Thai Journal of Nursing Research Vol 13 No 3 Jul 92974

Vol.13No.
3July-September2009ISSN0859-7685
EDITORS: Clinton E. Lambert, PhD, RN, CS, FAAN
Vickie A. Lambert, DNSc, RN, FAAN
Somchit Hanucharurnkul, PhD, RN
Aim and Scope: The Thai Journal of Nursing Research is an English language, refereed (peer-reviewed),
quarterly publication for nursing research, literature review and conceptual analysis papers.
AssistantEditor: Manee Arpanantikul, PhD, RN
EditorialBoardMembers:
Thailand
Ampaporn Puavilai, PhD, RN Aranya Chaowalit, PhD, RN
Jintana Yunibhand, PhD, RN Jiraporn Kespichayawattana, PhD, RN
Linchong Pothiban, DSN, RN Orasa Punpakdee, PhD, RN
Rutja Phuphaibul, DNS, RN Saipin Gasemkitvattana, DNS, RN
Siriporn Chirawatkul, PhD, RN Sophen Choonuan, PhD, RN
Sukunya Parisunyakul, PhD, RN Susanha Yimyam, PhD, RN
Tipaporn Wonghongkul, PhD, RN Veena Jirapaet, DNSc, RN
Wanapa Sritanyarat, PhD, RN Wandee Suttharangsee, PhD, RN
Wantana Maneesriwongul, DNSc, RN Warunee Fongkaew, PhD, RN
Wongchan Petpichetchian, PhD, RN Yajai Sithimongkol, PhD, RN
USA
Carol Loveland-Cherry, PhD, RN, FAAN Gail D Dramo Melkus, PhD, RN
Marjorie Meuke, PhD, RN Karin Olson, PhD, RN
Marilyn E. Parker, PhD, RN, FAAN
AdministrativeManager: Kanniga Punyaarmonwat, MA, RN
AdvertisingManager: Suchin Vichitkran, MS, RN
Ownership: Thailand Nursing and Midwifery Council
Nagarindrasri Building, Ministry of Public Health,
Tiwanon Rd., Amphur Muang, Nonthaburi 11000
Telephone: (02) 9510145-51
SubscriptionRates:
The subscription rates for the journal are:
Members of Thai Nursing and Midwifery Council: 300 Baht
Non-members: In Thailand: 400 Baht
Outside Thailand: 50 USD
Students: 200 Baht
Individual issue: 100 Baht
Disclaimer: The Thailand Nursing and Midwifery Council and the Editors of the Thai Journal of Nursing Research
are not to be held liable for errors or any consequences arising from use of information contained herein. The views
and opinions expressed, as well as the advertisements do not necessarily reflect those of the Editors or the Thailand
Nursing and Midwifery Council, and are not to be considered an endorsement by the Editors, the Publisher or
the Thailand Nursing and Midwifery Council.
Thai Journal of Nursing Research
Vol.13No.3 July-September2009ISSN0859-7685
Content
159 Environment for Scholarship and Journal Impact Factor in Thailand
Shak Ketefian, Somchit Hanucharurnkul
167 Quality of Diabetes Care in PCUs in Central Thailand
Rukchanok Koshakri, Nantawon Suwonnaroop, Kobkul Phancharoenworakul, Chanvit Tharathep,
Noel Chrisman
181 Relationship among Maternal Depressive Symptoms, Gender Differences
and Depressive Symptoms in Thai Adolescents
Nopporn Vongsirimas, Yajai Sitthimongkol, Linda S. Beeber, Nonglak Wiratchai, Sopin Sangon
199 Cognitive Performance after a Transient Ischemic Attack: Attention, Working Memory,
and Learning and Memory
Vishuda Charoenkitkarn, Saipin Kasemkitwattana, Barbara Therrien, Orapan Thosingha,
Thavatchai Vorapongsathorn
216 Participative Model of Child Protection in Northern Thailand
Naruemon Auemaneekul, Wilawan Senaratana, Yuwayong Juntarawijit, Kasara Sripichyakan,
Barbara J. Ensign
227 Buddhist Mothers Experience of Suffering and Healing After
the Accidental Death of a Child
Kallaya Wiriya, Urai Hatthakit, Wantanee Wiroonpanich, Lee Smith-Battle
Editorial : Writing an Appropriate Methods Section for a
Research Article: Design, Ethical Considerations and Sample

o... ... ,.... .... .+...._ ..... ......,.. . .... ...+ . ....... ,.... ...
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. +... ... . .. ... ..,...... ... ......... ... .... . .. ... .. ... ......., ..+
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i. _....... the method section, of a research article, needs to contain the following elements:
design, ethical considerations, sample, procedure, instruments or measurements, and data analysis.
r... . .... ...... ... .. +....+. ... ... ... . ... . ... Thai Journal of Nursing
Research. i. ... .... we will focus on what needs to be included in the: design, ethical consid-
erations and sample components of the method section of a research article.
Design: .. +.._. .,.... . ... ...+ ..... ...+ . ......, ..+..... ... .,,. .
+.._. . ..+ .. ... ..+, r. ..,... .. ... ..+, . qualitative .. ....... ... ..... ...+
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It is essential for the author to clearly identify what research design was used, in his/her
study. This is necessary so the reader will be prepared for what to expect in the procedure
component of the method section of the research article.
Ethical considerations: v....... .... . ..... ..,... ... ..+. .. . ..+,. .......
...+...... ... ......+ s.... . ....._ ..+.. .. .... ..,.... ...... .... .....
..,.... . ... .++.. .., ethical considerations related to human subjects. The author must
indicate that consent to engage in a study was obtained from his/her institution (i.e. university,
hospital, or clinic). i. . ....... ... ... .... ... ..... .. ......+ .,,..... . _.....
+.... .. ... ......... u... ....... c..... i. .++..... +.,..+.._ .,. ... .......
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...... It is essential that the author indicate that approval to gather data was granted, both
by the researchers institution and by each research site, prior to any form of data gathering.
In addition to indicating approval was obtained from the researchers institution and each
of the data gathering sites, the author is required to indicate that consent, either verbal or
written, was obtained from each research subject, prior to his/her involvement. i. .++..... ...
..... .. .... .... .... ..,... . .....+ . ... ....._ the purpose of the study; what
would be involved, if the subject agreed to become part of the study; how much of the subjects
time would be required in order to participate in the study; his/her confidentiality and
anonymity would be maintained; and, that he/she could withdraw, from the study, at any time,
without negative repercussions.
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respective parents signed a consent form granting approval for their children to participate i.
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....+ . ,......,.... .. . ..+,. ... ....+ ., .. ... . .. ......+ ... the author must
indicate whether children, who are old enough to understand, signed an assent form, in addition
to their respective parents signing a consent form.
Sample: i. ... ....... ........ ... ..... ...+ . ,...+. . .,........ +....,... . ...
..+, .,... ... ...+.. ..... ... ....... ...+.._. ..., .... . ...._. ..+.....+.._
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i....... .... ... .,.. .... .. .. .++...+ .....+. who was studied; how the
subjects were identified and contacted; the location of the subjects; the subjects inclusion
criteria; how many subjects were involved in the study; how many subjects either dropped out of
the study or were excluded from the study; information about why subjects dropped out or were
excluded; the characteristics of the subjects (age, education, income, gender, information
specific to the study, etc.); and how many (number and percentage) subjects were in each
characteristic category .. .,.. ............. ., ..., _....., +.,..+.._ .,. ... ...... ..+
... . ... ..+, The sample characteristics can be put either into a table format or described
in the narrative of the article. u..... the narrative and the table should not repeat the same
information, since doing so is redundant.
Summary: .. +.._.. ....... ...+...... ..+ .,.. .,.... . ... ...+ ..... .
. ....... ....... ... .., . . ... .,..... ...... .... . ......+ u...._ ... +....,.+
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...+ . .. .++...+ .. ... ,...+.... ........ . ......... ..+ +... ....,. .,....
. ... ...+ ..... . . ....... ....... Authors need to recognize that the likelihood of
having their manuscript accepted for publication is enhanced if ALL parts of the research
article are well written and thoroughly developed.
We, as editors of the Thai Journal of Nursing Research, look forward to you submitting
your research manuscripts for consideration for publication in the Thai Journal of Nursing
Research.

