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  1. 1. Thai Journal of Nursing Research Vol. 6 No. 4 October - December 2002 ISSN-0859-7685 Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Yupapin Sirapo-ngam, RN., DSN. Panwadee Putwatana, RN., D.Sc. Luppana Kitrungroj, MNS. Virat Piratchavet, M.D. Marital Developmental Tasks of Thai Spouses in Childrearing Families Rutja Phuphaibul RN. , D.N.S. Arunsri Tachudhong RN. , M.S. Chuanraudee Kongsaktrakul RN., M.P.H, M.N.S. Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Acharaporn Seeherunwong, Tassana Boontong RN. Ed.D., Siriorn Sindhu RN., D.N.Sc., Tana Nilchaikovit M.D. Chronic Dyspnea Self-Management of Thai Adults with COPD Supaporn Duangpaeng RN, D.N.S. Payom Eusawas RN, Ph.D. Suchittra Laungamornlert RN, DNSc. Saipin Gasemgitvatana RN, D.N.S. Wanapa Sritanyarat RN, Ph.D. Exploring Ethical Dilemmas and Resolutions in Nursing Practice : A Qualitative Study in Southern Thailand Aranya Chaowalit RN. Ph.D. Urai Hatthakit RN. Ph.D. Tasanee Nasae RN. M.Ed. Wandee Suttharangsee RN. Ph.D. Marilyn Parker RN. Ph.D. Concept Analysis: Self-Efficacy Wannipa Asawachaisuwikrom, Ph.D. Spirituality: A Concept Analysis Wanlapa Kunsongkeit RN. MNS.(Medical and Surgical Nursing) Marilyn A. McCubbin RN. Ph.D. FAAN.
  2. 2. Vol. 6 No.2 1 Office : Thailand Nursing Council Nagarindrasri Building, Ministry of Public Health, Tiwanon Rd., Amphur Muang, Nonthaburi 11000 Tel. (02) 9510145-51 Administrative Advisory Board Tassana Boontong RN., Ed.D Wichit Srisuphan RN., Dr. P.H. Editorial Advisory Board Ada Sue Hinshaw RN., Ph.D, FAAN. Barbara B. Germino RN., Ph.D. FAAN. Gail Dû Dramo Melkus RN., Ph.D. Karin Olson RN., Ph.D. Marilyn E. Parker RN., Ph.D. Marjorie Meuke RN., Ph.D. Paula Milone - Nuzzo RN., Ph.D. Editorial Board Editor Somchit Hanucharurnkul RN., Ph.D Assistant Editor Yuwadee Luecha RN., Ed.D Renu Pookboonmee RN., D.N.S. Ampaporn Puavilai RN., Ph.D Editorial Board Jintana Unibhand RN., Ph.D Darunee Rujkorakarn RN., Ed.D Yajai Sithimongkol RN., Ph.D Veena Jirapaet RN., D.N.Sc. Linchong Pothiban RN., D.S.N. Siriporn Chirawatkul RN., Ph.D Orasa Panpakdee RN., DNS. Aranya Chaowalit RN., Ph.D. Prakin Suchaxaya RN., Ph.D Waraporn Chaiyawat RN., D.N.Sc. Warunee Fongkaew RN., Ph.D. Sujitra Tiansawad R.N., D.S.N. Ownership Thailand Nursing Council Administrative Manager Prakin Suchaxaya RN., Ph.D Advertising Manager Saiyoud Siriphaphon RN., B.Sc. Aims and Scope : Thai Journal of Nursing Research is a fully refereed journal that publishes research and methodological papers. All papers are peer - reviewed by at least two researcher expert in the field of the submitted paper. Subscription Rates: Thai Journal of Nursing Research is published four times per year and the prices for 2002 are as follows: Members 300 bahts Non-member: Local 400 bahts Oversea 50 US$ Students 200 bahts Single copy 100 bahts Disclaimer: Thailand Nursing Council and the editors cannot be held responsible for errors or any consequences arising from the use of information contained in this journal; the views and opinions expressed do not necessarily reflect those of The Thailand Nursing council or The Editors, neither does The publication of advertisements constitute any endorsement by The Publisher or the Editors of the products advertised Thai Journal of Nursing Research Vol. 6 No. 4 ë October - December 2002 ISSN-0859-7685
  3. 3. Thai J Nurs Res • April - June 20022 Instructions for Authors The Thai Journal of Nursing Research publishes research and methodological papers. Manuscripts should be sent to the Editors or permanent Secretary of Thailand Nursing council at Nagarindrasri Building, Ministry of Public Health, Tiwanon Rd., Amphur Muang, Nonthaburi 11000, Thailand Manuscripts are accepted for publication in the Thai Journal of Nursing Research on the understanding that the content has not been published or submitted for publication elsewhere, which should be clearly stated in the covering letter. Except where otherwise stated, manuscripts are peer reviewed by two anonymous reviewers. The editorial board reserves the right to refuse any material for publication and advises that authors should retain copies of submitted manuscripts and correspondence, as material cannot be returned. The Editors reserve the right to modify typescripts to eliminate ambiguity and repetition and improve communication between author and reader. If extensive alterations are required, the manuscript will be returned to the author for revision. Papers accepted for publication become the copyright of the journal and all authors will be asked to sign a Transfer of Copyright form. Authors will be required to submit the final version as a hard copy and on disk. Preparation of Manuscripts Manuscripts should follow the style detailed in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, as presented in JAMA 1997; 277:972-34. Or Vancouver system. All submissions should be stylistically consistent. Submission of Manuscripts The original plus two copies must be submitted. Submissions should be typed, double spaced, on one side only of A4 paper. The top, bottom and side margins should be 3 cm. Laser or near-letter quality print is essential. All pages should be numbered consecutively in the top right-hand corner, beginning with the title page. The manuscript should be presented in the following order: title page, abstract and key words, text, acknowledgements, references, table, figure legends and figures. Each of these sections should begin on a separate page. The following guidelines apply to all manuscripts submitted. Title page : The title page should contain the title of the paper, the name(s) of the author(s) and the address of the institution(s) at which the work was carried out. It should also contain a separate list of the qualification(s) and positions held by the author(s), and the full postal address, telephone and facsimile numbers and email address of the author to whom correspondence about the typescript, proofs and requests for off-prints should be sent. The title should be short, informative and contain the major key words. A short running title (less than 40 characters including spaces) should also be provided. Abstract and key words: Submit abstract in duplicate both in English and Thai which must describe the methods used and the principal findings and conclusions of the study. The abstract should not contain abbreviations or references. Up to five key words should be provided to assist with indexing of the article.
  4. 4. Vol. 6 No.2 3 Text: Authors should consider the use of appropriate subheadings to label sections of their manuscript. Acknowledgements: The source of financial grants and the contribution of colleagues or institutions should be acknowledged. References: In the text, references should be made using superscript Arabic numerals in the order in which they appear. If cited only in tables or figure legends, number them according to the first identification of the table or figure in the text. In the reference list, the references should be listed in order of appearance in the text. Cite the names of all authors when there are six or less; when seven or more list only the first three followed by et al. References to unpublished data and personal communications should appear in the text only. References should be listed in the following form: Journal articles 1. Armitage P, Champney-Smit J, Andrews K. primary nursing and the role of the nurse preceptor in changing long-term mental health care : an evaluation. Journal of Advanced Nursing. 1991;16:413-22. 2. Orem DE. Nursing : Concepts of practice. 4th ed. St Louis : Mosby Year Book, 1991. 3. Lockhart CA. Nursingûs future in a shrinking health care system. In Sorensen GE, ed. The Economics of Health Care and Nursing. Atlanta : American Academy of Nursing. 1985:19-29. Tables: Tables should be self-contained and complement, but not duplicate, information contained in the text. Tables should be numbered consecutively in Arabic numerals, with a descriptive title above the table. Column headings should be brief, with units of measurement in parentheses. All abbreviations should be explained in a footnote. Tables should be double spaced and vertical lines should not be used to separate columns. Figure legends: Legends should be self-explanatory and typed on a separate sheet. The legend should incorporate definitions of any symbols used, and all abbreviations and units of measurement should be explained. Figures: Figures must be high-quality black and white photographs, line drawing or laser-printed graphs. Each figure should be on a separate page and labelled on the back (in pencil) with the figure number, orientation (noted with an arrow) and name of first author. Figures should be sized to fit within the column width (70mm) or the full text width (150mm). Figures should be numbered consecutively in Arabic numerals. Written permission to publish must be obtained from any subjects recognizable in photographs. Measurements All measurements must given in metric units. Statistics and measurements should always be given in figures (i.e. 10 mm), except where the number begins a sentence. When a number does not refer to a unit of measurement it is spelt out, except where the number is greater than nine. Abbreviations Abbreviations should be used sparingly and only where they ease the readerûs task by reducting repetition of long technical terms. Initially use the word in full, followed by the abbreviation on parentheses. Thereafter use the abbreviation. Abbreviations such as e.g. and etc. should only be used in parentheses.
