International Journal of Human and Health Sciences Vol. 03 No. 04 October’19 196 Original article: Factors Associated with Mothers’ Perceived Quality of Life among Young Children with Pneumonia in Dhaka, Bangladesh Happy Bandana Biswas1, Nujjaree Chaimongkol2, Yunee Pongjaturawit3, Abstract: Objective: This study aimed to examine factors associated with quality of life among young children with pneumonia. A simple random sampling was used to recruit a sample of 100 mothers of young Bangladeshi children with pneumonia admitted in pediatric wards at the Dhaka Medical College Hospital, Dhaka, Bangladesh from January to March 2014. Materials and Methods: Research instruments included a demographic questionnaire, the perceived severity of illness’ scale, the Parenting Stress Index and the quality of life scale for Pneumonia Module. Their reliability were .79, .91 and .77, respectively. Data were an- alyzed by using descriptive statistics, Pearson correlation, independent t-test and one-way ANOVA. Results: Results revealed that mean total score of quality of life of the children with pneumonia was 50.05 (S.D. = 11.11), and at a moderate level. There was a significant relationship between maternal stress and quality of life of pneumonia children (r = -.48, p < .01). However, there was no relationship between perceived severity of illness and quality of life. No significant difference of quality of life of pneumonia children was also found between levels of maternal education and yes/no co-morbidity. Conclusion: These findings indicate that maternal stress is a significant factor. Pediatric nurses and related health care providers should plan and intervene to lessen stress of the mothers, and that would result in increasing quality of life of young children with pneumonia. Keywords: Quality of Life, Pneumonia, Mothers’ Perception, Young Children, Bangladesh Correspondence to: Happy Bandana Biswas, RN, MNSc. Faculty of Child Health Nursing, Na- tional Institute of Advanced Nursing Education and Research (NIANER), Dhaka, Bangladesh. Email: bandana.happy@yahoo.com 1. Happy Bandana Biswas, RN, MNSc. Faculty of Child Health Nursing, National Institute of Ad- vanced Nursing Education and Research (NIANER), Dhaka, Bangladesh. 2. Nujjaree Chaimongkol, RN, PhD. Associate Professor, Dean of Faculty of Nursing, Burapha Uni- versity, Thailand 3. Yunee Pongjaturawit, RN, PhD. Assistant Professor, Faculty of Nursing, Burapha University, Thailand International Journal of Human and Health Sciences Vol. 03 No. 04 October’19 Page : 196-200 DOI: http://dx.doi.org/10.31344/ijhhs.v3i4.102 Introduction Pneumonia is the world’s leading killer of chil- dren under the age of five. One child dies from pneumonia every 15 seconds1. It is an inflamma- tory conditions of the lung-affecting primarily the microscopic air sacs known as alveoli. Each year, pneumonia takes the life of two million children before they reach their fifth birthday. According to the United Nation International Children’s Emer- gency Fund (UNICEF) in 2012 reports, pneumo- nia continues to be the number one killer of chil- dren around the world-causing 18% of all child mortality, an estimated 1.3 million child deaths in 2011 alone2. Only 30 percent of under 5-year-old children with suspected pneumonia are taken to an appropriate health care provider. The mortality rate in this age group under 5 years is estimated to be 0.29 episodes per child-year in developing and 0.05 episodes per child-year in developed coun- tries. Remarkably, Pneumonia is common in Ban- gladesh with significant mortality and morbidity. About 25% of all childhood death occurs in Ban- gladesh, due to pneumonia3. Young children with pneumonia commonly decreased their quality of life (QoL) due to fast breathing, cough, malaise to high fever, loss of appetite, fatigue and chest in 197 International Journal of Human and Health Sciences Vol. 03 No. 04 October’19 drawing at the beginning of their life. Usually at this age, child’s QoL depends upon a mother who always takes care of her child. QoL is an indicator of well-being and contentment of life which was the highest goal of a human being4. Recent stud- ied have shown mothers’ education that means knowledge or perception and level of understand- ing about various aspects of respiratory diseases including signs and symptoms, primary manage- ment and care, immunization and prevention of those respiratory diseases is closely related to QoL among young children. Parvez et al. (2010) also presented in Bangladesh that lower health related quality of life was associated with a lower level of education in household, especially the mother. Relatively, children with more severe illness re- porting lower health related quality of life5. Con- sequently, child’s severity of