Vickie A. Lambert, DNSc, RN, FAAN
Clinton E. Lambert, PhD, RN, CS, FAAN

159

Shak Ketefian and Somchit Hanucharurnkul

Vol. 13 No. 3

EnvironmentforScholarshipandJournalImpactFactorinThailand
Shak Ketefian, Somchit Hanucharurnkul
Abstract: An increasing number of institutions, internationally, are requiring their
faculties publish in journals with high impact factors (IF), and providing various types
of rewards to motivate scholars to do so. The literature describes appropriate and
inappropriate uses of such policies. Thus, this study, as part of a five country study,
aimed to explore, in Thailand: (a) the extent to which institutions are requiring faculty
to publish in high impact journals, and (b) how the pressure of publishing in high
impact journals influences a nurse scientists choice of topic for investigation, and the
development of nursing science. The design was qualitative, using a questionnaire
designed to obtain respondent views. One senior faculty member, from each of the
seven nursing doctoral programs in the country, was invited to participate; five did
so. Objective responses were summarized and descriptively presented. Content
analysis was used for narrative responses.
Results indicate that faculties were expected to publish in high IF journals. The
faculties stated this led to: competition instead of cooperation; and, authors wanting
to publish in journals of other countries, so as to bring prestige to their institutions.
However, they felt this does not contribute to resolving health problems of the
country, and further enumerated the hurdles and positive outcomes of the policy.
They said Thai scholars study health problems of the country, and frame the practical
applications of their work, in terms that might be of interest to their country, as well
as to other countries. Results were discussed and interpreted in view of current
realities in Thailand.
Thai J Nurs Res 2009; 13(3) 159 - 166
Keywords: Impact factor uses; Nursing science; Publications; Scholarship, Thailand
Background Information
Institutions of higher learning, throughout
the world, are seeking to improve their offerings,
research, and standing nationally and internationally.
This has led to competition and search for
objective measures to assess quality of various
aspects of their educational programs, especially as
it relates to the output of faculty, in the form of
their publications. The development of bibliometric
measures, such as the impact factor (IF), which is
Correspondence to: Shak ketefian, EdD, RN, FAAN Profess
or and Director of International Affairs University of Michigan,
School of Nursing, 400 North Ingalls, Ann Arbor, MI 48109,
USA. E-mail: ketefian@umich.edu
Somchit Hanucharurnkul, PhD, RN, Professor, Department of
Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University,
Bangkok, Thailand.
intended as a measure of a journals impact; and
citation analysis, which is the number of times a
scientific article is cited by others,
1
have spurred
the interest of academicians, and are being used for
a variety of purposes.
160
Environment for Scholarship and Journal Impact Factor in Thailand
Thai J Nurs Res July - September 2009
Some universities are requiring faculty
members to publish in high IF journals; using
rewards, such as cash bonuses, to spur faculty
members in this regard; and are using bibliometric
measures in faculty hiring and promotion
decisions.
2
Despite caution having been expressed
about unintended uses of such measures, institutions
of higher learning are using them in making
individual faculty decisions, such as in: hiring and
promotion; institutional rankings; determination of
research funding to individuals and/or institutions/
departments; and, national priority setting.
3
Some
authors have decried this tendency.
2, 3

Professionals often have complained that the
peer review process does not take into account the
social utility of published papers, while those who
practice, and provide services to the public,
recognize that social relevance is a major concern.
4

In addition, the way a journals IF is used, as a
measure of the quality of an individuals article, or
of a scholars body of work, has raised concern
among some scholars. For example, an investigation
of the predictive validity of journals IF scores, in
the hiring and promotion decisions of social work
faculty, was found to have a low effect, and led
the researchers to conclude their findings did not
justify using journal IF scores in hiring and
promotion decisions.
5

The relationship between the quality elements
of journal articles, and the frequency of citations of
articles in four psychiatric journals, was found to
have an IF of 0.88 - 11.2, over a 9-year period.
6

Quality features, such as: statistical errors; reporting
of sample size; poorly reported research questions;
and, the primary outcome of the study, were found
not to be related to the citation counts. However,
some of the quality features were related to the
visibility and prestige of the journal (in this case, two
of the four journals with high IF scores). The
investigators concluded the latter findings were due
to detailed author guidelines and rigorous peer
reviews, which are characteristic of high IF
journals.
6