  5. 5. Thai J Nurs Res • April - June 20024 Manuscripts on disk Authors are required to provide their manuscripts on disk. Authors should use a new disk rather than a reformatted disk and the disk should contain the relevant file(s) only. Authors should supply their accepted paper as formatted text (most word-processing formats can be handled). It is essential that the hardware and the word processing package are specified on the disk (e.g., MS word for Windows), as well as the first authorûs surname, the Journal title and the manuscript number. The entire article - (i) title page, (ii) text, (iii) acknowledgements, (iv) references, (v) figure legends, (vi) tables and legends, (vii) appendices - should be saved in a single file; only electronic figures should be supplied as separate files. The following instructions should be adhered to. ë It is essential that the final, revised version of the manuscript and the file saved on disk are identical (i.e. authors should supply a new disk if the article is revised). ë Do not use the carriage return (enter) at the end of lines within a paragraph. ë Turn the hyphenation option off. ë Do not use I (ell) for 1 (one), O (upper case oh) for 0 (zero) or B (German esszett) for β (beta). ë Include all figure legends and tables with their legends, if possible. ë Use a tab, not spaces, to separate data points in tables. ë If you use a table editor function, ensure that each data point is contained within a unique cell; do not use carriage returns within cells. ë Complete and return the File Description Form (supplied by the Editorial Office) specifying any special characters used to represent non-keyboard characters. Proofs and offprint Page proofs will be sent to the corresponding author and should be returned to the editorial office within 7 days of receipts. Alterations to text and illustrations are unacceptable at proof stage and authors will be charged for the cost of alterations, other than the correction of typesetting errors. Authors may order offprint with 200 bahts for 10 copies
  6. 6. Thai Journal of Nursing Research Vol. 6 No. 4 October - December 2002 ISSN-0859-7685 Content 163 Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Yupapin Sirapo-ngam, RN., DSN. Panwadee Putwatana, RN., D.Sc. Luppana Kitrungroj, MNS. Virat Piratchavet, M.D. 177 Marital Developmental Tasks of Thai Spouses in Childrearing Families Rutja Phuphaibul RN. , D.N.S. Arunsri Tachudhong RN. , M.S. Chuanraudee Kongsaktrakul RN., M.P.H, M.N.S.** 186 Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Acharaporn Seeherunwong, Tassana Boontong RN. Ed.D., Siriorn Sindhu RN., D.N.Sc., Tana Nilchaikovit M.D. 200 Chronic Dyspnea Self-Management of Thai Adults with COPD Supaporn Duangpaeng RN, D.N.S. Payom Eusawas RN, Ph.D. Suchittra Laungamornlert RN, DNSc. Saipin Gasemgitvatana RN, D.N.S. Wanapa Sritanyarat RN, Ph.D. 216 Exploring Ethical Dilemmas and Resolutions in Nursing Practice: A Qualitative Study in Southern Thailand Aranya Chaowalit RN. Ph.D. Urai Hatthakit RN. Ph.D. Tasanee Nasae RN. M.Ed. Wandee Suttharangsee RN. Ph.D. Marilyn Parker RN. Ph.D. 231 Spirituality: A Concept Analysis Wanlapa Kunsongkeit RN. MNS.(Medical and Surgical Nursing) Marilyn A. McCubbin RN. Ph.D. FAAN. 241 Concept Analysis: Self-Efficacy Wannipa Asawachaisuwikrom, Ph.D.
  7. 7. Yupapin Sirapo-ngam et.al. Vol. 6 No. 4 163 Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Yupapin Sirapo-ngam, RN., DSN.* Panwadee Putwatana, RN., D.Sc.* Luppana Kitrungroj, MNS.** Virat Piratchavet, M.D.*** * Associate Professor, Department of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University. ** Lecturer, Faculty of Nursing, Prince of Songkla University. *** Assistant Professor, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University Abstract: This descriptive study aimed to describe role adaptation and to ascertain the predictive power of severity of side effects, self-esteem, social support, and education on role adaptation of patients with cervical cancer receiving radiation therapy. The Roy Adaptation Model was used as the conceptual framework for the study. Eighty-six patients with cervical cancer receiving radiation therapy were recruited from the outpatient radiotherapy unit of six hospitals in Bangkok during February to June 2000. The inclusion criteria for the sample selected were women who (1) were married and lived with their spouse, (2) had no treatment of radiation or chemotherapy prior to participation in this study, (3) had been receiving radiation therapy for at least a 3-week period, (4) were able to understand, and speak Thai, and (5) agreed to participate in this study. There were five questionnaires used: 1) Demographic and Clinical Data Form, 2) Severity of Side Effects Questionnaire, 3) Rosenberg Self-Esteem Scale, 4) Personal Resource Questionnaire, and 5) Role Adaptation Questionnaire. It was found that patients with cervical cancer receiving radiation had a rather good level of role adaptation. The stepwise multiple regression analysis revealed that the combination of social support, self-esteem, and severity of side effects accounted for 54.8% of the variance in role adaptation of patients with cervical cancer receiving radiation. Education did not significantly account for the variance in role adaptation. The result of this study was congruent with the role function mode within the Roy Adaptation Model. Nurses should be concerned with the influence of social support, self-esteem, and severity of side effects on patientsû role adaptation and keep them in mind when caring of these patients. Future intervention research on role adaptation of patients with cervical cancer receiving radiation therapy should consider these factors. Thai J Nurs Res 2002 ; 6(4) : 163-176 Keywords: role adaptation, cervical cancer, radiation therapy
  8. 8. Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002164 Background and Objectives According to the annual statistical reports of the National Cancer Institute of Thailand from 1994 to 1996,1 cervical cancer was the most prevalent female cancer, with the highest incidence in the middle-aged group (35-60 years). Radiotherapy (RT) is one of the most common treatment modalities for curing cancer of cervix in its initial stages and for reducing complications of the disease in the terminal stages2 (Einhorn, 1996). Although RT has many advantages, it can produce many side effects that impact physical and psychosocial health3-5 . Most women may also undergo major role changes. These include reducing and losing current role tasks and integrating the sick role into their life. Experiencing a major role change or transition to a new role can be a stressful situation. Role changing and the adoption of new roles require the incorporation of new knowledge and standards of behavior for role performances6 . There is also a guarded effort and difficulty for these patients to maintain other existing roles effectively during the course of radiation. This is important because these roles to which women must adapt are often permanent and usually include significant problems for the remainder of their lives7 . These patients need much support from others to adjust to effective role functioning. Social support refers to the psychosocial and tangible aid provided by significant others and/ or social networks8 . It is a major mean of assisting patients to develop greater self-confidence and feelings of autonomy and control in responding to and modifying their environment. A person receives various types of social support including intimacy, opportunities for social integration, opportunities for nurture and reassurance of worth. An availability of informational, emotional, and material supports is also important9 . Many studies have confirmed the importance of social support for chronically ill patients10-13 . Social support enhances adaptive role performance which improves physical recovery, psychological well-being, and social functioning10-13 . Level of education has also been associated with role adaptation. Several studies have shown the positive relationships between educational achievement and role adaptation14-17 . The objectives of this research were to describe role adaptation of patients with cervical cancer receiving radiation therapy and to ascertain the predictive power of severity of side effects, self-esteem, social support, and years of formal education on role adaptation of patients with cervical cancer receiving radiation therapy. The Roy Adaptation Model18 was used as a conceptual framework to study the severity of side effects, self-esteem, social support, and education on role adaptation of cervical cancer patients receiving RT. This study focuses on roles of being a wife, work (inside and outside the home), and the sick role. The focal stimulus was the external alteration produced by the radiation therapy. The stimulus is acted upon by the coping mechanisms through cognator and regulator subsystems. The effects of the cognator and regulator activities are observed in the four modes of adaptation. In this study, the physiological, self-concept, and interdependence modes were deducted from empirical indicators that were severity of side effects,self-esteem,andsocialsupport,respectively. The behavioral responses of these three modes may act as a pooled effect on the fourth mode, the role function mode which reflects role adaptation. The results of this study are important for professional nurses to develop effective nursing interventions that promote role adaptation of patients receiving RT for cervical cancer. Providing interventions focused on support and resources can enhance role performance and in doing so patients can achieve social integrity.
  9. 9. Yupapin Sirapo-ngam et.al. Vol. 6 No. 4 165 Method Subjects and Settings The subjects were patients with cervical cancer receiving radiation therapy who were recruited from the outpatient radiotherapy department of six tertiary care hospitals in Bangkok. Data were collected in a five-month period, February to June 2000. Purposive sampling was used. The inclusion criteria were women who: 1) were married and lived with their spouse, 2) had no prior treatment with radiation or chemotherapy, and 3) had been receiving radiation (3,000 cGy), at least for a 3-week period. Instruments The instruments used for data collection are composed of the 5 following parts: 1. Demographic and Clinical Data Form. This included demographic and clinical data obtained from interviews and medical records. 2. SeverityofSideEffectsQuestionnaire. The severity of side effects questionnaire was developed by the researcher which was based on the Acute Toxicity Criteria of The Radiation Therapy Oncology Group19 , and the literature review. Only the frequent acute complications associated with the major problems of these patients were selected. Thus, the questionnaire was comprised of 10 items, covering skin reaction, food intake, nausea, vomiting, diarrhea, dysuria, frequent urination, fatigue, and emotional alteration. There were four descriptions of severity of side effects ranging from normal/no symptom = 1 to severe/abnormal symptom = 4. Total scores ranged from 10 to 40. The higher the scores, the greater the severity of side effects. The alpha Cronbachûs coefficient of the severity of side effects in this study was .73. 3. Self-Esteem Questionnaire. The researchers used the Rosenberg Self-Esteem (RSE) Scale20 for measuring patientsû self-esteem. The scale contains 10 items; half positive-score items and half negative-score items. The scores of negative items are reversed. Each item was indicated on a 4-point Likert-type scale from strongly disagree to strongly agree. The RSE Scale can yield a score from 10 to 40, with higher scores indicating higher self-esteem. The internal consistency of the RSE scale was tested in this study and gained reliably adequate (Cronbachûs alpha coefficients = .86). 4. Social Support Questionnaire. The Personal Resource Questionnaire 85 (PRQ 85)- Part II was used to measure the adequacy of the individualûs perceived level of social support. This instrument was developed and revised by Brandt and Weinert9 . In this study, the researcher used Soomlekûs questionnaire,21 which was modified from the PRQ 85-Part II. It consists of 21 items on a 5 point-Likert scale including never true = 1, rarely true = 2, somtimes true = 3, often true = 4, and always true = 5. The total scores ranged from 21-105. For the present study, the Cronbachûs alpha coefficient of the PRQ 85-Part II was .86. 5. Role Adaptation Questionnaire. The original role adaptation questionnaire was developed by Ounprasertpong22 for HIV positive and AIDS patients based on role function mode of the Roy Adaptation Model. This questionnaire was used for assessing patientsû ability to perform role behaviors. The questionnaire emphasizes three sub-roles: wife role, work role, and sick role. The Role Adaptation Questionnaire was on a 5-point-Likert scale itemized as follows: never perform =1, rarely perform = 2, sometimes perform =3, often perform = 4, and always perform =5. It contains 28 items including 20 positive items and 8 negative items. Total scores ranged from 28-140. It was found that the reliability as measured by Cronbachûs alpha coefficient in this study was .80.
