boxplot.
Figure 2 Distribution of Lower Back Pain Scores during Second Stage Labor among
Women Using Four Different Birthing Beds
Note: VAS = Visual Analogue Score; Group 1 = PSU birthing bed without the holding bar; Group 2 = PSU birthing bed
with the holding bar; Group 3 = Usual birthing bed with head elevated 45-600; Group 4 = Usual birthing bed
with head elevated 150
62
The level of comfort scores for subjects using
bed without the holding bar and the PSU birthing bed
each type of bed was strongly bimodal and, thus, could
with the holding bar had significantly higher comfort
not be analyzed via the Kruskal-Wallis test. Therefore,
levels than the women using the usual birthing bed
chi-square was used. As shown in Table 4, the
with the head elevated to 45-60 degrees and the usual
findings suggested that those using the PSU birthing
birthing bed with the head elevated 15 degrees.
Table 4 Frequency, Percentage, and Differences of Comfort Levels among Women Using Four Different
Birthing Beds
Comfort Score
(mm.)
0
1-20
21-40
41-60
61-80
81-99
100
1
n (%)
2 (3.3)
5 (8.3)
29 (48.3)
24 (40)
Groups (n = 60 per group)
2
3
n (%)
n (%)
15 (25)
10 (16.7)
13 (21.7)
1 (1.7)
12 (20)
4 (6.7)
4 (6.7)
30 (50)
4 (6.7)
25 (41.7)
2 (3.3)
²
4
n (%)
21 (35)
16 (26.7)
8 (13.3)
11 (18.3)
4 (6.7)
-
192.588*
Note: * = p < .001; Group 1 = PSU birthing bed without the holding bar; Group 2 = PSU birthing bed with the
holding bar; Group 3= Usual birthing bed with head elevated 45-60o; Group 4= Usual birthing bed
with head elevated 15o
Discussion
The findings that the subjects using the PSU
birthing bed without the holding bar and the PSU
birthing bed with the holding bar had shorter durations
of second-stage labor than the women using the usual
birthing bed with the head elevated 45 - 60 degrees
and the usual birthing bed with the head elevated 15
degrees most likely was due to the fact, as shown in
prior research, that supporting the lumbar area and
providing foot support can enable women to lie with
a knees-to-chest position (similar to the squatting
position in lying position) and can increase pelvic
dimensions.15, 26 The fact that those using the PSU
birthing bed with the holding bar and the PSU birthing
bed without the holding bar had similar durations of
second-stage labor possibly was due to the women in
Vol. 17 No. 1
the PSU birthing bed without the holding bar using the
side rails of their beds as a replacement for the holding
bar. It has been shown that a holding bar and bed side
rails can provide a similar mechanism to enhance a
force or promote power. 25 In addition, the fact that
the shortened duration for second-stage labor among
the subjects using the PSU birthing bed both with and
without the holding bar was consistent with prior
research that examined the use of the PSU LockedUpright position26 and the squatting position.32
However, this study did note a shorter duration of the
second-stage labor compared to the study that
examined the use of the PSU Locked-Upright
position.26 This most likely was because the women,
in this study, were able to lie in the PSU LockedUpright position all the time and received more
oxytocin. In comparison to previous research on the
63
use of the squatting position,32 the fact that those using
the PSU birthing bed (either with or without the
holding bar) had a shorter duration of second-stage
labor than women who used the squatting position
suggested the superiority of the PSU birthing bed over
use of a squatting position.
The findings that subjects using the PSU
birthing bed with and without the holding bar had lower
sensation and distress of labor pain during secondstage labor compared to the women who used the usual
birthing bed with the head elevated 45 - 60 degrees
or 15 degrees may have been due to the shorter time
of second-stage labor that these women experienced.
These results are inconsistent with prior research on
the PSU Locked-Upright position26 in which no
differences were noted among the women who were
placed in different positions during labor and delivery.
This inconsistency may have been related to the facts
that, in the present study, the women experienced a
shorter second stage of labor, encountered more
comfort, and were maintained in the PSU LockedUpright position all of the time while on the PSU
birthing bed.
The fact that women using the PSU birthing
bed with and without the holding bar were found to
have significantly less lower back pain and higher
comfort levels than those using the usual birthing bed
with the head elevated 45 - 60 degrees or 15 degrees
most likely was due to the support provided by the PSU
birthing bed in the women’s lumbar region. As a result,
muscle strain in the lumbar area was relieved and,
subsequently, the level of comfort was increased. It
was interesting to note that most of those using the
PSU birthing bed (with and without the holding bar)
experienced no lower back pain. Quite possibly this
could have resulted from the support and softness of
the mattress of the PSU birthing bed. The fact that less
lower back pain and higher comfort levels were found
among the women using the PSU birthing bed (with
64
and without the holding bar) is consistent with prior
research26 that suggested women using the PSULocked Upright position during labor and delivery (a
position consistently maintained by the PSU birthing
bed) experience less back pain and higher levels of
comfort than women not using such a position. These
findings also are consistent with the clinical suggestions
that support to the lumbar area, via a pillow, can lower
muscle strain in the lower back. 33
The results of this study indicated the PSU
birthing bed is an innovative bed that can decrease the
duration of second-stage labor, sensation and distress
of labor pain, and lower back pain, as well as enhance
the comfort level of women in labor. Thus, it would
be advisable to consider the use of the PSU birthing
bed to enhance a more positive labor and delivery
experience.
Like all studies, the limitations of the study
need to be taken into consideration when applying the
findings. First, most of the women, in all four groups
in this study, received oxytocin. Thus, the duration of
their second-stage labor may have been reduced. This
factor poses some limitations in inferring to the general
population of women experiencing labor and delivery.
Future research needs to examine the effects of the
PSU birthing bed on the duration of second-stage labor
among women who do not receive oxytocin. Secondly,
only primiparous women were included in the study.
Future research needs to consider the use of women
who are multiparous.
Acknowledgements
T he authors gratefully acknowledge the
financial support received from Prince of Songkla
University for implementation of this study.
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ผลของเตียงคลอด PSU ต่อระยะเวลา ความปวด และความสุขสบายใน
ระยะที่ 2 ของการคลอดในมารดาไทยครรภ์แรก
ศศิธร พุมดวง, บุญเรือง มานะสุรการ, กิตติ รัตนสมบัต,ิ สุกจิ มหัธนันท์, กัลยา มณีโชติ, เบญจมาศ จันทร์อดุ ม, สมบูรณ์ แก้วนาค
บทคัดย่อ : การศึกษานี้มีวัตถุประสงค์เพื่อทดสอบผลการใช้เตียงคลอด PSU (Prince of Songkla
University) ที่ประดิษฐ์ขึ้นต่อระยะเวลาในระยะที่ 2 ของการคลอด ความปวดและความตึงเครียดจาก
การปวด การปวดหลังส่วนล่าง และความสุขสบายของมารดาไทยครรภ์แรกในระยะที่ 2 ของการคลอด
กลุ่มตัวอย่างประกอบด้วยมารดาไทยครรภ์แรกจ�ำนวน 240 ราย ซึ่งได้รับการสุ่มแบบบล็อก
กลุ่มละ 60 ราย สุ่มมารดาเป็น 4 กลุ่มคือ กลุ่มใช้เตียงคลอด PSU ไม่มีบาร์โหน กลุ่มเตียงคลอด PSU
มีบาร์โหน กลุ่มเตียงคลอดปกติศีรษะสูง 45-600 และ กลุ่มเตียงคลอดปกติศีรษะสูง 150 เก็บข้อมูล
ด้านประชากร ด้านสูติศาสตร์และด้านทารกโดยใช้แบบสอบถามที่สร้างขึ้น ข้อมูลด้านประชากร
ได้จากการซักถามมารดา ข้อมูลด้านสูติศาสตร์และทารกได้จากแบบบันทึกในห้องคลอด เก็บข้อมูล
ประสบการณ์ความปวด ความตึงเครียดจากความปวด การปวดหลังส่วนล่าง และความสุขสบายโดย
ใช้มาตรวัดด้วยสายตา (100 mm VAS)
วิเคราะห์ข้อมูลโดยใช้สถิติบรรยาย, ANOVA, Kruskal-Wallis test, Mann-Whitney U test
และ Chi-square ผลการวิเคราะห์ข้อมูลพบว่ามารดาที่ใช้เตียงคลอด PSU ไม่มีบาร์โหน และ เตียง
คลอด PSU มีบาร์โหน มีระยะเวลาในระยะที่ 2 ของการคลอด ความปวดและความตึงเครียดจากการ
ปวดและการปวดหลังส่วนล่างน้อยกว่าและมีความสุขสบายมากกว่ามารดากลุ่มใช้เตียงคลอดปกติ
ศีรษะสูง 45-600 และกลุ่มใช้เตียงคลอดปกติศีรษะสูง 150 อย่างมีนัยส�ำคัญ
กล่าวได้ว่าเตียงคลอด PSU เป็นเตียงที่ช่วยย่นเวลาในระยะที่ 2 ของการคลอด ลดปวด ลด
ความตึงเครียดจากการปวด ลดการปวดหลังส่วนล่าง และเพิ่มความสุขสบายให้กับมารดาไทยครรภ์
แรกในระยะที่ 2 ของการคลอด
ค�ำส�ำคัญ: เตียงคลอด PSU; การเจ็บครรภ์; เวลาของระยะที่ 2 ของการคลอด; ความสุขสบาย;
การปวดหลัง ส่วนล่าง; มารดาครรภ์แรก
ติดต่อที่: ศศิธร พุมดวง, RN, PhD. ภาควิชาการพยาบาลสูติ-นรีเวชและ
ผดุงครรภ์ คณะพยาบาลศาสตร์ มหาวิทยาลัยสงขลานครินทร์ อ�ำเภอหาดใหญ่
จังหวัดสงขลา ประเทศไทย E-mail: [email protected]
บุญเรือง มานะสุรการ, MEng. ผู้ช่วยศาสตราจารย์ คณะวิศวกรรมศาสตร์
มหาวิทยาลัยสงขลานครินทร์ อ�ำเภอหาดใหญ่ จังหวัดสงขลา ประเทศไทย
กิตติ รัตนสมบัติ, MD. ผู้อ�ำนวยการโรงพยาบาลท่าศาลา อ�ำเภอท่าศาลา
จังหวัดนครศรีธรรมราช ประเทศไทย
สุกิจ มหัธนันท์, MD. หัวหน้าแผนกสูติ-นรีเวช โรงพยาบาลมหาราช
นครศรีธรรมราช อ�ำเภอเมือง จังหวัดนครศรีธรรมราช ประเทศไทย
กัลยา มณีโชติ, RN, MPH. หัวหน้าห้องคลอด โรงพยาบาลมหาราช
นครศรีธรรมราช อ�ำเภอเมือง จังหวัดนครศรีธรรมราช ประเทศไทย
เบญจมาศ จันทร์อดุ ม, RN, MSN. พยาบาลห้องคลอด โรงพยาบาลมหาราช
นครศรีธรรมราช อ�ำเภอเมือง จังหวัดนครศรีธรรมราช
สมบูรณ์ แก้วนาค, RN. หัวหน้าห้องคลอด โรงพยาบาลท่าศาลา อ�ำเภอท่าศาลา
จังหวัดนครศรีธรรมราช
Vol. 17 No. 1
67
Predicting Factors of Relapse among Persons with a Major
Depressive Disorder
Khwanjit Mahakittikun, Darawan Thapinta, Hunsa Sethabouppha, Phunnapa Kittirattanapaiboon
Abstract : Major depressive disorder is the diagnosis used when an individual has chronic
depression that may reoccur, whereby the affected person may experience a relapse of
the illness. In order to prevent relapse of a major depressive disorder, it is essential to
identify predictors of a potential relapse. Thus, this case-controlled study sought to examine psychosocial factors that might predict an impending relapse among persons with
a major depressive disorder. Seventy-four individuals, diagnosed with a major depressive
disorder, participated in the study. The data were analyzed via descriptive statistics and
binary logistic regression.