The Thai Journal Citation Index Centre
created a national system for evaluating journals
published within the country.
7
This evaluation is
conducted yearly, with national and international
journals being ranked according to established
criteria. The Thai Commission of Higher Education
provides funding for journals which are highly
ranked, as well as national journals which are
determined to have the potential to improve their
quality to meet the criteria to become international
journals. In order for a journal, published in Thailand,
to be classified as an international journal, it must:
be published in English; be listed in an international
data base; have at least 25% of its editorial board
comprised of scholars from other countries; have at
least 25% of the authors of papers published in the
journal be from outside Thailand; and, have 25%
of its reviewers for each issue be experts from
outside Thailand. On the other hand, in order to
be classified as a national journal: 25% of a
journals editorial board members must have the
academic rank of professor or have a doctoral
degree; 25% of the published papers, in each issue
of the journal, must be from outside the institution
that publishes the journal; and, 50% of the reviewers
for each issue must be from outside the institution
that publishes the journal. At present one Thai
nursing journal is classified, based on the established
criteria, as an international journal.
7
Thailand was selected as one of the
countries for this study, due to the emphasis it
places, as a result of governmental and institutional
policies, on academicians having articles published
in a high IF journal. It is important to study the
effects such policies have on the work of scholars
who conduct research, as well as to address the
broader question of how such policies influence the
production and direction of nursing science.
161
Vol. 13 No. 3

Research Questions
Many countries face similar situations as
Thailand, yet there have been no studies in nursing
that address how the behavior of scholars is
affected, or more importantly, how constraints
imposed by national or institutional policies affect
the development of nursing science. This
investigation, as part of a five country study, aimed
to address this vacuum in our understanding. Thus,
the research questions investigated were:
1. To what extent are selected institutions
in Thailand requiring their faculties to
publish in high impact factor journals?
2. How do the pressures to publish in high
impact factor journals, influence the behavior
of individual nurse scientists, choice of
topic for investigation and development
of nursing science?
Method
A descriptive inquiry, using a qualitative
survey design, was conducted regarding: the extent
to which journals impact factors are used in
Thailand as the venue for faculty publications; the
purposes for which such information is used; how
selected nurse scholars perceive the consequences
of prevailing practices; and, how their perceptions
regarding the consequences of prevailing practices
influence various decisions.
Study subjects. Five senior academic nurses,
one from five of the seven institutions of higher
learning which offer doctoral degrees in nursing in
Thailand, participated. A key informant provided
country-specific information regarding the institutional
ratings, or rankings, as well as identified senior
faculty to be solicited to participate. The key
informant was a senior academic, holding the rank
of professor in a major university, who has held
offices in professional organizations over many
years, and had overall familiarity with nursing
programs in the country, as well as being familiar
with nurse leaders. The respondents held the rank
of professor or associate professor and, due to their
faculty rank, were familiar with their respective
institutions policies and the state of nursing
science in Thailand, had taught in doctoral programs,
and had published in international journals. To
obtain the respondents, one potential participant,
who met the selection criteria, from each of the
seven nursing doctoral programs, in Thailand, was
invited to participate.
Procedure. Institutional Review Board (IRB)
approval was obtained from the institution of the
first author. Due to the low risk posed by the
study, the IRB required that a letter, with the
elements of informed consent, for information only,
instead of a signed consent form, be provided to all
potential respondents. Seven identified individuals,
one from each doctoral program, were invited to
participate through an approved letter, which
provided relevant information about the study and
included all elements of informed consent. Once
individuals agreed to participate, they received the
questionnaire and were asked to return it within
three weeks. All communication occurred electronically.
Several reminder letters were sent over an eight
week period, which resulted in five responses
being received.
Study instrument. A survey questionnaire,
containing 21 items, was developed by the investigators,
based on review of the literature, for use in the
collection of data regarding the extent and purposes
for which institutions and systems in Thailand
make use of the impact factor of journals in which
faculty members have published. The questionnaire
further sought to explore the ramifications and
effects the use of the impact factor of journals have
on individual scholars and the development of
nursing science.
A draft of the questionnaire was reviewed
162
by four individuals from five countries, for clarity
and relevance of the items to the study questions.
These individuals were senior faculty in research
universities, who also served as journal editors in
their countries. Revisions of items were made,
based upon the reviewers comments; thus, the
questionnaire had content validity. Eleven questions
presented a list of statements as options, five asked
for yes/no responses to be checked, followed by a
request for comments. The comments section
was provided to enable respondents to explain and
shed light on their choices. Five questions required
narrative responses. It was estimated that it would
take 30-40 minutes to complete the questionnaire.
Data Analysis. Data were analyzed via
content analysis and descriptive statistics, through
the use of frequencies. The participants objective
responses were summarized and described. For
comments and narrative responses, content analysis,
established by Wilson,
8
was used to elicit meaning
from the text and identify categories that emerged.
Wilson
8
established three basic elements of
content analysis: (1) deciding on the unit of
analysis; (2) borrowing or developing the set of
categories; and, (3) developing rationale and
illustrations to guide coding of data into categories.
Deciding on the unit of analysis means a decision
needs to be made whether the whole response, or a
breakdown of responses into separate words, phrases,
or sentences, will be used. Borrowing the set of
categories means a set of categories can be developed
before data collection, if the concepts are borrowed
from existing theory; data can be coded using the
pre-identified categories. In this study, the set of
categories, for the content analysis, were borrowed,
as they were primarily derived from the questions
asked in the questionnaire. Developing rationale
and illustrations to guide coding of data into
categories means in order to code data into
categories, the investigator has to make a judgment
on the right category for every response or unit of
analysis.
8(p470)
The analysis process was done manually.
Many respondents provided the same answers to
questions pertaining to citation counts as they did
for impact factor. To avoid redundancy, the
authors have not focused on citation counts.
Results
Results were described and organized around
categories relevant to the studys questions. The
bracketed numbers refer to the number of
respondents who checked each respective statement.
Context: All respondents agreed that the
concept of journal metrics, in the form of
expectation that faculty publish in high impact
factor (IF) journals and achieve high citation
counts for their publications (citation counts are
the basis for computation of IF), was in use in
Thailand. Further, the respondents indicated these
practices were promulgated and used by the
Ministry of Education and university administrators.
Other government agencies also were mentioned as
using such information, especially those concerned
with research funding and quality assurance of
universities. However, respondents did not indicate
nursing schools required their faculties to publish
in high IF journals. The five respondents indicated
several uses of information on publication in high
IF journals, including: assurance of the institutions
high ranking in national/international surveys [5];
measurement of individual faculty productivity [5];
measurement of collective faculty productivity [4];
measurement of a journals quality [4]; and,
measurement of overall quality of a department or
school [3]. In addition, faculty publication in journals
with a high IF served as the basis for obtaining
funding for a faculty members doctoral students.
How scholars behavior is influenced by the
existing policy: Respondents were queried on their
views regarding the extent to which the policy, on
163
Vol. 13 No. 3