  10. 10. Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002166 Protection of Human Subjects The rights of the subjects were respected in this study. Eligible subjects were individually approached to participate in the study. The study objectives, the data collection processes, expected research outcomes, subject rights, the type of questionnaires, length of time for completing the questionnaires, and right to refuse to participate in the study were explained. The subjects who agreed to participate were assured that the data would be kept confidential and reported as group data. Data Collection and Data Analysis All eligible subjects who met the criteria were approached and the protection of human subjectûs protocol was explained as previously described. The subjects, who volunteered to participate, read and completed the questionnaires by themselves in the following order: the Demographic and Clinical Data Form, the Severity of Side Effects Questionnaire, the Rosenberg Self-Esteem Scale, the Personal Resource Questionnaire (PRQ-85 part II), and the Role Adaptation Questionnaire. During this procedure, the investigator provided more information and clarification when needed. The researcher read the items on the questionnaires to any participants experiencing difficulty in reading. Reading the questionnaires by the researcher was done to ninety percent of the subjects. The Statistical Package for Social Sciences for Windows Program (SPSS/ FW) version 9.0 was used for data analysis. The predictive powers of severity of side effects, self-esteem, social support, and education on role adaptation of patient with cervical cancer receiving radiation therapy were analyzed using stepwise multiple regression analysis. Results Eighty-six patients participated in the study. The age of cervical cancer patients ranged from 25 to 65 with the mean age of 45.90 years. The majority of the subjects (70.93%) were middle-aged women (36-55 years). Most of the subjects (65.11 %) completed formal primary education. Approximately half of the subjects were housewives and the rest worked outside the home. Around thirty six percent of subjects had family income of less than 5,000 baht per month; the remainder had family income ranging from 5,001 to 90,000 baht. Nearly 47% of families had an income that exceeded their expenses. Most of the subjects (70.93%) were able to reimburse their medical expenses from the government or from their private insurance companies. The majority of the subjects (77.91%) were diagnosed with squamous cell carcinoma of the cervix and approximately 59% were at stage II of the disease. Nearly 70% of the subjects received doses of radiation ranging from 3,001- 4,000 cGy for 16 to 20 days. Based on the range of scores set up for the interpretation, the mean scores of role adaptation (role set score) were listed by each item from highest mean score to lowest in Table 1. The mean scores of role adaptation were 109.52 (S.D. = 11.77, min = 82, max = 132). It can be interpreted that the subjects of this study had levels of çRather Good Role Adaptationé.
  11. 11. Yupapin Sirapo-ngam et.al. Vol. 6 No. 4 167 Table 1.Means, standard deviations, and rank of role adaptation of cervical cancer patients receiving radiation therapy (n= 86) Role Adaptation Mean S.D. Rank Regularly receiving radiation as the physician 4.95 .26 1 prescribed Desiring to replace radiation with other alternative 4.90 .38 2 Treatments Appropriately caring for radiated skin 4.83 .51 3 Taking preserved, spicy, or strong tasting foods 4.67 .69 4 Being discouraged and desiring to discontinue the 4.67 .79 5 treatment Drinking adequate water 4.55 .90 6 Satisfied with my compliance with treatment 4.50 .72 7 regimens Being irritated by fighting with husband 4.31 1.09 8 Wishing to a love and care for my husband 4.19 .94 9 Choosing healthy diet 4.15 .86 10 Regularly taking good perineal care 4.15 .87 11 Sleeping adequately 4.01 1.1 12 Talking and listening to husband 4.00 .89 13 Being anxious but do not apparently express 3.85 1.31 14 Observing abnormal symptoms by myself 3.77 1.03 15 Working intentionally 3.76 1.05 16 Being inert at work 3.73 .95 17 Consulting physicians/nurses concerning health 3.67 1.23 18 problems Being proud of work. 3.66 .95 19 Exchanging experiences/ problems with other 3.57 1.15 20 similar patients Being bored with the trip to the hospital daily 3.57 1.32 21 Being worried about insufficient family care 3.53 1.32 22 Seeking information concerning self-care practices 3.50 1.33 23 Taking care of family expense 3.48 1.83 24 Providing time and being responsible for work 3.30 .90 25 Improving work 3.16 1.02 26 Helping friends who have problems 2.86 1.18 27 Exercising 10-15 minute a day 2.23 1.41 28 Min = 82 , max = 132 total 109.52 11.77
  12. 12. Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002168 As indicated in Table 2, the severity of side effects had a mean score of 19.02 (S.D.= 4.53, skewness = .37). It was found that the subjects tended to perceive a low severity of side effects. In contrary, self-esteem had a mean score of 34.30 (S.D. = 4.46, skewness = -1.13) and social support had a mean score of 84.85 (S.D. = 11.81, .45). So this indicated that the subjects potentially have high self-esteem and perceived high social support. Subjects tended to have a low formal education with a mean of 6.06. Table 2 Ranges, means, standard deviations, and skewness of the severity of side effects, self- esteem, social support, and education (n= 86) Variables Range Mean S.D. Skewness Possible Actual Range Range Severity of side effects 10-40 10- 34 19.02 4.53 .37 Self-Esteem 10-40 18-40 34.30 4.46 -1.13 Social support 21-105 61-105 84.85 11.81 -.45 Education (year) ≥0 0-16 6.06 4.46 1.16 The correlations among predictor variables and role adaptation were computed by using Pearsonûs product moment correlation. The correlation matrix among the studied variables is presented in Table 3. The results revealed that the role adaptation had a significant negative correlation with the severity of side effects (r = -. 43, p < .001). However, it is positively correlated with self-esteem, and social support (r = .52, p < .001; r = .68, p< .001) respectively. There was no significant relationship between role adaptation and education (r= .15, p > .05). In addition, there were significantly low to moderate relationships among predictors. Severity of side effects was significantly and negatively correlated with self-esteem and social support (r = -.28, p < .01; r = -.33, p< .01). Social support was significantly and positively correlated with self-esteem and formal education (r = .48, p < .001; r = .22, p < .05), respectively. Table 3 The correlation matrix of the studied variables (n = 86) Variables 1 2 3 4 5 1.Severity of side effects 1.00 2.Self-esteem -.28** 1.00 3.Social support -.33** .48*** 1.00 4.Education -.01 .09 .22* 1.00 5.Role adaptation -.43*** .52*** .68*** .15 1.00 *** p <.001, ** p < .01, * p < .05
  13. 13. Yupapin Sirapo-ngam et.al. Vol. 6 No. 4 169 Assumptions of regression analysis, which involved considerations of residual scatter plots were examined. The residual scatter plots indicated that the assumptions of regression analysis were met. All pairs of variables had linear correlation. Multicollinearity, diagnosed by having correlations among independent variables greater than .65, was not found. All independent variables had low to moderate correlations with one another (r = - .33 to .48). A Durbin-Watson value was 2.19, which indicated that the regression error had no autocorrelation23 . As shown in Table 4, stepwise multiple regression was used to analyze the predictive power of severity of side effects, self-esteem, social support, to role adaptation. Social support, which had the highest correlation with role adaptation, was first selected in the regression equation. Social support accounted for 46.4 % of the variance in role adaptation (F change 1,84 = 72.66, p < .001). This indicated that a one unit change in social support will cause a 0.51 unit change in role adaptation in the same direction (β = .51, t = 5.89, p < .001). Next, self-esteem was selected, which accounted for an additional 4.9 % of the variance in role adaptation (F change1, 83 = 8.39, p < .01). This indicated that a one unit change in self-esteem will cause a 0.22 unit change in role adaptation in the same direction (β = .22, t = 2.58, p < .05). Severity of side effects was lastly selected into the analysis and accounted for an additional 3.5% of the variance in role adaptation (F change1, 82 = 6.30, p < .05). This indicated that a one unit change in the severity of side effects will cause a 0.20 unit change in role adaptation in the opposite way (β = -.20, t = -2.51, p < .05). The findings indicated that the combination of social support, self-esteem, and severity of side effects significantly accounted for 54.8% of the variance of role adaptation of cervical cancer patients receiving radiation therapy (overall F 3, 82 = 33.11, p < .001). Education did not significantly account for the variance of role adaptation. Therefore, the result of hypothesis testing was partially supported. Table 4 Stepwise multiple regression of role adaptation of cervical cancer patients receiving radiation therapy (n = 86) Predictors RSQ RSQ change F change β t Social support .464 .464 72.66*** .51 5.89*** Self-Esteem .513 .049 8.39** .22 2.58* Severity of .548 .035 6.30* -.20 -2.51* side effects (Overall F 3, 82 = 33.11, p < .001),*** p < .001 ** p <.01 * p < .05
  14. 14. Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002170 Discussion The mean score on role adaptation (role set) was 109.52 which suggested that patients with cervical cancer receiving radiation had levels of çRather Good Role Adaptationû. The overall role adaptation was viewed as the combination of adaptation to three sub-roles including wife, work, and sick roles. However, when considering the ranking of mean scores by each individual item, it was apparent that the seven highest mean scores were in the sick role adaptation (Table 1). This can be explained by the social mechanisms within the role function mode of the RAM24 . It could be reflected that the women with cervical cancer receiving radiation may appraise and set the sick role as the significant priority in setting behavior priorities. The patients may have attempted to integrate the sick role (new role) into their life, while they had many current roles within their role set (i.e., work and wife roles). When their integration processes were challenged, compensatory processes were activated. The women formulated their effective role transition in order to meet the goal of adaptation (i.e.maintain their health and survival) by increasing their adaptation level through cognator processes. They simultaneously delegated their usual tasks to family members or co-workers in order to comply with radiation therapy schedules. Nevertheless, they tended to maintain system balance between roles of being sick, wife and work. The findings from this study support Soompoo and Tongtanunamûs studies17,25 of role adaptation of patients with receiving cancer treatments. In general, patients receiving cancer treatments perform an effective role adaptation or have a good sick role adaptation. However, during the course of treatment, patientsû role adaptation may change. As reported in two studies conducted by Pittayapan26 and Ruankon27 , the results showed that the outcomes of role function and quality of life of patients with cervical cancer in the third and the fifth week of radiation were significantly lower than those outcomes prior to radiation. These studies used a longitudinal design that allowed changes to be collected over time. Therefore, it is not surprising that the findings of these previous studies are not congruent with this present cross-sectional study. Based on their sick role during radiation, the patients should exercise 10-15 minutes a day. The results showed that sixty-three percent of the patients never or rarely exercised. Therefore, the mean score of this item was the lowest (mean = 2.23). It is possible that the patients might believe that household activities were already good exercise. In addition, being fatigued as a result of the side effects of the treatment and daily transportation diminished the desirability of exercise. Graydon, et al.28 also reported that patients who underwent cancer treatments were often suggested to limit their activity and get plenty of rest. In this study, nearly 50% of patients indicated that they were reluctant to exercise because of various reasons. For instance, they were unsure if exercise might be risky for their health. In addition, they rarely received advice from health professionals in this respect. Accordingly, performing exercise was reported to be the greatest self-care deficit in cervical cancer patients undergoing radiation5 . Obviously, additional findings in this study relate to sexual issues. Eight patients addressed sexual and marital conflict. Specifically, they mentioned the inability to have sexual relations with their partner. Some patients said that they could no longer have sex. However, this issue was not able to be explored because it was regarded as an embarrassing issue for the subjects. Thus, the issues of exercise and sexual relationships may add to the important problems where patients tend to have an ineffective role adaptation. Nurses, therefore, should be aware and plan intervention to prevent ineffective role behaviors.