The results revealed stressful life events, self-efficacy for coping with depression,
and expressed emotion of family members as significant predictors of an impending
relapse of a major depressive disorder. Together these three independent variables
explained 52% (Cog and Snell R2) or 69.3% (Nagelkerke R2) of the variance of relapse
among the subjects. Although the power of each independent variable in predicting the
likelihood of a relapse of the illness was not high, the results support cognitive theory
that hypothesizes stressful life events increase one’s likelihood of having a depressive
relapse. The findings also support those of previous studies wherein self-efficacy for
coping with depression and expressed emotion of family members have been found to
be factors that may influence the relapse of a major depressive disorder.
Key words: Major depressive disorder; Predictive factors; Relapse
Introduction
Major depressive disorder (MDD) is recognized
as a chronic mental health problem characterized by a
two-week episode of at least one of two major criterion
symptoms, depressed mood and loss of interest in
activities, in combination with at least five of the
following nine symptoms: depressed mood; loss of
interest in activities; weight loss or weight gain;
insomnia or hypersomnia; psychomotor agitation
or retardation; fatigue or loss of energy; feelings of
68
Correspondence to: Khwanjit Mahakittikun, RN, PhD (Candidate)
Faculty of Nursing, Chiang Mai University, 110 Inthawaroros Road,
Muang District, Chiang Mai, 50200 Thailand.
Darawan Thapinta, RN, PhD. Associate Professor, Faculty of Nursing,
Chiang Mai University, 110 Inthawaroros Road, Muang District,
Chiang Mai, Thailand.
Hunsa Sethabouppha, RN, PhD. Lecturer, Faculty of Nursing,
Chiang Mai University, 110 Inthawaroros Road, Muang District,
Chiang Mai, Thailand.
Phunnapa Kittirattanapaiboon, M.D. Senior Advisory Psychiatrist,
Department of Mental Health, Ministry of Public Health, 3rd Floor,
Main Building, Department of Mental Health, Ministry of Public Health,
Tivanon Road, Muang District, Nonthaburi, Thailand.
Khwanjit Mahakittikun et al.
worthlessness; diminished ability to think or
concentrate; and, suicidal ideations or a suicide
attempt.1 One may experience relapses and recurrences
of a MDD even though he/she undergoes treatment.2-5
A relapse has been viewed as a return of symptoms,
within the same episode, that occurs after treatment or
during a period of remission of the illness.6 Although
a recurrence involves the same signs and symptoms as
a relapse, a recurrence is recognized as a return of
symptoms or an onset of a new MDD, after one has a
period of recovery from a MDD episode.6
Prior research has revealed that treatment for
a MDD is not enough to prevent a relapse even when
one has responded positively to treatment and/or no
longer has depressive symptoms.7, 8 However, relapse
prevention or the implementation of any strategy or
treatment to prevent depressive symptoms, prior to a
relapse of a MDD, appears to enhance and extend the
effects of treatments and reduce the risk of a relapse
when continued or maintained.9, 10 Since a limited
number of studies have been undertaken regarding
factors that influence the relapse of a MDD, additional
research needs to be conducted regarding the causes
of relapses, so as to facilitate development of
appropriate interventions for preventing and/or
reducing relapses of the illness.
Review of Literature
Medical research has begun to examine
demographic, clinical, psychosocial, and environmental
factors that may lead one to experience a relapse of a
major depression. Even though examination of
demographic factors (i.e., age, sex, marital status, and
education) have revealed incompatible findings
regarding relapses,3, 11-15 clinical factors, related to
relapse, have been found to include: residual
symptoms;4, 16 partial remission; 15,17 medication
nonadherence;18 previous depressive episodes;4, 17, 19,
20
symptom severity; 13,15 and, psychiatric
comorbidity.11 The psychosocial factors found to be
Vol. 17 No. 1
associated with relapse include: cognitive
vulnerability;8, 19 stressful life events;7, 14, 21 selfefficacy for coping with depression;12, 22, 23 and,
expressed emotion of family members.20, 24 Although
most of the factors identified are difficult to modify,
the psychosocial factors may be managed through
nursing actions, so as to avoid a relapse.
Cognitive vulnerability has been described as
dysfunctional attitudes that are activated by
dysfunctional schemas or negative cognitions triggered
by naturally occurring stressors.25, 26 Several studies
have revealed cognitive vulnerability contributes to
relapse,8, 19 while others have not found cognitive
vulnerability to be a causal risk factor for relapse.2, 7
Thus, it appears that cognitive vulnerability needs to
be re-examined as a critical factor associated with
relapse.
Stressful life events (i.e., negative life events
such as loss of job, divorce, and death of a loved one)
that occur before or during a depressive episode have been
found to play a major role in the onset of a MDD.27, 28
These events have been found not only to precipitate
the onset of a major depression, but also to be
associated with a relapse of the illness.7, 14, 21
Self-efficacy for coping with depression has
been viewed as one’s confidence in his/her ability to
perform behaviors specific to controlling or coping
with the symptoms of a depression.23, 29 In addition,
self-efficacy for coping with depression is considered
a dimension of symptom control and a predictor of a
subsequent relapse of an illness.12, 22, 23
Expressed emotion of family members has been
recognized as the affective attitudes and behaviors that
a depressed person’s key family members express or
exhibit toward him/her.30 Although the expressed
emotion of family members have been studied in regards
to schizophrenia,31 there is growing concern about the
role of expressed emotion among persons with mood
disorders, including depression and bipolar
disorder.20,31,32 A high correlation has been found to
exist between expressed emotion of family members
69
and relapses among individuals with depression.20
However, inconsistencies have been noted in the
explanation of the construct, expressed emotion, as
well as regarding the role of expressed emotion in
predicting relapse among persons with depression.20, 24
Although little research has been supportive, the
available data suggest a need for additional examination
regarding whether expressed emotion of family
members predict a depressive relapse.
Only one Thai study could be located that has
explored factors related to the recurrence of
depression.33 Also, no study could be located that has
investigated factors that affect relapses among persons
with a MDD. Even though the etiology of relapse is
unknown, Western research has focused on the clinical
factors that may predispose relapse among individuals
with a MDD.13, 15, 16, 18 Less attention has been given
to the psychosocial factors related to relapse (i.e.,
cognitive vulnerability, stressful life events, selfefficacy for coping with depression, and expressed
emotion of family members) than to the clinical
characteristics related to relapse. Although a relapse
may originate from various factors, potential predictors
that may best explain a relapse remain unknown. Thus,
in order to provide a more comprehensive view of a
depressive relapse and gain insight into the factors that
contribute to an increased risk for a relapse, a need
exists for examination of the relationship among
psychosocial factors and relapse in persons with a
MDD.
In this study, a hypothesized model of relapse
among persons with a MDD was developed based on
cognitive theory,34 relevant literature, and empirical
findings regarding factors associated with relapse of a
MDD. According to cognitive theory, factors
associated with depressive relapse involve cognitive
vulnerability and stressful life events.34 Cognitive
theory focuses on cognitive structures (schemas),
developed from life experiences, that guide cognitive
processing. The schemas of vulnerable persons tend
70
to be rigid, unrealistic, and negative.26, 34 The belief
that dysfunctional schemas are inactive until activated
by relevant stimuli, 34 has become a condition for
empirical investigation of the role and functioning
of one’s cognitive vulnerability to depression and
relapse of a MDD. 8, 19, 25 Cognitive theory also
originated the idea of traumatic or negative life events
influencing depression. The belief is that when negative
life events occur early in one’s development, he/she
may become sensitized to negative events. In addition,
it is believed that generation of maladaptive cognitions
to information processing about such events leads to
activation of the schemas and, consequently,
depression when similar events occur.34 Accordingly,
stressful life events may be linked to the development
of a relapse of a depression.26
Relapse was defined in this study as a return,
within six months of symptom improvement, of
depressive symptoms required for a diagnosis of a MDD.
In addition, relapse was operationally defined as an
individual experiencing one or both of the following
criteria within six months of discharge after
hospitalization for a MDD: a depressive symptom score
of seven or more on the Nine-Question Assessment
for Depressive Disorders (9Q)35 and/or readmission
to a hospital due to the severity of depressive
symptoms. To explain factors contributing to relapse
among individuals with a MDD, four potential
psychosocial factors (cognitive vulnerability, selfefficacy for coping with depression, stressful life
events, and expressed emotion of family members)
were proposed as being uniquely related to relapse of a
MDD. Thus, based upon review of literature and prior
research, the research question for this study was: How
much of the variability of relapse in persons with a
MDD could be explained by the psychosocial factors
of cognitive vulnerability, stressful life events, selfefficacy for coping with depression, and expressed
emotion of family members?
Method
Design: A case-controlled design was used in
this study, which involved the use of subjects with a
relapse of a MDD and subjects without a relapse of a
MDD.
Ethical Considerations: Approval to conduct
the study was obtained from the Research Ethics
Committee of the Faculty of Nursing of the primary
investigator’s (PI) university and the Ethical Review
Board of the hospital used as a study site. All potential
subjects were informed about: the nature of the study;
what study involvement entailed; confidentiality and
anonymity issues; voluntary involvement in the study;
and, the right to withdrawn from the study at any time
without repercussions. Potential subjects who agreed to
participate were asked to give written consent.
Setting and Sample: The setting for the study
was the outpatient psychiatric clinic of a psychiatric
hospital in northern Thailand. Eighty-eight potential
subjects were identified from the psychiatric outpatient
clinic patient roster and approached by the researchers.
Fourteen of those identified declined to participate due
to: their caregivers not allowing them to do so (n =
3); wanting to rapidly return to work (n = 6); and,
wanting to “rush home,” which was a considerable
distance from the hospital (n = 5).