requiring publication in high IF journals, influenced
the behavior and decisions of scholars. The
respondents stated there was strong competition,
among colleges, to be published in high IF journals
[4]. Such pressure leads most scholars to publish
in journals from other countries, rather than their
own [4], and to publish in high quality journals,
regardless of a journals IF [2].
The respondents were queried further on
their perspective of publishing in national versus
international journals. They indicated that those
who publish: nationally are addressing domestic
health problems [4]; internationally add prestige to
their institutions and country [4]; internationally
are not providing the country the benefit of the
researchers findings [3]; and, in high IF journals
focus on problems of interest to those journals,
rather than on the interest of the country [3].
The effects of the existing policy and
perceived hurdles: Respondents were asked to
provide their views on the effects of the existing
policy to publish in high IF journals, and seemed
to agreed: graduate schools have improved research
training overall [5]; there is greater methodological
rigor seen in research [4]; and, published works
have become stronger in their theoretical grounding
[3]. Hurdles mentioned were: insufficient English
language skills [5]; topics that interest scientists
are not of interest to some journals [5]; and, those
who attended graduate school overseas are more
successful in publishing internationally [5]. Also
mentioned were that: English-speaking authors and
English language journals, as well as authors from
disciplines outside of nursing, do not cite Thai
nursing authors work; computation of IF does not
take into account various forms of scientific
publications; the emphasis on the IF can have the
effect of suppressing the pursuit of innovative
research directions that could be culturally relevant;
and, there are too many ways to raise a journals
IF, making it an artificial measure.
Perceptions of nursing science in Thailand:
Respondents were asked to assess the current
published works in Thailand. They stated that they:
are responsive to health needs of the country [5];
frame the practical application of their work in
terms of the health problems of the country [5];
involve replication of work done elsewhere to
determine the relevance and applicability to local
needs [5]; present research that is of interest to the
investigators, but not of value to the local
population [4]; and, frame the practical application
of their work, in terms of health problems of
interest, to other regions of the world [3].
Efforts to internationalize Thai journals:
Respondents provided information that Thailand
has clear criteria that must be met prior to a journal
being considered to be national or international.
They stated: international members have been
appointed to Thai journal manuscript review panels
[5]; scholars in Thailand have accepted positions
as assistant/associate editors, or members of
review panels, for journals in other countries [4];
and, these steps have changed the profile of Thai
journals, by strengthening their quality.
Discussion and Recommendations
Respondents generally had a good understanding
of what was being asked. They were able to
describe advantages and disadvantages regarding
the use of IF. However, they identified more
disadvantages regarding the use of IF to them, and
to nursing, than they did advantages. All indicated
that no Thai journals currently were listed in the
Web of Science (WoS), or had an IF assigned. At
present only one Thai journal, the Thai Journal of
Nursing Research, is considered international by
the criteria established by the Thai Journal Citation
Index Centre.
The respondents stated IF computations are
biased heavily toward English language journals.
164
This criticism appears justified when one reads the
publications of various disciplines in the country.
All agreed Thai university administrators
place a high degree of emphasis on faculty
publications for academic rank, prestige and
funding decisions. However, it is puzzling that
they did not feel that nursing schools placed the
same degree of emphasis on faculty publications,
compared to government and university administrators.
While faculty members, from the basic sciences
and medicine, have international publications, the
respondents stated that Thai nursing faculty do not
have international publications and are unfamiliar
with the requirements of international journals.
These statements are puzzling since many Thai
nurse scientists have studied, at the graduate level,
in English-speaking countries, and have been
socialized in the matter of publishing internationally.
Given the availability of electronic websites, where
author guidelines are available for the various
journals, it is a puzzle as to why nurse faculty
would not familiarize themselves with manuscript
requirements of international journals.
The constraints faculty members face, in
their efforts to conduct research and achieve
publication, need to be recognized. The first
constraint is the fact that faculty do not have
support systems to facilitate their scholarship, and
must do their own secretarial work. The second
constraint is the nursing shortage, in Thailand, has
lead to the enrollment of larger numbers of
students, which has increased the faculty workload.
Finally, the teaching of some masters level
specialties are offered only on weekends, leaving
faculty little time for scholarly activities.
A number of other findings were similar to
those found in the literature.
4, 9, 10
For example,
respondents indicated there are important disciplinary
variations that are not accounted for in the
computation of IF. They felt these computations
needed to be standardized, so that meaningful
comparisons can be made. Respondents also
pointed out that the IF does not measure the
quality of individual articles, but simply indicates
journal status. Therefore, to make a generalization
about an individual article from the overall journal
status, is a misuse of the IF score, and can lead to
erroneous conclusions about a specific article. The
respondents also noted that the IF does not address
the value of the research for patient care and
application to real world problem solutions, a
critical consideration in nursing.
Respondents noted the trend toward publication
in high IF journals can lead to research that is
more responsive to models, paradigms and themes
valued in other countries. Such a research focus
may or may not contribute to solutions of local
health care problems; whereas those who publish
locally contribute to solving health problems of the
country. However, we do not know to what extent
this is the case, as no examples were provided.
Thailand currently does not have any
journals listed in the WoS, nor with an IF
assignment. All of the respondents were in favor of
international efforts, now under way, to increase
the listing of Thai journals in the WoS, but it is
not clear whether the respective editors of the
journals are submitting applications to have their
journal so listed. The respondents felt such listing
would bring about a wider dissemination of Thai
research to those in other countries, as well as to
members of other disciplines.
Anecdotally obtained information revealed
that many schools of nursing, in Thailand, publish
their own journals, typically with local or national
circulation. Some of them do not meet the criteria
to be considered a national journal, and none meet
the established criteria for international journals.
However, there are eight journals, in Thailand, that
meet national standards, and one that meets
international standards, although it is not listed in
the WoS, nor has an IF assignment.
165
Vol. 13 No. 3