  15. 15. Yupapin Sirapo-ngam et.al. Vol. 6 No. 4 171 The findings indicated that the combination of social support, self-esteem, and severity of side effects significantly accounted for 54.8% of the variance of role adaptation is patients with cervical cancer receiving radiation therapy. Among predictors, social support was the strongest variable influencing role adaptation. The subjects reported that they received social support from various resources such as a spouse or close friends in several ways including intimate relationships and attachment, and instrumental support. Small social groups (i.e., a group of similar patients, neighbors) were potential sources of companionship and services. The work group may provide a sense of belonging, competence, and usefulness for them as well. Additionally, professional guidance is a useful resource. Taken together, it is not surprising that the subjects who participated in this study have adequate and compassionate social support that consequently may (1) give them a sense of self-esteem and personal efficacy, (2) enhance cognitive processing required for effective decision making and problem solving in stressful situations, and (3) reduce negative moods. As a result, social support would enhance cooperation in engaging in effective role performance, and consequently, role adaptation8,13,29-31 . These findings are similar to that of the previous studies in cancer patients receiving treatments12,25,32-34 The significant positive relationship between social support and role adaptation supports the conceptionwithintheRAM18 .Royûsconceptualization of interdependency and two major stimuli influencing role function, i.e., çaccess to facilitiesé and çcooperation or collaborationé was viewed as social support in this study. Thus, the findings support the proposition of the RAM which stated that there are interrelationships among adaptive modes. Specifically, social support, as a factor representing the interdependence mode, which helps modify role behaviors in the role function mode, influences role adaptation in this particular group of patients. Self-esteem was the second predictor influencing role adaptation. There was a positive relationship between self-esteem and role adaptation. It can be explained that self-esteem is an essential factor influencing behaviors leading to personal effective functions. High self-esteem empowers patients to be active participants in care, helps the patients develop confidence in interpersonal communication, and enhances the potential for successful role performance. Thus, patients with high self-esteem feel that they are worth the time and effort needed to maintain and improve health and eagerly take responsibility to meet self-care needs. Conversely, the individual with low self-esteem may be unable to make self-care decisions and assume responsibility for care outcomes35 . Obviously, during radiation, about 50% of the sample received their wages from actual employment. In addition, nearly half of the workers (22 cases) reported that their rela- tionship with friends and co-workers were as usual. The work settings and the support that they received in the work place or social environment possibly produced a positive self-esteem and value in these patients36-37 . In accordance with Uckanit38 , Vichitvatee39 , and Yoswattana40 , self-esteem was significantly and positively correlated with self-care behavior and role adaptation in patients with chronic diseases. Severity of side effects was selected last to enter in the regression equation, and had a negative relationship to role adaptation. It may be explained that the patients may have greater or lesser symptom distress depending on the perception of severity of side effects. According to Roy and Andrews18 , physical and/or emotional well-being affect the individualûs ability to fulfill the role. In this study, all subjects were informed about the disease, possible side effects, and how to deal with the side effects. Moreover, they had obtained information related to self-care practices from several sources. They also had developed strategies such as making appropriate
  16. 16. Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002172 plans for their routine activities, seeking information from similar cancer patients, or asking the physician to treat the side effects that would decrease the impact on their activities. These findings are consistent with the previous studies of Oberst and others4 and Irvine and others41 . These two studies found that symptom distress and fatigue were important factors contributing to the self-care deficit of role performance in cancer patients during chemotherapy or radiation. Similar to the study of Ruankon27 and Pongthavornkamol42 , the patients with cervical cancer receiving radiation who had greater complications of radiation had lower quality of life and more disruptions of function than those who had lesser complications. Also Kawsasri43 found that perception of radiation reactions could explain and accounted for 6.24% of the variance in sick role adaptation of patients with head and neck cancer who were receiving radiation therapy. Year of education was the only one predictor that was not significantly correlated with role adaptation. Possible explanations might be that a high proportion of the sample had a low formal education and received a high degree of support services. Another possible reason could be that most subjects in this present study were relatively homogenous with respect to education. Around 72% of the patients had primary school certificates, whereas only 12.79% of the patients had vocational or undergraduate education. With respect to receiving social support services, patients who had difficulty in reading still received information by listening to the instructions verbatim from their children or other family members. Moreover, the patients most likely received indirect information by talking to other patients, or learning through many other sources (e.g., television, radio, internet document). Receiving adequate information and increasing their understanding regarding their illness and treatments is helpful and may motivate them to express adaptive behaviors. One study has shown that patients who are informed about radiotherapy procedures, possible side effects, and therapeutic effectiveness do not experience disappointment, fear, and anger3 . These findings are similar to the study by Muhlenkamp and Sayle44 and by Kaveevichai45 , which reported that education was not correlated with positive health behaviors and adaptation in healthy adults, and in patients with mastectomy receiving chemotherapy. Education had no correlation with quality of life in a study of patients with cervical cancer receiving radiation46 , and adaptation in patient with head and neck receiving radiation32 . However, the studies by Changphuang14 and Tongtanuman17 found that education was correlated with adaptation or sick role adaptation in patients with mastectomy receiving chemotherapy. In conclusion, the combination of social support, self-esteem, severity of side effects accounted for 54.8% of the variance in role adaptation of patients with cervical cancer receiving radiation. The remaining 45.2 % other influencing factors were not covered in this study and need further investigation. Overall, the research findings were congruent with the RAM and contributed to the advancement of nursing knowledge. Recommendations The results of this study apparently signify the influences of social support, self-esteem, and severity of side effects. Nurses should consider the importance of these factors and keep them in mind when caring of these patients. Enhancing effective adaptation and preventing ineffective adaptation should be the primary focus. In doing so, factors influencing role adaptation should be assessed followed by specific nursing interventions based on the assessment. As the first leading factor influencing role adaptation, social support
  17. 17. Yupapin Sirapo-ngam et.al. Vol. 6 No. 4 173 should be assessed and facilitated. The essential element is the assessment of social support in terms of resource availability (e.g., social networks, financial or economic status, instrumental help), psychological conditions (e.g., sense of love and belonging, self worth), interpersonal relationships (e.g., spouse, family members, friends), and social activities. Interventions may include recognizing, contacting, and inviting significant others (i.e., spouse, children or relatives) to participate in assisting role adaptation of the patient during the course of radiation therapy. Nurses should facilitate formal or informal group support during treatment sessions as well as provide substantial information necessary for enhancing positive adaptation. Self-esteem, another important influencing factor on role adaptation, should be emphasized. Nurses should begin with an assessment of self- esteem to determine the level of the perception of self. Enhancing positive self-esteem is valuable. Nurses, therefore, should identify interventions to promote self-esteem. Family and sexual counseling should be provided to patients with cervical cancer receiving radiation therapy when needed. Although the severity of side effects was shown to be less predictive on role adaptation in this study, controlling the side effects is necessary because it enables the patient to be emotionally comfortable and be able to maintain daily activities. Nurses should regularly assess signs and symptoms indicating the side effects of radiation regularly. Assessment of patientûs knowledge regarding self-care practices to overcome such side effects and to provide required information is also essential. Moreover, a special topic of continuing education relating to role adaptation should be encouraged. This may result in an increase in nursesû awareness of the significance of this social aspect of the patients, consequently improving the quality of nursing care. This project was supported the research grant by the China Medical Board. References 1. National Cancer Institute of Thailand. Annual Report. 1994-1996. 2. Einhorn, N. Cervical Cancer (Cervix Uteri). Acta Oncologica (Supplementum 7) Vol. 2: A Critical Review of the Literature, 1996; 35, 75-80. 3. King,K.B.,Nail,L.M.,Kreamer,K.,Strohl,R.A.&Johnson, J.E. Patientsû descriptions of the experience of receiving radiation therapy. Oncology Nursing Forum, 1985; 12(4), 55-61. 4. Oberst, M. T.,Hughes, S. H.,Chang, A. S. & McCubbin, M.A. Self-care burden, stress appraisal, and mood among persons receiving radiotherapy. Cancer Nursing, 1991; 14(2), 71-78. 5. Teparux, S. Comparative Study the Effectiveness of Two Methods in Promotion of Self-Care on Self-Care Deficit and Radiation Side Effects among Cervical Cancer Patients. Masterûs Thesis in Science (Nursing), Faculty of Graduate Studies, Mahidol University, 1992. 6. Meleis, A. I. Role insufficiency and role supplementation: a conceptual framework. Nursing Research, 1975; 24(40), 264-271. 7. Nuwayhid, K.A. Role Transition, Distance and Conflict. In S.C. Roy & H. A. Andrews (Eds.), The Roy Adaptation Model : The Definitive Statement (pp.364-376). Norwalk: Appleton & Lange, 1991. 8. Tiden, V. P. & Weinert, C. Social Support and the Chronically Ill Individual. Nursing Clinics of North America, 1987; 22(3), 613-620. 9. Brandt PA. & Weinert C. The PRQ- A Social Support Measure. Nursing Research 1981; 30 : 277-280. 10. Cobb S. Social support as a moderator of life stress. Psychosomatic Medicine 1976 ; 38 : 300-314. 11. Gasemgitvatana S. A Causal Model Caregiver Role Stress among Wives of Chronically Ill Patients. A Dissertation of the Requirements for Degree of Doctor of Nursing Science. Faculty of Graduate Studies, Mahidol University, 1994. 12. Hanucharurnkul, S. Predictors of self-care in cancer patients receiving radiotherapy. Cancer Nursing, 1989; 12(1), 21-27. 13. Pender, N. J. Health Promotion in Nursing Practice. 3rd ed. Connecticut: Appleton & Lange, 1996. 14. Changpuang, V. The Relationship Between Perception of Disease, Spouse Support and Adaptation of Breast Cancer Patients. Masterûs Thesis in Science (Nursing), Faculty of Graduate Studies, Mahidol University, 1991.