Through use of a power analysis, with an alpha
of 0.05, a power of 0.80, and four selected predictors,
a sample size of 74 subjects was determined to be
needed. The inclusion criteria consisted of Thais who
were: 18 to 60 years of age; being treated with
antidepressant medications; able to demonstrate a score
≥ 3.5 on the Medication Compliance Inventory;36 in
full remission, for two to six months, upon hospital
discharge; living with a key family member, since the
Vol. 17 No. 1
onset of his/her current episode of MDD; able to
understand and communicate in Thai; and, willing
to participate in the study. Potential subjects were
excluded if they were: experiencing their first episode
of MDD; using alcohol/drugs during their current
episode; receiving additional treatment (e.g., intensive
psychotherapy, electroconvulsive therapy) during their
current episode; or, diagnosed with a MDD with
psychotic features.
To control the internal validity of the study, as
well as decrease the problem of alternative hypotheses,
a degree of control was imposed on the extraneous
variables that might confound the data of relapse. The
key extraneous variables of concern were: medication nonadherence; partial remission; previous depressive
episodes; psychiatric comorbidity; and, symptom
severity. The researchers screened all potential subjects
for these factors and eliminated those from the study
who had any of these factors present.
A s shown in Table 1, the subjects
predominantly: were female; had a mean age of 41.10
years; were married; had a primary school education;
were unemployed; had been hospitalized twice; and
were receiving selective serotonin reuptake inhibitors
as antidepressants. Half of them (n = 37) were found
to be experiencing a relapse of their MDD (had a score
of ≥ 7 on the 9Q test35). When the demographic
characteristics of the subjects currently in relapse were
compared to those who were not experiencing a relapse
no significant differences were noted with respect to
their: gender; age; marital status; educational level;
occupation; number of hospital admissions; or type of
antidepressant received. However, those who currently
were in relapse had a lower mean age and experienced
their first depressive episode at a younger age than
those currently not in relapse.
71
Table 1 Demographic Characteristics of Relapsed and Non-Relapsed Persons with a Major Depressive Disorder
Characteristics
Total
(n = 74)
n (%)
Sex
Male
Female
Age
18-30
31-40
41-50
51-60
Mean age
Mean age at first onset
Marital status
Single
Married
Divorced
Widowed
Education
Primary school
Secondary school
Diploma
Bachelor’s degree
Master’s degree
Occupation
Unemployed
Agriculturist
Employee
Tradesman
Businessman
Government official
Number of hospital admissions
1
2
3
≥4
Drug type of antidepressant used
TCAs
SSRIs
SNRIs
Other
Group
Relapsed
(n = 37)
n (%)
Non-Relapsed
(n = 37)
n (%)
18 (24.3)
56 (75.7)
10 (13.5)
27 (36.5)
8 (10.8)
29 (39.2)
10 (13.5)
13 (17.6)
13 (17.6)
38 (51.4)
= 46.10;
SD = 12.87
= 41.72;
SD = 13.39
5 (6.8)
11 (14.9)
8 (10.8)
13 (17.6)
= 43.32;
SD = 12.24
= 37.84;
SD = 12.67
5 (6.8)
2 (2.7)
5 (6.8)
25 (33.8)
= 49.89;
SD = 12.81
= 45.59;
SD = 13.11
17 (23)
40 (54.1)
6 (8.1)
11 (14.9)
9 (12.2)
21 (28.4)
4 (5.4)
3 (4.1)
8 (10.8)
19 (25.7)
2 (2.7)
8 (10.8)
29 (39.2)
19 (25.7)
5 (6.8)
17 (23)
4 (5.4)
10 (13.5)
11 (14.9)
4 (5.4)
11 (14.9)
1 (1.4)
19 (25.7)
8 (10.8)
1 (1.4)
6 (8.1)
3 (4.1)
27 (36.5)
9 (12.2)
10 (13.5)
11 (14.9)
2 (2.7)
15 (20.3)
15 (20.3)
4 (5.4)
4 (5.4)
5 (6.8)
0 (0)
9 (12.2)
12 (16.2)
5 (6.8)
6 (8.1)
6 (8.1)
2 (2.7)
6 (8.1)
5 (6.8)
59 (79.7)
4 (5.4)
6 (8.1)
3 (4.1)
28 (37.8)
1 (1.4)
5 (6.8)
2 (2.7)
31 (41.9)
3 (4.1)
1 (1.4)
10 (13.5)
46 (62.2)
7 (9.5)
11 (14.9)
7 (9.5)
20 (27)
3 (4.1)
7 (9.5)
3 (4.1)
26 (35.1)
4 (5.4)
4 (5.4)
p
0.588a
0.013a
0.027t *
0.012t *
0.377a
0.110a
0.618a
0.259a
0.342a
Note: a = Chi-square test ( 2); t = Independent t-test; * p < 0.05
TCAs = Tricyclic antidepressants; SSRIs = Selective serotonin reuptake inhibitors;
SNRIs = Selective norepinephrine reuptake inhibitors.
72
Instruments: Data were collected via seven
different instruments. They included the: Demographic
Data Form (DDF); Medication Compliance Inventory
(MCI);36 Nine-Question Assessment for Depressive
Disorders (9Q);35 Dysfunctional Attitude Scale
(DAS);37 Life Experiences Survey (LES);38 Depression
Coping Self-Efficacy Scale (DCSES);29 and, Perceived
Criticism Scale (PCS).30 The researcher-developed
Demographic Data Form (DDF) consisted of seven
items that obtained information about each subject’s:
gender; age; age at onset of first MDD; marital status;
educational level; occupation; number of hospital
admissions; and, type of antidepressant used during
current episode.
The Medication Compliance Inventory
(MCI)36 consisted of five items that assessed the
medication adherence of potential subjects for the
purpose of determining if they met the inclusion criteria
for participation in the study. The items were designed
to measure each respondent’s compliance in taking
medications and the amount of medication taken.
Examples of the items were: “You decrease or increase
the dosage of your medication by yourself” and “When
you get well, you stop taking your medication.” Each
subject was asked to rate each item, on a five-point
Likert-like scale, ranging from 1 = “usually” to 5 =
“never.” A total score was obtained by summing the
rated points and dividing by the total number of items
to obtain an average score. The possible range for the
total score was 1 to 5. A total score ≥ 3.5 was considered
to show a high likelihood of medication adherence; while
a total score < 3.5 was considered to indicate a low
likelihood of medication adherence. The reliability of
the instrument, for this study, was found to be 0.81.
The Nine-Question Assessment for Depressive
Disorders (9Q)35 was a nine item questionnaire that
was used to assess the presence of depressive
symptoms. Examples of items were: “I have low
interest or pleasure in doing things” and “I am feeling
down, depressed, or hopeless.” Each item had possible
responses that ranged from: 0 = “have not experienced
Vol. 17 No. 1
any of these symptoms over the past two weeks” to 3 =
“have experienced, to a significant degree, these
symptoms every day over the past two weeks.” A total
score, which could range from 0 to 27, was obtained
by summing the numerical values for all responses. A
score ≥ 7 suggested the presence of a significantly
depressed mood, thereby indicating a relapse of a
MDD. The reliability of the 9Q, for this study, was
0.93.
The Dysfunctional Attitude Scale (DAS)37 was
a 40-item questionnaire used to assess a depressed
individual’s underlying cognitive vulnerability for
relapse. The content of items represents major concerns
for approval, love, achievement, perfectionism
performance standards, omnipotence, autonomy, and
rigid ideas about the world. Examples of the items
were: “People probably will think less of me if I make
a mistake”; “I am nothing if a person I love doesn’t
love me”; “To be a good, moral, worthwhile person,
I must help everyone who needs it”; and, “I can reach
important goals without pushing myself.” Possible
responses to the items ranged from 1 = “totally agree”
to 7 = “totally disagree.” A total score, which could
range from 40 to 280, was obtained by summing the
numerical values of the responses across all items.
Scores above 125 were considered high and suggested
the presence of more dysfunctional attitudes or beliefs,
and, thus, cognitive vulnerability to a depressive
episode.7 Reliability of the instrument, for this study,
was found to be 0.81.
The Life Experiences Survey (LES)38 was used
to assess stressful life events. The LES was a selfreport scale containing 57 life events. Although the
LES has two sections, only Section I of the scale,
comprised of 47 life events, was use in this study.
Section II was excluded because it was specifically
designed for students. Section I of the LES requested
respondents to indicate the life events they have
experienced during the past six months (i.e., death of
close family member, new job, trouble with employer
[in danger of losing job, being suspended, being
73
demoted], major change in financial status [a lot better
off or a lot worse off], divorce, and retirement from
work). Each life event was then assessed using the
following range of responses: -3 = “extremely
negative” to +3 = “extremely positive.” If an event
had no impact or did not occur a value of 0 was
indicated. Because positive life events do not tend to
cause the type of life stress that could potentially lead
to thoughts about depressive relapse, only negative life
events were used in the analysis for the present study.
To obtain a total score, which could range from 0 to
141, responses to all negative life events were
summed. The total scores were classified as high
negative impact (≥ 14); medium negative impact
(4-13); or, low negative impact (0-3). The
reliability of the instrument, for this study, was 0.84.
The 24 item Depression Coping Self-Efficacy
Scale (DCSES)29 was used to measure the subjects’
confidence in their ability to manage their depressive
symptoms and follow their treatment regimens. The
items regarding coping self-efficacy were divided into
three domains: seven negative cognitions items (i.e.,
“I am this percent confident (0-100) that I can
recognize when I am blaming myself for my symptoms
and try to stop.”); ten behaviors items (i.e., “I am this
percent confident (0-100) that I can plan pleasant
things to do in my free time.”), and seven somatic
problems items (i.e., “I am this percent confident
(0-100) that I can go to bed and get up at the same
time every day.”) Subjects were asked to rate their
degree of confidence or self-efficacy in managing
tasks, specific to coping with depressive symptoms
and its treatment, by writing down a numerical value
that could range from 0 = “not at all confident” to
100 = “completely confident.”
A total score was calculated by summing the
numerical values of the responses and dividing by
24 to obtain an average score. A score less than 50
represented a low sense of self-efficacy, scores between
50 and 75 represented moderate self-efficacy, and a
score more than 75 represented a high sense of
74
self-efficacy. A high total score suggested a more
positive sense of self-efficacy or confidence for coping
with depression.23, 29 Reliability of the DCSES, for
this study, was 0.96.
The Perceived Criticism Scale (PCS)30 was
used to assess the expressed emotion of family
members from a depressed person’s perspective.