From the reported data, it can be concluded
a great deal of nursing research is being carried
out, but only is published locally. Local publications
do not have international visibility, and, thus, have
limited impact beyond the country. Respondents
mentioned that nurse and non-nurse scholars in
other countries do not cite Thai nurses published
works. One of the reasons for this is that scholars
outside of Thailand often do not have access to
local or national Thai publications. It is suggested,
therefore, that schools of nursing, in Thailand,
consolidate their energies and resources, and
jointly publish fewer journals of high quality, with
a view to establishing international reputations for
the journals.
Thai universities have, for a long time,
emphasized the importance of having graduate
students, especially those enrolled in doctoral
programs, attain competence in the English
language, regardless of whether the students are
studying within the country or overseas. The
reason is that much of the advanced literature
students need to access, for their work, is published
in English. The fact that some researchers lack of
sufficient English language skills, gets in the way
of publishing in international journals, remains
unclear. This factor requires future examination.
Limitations
This study has several limitations. The first
is that the questionnaire presented options to
check, and, thus, was a recognition task, rather
than a generation task, with ideas derived from
the literature. It is possible the respondents task
was made easier, in that they could check an item
if it appealed to them, whether or not they knew it
to be true. In addition, it is not clear whether the
same ideas would have emerged had the participants
been asked to generate the ideas, rather than
recognize them.
Two other limitations were the qualitative/
descriptive design and the small sample size.
Neither of these factors enabled the use of
statistical procedures or provided a basis for
generalizations. Therefore, if deans and faculties
wish to better understand the phenomenon examined
in this study, it will be necessary to design a study
that has a national scope.
References
1. Meho LI. The rise and rise of citation analysis. Physics
World. 2007; 20: 32-6.
2. Monastersky R. The number thats devouring science.
Chron High Educ. 2005; 52(8): A12.
3. Campanario JM, Gonzales L, Rodriguez C. Structure of
impact factor of academic journals in the field of
education and educational psychology: Citations from
editorial board members. Scientometrics. 2006; 69(1):
37-56.
4. Freshwater D. Impact factors and relevance of research
outputs: One step forward, two back? J Psychiat Ment
Health Nurs. 2006; 13: 473-4.
5. Holden G, Rosenberg G, Barker K, Onghena P. An
assessment of the predictive validity of impact factor
scores: Implications for academic employment decisions
in social work. Res Soc Work Pract. 2006; 16(6):
613-24.
6. Nieminen P, Carpenter J, Rucker G, Schumacher M.
The relationship between quality of research and citation
frequency. BMC Med Res Methodol. 2006; 6: 42-9.
7. Thai Journal Citation Index Centre [updated 2008
November 10; cited 2009 April 28]. Available from:
http://www.kmutt.ac.th/jif/publichtmcriteria.htm. (in
Thai).
8. Wilson HS. Research in nursing. 2
nd
ed. New York
(NY): Addison-Wesley Publishing Co.; 1989.
9. Smith, R. Measuring the social impact of research;
difficult but necessary. BMJ. 2001, 323: 328.
10. Smith, R. Commentary: The power of the unrelenting
impact factor is it a force for good or harm? Int J
Epidemiol. 2006, 35: 1129-30.

166

Shak Ketefian,

:
(Impack facter)

5 1)
2)

7 1
5

2009; 13(3) 159 - 166
:

:Shakketefian, EdD, RN, FAAN Professor and Director of

International Affairs University of Michigan, School of Nursing,
400 North ingalls, Ann Arbor, MI 48109, USA. E-mail:
ketefian@unich.edu
, RN, PhD,

167
Rukchanok Koshakri et al.
Vol. 13 No. 3

QualityofDiabetesCareinPCUsinCentralThailand
Rukchanok Koshakri, Nantawon Suwonnaroop, Kobkul Phancharoenworakul, Chanvit Tharathep,
Noel Chrisman
Abstract: This descriptive study, using a mixed method design, sought to describe,
within Central Thailand, the quality of diabetes care in terms of the structure of
Primary Care Units (PCUs), care processes for diabetics and outcomes of diabetic
care; and the relationships among these factors. Three hundred health care providers
from 300 PCUs completed a researcher-designed questionnaire which sought
information regarding the structure and care processes, used in the PCUs, with
diabetics. Outcomes of diabetic care were assessed using fasting plasma glucose
reports obtained from the PCUs. In addition, 9 care providers, who completed the
questionnaire, served as key informants, for in-depth interviews, which validated and
further explained the quantitative data. Quantitative data were analyzed using
descriptive statistics and Pearsons product moment correlation, while qualitative data
were examined by way of content analysis.
Almost one-quarter of the PCUs met all components of structure, based upon
PCU standards. Results revealed the structure of most PCUs were sufficient in terms
of facility, financing and networking. Although the majority of staff consisted of
nurses, the PCUs were considered insufficiently staffed, and 825 demonstrated
improper preventive care. However, 43% of the diabetics, being cared for in the
PCUs, showed sound glycemic control.
Good PCU structure suggested an increase in the likelihood of appropriate
care processes and corresponding positive outcomes. In addition, the presence of
well- trained health volunteers provided assistance to the PCU staff, particularly when
professional staffing levels were low. Thus, a need for an increase in the number of
professional staff in PCUs, enhanced training for health care volunteers and revision
of the standards of diabetic care was evident.
Thai J Nurs Res 2009; 13(3) 167 - 180
Keywords: quality of diabetes care, primary care units, Thailand
Background and Significance of
the Problem
Diabetes mellitus represents a significant
public health problem in Thailand, with a
prevalence rate ranking three times higher than the
global average.
1
In 2000, the prevalence of
diabetes, among Thai adults, was reported to be
Correspondenceto:RukchanokKoshakri, RN, PhD Candidate, Faculty
of Nursing, Mahidol University, Thailand. E-mail:rukchanok. koshakri@
gmail.com
Nantawon Suwonnaroop, RN, PhD, Assistant Professor, Faculty of
Nursing, Mahidol University, Thailand.
Kobkul Phancharoenworakul, RN, PhD, Associate Professor, Faculty
of Nursing, Mahidol University, Thailand.
Chanvit Tharathep, MD, FRCST, Bureau of Health Service System
Development, Ministry of Public Health, Nonthaburi, Thailand.
Noel Chrisman, PhD, Professor, School of Nursing, University of
Washington, USA.