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  20. 20. Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002176 ªí®®—¬∑’ˇ°’ˬ«¢âÕß°—∫°“√ª√—∫µ—«„π¥â“π∫∑∫“∑Àπâ“∑’Ë¢ÕߺŸâªÉ«¬ ¡–‡√Áߪ“°¡¥≈Ÿ°∑’ˉ¥â√—∫√—ß ’√—°…“ ¬ÿæ“æ‘π »‘√‚æ∏‘Ïß“¡* D.S.N.(Adult Health Nursing) æ√√≥«¥’ æÿ∏«—≤π–* «∑.¥. (‚¿™π»“ µ√å) ≈—æ≥“ °‘®√ÿàß‚√®πå** æ¬.¡. (°“√欓∫“≈ºŸâ„À≠à) «‘√—µπå ‰æ√—™‡«∑¬å*** æ.∫. ∫∑§—¥¬àÕ: °“√«‘®—¬‡™‘ß∫√√¬“¬π’È¡ÿàß»÷°…“ °“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë ·≈–§«“¡ “¡“√∂¢Õß §«“¡√ÿπ·√ߢÕßÕ“°“√¢â“߇§’¬ß §«“¡√Ÿâ ÷°¡’§ÿ≥§à“„πµπ‡Õß ·√ß π—∫ πÿπ∑“ß —ߧ¡ ·≈–°“√»÷°…“ ∑’Ë√à«¡°—π„π∑”𓬰“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë¢ÕߺŸâªÉ«¬¡–‡√Áߪ“°¡¥≈Ÿ°∑’ˉ¥â√—∫√—ß ’√—°…“ ‚¥¬„™â √Ÿª·∫∫°“√ª√—∫µ—«¢Õß√Õ¬ (1991)‡ªìπ°√Õ∫·π«§‘¥ »÷°…“„πºŸâªÉ«¬ 86 §π∑’ˉ¥â√—∫√—ß ’√—°…“·∫∫ ºŸâªÉ«¬πÕ°¢Õß‚√ß欓∫“≈ 6 ·Ààß„π°√ÿ߇∑æ¡À“π§√√–À«à“ß ‡¥◊Õπ°ÿ¡¿“æ—π∏å∂÷߇¥◊Õπ¡‘∂ÿπ“¬π 2543 §—¥‡≈◊Õ°°≈ÿࡵ—«Õ¬à“ß∑’Ë¡’§ÿ≥ ¡∫—µ‘µ“¡∑’Ë°”Àπ¥ §◊Õ ¡’ ∂“π¿“æ ¡√ §Ÿà·≈–Õ“»—¬Õ¬Ÿà°—∫ “¡’ ‰¡à‡§¬ ‰¥â√—∫√—ß ’√—°…“¡“°àÕ𠉥â√—∫√—ß ’√—°…“Õ¬à“ßπâÕ¬ 3,000 cGy.,3  —ª¥“Àå 查·≈–‡¢â“„®¿“…“‰∑¬‰¥â¥’ ·≈–¬‘π¥’‡¢â“√à«¡„π°“√«‘®—¬ ‡°Á∫¢âÕ¡Ÿ≈¥â«¬·∫∫ Õ∫∂“¡ 5 ™ÿ¥ ‰¥â·°à (1) ·∫∫∫—π∑÷°¢âÕ¡Ÿ≈ à«π∫ÿ§§≈ ·≈–¢âÕ¡Ÿ≈∑“ߧ≈‘π‘° (2) §«“¡√ÿπ·√ߢÕßÕ“°“√¢â“߇§’¬ß (3) §«“¡√Ÿâ ÷°¡’§ÿ≥§à“„πµπ‡Õß (4) ·À≈àß ª√–‚¬™πå à«π∫ÿ§§≈ ·≈– (5) °“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë º≈°“√«‘®—¬æ∫«à“ºŸâªÉ«¬‚√§¡–‡√Áߪ“°¡¥≈Ÿ°∑’ˉ¥â√—∫√—ß ’√—°…“ ¡’°“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë ‰¥â§àÕπ¢â“ߥ’°“√«‘‡§√“–Àå¥â«¬ ∂‘µ‘∂¥∂Õ¬æÀÿ§Ÿ≥·∫∫‡™‘ß™—Èπæ∫«à“·√ß π—∫ πÿπ∑“ß —ߧ¡§«“¡√Ÿâ ÷° ¡’§ÿ≥§à“„πµπ‡Õß ·≈–§«“¡√ÿπ·√ߢÕßÕ“°“√¢â“߇§’¬ß  “¡“√∂√à«¡°—πÕ∏‘∫“¬§«“¡·ª√ª√«π¢Õß °“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë¢ÕߺŸâªÉ«¬¡–‡√Áߪ“°¡¥≈Ÿ°∑’ˉ¥â√—∫√—ß ’√—°…“‰¥â√âÕ¬≈– 54.8 °“√»÷°…“ ¢ÕߺŸâªÉ«¬‰¡àæ∫«à“‡ªìπµ—«·ª√∑’Ë¡’π—¬ ”§—≠∑“ß ∂‘µ‘ „π°“√¥Ÿ·≈ºŸâªÉ«¬‚√§¡–‡√Áߪ“°¡¥≈Ÿ° ®÷ߧ«√„Àâ §«“¡ ”§—≠°—∫ªí®®—¬¥â“π·√ß π—∫ πÿπ∑“ß —ߧ¡ °“√‡ÀÁπ§ÿ≥§à“„πµπ‡Õß ·≈–§«“¡√ÿπ·√ߢÕß¿“«– ·∑√°´âÕ𠧔 ”§—≠: °“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë ¡–‡√Áߪ“°¡¥≈Ÿ° √—ß ’√—°…“ * √Õß»“ µ√“®“√¬å ¿“§«‘™“欓∫“≈»“ µ√å §≥–·æ∑¬»“ µ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈ ** Õ“®“√¬å§≥–欓∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å *** ºŸâ™à«¬»“ µ√“®“√¬å ¿“§«‘™“√—ß ’«‘∑¬“ §≥–·æ∑¬»“ µ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈
  21. 21. Rutja Phuphaibul et.al. Vol. 6 No. 4 177 Marital Developmental Tasks of Thai Spouses in Childrearing Families Rutja Phuphaibul RN. , D.N.S.*Arunsri Tachudhong RN. , M.S.** Chuanraudee Kongsaktrakul RN. , M.P.H, M.N.S.** * Associate Professor, Pediatric Nursing Division, Ramathibodi Department and School of Nursing, Mahidol University, Thailand. ** Assistant Professor * Pediatric Nursing Division, Ramathibodi Department and School of Nursing, Mahidol University, Thailand. Abstract: A comparative study was designed to compare the marital developmental tasks of spouses in families with infants, preschoolers, schoolagers, and teenagers. The sample consisted of 2,031 parents in the Bangkok metropolitan area whose first child fell into one of these age groupings. The sample size of each age group was approximately 500. Schools and hospitals were randomly selected to access families with children of various age groups. A questionnaire developed by the researchers was used in data collection. It was comprised of 2 parts , one of which addressed family demographic data and the second addressed marital developmental tasks. The results of the study revealed four major marital developmental tasks including : a) financial tasks, b) family function delegation, c) spousal relationship, and d) relationship with extended family members. In comparing families with children in the various age groupings on marital developmental tasks, the analysis of variance ( F=18.27, p<0.001) showed significant differences. Post hoc analysis (Scheffeûs test) indicated significant differences between families with preschoolers and all other age groupings, and between families with schoolagers and families with infants. The families with infants had the lowest score, and the highest score was in families with preschoolers. There was a decreasing trend in families with schoolagers and further decline in the families with adolescents. Thai J Nurs Res 2002 ; 6(4) : 177-185 Keywords: spouse, family, development task,.