Subjects were asked two questions (“How critical of
you do you think your relative is?” and “How critical
of your relative do you think you are?”) about the
feelings they perceived regarding criticism from their
key family member at the time of becoming ill, with
the current episode, to when the scale was completed
by the subject. Both questions required responses on
a 10-point scale that ranged from 1 = “not at all
critical” to 10 = “very critical.” In this study, the key
family member was one whom the depressed person
perceived to be a significant other. In other words, the
key family member was the individual who directly
took care of and lived with the depressed person at the
time the depressed person became ill with the current
episode to when the scale was completed by the subject.
A total score was obtained by summing the numerical
values of the responses to the two items and then
dividing by two to obtain a mean score. A score of four
or more was considered a high expressed emotion from
the key family member. The reliability of the PCS, for
this study, was 0.82.
Appropriate approval was obtained for the use
and translation of the instruments used in the study.
The MCI and 9Q originally were written in Thai and,
therefore, did not require translation. However, the
DAS, LES, DCSES, and PCS originally were written
in English and translated from English to Thai by the
PI and a translator, who was an expert in foreign
languages, and then back translated from Thai to
English by two psychiatrists, who were bilingual
experts. The PI and one native English speaker
compared the English back translated versions of the
instruments to the original English versions of the
instruments to assure no changes in meaning had
occurred. Finally, five patients with MDD assessed
the Thai translated versions of the instruments for
clarity, readability, and meaning. Based upon their
feedback some minor revisions were made in the
wording of several of the items.
Procedure: Once consent to conduct the study
was obtained, data collection commenced. While
waiting to be seen or after being seen by their respective
psychiatrist, potential subjects who met the inclusion
criteria were informed about the study and the ethical
considerations. Those who agreed to participate were
asked to sign a consent form. The PI then took each
subject to a private area of the waiting room and read
the questions, from each of the seven questionnaires,
to each respective subject. The subjects’ verbal
responses were recorded on their respective copies of
the questionnaires. Administration of all seven
questionnaires took about 25 minutes. If a subject
obtained a score < 3.5 on the MCI, data collection
ceased because the subject did not meet one of the
inclusion criteria (acceptable medication adherence).
The excluded subject was thanked for his/her time and
given information about the importance of medication
adherence. Each questionnaire was given a code
number for the purpose of identification. All completed
questionnaires were kept in a locked cabinet to assure
confidentiality.
Data Analysis: The demographic data and
scoring for the questionnaires were assessed via
descriptive statistics. Examination of difference among
the variables between the two groups (subjects in
relapse and subjects not in relapse) was accomplished
via chi-square and the independent t-test, while
examination of the variables predicting relapse for a
MDD was accomplished by way of binary logistical
regression.
Vol. 17 No. 1
Results
Based on the depressive symptom scores on
the 9Q, within six months after discharge from the
hospital, the persons with MDD were categorized into
two groups: relapse (n = 37) and non-relapse (n = 37).
Table 2 shows the descriptive analysis of the study
variables. There was no difference in distribution of
cognitive vulnerability between the relapse and nonrelapse groups. Independent t-test analysis also showed
that the mean scores of cognitive vulnerability between
the relapse and non-relapse groups were not different.
On the contrary, it was found that significant differences
existed, between the relapse group and non-relapse
group, regarding stressful life events, self-efficacy for
coping with depression, and expressed emotion of family
members. Most subjects in relapse: perceived a high
negative impact of stressful life events at a high level;
had moderate self-efficacy for coping with depression;
and, perceived high expressed emotion of family
members. While, most of those without relapse:
perceived a low negative impact of stressful life events;
had high self-efficacy for coping with depression; and,
perceived low expressed emotion of family members.
In regards to factors predicting a relapse of a
MDD, stressful life events, self-efficacy for coping
with depression, and expressed emotion of family
members entered into the predictive model (see Figure 1
and Table 3). Interestingly, cognitive vulnerability did
not significantly contribute to the prediction of relapse.
The total variance in predicting relapse from the
combination of the three variables was 52% (by the
Cog and Snell R2) or 69.3% (by the Nagelkerke R2).
The model was able to classify 89.2% of the subjects
who relapsed and 81.1% of those who did not. Overall,
85.1% of the sample was correctly predicted.
75
Table 2 Comparison of Psychosocial Factors between Relapsed and Non-Relapsed Persons with a Major
Depressive Disorder
Psychosocial
Factors
Cognitive vulnerability
Low level
High level
Stressful life events
Low level
Moderate level
High level
Possible
Scores
40-124
125-280
40-280
0-3
4-13
14-141
0-141
Self-efficacy for coping with depression
Low level
0-49
Moderate level
50-74
High level
75-100
0-100
Expressed emotion of family members
Low level
1-3
High level
4-10
1-10
Total
(n = 74)
n (%)
Relapsed
(n = 37)
n (%)
Groups
Non-relapsed
(n = 37)
n (%)
26 (35.1)
48 (64.9)
= 139.59;
SD = 30.52
13 (17.6)
24 (32.4)
= 139.86;
SD = 32.92
13 (17.6)
24 (32.4)
= 135.32;
SD = 27.75
35 (47.3)
21 (28.4)
18 (24.3)
= 9.59;
SD = 13.01
7 (9.5)
14 (18.9)
16 (21.6)
= 15.73;
SD = 14.70
28 (37.8)
7 (9.5)
2 (2.7)
= 3.46;
SD = 7.09
14 (18.9)
32 (43.2)
28 (37.8)
= 65.20;
SD = 17.73
13 (17.6)
19 (25.7)
5 (6.8)
= 54.68;
SD = 16.12
1 (1.4)
13 (17.6)
23 (31.1)
= 75.73;
SD = 12.24
34 (45.9)
40 (54.1)
= 3.95;
SD = 2.35
6 (8.1)
31 (41.9)
= 5.01;
SD = 1.79
28 (37.8)
9 (12.2)
= 2.89;
SD = 2.38
p
1.000a
0.523t
0.000a *
0.000t *
0.000a *
0.000t *
0.000a *
0.000t *
Note: a = Chi-square test ( 2); t = Independent t-test; * p < 0.05
76
Table 3 Predictors of Relapse among Persons with a Major Depressive Disorder
Predictors
B
Wald
p
Exp.
(B)
0.140
7.905
0.005*
1.150
Self-efficacy for coping with
-0.113 11.797
0.001*
0.894
depression
Expressed emotion of the
0.440
7.729
0.005*
1.553
family members
Note: * p < 0.05; CI = confidence interval; Exp. (B) = exponentiation of the B coefficient
Predicted Outcome
95% CI
for Exp. (B)
Lower
Upper
1.043
1.267
0.838
0.953
1.139
2.117
Predictors
Self-efficacy for coping
with depression
Depressive Relapse
Expressed emotion
of family members
Hosmer-Lemeshow goodness-of-fit; Chi-square ( 2) = 6.98; df = 8; p = 0.54
Figure 1 Model of Relapse for Persons with a Major Depressive Disorder
Discussion
Since no previous study in Thailand assessed a
predictive model of relapse in persons with a MDD,
the results of this study provided a model explaining
depressive relapse in a Thai sample. As three
psychosocial predictors in this model could explain
52% (by the Cog and Snell R2) or 69.3% (by
Nagelkerke R2) of the variability of relapse in
depressed persons, the remainder of the variance in
predicting relapse might be explained by either constant
variables or other modifiable variables.
The model of the current study was consistent
with the model studied among Canadian women with
a MDD.39 Interestingly, a similarity in a set of
psychosocial factors, between the current study and
the Canadian study, to create the fitting model of
Vol. 17 No. 1
relapse was that both models had more to do with the
combination of life stressors, coping styles, and
interpersonal relationships, but less to do with
cognitive dimension. It should be noted that when
creating relapse prevention strategies, health care
providers need to simultaneously target the reduction
of life stress, as well as improvement of coping
responses and interpersonal relationships in persons
with a MDD.
Cognitive vulnerability, between the relapse and
non-relapse groups, demonstrated no significant
differences. Both groups had a high level of cognitive
vulnerability. This data supported the fact that
cognitive vulnerability could not predict relapse.
Possible explanations for this finding include:
cognitive vulnerability is a result of the cognitive nature
of persons with a MDD, regardless of whether they
77
are or are not in relapse; the direct effect of cognitive
vulnerability may not be sufficient to predict relapse
among persons with a MDD; and, cognitive
vulnerability, as explained by cognitive theory, is
interrelated to stressful life events leading to relapse
rather than cognitive vulnerability itself having a direct
effect on relapse. Prior research has suggested there is
congruency between dysfunctional schemas and life
events in relapse prediction.40, 41 These studies have
shown that persons with dysfunctional schemas are
more likely to experience relapse when they have
encountered stressful life events. Thus, it can be
concluded that cognitive vulnerability may not be able
to independently predict relapse among persons with
a MDD. Cognitive vulnerability, instead, may be
associated with stressful life events in predicting
relapse.
Not everyone who experiences stressful life
events will relapse. However, the fact that stressful
life events, in this study, was a predictor of relapse in
persons with a MDD was similar to the findings of
previous studies that have examined stressful life
events and depressive relapse. 7, 14 This finding
demonstrates that, in this study, stressful life events
played a role in relapse during the course of an episode
of depression.
Depressed persons may fail to adapt to their life
stressors and, as a result, become vulnerable to a
relapse. Based on cognitive theory, stressful life events
occurring during an episode of depression may be
linked to the vulnerability to relapse. Stressful life
events that are similar to the original traumatic
experiences appear to reinforce existing dysfunctional
schemas and induce a return of depressive symptoms.
According to a dimension of symptom control,
this study found self-efficacy for coping with
depression to be a predictor of relapse. This finding is
consistent with those of previous studies regarding
78
self-efficacy for coping with depression among
hospital patients and primary care patients.12, 29 A
potential explanation of self-efficacy for coping with
depression as a risk factor for relapse is the nature of
a MDD itself. Since depressive symptoms may be a
barrier to performing adaptive coping responses,
persons with a MDD, who have low self-efficacy for
coping depression, are less likely to perform successful
coping behaviors through an episode of depression.22,
23
Furthermore, persons with a MDD, who have
relapsed, may have less improvement in coping with
their symptoms. They are known to experience more
symptom distress, perceive a decreased sense to manage
their symptoms, and be less confident in their abilities to
follow treatment recommendations after discharge
from the hospital.22, 23 Therefore, they are more likely
to relapse.
Consistent with prior research,24 high expressed
emotion of family members predicted relapse in the
study subjects. It is very likely that the psychopathology
of a MDD (i.e., concentration on negative stimuli)
makes depressed persons more vulnerable to criticism
from key family members who are less willing to
tolerate the depressed persons’ behaviors that are
perceived to be undesirable. Hence, when persons with
a MDD are exposed to criticism, they are at an increased
risk of relapse. Another possibility may be
associated with the source of criticism. A key family
member is an individual whom the person with a MDD
perceives to be a significant other. He or she has the
most important role in taking care of and living with
the person with a MDD. Thus, criticism from a key
family member may be more distressing for a person
with a MDD than criticism from other relatives,
because it is more likely to lead to feelings of
insecurity, and fear concerning possible loss of
affection and care.