168
Quality of Diabetes Care in PCUs in Central Thailand


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

While evidence suggests 38% of diabetics attending
PCUs have glycemic control,
3
the glycemic control
rates at PCUs, in Central Thailand, were found to
be 29.5 %.
4
In addition to enhancing significant factors
that improve diabetic health, the organizational
structure of the health care system has been found
to be a major contributing factor in good diabetes
management.
3
As a result of the reform of
Thailands health care system, emphasis has been
placed on the quality of primary health care
delivery, including the care of diabetics. Using the
guidelines established by the Thai National Health
Plan of 2008, the PCUs have focused on quality
of care.
5
Nurses play a major role in providing
individuals with diabetes quality health care,
including: service delivery, health promotion,
health prevention, and coordination and continuity
of care. All these factors serve as indicators of the
delivery of quality care.
Factors that reflect the quality of care for
diabetics can be grouped into the categories of:
organizational structure; processes of care; and, care
outcomes. Previous studies, regarding organizational
structure, have found that finance,
6, 7
human
resources,
8, 9
equipment
10
and networks
11, 12
positively
influence the process of care. Adherence to guidelines
for diabetes management, in terms of processes of
care, also has been found to improve the outcome
of care,
13, 14
while continuity of care has been
shown to be associated with higher glycemic
control rates.
15, 16
In addition, evidence suggests
that coordination, such as referrals, is positively
associated with care outcomes of individuals with
diabetes.
17

Organizational structure, processes of care
and care outcomes also have been identified as key
factors in quality of care.
18, 19
Since most studies have
been conducted in Western countries, the quality
and outcome of the care, in response to these
standards, remains unclear in Central Thailand.
Thus, the purpose of this study was to describe the
quality of diabetes care in terms of the structure of
PCUs, care processes for diabetics and outcomes of
diabetic care, as well as to determine the relationships
among these factors, in Central Thailand.
Method
Design: The study was descriptive in nature,
using both quantitative and qualitative methods,
undertaken within two phases. In Phase I, the
quantitative portion of the study, the primary
researcher obtained data by way of a structured
questionnaire, regarding the PCUs structure,
diabetes care processes and diabetes care outcomes.
In addition, 6-month fasting plasma glucose
(FPG) reports of patients receiving care in the
participating PCUs were obtained. Phase II, the
qualitative portion of the study, involved in-depth
interviews of 9 health care providers, each from a
different PCU, who were selected from the survey
sample and represented varying degrees of experience.
The interviews were conducted in an effort to extend
an understanding of the diabetes care phenomena.
Instruments: The quality of diabetes care
was assessed by way of a, 85 item, researcher-
designed questionnaire based on the: standards set
forth for Primary Care Units;
20
Standards and
Indicators for Setting up PCUs;
21
and, Diabetes
Care Guidelines for Practitioners in PCUs.
22
The 3
part questionnaire sought information regarding the
PCUs: (a) staff demographics and reports on
169
Vol. 13 No. 3

participating patients FPG; (b) structure; and, (c)

diabetes care processes. Part one of the
questionnaire consisted of 15 items, which sought
general information about the demographics of
participating PCUs, as well as their monthly
reports of patient FPGs. Examples of questions
were: What kind of PCU is this? and, How
many diabetics visit the clinic daily?
Part two of the questionnaire consisted of
30 items, which requested information about the
structure of the facilities, as well as the financial,
staffing and networking aspects of the PCUs.
Examples of questions included: Does your PCU
have a glucose test machine? and, Have you
received up to date diabetes mellitus training?
Forty items, in part three of the questionnaire,
sought data regarding the PCUs diabetes care
process, specifically service delivery, continuity of
care and coordination. Examples of questions were:
How many times did you visit people with
diabetes at their home last year? and, Does the
PCU have a counseling system?
Consideration was given to the format of the
questionnaire to ensure that it was user-friendly
and easy to complete. A check list was used in
Parts I and II. The items which represented the
standard level of performance were rated as 1,
while items failing to met the standard were rated
as 0. A Likert-like scale was used in Part III.
Items which were positively stated were rated as 1
for strongly agree and 5 for strongly disagree.
Items which were negatively stated were rated as 5
for strongly agree and 1 for strongly disagree.
The researcher developed an interview
guide, after the quantitative data were gathered, to
obtain in-depth qualitative information about: how
health care providers administered diabetes care;
provision of services: continuity of diabetes care in
the past year: and, what things were needed to
provide quality care. The interview guide consisted
of five open-ended questions, including: How do
you provide care for a diabetes patient?; What
are the barriers to providing good diabetes care?;
How do you manage such problems;? and, If
you could change everything, what would you
want to change in order to improve the quality of
diabetes care?
Seven experts in PCUs diabetes care and
research were asked to review the questionnaire
and interview guidelines for validity, understanding
and practicality. Sixty-eight of the 85 items were
considered valid; however, some wording was
refined to make the questions more practical.
Seventeen of the 85 items were deleted.
Once the questionnaire was finalized, a pilot
study was conducted, using 20 health care
providers working in a PCU, for the purpose of
testing the questionnaires reliability and face validity.
Participants were selected from health care providers
who had a main responsibility in diabetes care in
PCUs, in Central Thailand, which were not part of
the study sample. Subjects, in the pilot study, were
asked to assess comprehensibility of the wording of
each item and determine which aspect of diabetes
care quality was being measured by each item.
Based upon the results, item wording was adjusted
and similar items were placed under the specific
factors being measured, in each of the three parts
of the questionnaire.
The refined questionnaire consisted of 68
items. Part I consisted of 13 items regarding general
information; while Part II consisted of 22 items
regarding finance, facility, staffing and networking.
The 33 items that made up Part III assessed service
delivery, continuity of care and coordination. All
items in the interview guidelines were justified as
being valid. The content validity index (S-CVI) of
the questionnaire was found to be 0.97, while the
reliability, using Cronbachs alpha, was 0.86.
Interpretation of the content, from the in-depth
interviews, was validated with individuals who
took part in the interview process.
170