  22. 22. Marital Developmental Tasks of Thai Spouses in Childrearing Families Thai J Nurs Res ë October - December 2002178 Rationale The family provides an important sociocultural context for individual members and represents the basic social subsystem. The structure of Thai families has changed gradually as shown in the survey results of the National Statistic Institution of Thailand. The findings showed a declining family size as well as a changing pattern of marital behavior1 Marital tasks remain essential in all couples during the family development stages. Marital and family relationship shows its impacts on mental health problems of its members2-4 . Pasch and Bradbury studied newly married couplesû participation in 2 interaction tasks : a problem-solving task in which spouses discussed a marital conflict and a social support task in which spouses discussed personal, nonmarital difficulties. The couples who exhibited relatively poor skills in both tasks were at particular risk for marital dysfunction 2 years later5 . From literature review on spousal marital tasks. a number of studies were found that focused on marital relationship in particular stages of family life such as the beginning family, late adulthood and retired couples, and couples who have a chronically ill spouse5-7 . There was no evidence of studies that examined the tasks of spouses in different stages of family life. Normally, Thai couples decided to have offspring after 2-3 years of marriage. The number of children desired has been between 1-2. Alterations in family roles from a couple without children to a family with children of different ages are expected to have an effect on spousal relationships and role sharing. Additionally, child rearing families at present have more dual-career parents. This will certainly add a burden on the nuclear family without child rearing support from relatives. These couples will have to share responsibilities in child care and household work. Thus, family role performances were expected to vary according to the family developmental stages, that are usually defined by the age of the first born child. Family developmental tasks consist of 8: 1) Being an independent family after marriage 2) Generating adequate income 3) Role sharing among members 4) Sexual satisfaction between couple 5) Communicating and relating among members 6) Relating to family relatives 7) Interacting with organizations, groups, and the community 8) Ability to provide care to offspring. 9) Having an appropriate life philosophy Objectives of the study The objectives of the study were to: 1. Examine the marital developmental tasks of spouses in families with infants, preschoolers, schoolagers, and adolescents. 2. Compare the marital developmental tasks of spouses among families with infants, preschoolers, schoolagers, and adolescents. Hypotheses There are significant differences among marital developmental tasks of families with infants, preschoolers, schoolagers, and adolescents. Scope of the Study The study was conducted among families with firstborn children from newborn to 19 years old living in Bangkok, whose children were receiving educational, health care, and child care services in various organizations. Conceptual Framework The conceptual framework of the study was derived from the early work of Duvall in 1977 9 , the researchersû pilot study in 1997, and a literature review that addresses the changing
  23. 23. Rutja Phuphaibul et.al. Vol. 6 No. 4 179 relationship within families according to the period of the family life cycle. Family developmental tasks 9 related to spousal relationships at various child rearing periods have been discussed in the literature. The spousal roles or so called çmarital tasksé, may therefore, be reconceptualized as çmarital developmental tasksé as they would be expected to change as the child grows older. Four dimensions of marital developmental tasks were derived from pilot study data collected by of the researchers with 20 families as followed 1) Generating adequate family income, including financial management within the family. This dimension is referred to as çfinancial taské 2) Sharing family roles between spouses. This dimension is referred as çfamily function delegationé. Child care and housework flexibility are important aspects of this dimension. 3) Maintaining good relationship between the couple, including collaborative problem solving, sharing feelings, sharing leisure time, agreement on family planing, and sexual satisfaction. This dimension is referred as çspousal relationshipé. 4) Maintain good relationship between the couple and relatives. This dimension is referred to as çrelationship with extended family membersé. Definition of Terms 1. Marital developmental task performance is referred as the activities of both husband and wife in maintaining roles, functions, and optional interaction between the couple, family members, and relatives as measured by the questionnaire developed by the researchers. The questionnaire is based on Duvallûs Family Development Theory and the results of a pilot study by the researcher in 1997. A high score indicates good performance. A low score indicates poor performance of marital developmental tasks. 2. Family developmental stage signify periods of the family life cycle which change over time. The child-rearing families in this study were divided into 4 groups according to the age of the first child in the family. 2.1 Family with infant was the family with the first born aged between newborn and 2 and a half years old. 2.2 Family with preschooler was the family with the firstborn aged between 2 and a half years old and 6 years old. 2.3 Family with schoolager was the family with the firstborn aged between 6 and 13 years old. 2.4 Family with adolescent was the family with the firstborn aged between 13 and 19 years old. Literature Review Major concepts of family development theory include the integration of family structural and role functions during discrete time periods. Family structure and function are derived from structural functional theory10 . The interaction between family members was viewed as a semi-closed system which changes thoughout the cycle of family life Duvall described the essence of family development in child-rearing periods as follows 9 : Stage I : Beginning family. This stage starts from marriage through the pregnancy of the first child. During this period, the couple develop their life as a couple and acquire skills in understanding and adjusting to each other. Family planning is essential during this period. Stage II : Family with infant. The main family developmental task here is focused on adjusting to parenting roles and child rearing. Stage III : Family with preschooler. Preparation for school and socialization of the preschool child are emphasized here. The couple might plan to have the second child during this period.
  24. 24. Marital Developmental Tasks of Thai Spouses in Childrearing Families Thai J Nurs Res ë October - December 2002180 Stage IV : Family with schoolager. As the child is able to help himself more, the family focuses on providing educational opportunities and promoting the childûs academic skill. Parentsû role in socialization of the child and the influence of their philosophy of life become more evident. Stage V : Family with adolescent. Parents need to become more flexible in the relationship with their teen children. Teens are gradually allowed to become more responsible for themseleves. Communication between parents and their child is the most essential component of this period. Four family developmental stages have been selected for inclusion in this study (stagesII-V). Family life cycle theory of Carter & McGoldrick 1988 emphasized the expansion and contraction of family boundary and size, in addition to the adjustment in family relationships during the developmental course11 . Families with marital problems have been investigated in Thai couples revealing the need for better understanding of the problem. A study of familyûs problems in 115 couples from the Psychiatric Outpatient Unit, found that most of the clients who asked for assistance were female. The most frequent psychiatric problems were related to marital problem including depression (27%), dysthymia (22.6%), and adaptive disorder (19.1%), The main causes underlying these problems were their spouse having affairs with others (34.8%), psychological neglect (19.1%), inability to love their spouse (10.4%), fear that their spouse would have an affair (7.8%), their spouse not sharing family roles and child care (70%), their spouse being a drug addict (6.0%), their spouse being a gambler (5.2%), problems with relatives of their spouse (3.5%), sexual problems (2.6%), family violence (1.7%), financial problems (0.9%), and decision making power (6.9%)12 . Many studies suggested both positive and adverse impact of the marital relationship on physical and mental problems. Symptoms of depression and sudden cardiac risk in cardiac patients were adverse outcomes reported by Irvine et al.in 19996 . A study in 2000 by Kung and Elkin indicated that the patientûs level of marital adjustment at termination of treatment of depression and the extent of marital improvement over the course of treatment significantly predicted the treatment outcome at follow-up3 . From the review of literature and pilot study, it was evident that family problems derived primarily from difficulties in the spouse relationship dimension. The problems of role sharing, finances, and relationship with relatives were less intense. There has not been a study comparing these tasks during various family stages according to child rearing periods. Therefore, this study was designed to explore the differences in marital task performance among the different child rearing stages. Methodology A descriptive design was used to examine and compare the marital developmental tasks among families with infants, preschoolers, schoolagers, and adolescents. Sample The study sample was comprised of parents in the Bangkok Metropolitan area with the firstborn children in 4 specific age groups, living in the same household. Only parents who were literate and who agreed to participate were included in the study sample. The data were collected from 2,031 parents which included 514 family with infants, 511 families with preschoolers, 506 families with schoolagers, and 500 families with adolescents. The table of random numbers was used for sample selection. Families with infants were selected from 10
  25. 25. Rutja Phuphaibul et.al. Vol. 6 No. 4 181 Bangkok hospitals in the Pediatric Out Patient and Obstetric Out Patient Departments. Families with preschoolers were selected from 6 settings : 2 hospitals, 2 day care centers, and 2 kindergartens. Families with school age children were selected from the following 10 settings : 5 government schools and 5 private schools. Lastly, the adolescentsû families were selected from 10 settings including 8 high schools and 2 University / Colleges. Instruments The instruments used in the study were questionnaires developed by the researchers and consisted of 1) Family demographic data and 2) Marital developmental tasks. Seven experts reviewed the questionnaire for its content validity. The Cronbachûs alpha was 0.82. The marital developmental tasks questionnaire was comprised of 22 items with 5 items on financial tasks, 4 items for family function sharing on delegation, 8 items on spouse relationship, and 5 items on relationship with relatives. The responses were measured on a Likert scale with scores ranging from 1-4 (from çneveré to çalways practiceé) Results The findings showed that the educational level of the majority of the parents was below 10th grade. The majority of the families with infants (52.7%) were living in an extended family structure. In families with preschoolers, schoolagers, and adolescents the proportion of extended family living situations decreased with the increasing age of the first child (49.1%, 38.3%, and 29.3%). (Here would be a good place to comment about how the fact that the majority of the families had more than one child was accounted for in your interpretation of the findings. Do you have data on what the ages of the children were in families with more than one child? I see this as a major confounding variable since a family may have a child in any 2 of the stages if there are 2 children or even 2 in one stage. I realize that developmental theorists base their ideas on the age of the first child, but this makes your research findings difficult to interpret with any confidence.) The majority of the subjects were families with 1-2 children who lived in urban areas. The mean scores in each of the 4 stages were as show in Table 1 and Figure 1. Table 1 and Figure 1 display the variation of subscores in families at different stages. It shows that the marital task score was highest in the preschool group (mean=68.14), while lower scores were found in the school-age group (mean=66.17) and the adolescent group (mean=65.20). The lowest scores were found in the infant group (mean=63.84) Table 1 : Mean of the subscores and total scores of marital developmental task. Tasks Stages (Families with) Total Infant Preschool Schoolage adolescent Scores 1. Finance 15.30 18.07 18.16 18.12 63.84 2. Role / function 12.25 12.79 12.59 12.21 68.14 3. Spouse 24.33 24.01 22.61 22.23 66.17 Relationship 4. Relative 11.96 13.27 12.67 12.64 65.20 Relationship
  26. 26. Marital Developmental Tasks of Thai Spouses in Childrearing Families Thai J Nurs Res ë October - December 2002182 The scores in each stage were then analyzed in order to identify the differences between each stage by comparing the mean differences using ANOVA and Scheffeûs Test. The results in Table 2 and 3 show that there were mean differences among the 4 groups (F=18.30, Figure 1 : Marital developmental Task Scores for families in 4 developmental stages p < 0.001) and there were significant differences in the means between infancy and preschool periods, infant and schoolage periods, schoolage and preschool periods ,and preschool and adolescent periods (p < 0.05). Table 2 : Comparison of mean of marital developmental task scores between families with infants, preschoolers, schoolagers, and adolescents. Source SS MS F p. Between group 5,087.8 1,695.3 18.3 0.000 Within group 187,987.3 92.8 Total 193,073.0 Table 3 : Comparison of the mean score difference between each group using Scheffeûs test. Stages Stages of Families (Mean) Infant Adolescents Schoolage Infant (63.84) Adolescent (65.20) 1.36 Schoolage (66.17) 2.33* 0.97 Preschool(68.14) 4.30* 2.94* 1.97* *P < 0.05
  27. 27. Rutja Phuphaibul et.al. Vol. 6 No. 4 183 Discussion The study findings revealed a variation in marital task performance over the family life cycle from infancy through adolescence. The lowest marital task performance was found during the infant period while the highest was during preschool stage. After the preschool stage, the score again decreased. Possible factors contributing to decreased marital task performance during the infant period include the length of time that the couple has had to develop their relationship and their need to adjust to family life with child rearing. Although the comparing spouse task according to the family life cycle was limited, but when the tasks related to financial task, family function delegation, spousal relationship, and relationship with extended family are not yet well adjusted. Specially when the first child was an infant, the overwhleming tasks caused the interaction between distressed couple to be more negative. It is notably that when measure marital developmental tasks, the indicators are not only the marital relationship, but including other financial and relationship with extended family and so on. Thus, it is not based only on symbolic interaction framework like in many other studies13 , but focused on the different tasks at different developmental stages from developmental perspectives. Family at different stages of development focus on certain tasks that might as well effect the spouse relationship. It is suggestive that there should be further study to examine the relationship between developmental tasks and marital satisfaction. It will combined the family perspectives from both the family structure and functions and the interactionistic worldview. The study showed that the Thai families with adolescents show some difficulties in relation to task performances as evidenced by having the second lowest score on marital task performance. There should be family counseling services available to vulnerable families for adaptation difficulties, particularly at the infant child rearing and families with adolescents. Possible factors contributing to decreased marital task performance duringadolescenceincludedpotentialdisagreements about the degree of independence permitted for the adolescent in terms of sharing leisure time with the family, communicating feelings and collaborative problem solving. Findings from this study suggest that family counseling might best be targeted for families with infants and families with adolescents. Further study is needed to enhance understanding of the vulnerability to family problems during different stages of family development. Reference 1. Limanond P. A Survey of Thai Families. The Institution of Population Studies. Chulalonkorn University, 1996. 2. Gottman J. M. Psychology and the study of marital process. Annual Review of Psychology, 1998 ; 49 : 169-197. 3. Kulik L. Marital relationship in late adulthood : synchronous versus a synchronous couple. International Journal of Aging and Human Development, 2001; 52(4) : 323-339. 4. Margolin G and Gordis E.B. The Effects of family and community violence on Children. Annual Review of Psychology, (2000); 51:445-476. 5. Pasch L.A. and Bradbury T.N. .Social support, conflict, and the development of marital dysfunction. Journal ofConsultationandClinicalPsychology, 1998 ; 66(2): 219-230. 6. Irvine J.I. Basinski A. Baker B. Jandciu S. Paquette A. Cairns J. Connolly S. Roberts R. Gent M. and Dorian P. Depression and risk of sudden cardiac death after acute myocardiac infarction : Testing for the confounding effects of fatigue. Psychosomatic Medicine, 1999 ; 61 : 729-737. 7. Kulik L. Marital relationship in late adulthood : synchronous versus a synchronous couple. International Journal of Aging and Human Development, 2001; 52(4) : 323-339. 8. Rowe G.P. The development of conceptual framework to study the family. In F.I. Nye and F.M. Berardo (ed.) Emerging Conceptual Frameworks Family Analysis. New York:Prager, 1981.