Acknowledgement
When applying the findings of the study, the
study limitations need to be taken into consideration.
First, based upon cognitive theory,34 persons with a
MDD, who relapse, are more likely to perceive
themselves and their world in a more negative manner
than those with a MDD who are not in relapse. Thus,
regardless of the factors that may be related to relapse,
a person with a MDD, who is in relapse, will be more
likely to maintain symptoms of depression than a
person who has a MDD but is not in relapse. This factor
will continue to be a problem in future research studies.
Secondly, recall bias regarding the reporting of
stressful life events and expressed emotion of the
family members, over the past six months, could have
been present. Future studies may need to implement
multiple means of data gathering (i.e., observations,
interviews of family members and persons with a
MDD, and daily journal recordings of persons with a
MDD) in addition to questionnaires that utilize recall.
Thirdly, although the proposed model worked
well for predicting relapse, the odds ratio of each
independent variable had weak predictive power for
representing the probability of relapse. It is likely the
mean score of depressive symptoms of the sample
(7.85) was too close to the cut-off score (7) on the
9Q for determining relapse. For predicting relapse,
this may not be sufficient for clearly defining a
difference between persons with a MDD who are in
relapse and those who are not in relapse. As a result,
future researchers may want to consider the use of a
more robust instrument for measuring depressive
symptoms.
Finally, the study was conducted on subjects
from only one hospital in one geographic location
within Thailand. Thus, generalizability to the overall
population of persons with a MDD is limited. Future
studies need to consider using persons with a MDD
from various locations throughout Thailand who are
being treated in a variety of mental health settings.
The researchers wish to acknowledge the Thailand
Nursing and Midwifery Council for providing funding
for this study.
Vol. 17 No. 1
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Vol. 17 No. 1
37. Weissman AN, Beck AT. Development and validation
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of an integrated model of relapse in depression. J Affect
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81
ปัจจัยท�ำนายการกลับเป็นซ�้ำในผู้ที่เป็นโรคซึมเศร้า
ขวัญจิต มหากิตติคุณ, ดาราวรรณ ต๊ะปินตา, หรรษา เศรษฐบุปผา, พันธุ์นภา กิตติรัตนไพบูลย์
บทคัดย่อ: โรคซึมเศร้าเป็นการวินิจฉัยที่ใช้เมื่อบุคคลมีอาการซึมเศร้าเรื้อรังที่ซึ่งอาจเกิดขึ้นซ�้ำได้
โดยผู้ที่ได้รับผลกระทบนี้อาจมีประสบการณ์การกลับเป็นซ�้ำของการเจ็บป่วยได้บ่อยครั้งขึ้น เพื่อ
ป้องกันการกลับเป็นซ�้ำของโรคนี้จึงมีความส�ำคัญที่ควรระบุถึงตัวท�ำนายการกลับเป็นซ�้ำที่เป็นไปได้
การศึกษานี้เป็นการศึกษาย้อนหลังแบบที่มีกลุ่มควบคุมเพื่อตรวจสอบปัจจัยทางจิตสังคมที่น่าจะใช้
เพื่อท�ำนายการกลับเป็นซ�้ำในผู้ที่เป็นโรคซึมเศร้า โดยมีผู้ที่ได้รับการวินิจฉัยว่าเป็นโรคซึมเศร้าเข้า
ร่วมในการศึกษาจ�ำนวน 74 ราย วิเคราะห์ข้อมูลโดยใช้สถิติ เชิงพรรณนาและสถิติถดถอยโลจิสติค
ผลการศึกษาพบว่าเหตุการณ์ที่ก่อให้เกิดความเครียดในชีวิต สมรรถนะแห่งตนในการจัดการ
กับอาการซึมเศร้า และการแสดงออกทางอารมณ์ของสมาชิกครอบครัว เป็นตัวท�ำนายการกลับเป็น
ซ�ำ้ ของโรคซึมเศร้าทีส่ ำ� คัญ ตัวแปรอิสระทัง้ 3 ตัวร่วมกันอธิบายความผันแปร ของการกลับเป็นซ�ำ้ ในผู้ที่
เป็นโรคซึมเศร้าได้รอ้ ยละ 52 (โดยวิธขี องค็อกและสเนลล์) หรือร้อยละ 69.3 (โดยวิธขี องเนเกลเคิรก์ )
แม้วา่ ค่าอ�ำนาจท�ำนายของตัวแปรอิสระแต่ละตัว ในการท�ำนายความเป็นไปได้ของการกลับเป็นซ�้ำ
ของการเจ็บป่วยไม่สูงมากนัก แต่ผลการศึกษานีส้ นับสนุนทฤษฎีทางปัญญาทีม่ สี มมติฐานว่าเหตุการณ์
ทีก่ ่อให้เกิดความเครียดในชีวติ ท�ำให้บคุ คลมีโอกาสกลับเป็นซ�้ำของโรคซึมเศร้าเพิม่ ขึน้ ผลการศึกษา
นีส้ นับสนุนผลการศึกษาทีผ่ า่ นมาอีกด้วยว่าสมรรถนะแห่งตนในการจัดการกับอาการซึมเศร้า และการ
แสดงออกทางอารมณ์ของสมาชิกครอบครัว เป็นปัจจัยส�ำคัญที่น่าจะมีอิทธิพลต่อการกลับเป็นซ�้ำของ
โรคซึมเศร้า
คำ�สำ�คัญ โรคซึมเศร้า ปัจจัยทำ�นาย การกลับเป็นซ้ำ�
ติดต่อที่ : ขวัญจิต มหากิตติคุณ, RN, PhD (Candidate)
นักศึกษาปริญญาเอก คณะพยาบาลศาสตร์ มหาวิทยาลัยเชียงใหม่ 110
ถ.อินทวโรรส ต.ศรีภูมิ อ.เมือง จ.เชียงใหม่ ประเทศไทย 50200
ดาราวรรณ ต๊ะปินตา, RN, PhD. รองศาสตราจารย์ คณะพยาบาลศาสตร์
มหาวิทยาลัยเชียงใหม่ 110 ถ.อินทวโรรส ต.ศรีภูมิ อ.เมือง จ.เชียงใหม่
ประเทศไทย
หรรษา เศรษฐบุปผา, RN, PhD. อาจารย์ คณะพยาบาลศาสตร์ มหาวิทยาลัย
เชียงใหม่ 110 ถ.อินทวโรรส ต.ศรีภูมิ อ.เมือง จ.เชียงใหม่ ประเทศไทย
พันธุ์นภา กิตติรัตนไพบูลย์, M.D. ที่ปรึกษากรมสุขภาพจิต กระทรวง
สาธารณสุข ส�ำนักงานกลุ่มที่ปรึกษา กรมสุขภาพจิต กระทรวงสาธารณสุข
ถ.ติวานนท์ อ.เมือง จ.นนทบุรี ประเทศไทย
82
Thaparat Rakpanusit et al.
Menopausal Transition with a Yogic Lifestyle: Experiences of Thai
Yogi Masters
Thaparat Rakpanusit, Urai Hatthakit, Umaporn Boonyasopun, Amrita Bagga
Abstract : This ethnographic study, as part of the larger research project, “Living Healthy
through Yoga of Yoga Masters: A Qualitative Inquiry,” sought to explore the experiences
of nine female yogi masters as they managed their menopausal transition (i.e., women’s
reproductive senescence in the continuum of reproductive aging) via a yogic lifestyle.
Their yogic lifestyle included regular yoga practice, healthy food habits, adequate sleep,
and the use of nature cure techniques (i.e., fasting, detoxification, selection of suitable
food products, and living in well-ventilated houses) that facilitated the art of living in
tune with nature. Personal interviews, supplemented with telephonic interviews, participant observations, administration of a questionniare, and field notes were carried out to
explore the yogi masters’ experiences. Using Spradley’s method of analysis, qualitative
data were gathered and analyzed simultaneously.
The findings revealed the yogi masters perceived having: mild menopausal
symptoms; positive attitudes towards their menopausal experiences; and, a smooth
menopausal transition.
Their yogic lifestyle helped the middle-aged Thais deal with their menopausal
transition and provided them with a positive step towards healthier aging. Thus, it
appears that health professionals need to encourage positive attitudes, among women,
towards menopause and mind-body awareness, through use of yoga.
Keywords:menopausal transition; yogi masters; yogic lifestyle
Background
Menopause is a naturally occurring reduction
of women’s female hormone secretions as they move
from being sexually reproductive to becoming sexually
non-reproductive (menopausal transition). During
this transitional event, some women experience
physical changes (i.e., hot flushes that are commonly
activated by estrogen deficiency); 1 fatigue; headaches;
Vol. 17 No. 1
Correspondence to: Thaparat Rakpanusit, RN, PhD (Candidate)
Doctoral of Philosophy in Nursing Program, Faculty of Nursing, Prince
of Songkla University, Hat Yai, Songkhla, 90112 Thailand. E-mail:
[email protected]
Urai Hatthakit, RN, PhD. Assistant Professor, Faculty of Nursing, Prince
of Songkla University, Hat Yai, Songkhla, Thailand.
Umaporn Boonyasopun, RN, PhD. Assistant Professor, Faculty of Nursing
Prince of Songkla University, Hat Yai, Songkhla, Thailand.
Amrita Bagga, PhD. Professor, Emeritus Fellow, Department of Anthropology,
University of Pune, Pune-411037, India.