Sample: The sample consisted of employees
of PCUs in Central Thailand. The PCUs were
randomly selected, using two stage cluster sampling.
Inclusion criterion were: being an employee who
worked in a PCU, managed by the Minister of
Public Health (MOPH), and providing care to
individuals with diabetes. Since the National
Health Security Office divided the area of Central
Thailand into 6 zones,
23
the steps of the two-stage
sampling involved the following: 1) randomly
selecting a province from each zone; 2) randomly
selecting 50 PCUs from each selected province;
and, 3) identifying employees, at each selected
PCU, to serve as respondents, to the questionnaire,
for their respective PCU.
Using Yamanes formula,
24
a sample size of
295 participants was considered adequate for
completing the questionnaire. However, to assure an
adequate return rate, 325 questionnaires were distributed.
Three hundred, usable, questionnaires were return,
for a return rate of 92.3%.
The majority (n = 251, 83.7%) were female
with an average age of 36 years. Nearly all (n = 245,
81.7%) had a bachelors degree in nursing or
public health. Most (n = 289, 96.3%) reported
the structure of their PCU had been developed
from the health posts to meet MOPH standards,
while only 3.7% (n = 11) of the PCUs were
newly established within a hospital. An average of
64 diabetics were registered in each of the PCUs,
with a range of 2 to 575 (SD =75.20) individuals
with diabetes per PCU.
In addition, a total of 9 employees served as
key informants for the in-depth interviews. The
informants were interviewed until no new categories,
concepts, dimensions or incidents emerged
23
from
the data. They represented 9 PCUs, had a broad
range of experiences
24
and were identified from the
completed and returned questionnaires. Five key
informants were selected from PCUs that provided
the best diabetes care (i.e. highest glycemic control
rates among all PCUs in the study). Four key
informants also were selected from PCUs with the
lowest glycemic control rates among all of the PCUs
in the study. The key informants were purposely
chosen to reflect the gender, average age, average
level of education and average work experience
characteristics of the 300 questionnaire respondents.
Ethicalconsiderations: Approval to conduct
the study was granted by the Committee on Human
Rights Related to Human Experimentation at the
primary researchers university. Each participant
was informed about: the studys purpose; what was
involved in participating in the study; maintenance
of participants anonymity and confidentiality; and,
the right to withdraw, at any time, without negative
repercussions. Informed consent was obtained from
all participants and key informants. All participants
were asked to sign a consent form before they
completed the questionnaire or were interviewed.
Anonymity was maintained by placing code numbers
on the completed questionnaires after they were
returned to the primary investigator. Confidentiality
was addressed by keeping the completed questionnaires
in a locked file and viewed only by members of
the research team.
Procedure: Survey data were obtained from
October 2007 through February 2008, while
interview data were obtained between April and
June 2008. The procedure for obtaining data
consisted of two parts.
Part I: The primary researcher requested
permission, by way of a formal letter to the Director
of the Provincial Health Office, to collect data.
After approval was granted, the Coordinator of
each provincial public health office was called so
as to build a relationship, explain objectives of the
study and request assistance in collecting data.
The researcher and each Coordinator then created a
timetable for collecting data together.
Data were collected the days the monthly
provincial meetings with healthcare providers,
171
Vol. 13 No. 3

working in each PCU, were held. After the
meeting, at the provincial health office, the
researcher and/or the coordinators explained the
objectives of the study and requested the healthcare
workers informed consent. Those who gave consent
to participate were given the questionnaire and
asked to complete and return it that day. It took an
average of forty-five minutes to complete the
questionnaire. The participants also were asked to
save, on a researcher provided CD, their FPG data
or to copy the FPG data and send it, via mail or
e-mail, to the researchers.
Part II: After the quantitative information
were analyzed, appointments were made, telephonically,
with the participants working in the PCU with the
lowest, as well as the PCU with the highest
glycemic control rates, as compared with the
sample value, to conduct in-depth interviews.
Seven participants were interviewed, in private, at
his/her respective PCU. Two participants were
interviewed, by phone, to reduce interviewer effect,
since one interviewee was a former student of the
primary researcher and one was the researchers
classmate. An interview guide was employed, as
needed, during the interviews. Each interview was
audio-taped, and lasted approximately one-half
hour. During the interviews, changes sometimes
were made changes in data collection techniques,
i.e. re-wording questions, changing the sequence
of questions, and/or modifying the interview
locations. Field notes were written regarding
interactions, observations and occurring events, as
soon as possible, after each interview.
The researcher performed member checks,
after each interview, so as to provide the respective
participant an opportunity to confirm and/or clarify
the researchers interpretation of the interview data.
Sometimes, new data emerged and was recorded.
Data analysis: Descriptive statistics were
used to analyze contents of the questionnaire,
while Pearsons product moment correlation was
carried out to examine correlations among the
structure of PCUs, care processes for diabetics and
outcomes of diabetic care. Each interview was
recorded and transcribed, wherein, content were
analyzed, via descriptive categories, naming
substantial phenomena and coding.
25
Findings
PCU Structure: Over two-thirds of the
PCUs had sufficient financial support for delivery
of services for diabetics, and three-fifths o f them
had sufficient financial support for coordination
and continuity of care (Table 1). The major source
of support was drawn from Contracting Units for
Primary Care (CUP). PCUs with insufficient financial
support searched for other financial support sources,
i.e. donation boxes, local administrative organizations,
national health security offices and other local
organizations. However, information from the
survey showed that over half (56.7 %; n =170)
were unable to find additional financial support
sources; wherein, the key informants explained that
this was because they did not have good
connections with other organizations. One key
informant commented:
I didnt obtain funds from other
financial support sources because I
didnt know the sub-district administrator. I
got my only budgetary funds from the
hospital and it was not enough to visit
patients at home
Some 59.7 % (n = 179) of the PCUs had
sufficient facilities for diabetes care in terms of
both general office supplies and medical supplies.
The PCUs could draw supplies from CUP and
share supplies with other PCUs. All of them had
blood glucose testing machines, and the vast
majority had a sufficient amount of diabetic drugs
172