  28. 28. Marital Developmental Tasks of Thai Spouses in Childrearing Families Thai J Nurs Res ë October - December 2002184 9. Duvall E. Marriage and Family Development, 5th edition, Philadelphia: Lippincott, 1977. 10. Friedman M. M.Family Nursing : Theory and Assessment. 2nd edition,New York : Appleton-Century - Croft, 1986. 11. Carter B. and McGoldrick M.The Changing Family Life Cycle : A Framework for Family Therapy. 2nd edition. MA: Allyn and Bacon, 1989. 12. Paholpak S. Marital problem : an analysis of the causes among 115 clinical couples. Thai Medical Archives, 1991; 74 (6) : 311-317. 13. Wampler K.S. and Halverson Jr. C.F. Quaniitative Measurement in Family Research. In P.G. Boss et al. (eds.) Sourcebook of Family Theories and Methods. New York :Prenum Press, 1993 ; 181-194.
  29. 29. Rutja Phuphaibul et.al. Vol. 6 No. 4 185 æ—≤π°‘®¢ÕߧŸà ¡√ „π§√Õ∫§√—«√–¬–‡≈’ȬߥŸ∫ÿµ√ √ÿ®“ ¿Ÿà‰æ∫Ÿ≈¬å RN., D.N.S.* Õ√ÿ≥»√’ ‡µ™— Àß å RN. M.S.** ™◊Ëπƒ¥’ §ß»—°¥‘ϵ√–°Ÿ≈ RN., M.P.H., M.N.S. ∫∑§—¥¬àÕ: °“√»÷°…“‡™‘߇ª√’¬∫‡∑’¬∫§√—Èßπ’ȇªìπ°“√‡ª√’¬∫‡∑’¬∫æ—≤π°‘®¢ÕߧŸà ¡√ „π§√Õ∫§√—« √–¬–‡≈’ȬߥŸ ∫ÿµ√«—¬µà“ßÊ 4 √–¬– ‰¥â·°à√–¬–‡≈’ȬߥŸ∫ÿµ√«—¬∑“√° «—¬°àÕπ‡√’¬π «—¬‡√’¬π ·≈–«—¬√ÿàπ °≈ÿà¡ µ—«Õ¬à“ß ª√–°Õ∫¥â«¬ §Ÿà ¡√  2,031 §√Õ∫§√—«„π‡¢µ°√ÿ߇∑æ¡À“π§√∑’Ë¡’∫ÿµ√§π·√°Õ“¬ÿÕ¬Ÿà„π√–¬– °“√‡≈’ȬߥŸ∑’Ë°”Àπ¥ °≈ÿࡵ—«Õ¬à“ß·µà≈–√–¬–¡’®”π«πª√–¡“≥ 500 √“¬ ‡°Á∫‚¥¬„™â·∫∫ Õ∫∂“¡∑’Ë ºŸâ«‘®—¬ √â“ß„π‚√߇√’¬π·≈–‚√ß欓∫“≈∑’Ë ÿࡇ≈◊Õ°‡æ◊ËÕ„À≥â°≈ÿࡵ—«Õ¬à“ß„π·µà≈–°≈ÿà¡Õ“¬ÿ∫ÿµ√ ·∫∫ Õ∫∂“¡¡’ 2  à«π‰¥â·°à ¢âÕ¡Ÿ≈∑—Ë«‰ª¢Õߧ√Õ∫§√—«·≈–æ—≤π°‘®¢ÕߧŸà ¡√  º≈°“√»÷°…“æ∫«à“ æ—≤π°‘®¢ÕߧŸà ¡√  4 ¥â“π§◊Õ ¥â“π°“√‡ß‘π ¥â“π°“√·∫àßÀπâ“∑’ ¥â“π —¡æ—π∏¿“槟ࠡ√  ¥â“π —¡æ—π∏¿“æ°—∫‡§√◊Õ≠“µ‘ º≈°“√»÷°…“‡¡◊ËÕ«‘‡§√“–À姫“¡·ª√ª√«π‡æ◊ËÕ‡ª√’¬∫‡∑’¬∫§–·ππ æ—≤π°‘®„π·µà≈–°≈ÿà¡ æ∫«à“¡’§«“¡·µ°µà“ßÕ¬à“ß¡’π—¬ ”§—≠ (F=18.27, p<0.01) ‡¡◊ËÕ«‘‡§√“–ÀåµàÕ ‚¥¬ Post hoc analysis (Scheffeûs test) æ∫«à“¡’§«“¡·µ°µà“ß√–À«à“ߧ√Õ∫§√—«∑’ˇ≈’ȬߥŸ∫ÿµ√«—¬°àÕπ ‡√’¬π°—∫°≈ÿà¡Õ◊ËπÊ Õ¬à“ß™—¥‡®π ·≈–æ∫§«“¡·µ°µà“ß√–À«à“ß°≈ÿࡇ≈’ȬߥŸ∫ÿµ√«—¬‡√’¬π°—∫«—¬∑“√° °≈ÿà¡∑’Ë¡’§–·ππµË” ÿ¥§◊Õ §√Õ∫§√—«√–¬–‡≈’ȬߥŸ∫ÿµ√«—¬∑“√° °≈ÿà¡∑’Ë¡’§–·ππ Ÿß ÿ¥§◊Õ §√Õ∫§√—« ‡≈’ȬߥŸ∫ÿµ√«—¬°àÕπ‡√’¬π À≈—ß®“°π—Èπ§–·ππ®–≈¥µË”≈ß„π√–¬–‡≈’ȬߥŸ∫ÿµ√«—¬‡√’¬π ·≈–«—¬√ÿà𠧔 ”§—≠: §Ÿà ¡√  æ—≤π°‘® §√Õ∫§√—« * √Õß»“ µ√“®“√¬å ¿“§«‘™“欓∫“≈»“ µ√å §≥–·æ∑¬»“ µ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ** ºŸâ™à«¬»“ µ√“®“√¬å ¿“§«‘™“欓∫“≈»“ µ√å §≥–·æ∑¬»“ µ√å‚√ß欓∫“≈√“¡“∏‘∫¥’
  30. 30. Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Thai J Nurs Res ë October - December 2002186 Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women* Acharaporn Seeherunwong**, Tassana Boontong***RN. Ed.D., Siriorn Sindhu***RN., D.N.Sc., Tana Nilchaikovit***M.D. * A Dissertation for the Degree of Doctor of Nursing Science, Faculty of Graduate Studies, Mahidol University ** Assistant Professor, Department of Mental Health and Psychiatric Nursing, Faculty of Nursing, Mahidol University *** Dissertation Committee Abstract: Although, somatic treatments can effectively decrease depressive symptoms, the opportunity of full recovery from depression in women is still limited. This study aimed to generate a substantive theory that described and explained how middle-aged Thai women, diagnosed with major depressive disorder, experience and manage the problems in their lives and move from depression toward recovery. The qualitative research method of grounded theory was used. The participants consisted of 31 women who were diagnosed with major depressive disorder in the three medical school hospitals in Bangkok. Building rapport and in-depth interviews were the main methods for data collection. Constant comparison and theoretical sensitivity were the basic analysis methods. The substantive theory entitle çSelf-Regaining from Loss of Self-worth in DepressiveMiddle-agedThaiwomenéwasdiscoveredfromrawdata.çSelf-Regainingé has been found to be a basic social psychological process of recovering from depression. This process consists of 3 phases - Causal condition of depression, Learning about depression, and Recovering from depression. The first phase explains how the women lose their self-worth until they recognize the deviance of their life. The second phase consists of three overlapping sub-phases - Depression self-management, Help seeking, and Contemplation about my self. These sub-phases are strategies that contribute the women regained oneûs self. Finally, the final phase involves Untying the knot and performing Self-growth of which is the positive consequence in the process. By better understanding the process of recovering from depression, nurses and other healthcare providers can develop intervention to facilitate full recovery from depression of middle-aged Thai women. The healthcare policy and education policy can also be implicated with gender sensitivity. Future research also needs to be carried out to derive a formal theory and to expand the scope of knowledge about depression. Thai J Nurs Res 2002 ; 6(4) : 186-199 Keyword: grounded theory study/ middle-aged Thai women/ recovering from depression
  31. 31. Acharaporn Seeherunwong et.al. Vol. 6 No. 4 187 Introduction Women are more than twice as likely as men to experience clinical depression both in the clinic and in the community and in both developed and developing countries.1-4 Also, the number of out-patient Thai women in the year 1999-2000 were double the number of men.5 Moreover, one in four women can expect to develop clinical depression during her lifetime. Clinical depression can occur in any women, regardless of age, race, or income. In addition, it is serious enough to lead to suicide. Middle-aged women are one of the most at risk for depression in a life span. It has been found that 27% of the women aged 40 years and over in Thailand suffer from depression.6 Another research result shows that 13% of middle-aged out-patient women with somatic symptoms at Rachaburi hospital were detected for depression.7 In spite of an effort to decrease the numbers of people with depression, various countries demonstrates that major depression is a chronic, recurrent condition. Between 15% and 20% of patients have symptoms that persist for at least 2 years, and often these patients do not fully recover from depressive episodes.8 Also, the likelihood of an individual who has suffered one episode of depression will experience a second episode is probably greater than 40%.9-10 Furthermore, when a patient experiences a second episode of depression, the probability that he or she will develop a third episode is increased.9 Although, somatic treatment is a great success for recovery from syndromes symptoms, it is not successful for recovery from functional symptoms.11-12 Therefore, the results indicate a need for continued progress in developing optimal treatment strategies for full remission and to maintain long-term recovery. Understanding strategies that the client manages herself/himself toward recovery in their culture and context will be an advantage to complement the knowledge of health care providers to help clients recover from depression. Pluralistic management techniques to decrease the cost of medical treatment which corresponds with the special needs of women in Thai society is also expected to be discovered. However, research about depression in Thailand is very limited. This Knowledge gap regarding recovering from depression is needed to provide base knowledge to understand and provide support for Thai women with depression. As a result, Grounded Theory is a suitable methodology to investigate the phenomenon. The purpose of the study was to generate a substantive theory that described and explained how middle-aged Thai women, diagnosed with major depressive disorder, experience and manage the problems in their lives and move from depression towards recovery. Methods Grounded theory calls for an open approach to data collection rather than adherence to structured procedures. The purpose of data collection is to get as wide as possible in the effort to capture data that pertain to the phenomenon of interest.13-14 In this study, a variety of sources of data were obtained. Middle-aged women who were diagnosed with major depressive disorder were the primary sources of data collection. In-depth interviews were the main method for collecting data. The participants who had delusion or hallucination were excluded. The final participants contained 31 women, range of age from 35 to 63 years (mean=48,SD=8), whose depression experiences varied widely, ranging from two months to thirty years. More than three-quarters of the participants were from Ramathibodi Hospital (n=27). The rest were from Siriraj Hospital and King Chulalongkorn Memorial Hospital. Almost half of the participants