83
sleep disturbances; musculoskeletal pain; 2 and/or, a
nonspecific psychological syndrome characterized by
mood disturbances (i.e., anxiety, depression, and low
self-esteem) and cognitive impairment.3 Such
changes often lead to significant alterations in women’s
quality of life (QOL), prompting them to seek
complementary and alternative therapies as they seek
to manage their menopausal symptoms. 4
Although 20% of American menopausal
women, reportedly, do not experience menopausal
symptoms, approximately 20% suffer from severe
menopausal symptoms and 60% experience mild
menopausal symptoms. 5 In Thailand, 23% of
menopausal women suffer from severe menopausal
symptoms, especially muscle and joint pains; however,
nearly 31% do not experience menopausal symptoms.6
Prior research has revealed that the intensity of
women’s menopausal experiences reflect their life
changes, lack of knowledge about the changes
(including self-care activities), and how the changes
complicate their middle years of life. 7 This is especially
important, in Thailand, where women have a mean
life expectancy of approximately 75 years,8 and
experience menopause between 47 and 50 years of
age.9
As one may suspect, the occurrence of
menopausal symptoms can lead to a significantly
reduced QOL for Thai women.10 Thus, the women
often seek medical interventions to alleviate or decrease
their symptoms. Although hormone replacement
therapy (HRT) has been shown to be the most effective
medical treatment for menopausal symptoms,11 clinical
trials have found that HRT increases women’s risk for
breast and endometrial cancer, coronary artery disease,
stroke, and thromboemboli.12, 13 Thus, menopausal
women, throughout the world, have sought out and
used various alternative therapies and treatments for
relief of their symptoms. The most popular therapies,
in this regard, have been consumption of vitamins and
soy products, and participation in relaxation activities,
including yoga and meditation. 14
84
Yoga , a Sanskrit word meaning to “yoke” or
“union” the mind, body, and spirit was developed, as
a spiritual practice, over 4000 years ago.15 Patanjali,
the founder of yoga, described it as a sacred science
involving evolution through eight pathways or limbs:
yama (universal ethics); niyama (individual ethics);
asana (physical postures); pranayama (breath
control); pratyahara (control of the senses); dharana
(concentration); dhyana (meditation); and, smadhi
(bliss).15 With regular practice, yoga claims to teach
the practitioner how to develop a greater awareness of
one’s physical and psychological states and, thus,
increase one’s ability to cope with everyday stresses
and situations, and assess one’s reactions and coping
mechanisms. Although different styles of yoga,
including Hatha, Ashtanga, Vinyasa, Bikram, and
Kundalini, are popular today, the goal in practicing
yoga is attainment of a state of bliss and oneness with
the universe via blending physical, mental, and
spiritual practice.16
Prior research has shown yoga to be significantly
associated with improved psychological and spiritual
well-being, and overall physical health,17-19 and is a
popular alternative therapy20 among Thai women.21 In
addition, since it has been found to decrease menopausal
symptoms,4, 22, 23 yoga often is recommended as an
alternative to HRT.20, 24
Yogi masters, as knowledgeable practitioners
of yoga, live healthy, balanced, and contented lives.15
From a yogic perspective, health is related to the
balance of the five body sheaths of human existence:
physical, vital, mindful, intellectual, and blissful. The
physical body, the outermost sheath, consists of one’s
skin, bones, muscle, and internal organs, and
encompasses the other four subtle body sheaths. The
vital body sheath is where breath and emotions reside,
while the mental body sheath consists of one’s thoughts
and obsessions that can be mastered. The intellectual
body sheath is where intelligence and wisdom can be
found, while within the blissful body sheath the
universal soul resides.25 To attain balance within the
five body sheaths, one must engage in use of nature
cures which involve use of techniques that facilitate
the art of living in tune with nature.26 Thus, the use of
such techniques (i.e., fasting, detoxification, good
physical posture, breath control, consumption of fish
oil and fresh water, yoga exercises, sound sleep,
meditation, and a yogic diet which consists of low
protein, fresh, and natural foods of good quality) are
recommended for balancing the five body sheaths of
human existence.27, 28
Although prior studies have utilized Hatha
yoga, which includes physical poses, breath control,
and deep relaxation, for improving quality of life and
relieving menopausal symptoms,4,17 none have
investigated how menopausal women integrate yoga,
as a nature cure, into their daily activities as they seek
to manage their menopausal transition. Although a
systematic review of the effects of yoga on women’s
menopausal symptoms revealed no statistical
significance difference, when compared to the
menopausal symptoms of women not practicing
yoga,29 the practice of yoga has been found to reduce the
frequency and intensity of hot flashes,22,30 as well as
decrease stress among menopausal women.3 Thus, this
ethnographic study sought to explore how nine female yogi
masters managed their menopausal transition via a yogic
lifestyle.
Method
Design: This qualitative study drew on
ethnographic principles to facilitate understanding of
human behavior, values, beliefs, and meanings
relevant to health.31, 32
Ethical considerations: Prior to implementation,
the study was approved by the Research Ethics Review
Committee of the primary investigator’s (PI) academic
institution. Each potential subject was informed about:
the nature of the study; what study involvement
entailed; anonymity and confidentiality issues;
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voluntary involvement; and the right to withdraw at
any time without ramifications. Participants consenting
to take part were asked to sign an informed consent
form. All data obtained were identified by way of code
numbers so as to ensure confidentiality and anonymity.
Sample: The sample was comprised of nine
yogi masters who were well known and practiced yoga on
a daily basis. The names of potential participants, which
were small in number because of the limited presence of
yogi masters, were purposively identified through the PI’s
yoga teacher and via the snowball technique. A total of ten
participants were directly approached by the PI. However,
only nine consented to take part in the study. One potential
participant chose not to take part in the study because she
had limited available time and used limited aspects of
yoga as an exercise. The study’s inclusion criteria were
Thai women who: were either perimenopausal,
menopausal, or post-menopausal; had participated in
a formal yoga training course for at least one week;
were engaged in intensive and ongoing regular yoga
practice; had practiced yoga for at least five years; and,
were willing to participate in the study.
The nine participants had a mean age of 55 years
(range = 48 to 61 years) and had been practicing yoga,
on average, for 11 years. Six of them were health
professionals (five nurses and one audiologist) and three
were housewives. Five participants were married and
lived with their children; two were married, but
childless; and, two were not married. Regarding level
of education, five held a master’s degree, three a
baccalaureate degree, and one a doctoral degree. All
were Buddhists. Eight were non-vegetarian and one
was a vegetarian. Six participants were postmenopausal (mean age of 58.5 years), two were
perimenopausal, (mean age of 48.5) and one was
premenopausal (48 years of age). Three participants
reported mild menopausal symptoms, while the other
six did not report any menopausal symptoms.
Instruments: Data were obtained via three
instruments: a Demographic Data Questionnaire
(DDQ); the Menopause Rating Scale (MRS);33 and,
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a semi-structured interview. The DDQ requested
information on each participant’s: age; marital status;
highest level of education; occupation; menopausal
status; and, food habits.
The MRS33 was used to determine and describe
the severity of the participants’ menopausal symptoms.
The instrument consisted of 11 items that addressed
psychological (4 items; depressed, irritable, anxious
and exhausted), somato-vegetative (4 items;
sweating/flushing, cardiac complaints, sleep disorders,
and joint/muscle complaints), and urogenital
symptoms (3 items: sexual problems, urinary
complaints, and vaginal dryness). The items asked if
each of the 11 symptoms was present and, if so, what
was their level of severity (i.e., “Which of the
following symptoms apply to you at this time and to
what degree?”). Possible responses to each item were:
0 = “not present or minimal;” 1 = “mild;” 2 =
“moderate;” 3 = “severe;” and, 4 = “extremely
severe.” A total score, which could range from 0 to
44, was obtained by summing the response scores
across items. Interpretation of the total score was as
follows: 0 to 4 = presence of no or few menopausal
symptoms; 5 to 8 = presence of mild menopausal
symptoms; 9 to 15 = presence of moderate menopausal
symptoms; and, 16 and over = presence of severe/
extremely severe menopausal symptoms. Thus, higher
scores indicated a more severe level of menopausal
symptoms. Test-retest reliability of the MRS, across
cultures in prior research, was found to be between
0.6 and 0.9.34 The MRS was available on the internet
and did not require permission for use. However, since
the MRS was written originally in English, it required
translation from English into Thai and then back
translation into English. The back translated version
of the instrument was then comparison to the original
English version to assure no changes in meaning
occurred. The translation and back translation were
carried out by two Thai-English bilingual teachers.
The semi-structured interview focused on each
participant’s: stage of menopause; experiences with
86
menopausal symptoms; perceived health changes
during menopause; daily activities; ways and duration
of yoga practice; lifestyle; management of menopausal
symptoms; and, understanding of how yoga practice
influenced health and well-being during menopausal
transition. Examples of the initial interview questions
included: “In what stage of menopause are you?;”
“Please describe your experiences with menopause?;”
“What have been your most important experiences and
health changes during menopause?;” “What are your
daily activities in taking care of your health?;” “What
special aspects of yoga do you practice for dealing with
menopause?;” “How long do you practice yoga?;”
“What other techniques do you use for management
of menopausal symptoms?;”and, “Do you think yoga
influences your health and well-being during your
menopausal transition? If so, in what way does yoga
influence your health and well-being?” As the
interview proceeded probing comments or questions
(i.e., “Please explain what you mean;” “Please
provide more information about what you are saying;”
and, “Am I correct in my understanding that you
mean…….?”) were used to clarify information and gain
more depth in the content being addressed.
Procedure: Once a participant was determined
to have met the inclusion criteria and consented to take
part in the study, she was administered, by the PI via
interview, the DDQ and MRS.33 This process took
approximately 12 minutes. The interview was then
used to obtain in-depth data. Over one year, each
participant was formally interviewed two to four times
in her home or work place, depending upon which
location was most convenient for her. Each interview
lasted approximately 60 to 90 minutes. The number
of times a participant was interviewed depended upon
saturation of the data obtained (i.e., hearing the same
information over and over.). Upon consent of each
participant, interviews were tape-recorded. In
addition, field notes were written regarding observations
made during the interview process. While the data were
being analyzed, telephonic follow-up interviews were
used to confirm understanding of the data obtained.
to analyze the demographic data and information
obtained from the MRS. Content on the audiotapes
were transcribed verbatim. The transcripts and field
notes were read repeatedly to foster insight regarding
the participants’ experiences within their context and
background. Data analyses then were accomplished
throughout the process of: coding the folk terms and
symbols; organizing symbols into domains with
semantic relationship; categorizing many domains into
a few domains; and conceptualizing themes as set
forward by Spradley.31
Rigors of the study: Trustworthiness was
established by following several principles established
by Lincoln and Guba 35 which served to ensure
credibility, transferability, dependability, and
confirmability of the findings. Strategies to ensure
credibility were achieved when the PI’s descriptions
were recognized as valid by those who had experience
in qualitative research (i.e., other members of the
research team) and by participant checks during the
interview process. This was done by restating,
summarizing, and paraphrasing participants’ responses
to clarify and confirm the PI’s understanding of what
participants had verbalized. To ensure transferability,
the details regarding participants’ recruitment and
study context were provided. However, no claim was
made that participants’ experiences represented the
experiences of every female yogi master in Thailand.
Dependability was established by providing enough
information to enable future researchers to replicate
the work. Confirmability, the degree in which the
findings were determined by participants, involved
participants’ validation of the analyzed content,
interpretation, and completeness of each of their
interviews.
Findings
The findings fell within six main themes that
reflected experiences of nine female yogi masters as they
managed their menopausal transition via a yogic lifestyle.
The themes consisted of: perceptions of menopause;
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positive attitudes towards menopause; daily
performance of yoga; healthy food habits; adequate
sleep; and, use of a nature cure as a complement to a yogic
way of life.
Perceptions of menopause: Although six
women did not have menopausal symptoms, three
reported, via the Menopause Rating Scale,33 the
presence of several symptoms related to menopause
(i.e., sweating/flushing, vaginal dryness, irritability,
and sexual problems). Those who experienced
symptoms of menopause perceived their symptoms as
mild and not bothersome as they went about their daily
lives. The three women who dealt with several
symptoms of menopause described their experiences
as follow:
“This year, I experienced some hot flushes.