illness and frequency of illness was a health related factor influencing on maternal stress6. On the other hand, co-morbidity and delay in seeking appropriate treatment are the main risk factors for severe pneumonia7. Pneumo- nia can be managed to improve quality of life, as well as by controlling factors in the environment, education, and close monitoring. In addition, if the QoL is cumulative in the sense that problems in early childhood manifest themselves in adoles- cence and adulthood, then focusing on children’s QoL at an early age may be an effective way of reducing problems later in development. Further, it is typically parents’ perceptions of their chil- dren’s QoL that influences healthcare utilization8. For these reasons, this study aimed to determine association between potential influencing factors, including maternal education, severity of illness, co-morbidity of pneumonia and maternal stress of mother having young children with pneumonia. Findings from this study would be beneficial for nurses and related health care personnel to plan an effective intervention to enhance and promote quality of life of young Bangladeshi children with pneumonia. Materials and Methods: This study was a survey descriptive design. Sample: Two days a week per ward, except Friday, were randomly selected to collect the data in each of 3 pediatric wards at Dhaka Medical College Hospi- tal from January 2014 to March 2014. Inclusion criteria were age of 18 years old or older, able to communicate and reading ability in Bangla language, and the children were admitted for 24 hours or more. Setting: Bangladesh, is approximately 147,570 km2, and in 2013 the population more than150, 039,000 million. The number of children under five years old was 53.6 % of registered. Dhaka is the cap- ital and largest city in center of Bangladesh and the area of Dhaka approximately 815.85 Sq. kilo- meters, and population in Dhaka approximately 7 million. However, for conducting of study about QoL of pneumonia in young children Dhaka med- ical college hospital inpatient department or pedi- atrics ward was selected to be the study settings. The Dhaka Medical College Hospital is the central point of public health services of all the govern- ment hospitals in Bangladesh, there are 2300 bed with 25 departments, 48 units, and 45 wards in- cluding 3 pediatrics wards in this hospital at pres- ent. In addition, there were about 50-70 children with pneumonia who admitted in pediatrics ward monthly. Research Instruments: A demographic questionnaire contained informa- tion about mother’s information, including age and education, and the child’s characteristic, including age, sex and co-morbidity of pneumonia. The per- ceived severity of illness’s scale was a visual an- alogue scale (VAS) developed by Wongcheree et al9. It was used by asking the mother rating with- in the range from none (0) to very severe illness (10). Zero score indicates not being perceived as ill and ten scores indicate being perceived as very severely ill. Moreover, scores between 1-3 was classified as mild, 4-6 scores as moderate, and 7-10 as a severely ill child with pneumonia. The Parenting Stress Index-Short Form (PSI-SF) de- veloped by Abidin10 was used to assess the stress in the parent-child system. It consisted of 36 items with three subscales of parental distress (PD), par- ent-child dysfunctional interaction (P-CDI) and difficult child (DC). The mothers were asked to rate each item of 1-5 response from 1 (strongly agree) to (strongly disagree). Higher scores indi- cate higher level of maternal stress. It was also categorized as low (scores 36 to <84), moderate (scores 84 to <132) and high (scores 132 to <180) level of maternal stress. The quality of life scale for Pneumonia Module was developed by Varni et al11. It was used to measure quality of life of young children specifically with pneumonia by asking the mother to complete. The scale contained a to- tal of 20 items comprising 2 dimensions pneumo- nia symptoms (11 items), and treatment problems (9 items). The mother chose one response among International Journal of Human and Health Sciences Vol. 03 No. 04 October’19 198 five rating scales (0-4) from ‘Never=0’to ‘Almost always=4’. For the ease of interpretability, items were reversed scores and linearly transformed to a 0-100 scale. To reverse answers, transform the 0-4 scale items to 0-100 points as follows: Never = 100, Almost = 75, Sometimes = 50, Often = 25, and then Almost Always = 0, so that higher scores indicate better Quality of Life. All research instru- ments were in English and translated into Bangla by using back-translated method as recommend- ed by Cha et al12. Reliability testing of the instru- ments were .79, .91 and .77, respectively. Data collection procedures: After the proposal was granted ethical approval from the Faculty of Nursing, Burapha University, Institutional Review Board, the letters of asking permission to collect the data by the researcher from the Dean of the Faculty of Nursing, Burapha University was issued to the director of the Dhaka Medical College hospital in Dhaka, Bangladesh. Then, the researcher was obtained the permission from the director of the hospital as well as from nursing superintendent to collect the data. Data were collected at the Dhaka Medical College Hos- pital. Two days a week per 1 of 3 Pediatric wards of the hospital, except Friday as a regular holiday of Bangladesh, were randomly selected to collect the data. After receiving the written consent from the participants, all questionnaires were delivered hand to hand to the participants by the research- er. The participants were asked to complete them and return them directly to the researcher. The re- searcher was available nearby the completion and collection the responses. The researcher was re- view all the data and ask the subjects to make sure whether or not they had completes all responses if there were some missing answers. Then the re- searcher entered the data into the computer for subsequent analyses. Data analyses: Data were analyzed by using a statistical software computer program. The alpha level of significance was set at <.05. Descriptive statistics included fre- quency, percent, mean, standard deviation were utilized to describe the demographic character- istics of the mothers and their young children with pneumonia, quality of life of the children, perceived severity of illness, maternal stress and co-morbidity. Pearson correlation coefficient was used to determine correlation between indepen- dent variables with continuous data (severity of ill- ness and maternal stress) and quality of life among young Bangladeshi children with pneumonia. In- dependent t-test and one-way ANOVA was used to determine the differences between independent variables with categorical data (maternal educa- tion and co-morbidity) and quality of life among young Bangladeshi children with pneumonia. Results Demographic data: Mean age of mothers was 25.0 years (SD = 4.67, range = 18-40). Forty-nine percent of the moth- ers had their education level up to high school, 40.0% had completed up to primary school, and the rest (11.0%) had completed college/university degree. The children with pneumonia were 61.0% for boys and 39.0% for girls. Their mean age was 8.66 months (S.D. = 9.50, range = 1-53). Seventy three % of the children had co-morbidity, and 27% had no co-morbidity of pneumonia. Among those with co-morbidity, there were diarrhea (11.0%), malnutrition (34.0%), vomiting (28.0%), heart disease (10.0%), and others (17.0%). Descriptive data of the children’s quality of life, severity of illness and maternal stress: Mean total score of quality of life for pneumonia scale was 50.05 (S.D. = 11.11, range = 25.00-75.00), and at a moderate level. In addition, it contained to two subscales of pneumonia symptoms with mean score of 55.09 (S.D. = 10.81, range = 27.27- 84.09) and treatment problems with mean score of 43.88 (S.D. = 14.77, range = 11.11-75.00) (Table 1). Table 1: Mean, standard deviation, and range of quality of life, specifically for pneumonia, among young Bangladeshi children (n=100) Quality of life M S.D. range Interpreta- tion Total scores 50.05 11.11 25.00-75.00 Moderate Subscale Pneumonia symptoms 55.09 10.81 27.27-84.09 Moderate Treatment problem 43.88 14.77 11.11-75.00 Moderate The mothers perceived children’s severity of ill- ness with a mean score of 6.58 (S.D. = 2.90, range = 1-10). The mothers perceived that 57.0%, of the children had severely illness, 22.0% had moderate and 21.0% had mild. Mean total score of mater- nal stress was 115.14 (S.D. = 23.03, range = 61- 154). In terms of its subscales, mean score of pa- rental distress (PD) was 35.61 (S.D. = 8.44, range = 19-54), parent-child dysfunctional interaction (P-CDI) was 40.95 (S.D. = 9.55, range = 17-53), and for difficult child (DC) was 38.58 (S.D. = 8.45, 199 International Journal of Human and Health Sciences Vol. 03 No. 04 October’19 range = 17-51). For the level of stress, more than half (62.0%) of the mothers had moderate stress, 24.0% had high stress, and 14.0% had low stress level. Association between the study variables and quality of life among young children with pneu- monia: It was found that there was a negatively signifi- cant relationship between total score of maternal stress and quality of life. When considering each subscale of maternal stress, there were negatively relationships between each subscale of parental distress (PD), parent-child dysfunctional interac- tion (P-CDI), and difficult child (DC) and