  32. 32. Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Thai J Nurs Res ë October - December 2002188 (n = 15) had a full recovery and 10 of them perceived stable health. Almost all of the participants were Buddhists (n = 27). The rest were Christian and Islamic. The home province of the participants was diverse; they came from every part of Thailand. The majority of the participants grew up in Bangkok (n = 16). Eight participants grew up in the central part of Thailand. However, 23 of them resided in Bangkok and the suburbs during the time of data collection, whereas eight of them resided in the provinces. Moreover, one-quarters of educational background for the participants were a bachelor degree (n=10). Nine had a primary education. Three participants did not attend any school and were unable to read and write. The majority of the participants (n = 10) were housewives. Nine of the participants were government official and six of them were employees. Tape-recorded, open-ended, interactive interviews were conducted with each participant after the informed consent form was signed. The interview began by asking for the symptoms of the interview day and tracing back to the history of their experience with depression from the first moment they realized that something was wrong with them, even if they did not initially define the problem as depression. When asked, çPlease tell me what it is like for you since the beginning of your illnessé at the beginning of the interview, five participants were encouraged to recollect their experience from beginning toward recovery as much as they could. The interview guide was employed as appropriate during the interviews. Gentle probes were also employed to enrich the description of the experience and to maintain the focus of the interview. Interview questions were modified throughout the study according to the emergence of the information to verify hypotheses and concepts. Evidently, discussion of issues related to depression often involves recounting painful and emotionally sensitive experiences. During the interviews, several participants expressed suffered feelings and cried. The interviews were paused and opportunity was given to the participants to express their feelings until they felt better. Before the end of each interview, the researcher made sure that the participants were in a peaceful state of mind, observing their feelings and asked for the feelings they were having at that moment. The researcher and the participants parted only when it was certain that they were emotionally calm. Each interview lasted at least 30 minutes and most ran for well over 21 /2 hours. The average was 112 minutes (S.D. = 48.85). The variation of the time was due to the personality of the participants as well as the richness and complexity of information. For instance, some participants had considerable self-observational skills and analytical skills, so they could describe their experiences in detail. Of the 25 participants, two were interviewed twice to capture the complexity and the richness of the participantsû experiences and to test some hypotheses. For other participants, the interview was conducted only once because they did not come to see the doctor on the appointment date and the researcher could not communicate with them because they lived in a remote province and they moved around, so they could not remember their address. Documents from technical literature and non-technical literature served as the secondary sources of data. Technical literature included research publication and existing theories related to experiences of depression, management, and recovery from depression. Non-technical literature included diaries, biographies, and other materials related to depressive persons in the magazines, or descriptive experience on a television talk-show program. Medical records of the participants, general observations made during interview process and during home visits, and interviews of psychiatrists were also employed as secondary sources. The reason for the use of secondary
  33. 33. Acharaporn Seeherunwong et.al. Vol. 6 No. 4 189 TyingtheKnot TheCenterofMylife NegativeAppraisalof theCenterofMy LifeûsReactions Perceived LossofSelf-Worth UntyingtheKnot -DiscoveringMySelf -RedefinedMySelf& theRelationWithOtherPeople -RestartingMySelf Self-Growth Regaininga NewPerson Figure1:TheSubstantiveTheoryofSelf-RegainingfromLossofSelf-WorthofDepressiveMiddle-AgedThaiWomen. ContemplationaboutMySelf -Self-Awareness -ReappraisalofReaction/Action ofThoseWhoWeretheCenter ofMyLife PhaseI Causalconditionofdepression PhaseII Learningaboutdepression Symptomsof Depression DevastatedSelf DepressionSelf-Management -Tamjai(AcceptingSituation) -DivertingMySelf Recognitionof Depression Recognizing Self-Deviance HelpSeeking -SeekingInformalHelp -SeekingProfessionalHelp PhaseIII Recoveringfromdepression
  34. 34. Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Thai J Nurs Res ë October - December 2002190 sources was to increase theoretical sensitivity and guide questioning for collecting and analyzing data. As the study proceeded, data collection was modified as necessary in order to focus on concepts with relevance to the emerging theory. The data analysis procedure in grounded theory is the tool to generate new concepts and theories from the data in the phenomenon of interest. This analysis follow the Strauss and Corbinûs procedure.12-13 The analysis procedure began after the first interview was transcribed verbatim until the writing of the findings was finished, over one year and three months. Three types of coding (open coding, axial coding, and selective coding), constant comparison, theoretical sampling, and memo writing were used as the main strategies through the established theoretical sensitivity of the researcher. In addition, the trustworthiness of this study was established based on the four criteria of credibility, transferability, dependability, and confirmability. Formal member check technique was employed by having two fully recovered participants to verify the developed theory. The peer debriefing technique was also employed by having two nursing lecturers and members of research committee review analyzed data and findings. Findings The theoretical finding from grounded theory analysis is the çTheory of Self-Regaining from Loss of Self-Worth of Depressive Middle-Aged Thai Womené as shown in Figure 1. This developed theory consists of three phases including : Phase I : Causal condition of depression ; Phase II : Learning about depression ; Phase III : Recovering from depression. Definition of the constructs and concepts and their relationships obtained from the study are proposed. Phase I, ùCausal Condition of Depression:û The findings reveal that ùTying the Knotû is a basic social psychological problem. It is abstracted from the process of interaction between ùThe Center of My Lifeû and ùNegative Appraisal of the Center of My Lifeûs Reactionû lead to a consequence of ùPerceived Loss of Self-Worth.û The more ùPerceived Center of My Life,û the greater ùNegative Appraisal of the Center of My Lifeûs Reaction.û The more ùNegative Appraisal of the Center of My Lifeûs Reaction,û the greater ùPerceived Loss of Self-Worth.û This consequence leads to ùSymptoms of Depressionû abstracted from ùDevastated Self;û that is, the response of perceived Loss of Self-Worth,û until ùRecognition of Depressionû abstracted from ùRecognizing Self-Deviance.û Following, concepts in this phase are described: ùThe Center of My Lifeû referred to a person or a group of people who were important, and of great value for the women, as well as being their source of pride. The centers of these womenûs lives were not static and could be changed by places, times, and events which occurred in their lives. At the same time, the persons who were the centers could come from many sources, depending on which ones were considered more important than the others. The participantsû perception of ùThe Center of My Lifeû was based on Thai social values. The person or the group might be their children, husbands, or other people. As a participant stated: My children are my heart, I would die for them, and whatever might happen to them, I wish it would happen to me instead. ùNegative Appraisal of the Center of My Lifeûs Reactionsû referred to the appraisal of participants who thought that they were treated as unvalued people, had overloaded burdens, and/or had sense of loss resulting from the behavior of the centers of life. Participants sacrificed their energy, ideas and intelligence to their centers of life according to the social beliefs and values to which they had been socialized. At the same time, the participants also expected to

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