However, I feel good about it; it reminds me
that I am in the menopausal stage. (However)
my yoga way of life will help me in my transition
with menopause.”(Mrs. A)
“Although I have experienced a decrease in
sexual desire during my menopausal stage and
I get easily irritable with my husband, I realize
and am aware of these changes, so they do not
disturb me.”(Mrs. B)
“My uterus and ovaries were removed several
years ago. I don’t have any experience with
menopausal symptoms. I think it is because
my yoga way (of living) has helped me take
care for my body and mind. This has lead to
a balance in my life and health.” (Ms. C)
Attitudes towards menopause: The subjects
described menopause as a natural life transition that
every woman has to face. All participants reported
positive experiences as they transitioned through
menopause. Their positive attitude and experiences
appeared to facilitate confidence regarding their sense
of well-being. Three of the women described their
attitudes as follows:
87
“My menstruation stopped several years ago,
I didn’t have any ‘vai-tong’ (menopausal)
symptoms like others. I just sometimes felt
down or had a lack of drive. My transition
through this stage of life hasn’t given me any
trouble.” (Mrs. D)
“I entered menopause several years ago,
but I didn’t have the symptoms that others
had, such as hot flushes, night sweats, sleep
disturbances, and so on. One’s attitude toward
life is very important when it comes to dealing
with menopause. Our state of mind makes us
aware of the importance of the changes that
occur in life. Although some symptoms may
happen during menopause, they occur naturally.
I feel…menopausal symptoms should not affect
our quality of life.” (Mrs. E)
“I became post-menopausal ten years ago.
I didn’t have any ‘vai-tong’ (menopausal
symptoms). My menstruation simply disappeared.
I felt good because yoga practice helped me
experience a smooth transition.” (Ms. H)
Daily performance of yoga: All participants
stated that, every morning, they engaged in yoga asanas
(a body position/posture), pranayama (breath
control), meditation, and relaxation. They described
asana in two forms: asana on-a-mat and asana offa-mat. Asana on-a-mat was performance of a yoga
body position/posture either sitting or lying down on
a mat, while asana off-a-mat could take place
anywhere without a mat and involved consciously
uniting the body and mind. Participants performed asana
on-a-mat, each morning, for 15 to 60 minutes. If they
had sufficient time, they performed a variety of basic
body positions/postures and deep relaxation. The
positions they used included the: crocodile (lying on
abdomen with head down, arms bent, and hands placed
under forehead for support); cobra (lying on abdomen,
88
back arched, with arms extended to support head and
torso so they are perpendicular to floor); locust (lying
on abdomen, arms extended along the back, knees bent
with lower legs elevated off floor, and head and chest
hyper-extended off floor); corpse (lying on back,
arms placed on the floor and extended perpendicular
to torso, legs spread apart, and whole body relaxed);
half plough (lying on back, arms extended down, both
legs raised slowly and steadily without support, then
creating angles of 30o, 60o and 90o with the legs, and
then bringing both legs slowly down to the floor);
sitting (sitting with back perpendicular to floor, knees
bent with ankles crossed, and lower part of arms placed
on knees with palms up); head-to-knee (siting with
back perpendicular to the floor, right leg extended, left
knee bent, sole of left foot brought to inner-right thigh,
and torso and head brought down toward the extended
right leg); seated-forward-bend (sitting with back
perpendicular to the floor, legs extended, torso bent
forward from the hips while keeping the spine as
elongated as possible, hands grasping feet, and head
placed on both knees); kneeling (sitting with lower
legs placed under buttocks, back perpendicular to the
floor, and palms placed on knees); yoga-symbol
(sitting with lower legs placed under buttocks, holding
the left wrist with the right palm at the lower back,
then placing the forehead on the floor); spinal-twist
(sitting with spine erect and the right knee bent, left
leg crossed over the right leg, twisting the torso by
bringing the left shoulder towards the bent right knee,
turning further towards the right, and locking the right
knee into the left armpit while keeping the right hand
unbent and near the body); tree (standing erect and
keeping feet together, lifting right leg and bending it
at the knee, placing the sole of the right foot against
the upper left thigh, placing palms of hands together
in front of the torso, and raising both hand up over the
head); wheel (standing with legs apart, hands at the
side of the body, raising the left hand straight over the
head, slowly bending in a semi-circle to the right with
the right hand hanging down, and then repeating the
motion on the left side); and shoulder stand (lying on
shoulders with the head on floor, and torso and legs
extended perpendicular to the floor while using the
arms to support the back). These various poses have
been recommended for facilitation of good health.36
One participant described her practice of yoga as
follows:
“I usually practice a variety of simple poses,
breath control, and meditation that have been
recommended in Kaivalyadhama. When one
regularly practices yoga, the body becomes
balanced. Thus, no suffering from symptoms
occurs.” (Mrs. G)
Since all participants were yogi masters, they
performed additional postures, such as sun-salute
(a specific sequence of yoga postures that are
performed with a particular type of breathing) and
lying-on-stomach-posture (reclining on the floor on
one’s stomach and pulling the legs up and back) when
they taught yoga to others during weekly evening
classes. They believed that when they performed asana,
especially the lying-on-stomach-posture, it affected
the sex organs. As one participant stated:
“When using lying down poses during yoga,
a woman’s ovaries and other organs in the
abdomen get massaged. This improves the
circulation of blood to these organs and their
functioning becomes better.” (Mrs. E)
Four participants mentioned additional postures
they practiced, which included the: butterfly (knees
bent, soles of feet placed together with heels placed
against crotch) and moola-bandha (sitting in a
comfortable position, applying pressure to the perineal
area by contracting muscles of the pelvic floor, and
then following this by relaxation of these muscles).
These postures generally are recommended for
regulating menstruation, facilitating healthy
functioning of the ovaries, improving sex organ
Vol. 17 No. 1
functioning, and having a positive influence on one’s
intellect and memory.37 One participant stated:
“In every yoga class, we perform 12 poses of
the sun-salute and then continue with other
poses. The last thing we do is deep muscle
relaxation. After class we share our experiences
regarding the practice of yoga and ways to
improve our health. All members of our yoga
class are educated, so that helps.” (Mrs. B)
“I always practice the lying- on-stomach-posture
and moola-bandha. These poses help regulate
the sex organs and improve menstruation.”
(Mrs. F)
One participant was not concerned about
postures related to menopause. She believed that every
yoga position/posture of the body helped to balance
all of the body’s hormonal secretions, including the
sex hormones. She expressed:
“I have practiced yoga regularly for twelve
years. I am not concerned about body postures
specific to menopause. During yoga practice,
many organs in my body are massaged, especially
when using lying down poses because they help
to balance the hormones. I always tell my students
that yoga poses help to massage the glands, which
helps them improve. If you do yoga poses as much
as you can, your body will tell you about the
benefits.” (Mrs. E)
Another participant indicated:
“I always practice yoga poses, every morning,
for an hour, using a mat. However, when I don’t have
enough time or I am in a hurry, I perform yoga poses
for at least 15 minutes. When I want to obtain awareness,
I do yoga poses without a mat. I have done yoga for five
years. My health is much better. My colleagues tell me
that because of yoga, I am a calmer person (Jai-yen).”
(Mrs. B)
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Seven participants agreed that doing yoga poses
off-a-mat helped connect body and mind, as well as
improve wisdom and awareness of self. One participant
stated:
“I prefer to practice yoga poses, each day,
off-a-mat. Because of this, I am always aware
of myself during work, as well as while sitting
or walking. My mind and body are always
connected by keeping my senses focused. My
yoga practice helps me to have an inner sense of
relief from any problems before they affect my
physical body. Even now, while I am talking
with you, my mind is awakened and interacting
with my physical body.” (Mrs. A)
Breath control (pranayama) and meditation are
two techniques often performed during the practice of
yoga. Meditation and breath control are thought to help
calm the mind. Four of the participants stated they
practiced meditation, along with breath control for an
hour, every morning and evening. One participant
indicated:
“Usually, I wake up at 4:30 in the morning. I
practice yoga as much as I can, depending upon
my available time. Then, I continue with the
practice of meditation by focusing on breathing
and being aware of my body and mind. I do this
for one hour every day, in the morning, as well
as an hour before going to sleep. I get clarity of
mind before sleeping.” (Mrs. A)
Three participants engaged in meditation every
day, but not at a fixed time. The others practiced
meditation, but not regularly. They felt that if emotions
changed, breathing patterns also changed. Instead,
they practiced concentrating on breathing. Four
participants felt that even after many years of practice,
they still had emotions left in them. Since they were
aware of them, they could release them easily, since
they believed that breath control helped to balance their
emotions. This was reflected by the following
statement:
90
“When my mood changes, I focus on breathing
and then my emotions feel better.” (Mrs. B)
All participants agreed that yoga practice for
health was achieved not only from practicing physical
body poses, breath control, and meditation, but also
by following yama (universal ethics) and niyama
(individual ethics), because they helped to achieve a
positive social attitude and develop self-discipline.
When these became their daily life practices, their
behaviors were modified so as to make them more
pleasant and friendly towards others. In their words:
“Yoga teaches us how to understand ourselves
and other people, especially while we are
working. It teaches us to be patient and diligent
and not to oppress ourselves and other people.”
(Mrs. B)
“Yoga does make me listen to other people. I
do not hate them. I know that my yoga practice
changes my mood and makes me think more
positively about the situation than about the
force of anger. Yoga helps me with my relationship
with friends.” (Mrs. I)
Healthy food habits: Since food is important
for maintaining the physical body sheath, as well as
the mind body sheath, the food habits of participants
were taken into consideration. Although most
participants were non-vegetarians, they consumed
mainly seafood and poultry, while avoiding other
meats. They also consumed a lot of vegetables, fruits,
and brown unpolished rice. They preferred fish because
of being aware of its health benefits. These beliefs were
reflected in such statements as:
“I like to consume fruits and vegetable. I have
vegetables, at every meal. I have a small garden
where I plant several kinds of vegetables that are
free from chemicals. I and my youngest daughter
consume similar food, such as brown unpolished
rice, Ginkgo nuts, and fresh vegetables.” (Mrs. B)
“I noticed that by not eating meat, but eating
a lot of vegetables makes my body light and
helps with excretion of wastes. I have focused
on eating healthy food, which I practiced before
entering menopause.” (Mrs. F)
Only one participant was a total vegetarian and
regularly used soy bean, other soy products, and
mushrooms in her food. All participants preferred soya
milk, tofu, and coconut juice. All of these are sattvic
(pure fresh grains, legumes, vegetables, fruits, nuts,
milk and honey) yogic foods. These types of food are
believed to increase one’s vitality, purity, strength,
cheerfulness, and appetite.38 One participant commented:
“I got fibroids (myoma) and underwent a total
hysterectomy. The doctor prescribed hormone
replacement therapy for me, but I got headaches
from the medication. So I did not take it. I find
that several food items, such as soya milk, tofu,
and coconut juice from young fresh coconuts,
balance my health. I have not had any problems
with my health since then.” (Ms. C)
Adequate sleep: All participants experienced
adequate sleep (average = 6 to 7 hours/night). They
usually went to bed early and woke up early. Upon
awakening, some of them performed yoga, followed
by meditation. Others did yoga and breath control.