quality of life (Table 2). Table 2: Relationships between perceived severi- ty of illness, maternal stress, and pneumo- nia quality of life by Pearson correlation coefficient (n = 100) Variable Quality of Life (r) Perceived severity of illness -.08ns Maternal stress -.48** Subscales Parental distress (PD) -.22* Parent-child dysfunc- tional Interaction (P-CDI) -.47** Difficult child (DC) -.56** *p < .05, **p < .01, ns = non-significant (p >.05) There was no significant difference of pneumonia quality of life between yes and no co-morbidity (t = -.119, p > .05). Likewise, it was found that there was no statistical significant difference of pneu- monia quality of life between three educational levels of mother in primary school, high school, and college /university (F2, 97 = 2.60, p >.05). Discussion: Quality of life of pneumonia children and in over- all, symptoms and treatment problems were at moderate level, which were acceptable. It could be explained that mothers could monitor the changes for her child’s health status or in detecting respons- es to treatment. It could be also explained that in this study that the mother was concerned more during admitted in the hospital. The study results showed that there was a negatively significant re- lationship between mean total score of maternal stress and quality of life which was similar to find- ings by Cummings et al13, Laurvick et al14 and Ya- mada et al15. They reported that mothers in the high stress group perceived their children’s disability as being more severe than the mothers in low stress group and contributed to perceptions of high quali- ty of life scores for child’s illness. In regard of con- sidering each aspect of parenting stress subscales, the PD subscale incorporates the mother’s percep- tion of their child rearing abilities, availability of social support and restrictions in their other life roles15. The mother of this study feel more stress which could be because most of the children were infants (74.0%) and unable to speak or tell about their problem regarding to infant development, but crying. Therefore, the mothers might feel more stress to carry on her young children with this con- dition. The P-CDI subscale assessed the mother’s perception of whether the child meets their expec- tations and the interactions with her child that not reinforcing to her as a mother15. Lastly, the DC subscale focused on the mother’s perception of their child behavior and temperament, which make them difficult to manage15. Limitations: In regard to study limitations, all of this study measures were based on mothers self-report. Therefore, the researcher cannot rule out potential biases because of social desirability or faulty rec- ollection. The present study was conducted during winter season in Bangladesh, which was the peck time for respiratory infection especially for the children. Recommendations: Intervention studies to improve quality of life of Bangladeshi children under 5-year-old with pneu- monia need to be further study. It is also import- ant to focus both generic and disease specific of quality of life, then it will be easier to relate the factors which are affected their growth and de- velopmental status due to disease conditions. In addition, research in specific age of children, for example, infant, toddler, or preschooler will be clearer to determine the children quality of life. Comparing settings between government and non-government hospitals would also be of in- terest. Pediatric nurses, especially who are taking care of the hospitalized children, need encourage and provide more information to the mother with supportive educative nursing system to prevent maternal stress as well as to improve quality of care versus quality of life among under 5-year-old children with pneumonia. Acknowledgements: The authors would like to thanks Faculty of Nurs- ing, Burapha University, Thailand, Dhaka Medi- cal College Hospital, Dhaka, Bangladesh and all participants who made this study possible. International Journal of Human and Health Sciences Vol. 03 No. 04 October’19 200 References: 1. World Health Organization (WHO). Pneumonia fact sheet: Pneumonia the forgotten killer. 2010. Re- trieved June 15, 2013, from: URL: http://www.who. int/ media Centre/factsheets/fs 331 /en / index.html 2. United Nation International Children Emergency Fund (UNICEF). Pneumonia progress report, Inter- national Vaccine Access Center (IVAC), 2012; 1-7 3. Parvez, M. M., Wiroonpanich, and Naphapunsakul. The effects of educational program on child care knowledge and behaviors of mothers of children un- der five years with pneumonia. Bangladesh Journal of Medical Science. 2010; 9:136-142 4. Varni, J. W., Seid, M., and Rode, C. A. 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