These practices were reflected in such comments as:
“Health requires enough sleep. I don’t go to
sleep late at night. Usually, I go to bed between
9 and 10 pm and, automatically, wake up at 4
am. If we don’t have enough sleep, our body
still needs more rest because bio-chemicals
related to sleep are still being produced in the
body.” (Mrs. E)
“I go to sleep early…... some people are envious
of me that I can sleep so well. This causes me
to feel more energetic. I usually get up early,
practice yoga, and then meditate.” (Ms. C)
Vol. 17 No. 1
Sleep is an unconscious state when one is not
aware of his/her surroundings. Adequate sleep is
essential for the maintenance of a healthy body, as well
as a healthy mind. The body restores its energy supply
and makes the necessary repairs to the damaged tissues
during deep sleep. Lack of sleep can leave an individual
feeling tired, listless, and irritable. In the yogic way a
person should go to bed early at night and wake up
early in the morning (i.e., before the sun rises0.38
Use of a nature cure as a complement to a yogic
way of life: Most participants indicated they used a
form of nature cure because they believed nature cures
helped with health promotion, disease prevention, and
curative and restorative actions. Several techniques
were used, such as fasting, detoxification, selection
of the suitable food products, and living in wellventilated houses. All participants were sensitive to the
amount of food they required at each meal. They did
not want to over or under eat.
Fasting for elimination and providing rest to
the digestive system was religiously followed. Shortfasting with certain fruits (i.e., apples, papayas, or
bananas, complimented with coconut juice) was
regularly performed. When three participants felt their
bodies were feeling heavy, they fasted, for one day,
by consuming only coconut juice or plain water. Two
of the participants practiced detoxification, with coffee
or tiliacora triandra (yanang leaf), on a weekly basis,
or when they consumed too much food or unhealthy
food. Another technique used was the selection and
eating of fresh seasonal fruits and vegetables. All of
the participants appeared to live in a natural environment
that provided good ventilation. Two participants
indicated:
“I am a non-vegetarian, but I consume many
fruits and natural food items. I look at several
types of food and the correlation they have with
certain emotions. I also look at how much food
is enough for me, how much food will cause
me to have indigestion and give me a tight
91
feeling in my stomach, and what kind of foods
will keep me happy. I eat many fruits because
they are easily digested and are good for body
cleansing.” (Mrs. E)
“Since I have used yoga as my way of life,
conventional medicine has disappeared totally
from my life. I have done detoxification by not
eating food for a day. However, I still drink
plain water or coconut juice for detoxification.
If I feel sick, such as having a headache or
fever, I sometimes use water from the yanang
leaf, plain water, or my own urine to do enema
detoxification.” (Mrs. A)
Discussion
The yogic masters, who served as participants
in this study, perceived menopause as a natural part of
their life cycle. All of them were well educated, with
most being healthcare professionals. All participants
were well informed about menopausal changes, did
not appear to manifest stress, and maintained a positive
attitude towards menopause. Ayers and associates,39
concluded, in their study, that women with high levels
of education and a strong social support system tend
to maintain a positive attitude toward menopause. Prior
research has revealed that the menopausal syndrome
is effectively alleviated by yoga practice.23, 31 This
factor could help explain why six of the participants
did not indicate the presence of menopausal symptoms.
Vaze and Joshi40 have suggested that through the use
of yoga, a correct diet, and a healthy lifestyle, a
woman, more easily, can manage menopausal
symptoms.
All participants were yogic masters who
regularly practiced yoga. This factor most likely helped
them maintain a high sense of emotional well-being.41
Furthermore, all participants consumed sattvic foods,
which are supposed to improve one’s vitality, purity,
strength, cheerfulness, and appetite.36 Participants
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preferred food items included soya milk, tofu, fresh
vegetables, coconut juice, and brown unpolished rice.
All of these foods provide a rich source of phytoestrogens
that can help mitigate the drop in estrogen concentration
that occurs during menopausal transition.42 Thus, the
trigger for the onset of common symptoms (i.e., hot
flashes, cold sweats, and vaginal dryness) and the
prime organic factor associated with depletion of
female hormones are minimized. A diet high in
phytoestrogen is known to be effective in reducing hot
flashes and improving vaginal mucosal dryness among
post-menopausal women.43
The fact participants had adequate sleep and
engaged in a nature cure appeared to facilitate their
levels of health and decrease the presence of menopausal
symptoms. Adequate sleep is essential for maintenance
of a healthy body and mind. Similar to prior research,44
the fact participants engaged in regular yoga practice
and were long-time yoga practitioners, most likely,
improved the quality of their sleep. Finally, as reflected
in the literature, the participants’ use of various
types of nature cures (i.e., detoxification, fasting, and
living in an open and well-ventilated environment)
appeared to facilitate the promotion of their health
and sense of well-being.38
When applying the findings, the limitations of
the study need to be taken into consideration. First, all
participants were yogic masters from one geographic
location in Thailand, who were highly educated and
primarily health care providers. Thus, generalizability
of the findings is limited to yogic masters who are
similar to those who served as study participants.
Secondly, the sample size was very small. Thus, the
findings do not necessarily reflect the beliefs of all
Thai yogic masters who experience a menopausal
transition. Future research needs to include a larger
number of participants, from various locations
throughout the country, who are representative of a
broader cross-section of Thais. Finally, one has to
assume the participants were truthful regarding their
comments about their personal menopausal transition.
Thus, future research needs to include a variety of
methods for obtaining data (i.e., review of medical
records, video-taping, journal recordings, and
interviews with family members and co-workers) and
not rely, solely, on interviews.
Acknowledgements
The authors wish to thank the Faculty of
Nursing and Graduate School, Prince of Songkla
University, Thailand, and the Thailand Nursing and
Midwifery Council for their financial support of this
research.
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การเปลี่ยนผ่านภาวะหมดประจ�ำเดือนด้วยวิถีโยคะ : ประสบการณ์ของครู
โยคะไทย
ฐปรัตน์ รักษ์ภาณุสิทธิ์, อุไร หัถกิจ, อุมาพร ปุญญโสพรรณ, Amrita Bagga
บทคัดย่อ: การวิจัยเชิงชาติพันธุ์วรรณานี้มีวัตถุประสงค์เพื่อศึกษาประสบการณ์ครูโยคะไทยใน การเปลี่ยนผ่านภาวะการหมดประจำ�เดือนด้วยวิถีโยคะ การคัดเลือกกลุ่มตัวอย่างแบบเฉพาะเจาะจง
เป็นครูโยคะจำ�นวน 9 คน ที่อยู่ในวัยภาวะหมดประจำ�เดือนและกำ�ลังจะหมดประจำ�เดือน เก็บข้อมูล
โดยการสัมภาษณ์เจาะลึกร่วมกับการสัมภาษณ์ทางโทรศัพท์ การสังเกตแบบมีส่วนร่วม และการจด
บันทึกภาคสนาม เพื่อศึกษาประสบการณ์การปฏิบัติโยคะในวิถีชีวิต ในช่วงของการเปลี่ยนผ่านภาวะ
หมดประจำ�เดือน การวิเคราะห์ข้อมูลเชิงเนื้อหาโดยใช้รูปแบบตามแนวคิดของสปราดเล่
ผลการศึกษาพบว่า ครูโยคะรับรู้ภาวะการหมดประจำ�เดือนในระดับความรุนแรงที่ตํ่าและมี
ทัศนะคติที่ดีกับภาวะหมดประจำ�เดือน ซึ่งสามารถก้าวผ่านพ้นไปได้อย่างราบรื่นไม่เกิดความทุกข์ ทรมาณจากอาการภาวะหมดประจำ�เดือน โดยการปฏิบัติตามแนววิถีโยคะ คือการปฏิบัติโยคะอย่าง
สม่ำ�เสมอร่วมกับการรับประทานอาหารสุขภาพ นอนพักผ่อนอย่างเพียงพอ และใช้วิถีโยคะผสมผสาน
กับธรรมชาติบำ�บัด
จากผลการวิจัยครั้งนี้แสดงให้เห็นว่าวิถีโยคะช่วยให้ผู้หญิงวัยกลางคนเปลี่ยนผ่านภาวะหมด
ประจำ�เดือนไปได้ด้วยความราบรื่นไม่เกิดความทุกข์ทรมาณ ซึ่งจะส่งผลไปสู่การมีชีวิตในวัยสูงอายุที่มี
สุขภาวะต่อไป บุคลากรทางด้านสุขภาพควรตระหนักและกระตุ้นให้ผู้หญิงมีทัศนคติที่ดีต่อการหมด
ประจำ�เดือนซึ่งเป็นเหตุการณ์ปกติของชีวิตและนำ�โยคะมาปฏิบัติอย่างสม่ำ�เสมอจนเกิดการตระหนักรู้
ในการดำ�รงชีวิตตั้งแต่เนิ่นๆ
ค�ำส�ำคัญ: การเปลี่ยนผ่านภาวะหมดประจ�ำเดือน, ครูโยคะ, วิถีโยคะ
ติดต่อที่: ฐปรัตน์ รักษ์ภาณุสิทธิ์, RN, PhD (Candidate) หลักสูตรปรัชญาดุษฎี
บัณฑิต สาขาการพยาบาล (หลักสูตรนานาชาติ) คณะพยาบาลศาสตร์ มหาวิทยาลัย
สงขลานครินทร์ อ�ำเภอหาดใหญ่ จังหวัดสงขลา ประเทศไทย
อุไร หัถกิจ, RN, PhD, ผู้ช่วยศาสตราจารย์ คณะพยาบาลศาสตร์ มหาวิทยาลัย
สงขลานครินทร์ อ�ำเภอหาดใหญ่ จังหวัดสงขลา ประเทศไทย
อุมาพร ปุญญโสพรรณ, RN, PhD. ผู้ช่วยศาสตราจารย์ คณะพยาบาลศาสตร์
มหาวิทยาลัยสงขลานครินทร์ อ�ำเภอหาดใหญ่ จังหวัดสงขลา ประเทศไทย
Amrita Bagga, PhD. Professor, Emeritus Fellow, Department of Anthropology,
University of Pune, Pune-411037, India.
Vol. 17 No. 1
95

Pacific Rim Vol 17 No.1

Transcription

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