to prescribe in their clinic (Table 1). Those that
needed additional facility supplies also could share
supplies with other organizations. One key informant
explained obtaining secondary supply needs as follows:
We used to have more glucose test
strips, needles, and weight scales of
our own. Sometimes, we can borrow
things from other PCUs.
Sufficient staff were available in only 19 %
(n = 57) of the PCUs, with only 9.7% (n = 29)
having full-time physicians and 81% (n = 243)
having full-time registered nurses. The standards,
provided by the MOPH, regarding total number of
staff members, was met only by 2.7% (n = 8) of
the PCUs, with an average of 2-3 full-time staffs
per PCU, including one to two nurses. Some CUPs
supported the PCUs by rotating staff, at least once
a month, from the CUP to work in one of the
PCUs. However, only 57% (n = 171) of the
participants reported their PCU received such staff
support. Almost one-fourth (n = 71; 23.7%) of
the PCUs reported that, even though they had
support, they continued to experience staff
shortages (See Table 1).
PCU Financing Budget for diabetes service delivery 208 69.3
Structure Budget for coordination and continuity of care 184 61.3
Other sources of budget 130 43.3
Facilities Glucose test machine 300 100.0
Family folder 282 94.0
Safety & privacy clinic 267 89.0
Diabetes mellitus drugs 250 83.3
Computer databases 202 67.3
Mission and goal 109 36.3
Staffing Staffs supported by the CUP 171 57.0
Continuity of diabetes mellitus training 242 80.7
Physician: Population1:10,000 22 7.3
Nurse: Population1:1250 110 36.7
Networking CUP and other PCUs 300 100.0
Community participation 235 78.3
Local organizations 152 50.6
Local people in community 300 100.0
CUP = Contracting Units for Primary Care
PCU = Primary Care Units
Table 1 Structure of primary care units (n = 300)

Quality of Factors Standard PCU met the
Care standard
N %
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Vol. 13 No. 3

The key informants explained that, due to staff
insufficiency, the PCUs could not provide quality
care, nor provide certain procedures, i.e. home visits
and/or health education. The PCUs managed this
problem by training health volunteers to help nurses
take blood pressures and weights, while managing
their outpatient department (OPD) cards. One described
the insufficiency of staff and quality of care as:
We had a lot of work, but we had
only 3 staff membersThis insufficiency
of staff caused us to provide low
quality care, as we could not perform
everything that we were supposed to.
The key informants also explained that the
major network, for sharing staff, knowledge and
supplies, was the CUP. However, 23% (n = 69)
of the participants indicated they had networks
with local administrative organizations, and all
reported having connections with health volunteers.
Some of them stated health volunteers were able to
help with home visits, referrals from the community
and community-based disease surveillance.
Diabetes Care Process: The diabetes care
process was explained in terms of service delivery,
continuity of care and coordination. Only 35% (n =
103) of the PCUs provided proper service delivery,
i.e. medical treatment, health prevention and health
promotion, while 84.3% (n = 253) regularly
provided proper diabetes treatment.
As shown in Table 2, 90.3% of the time,
nurses in the PCUs administered, to those with a
normal range blood-glucose level, the prescribed
dosage of diabetic medication. This was done in
accord with the clinical practice guidelines and
under the physicians orders, without need for
consultation with, or another order from, each
individuals physician. However, for those unable to
control their blood-glucose level, the nurses, 32%
of the time, adjusted their medications according
to the clinical practice guidelines or referred them,
47 .3% of the time, to the CUP, in accord with the
clinical practice guidelines. One key informants
description of the medical treatment process was:
If patients had high blood glucose
levels, we would adjust drugs or refer
patients to the CUP. Nurses could adjust
diabetes drugs under the physicians
permission or clinical practice guidelines.
Although only 18.3 % (n = 55) of the
participants indicated their PCU regularly provided
preventive care, which met the clinical standards,
58% reported receiving annual triglyceride and
cholesterol blood tests. Less than one-third (30%,
n = 90) of the PCUs provided annual foot and eye
examinations, while 19.0% provided HbA1Cc
examinations at least once yearly, and 11.0%
provided neuro-examinations, at every visit, in
order to meet MOPH standards (See Table 2).
With respect to health promotion, all PCUs
provided education to each diabetic, while only
35.3% reported providing diabetic care education
to the families of the diabetics. Furthermore, 85%
of PCUs provided proper continuity of care, and
82.0% had an appointment system and made
appointments every 4-6 weeks for both poor and
well glycemic controlled individuals. Health volunteers
followed-up with those who missed appointments,
by visiting them in their homes. One key informant
described the follow-up system in this manner:
We had appointment registration in
paper form. If patients missed their
appointments for more than 1 month,
we would follow-up on the patients
by making calls or visiting the patients
at home.
174


Some 69.3% of PCUs provided proper
coordination services regarding referral and consultation.
The PCUs referred those with poorly controlled
glycemia (100%), new cases of diabetes (100.0%),
emergency cases (66.0%), laboratory tests (56.7%)
and diabetic patients with complications (78.0%).
Key informants explained that full-time nurses
consulted the respective physician and/or pharmacist
regarding FPG levels between 100-126mg%,
while managing those with complications and
drug-related side effects.
Care Outcomes: As shown in Table 2, the
outcome of care (See Table 2) was measured from
the average six-month FPG level, of 19,141
diabetics who were seen in one of the 300 PCUs,
with approximately two-fifths demonstrating good
glycemic control (FPG = 100-126 mg%). The
average FPG level was 147.10 mg% (min =
109.96 mg%; max = 190.71 mg%; SD =
16.27 mg%). A significant relationship was found
between each of the components of the PCUs
structure and care processes, and the service
delivery component of the process of diabetes care
and outcome (See Figure I).
Quality of Factors Standard PCUs met
Care standard
n %
Table 2 Process and outcome of diabetes care in primary care units (n = 300)
Care Service Medical treatment
Process Delivery Distribution of the correct diabetes mellitus drugs 253 84.3
No long waiting for services 173 57.7
Adjusted drugs under the monitoring of a physician 142 47.3
Adjusted drugs using clinical practice guidelines 96 32.0
Preventive care
Blood pressure examinations at least 4 times/yr 271 90.3
Fasting blood sugar examinations at least 4 times/yr 246 82.0
Triglyceride and cholesterol testing once a year 174 58.0
Foot examination at least once a year 91 30.3
Eye annual check-ups 90 30.0
HbA1Cc examination at least once a year 57 19.0
Neuro- examinations at every visit 33 11.0
Health promotion
Individual health education 217 72.3
Family education 106 35.3
Continuity of Out-patient department cards and report system 262 87.3
Care Appointment system 246 82.0
Continuity of health history to physicians 204 68.0
Follow-up system 141 47.0
Home visits 4 times a year 109 36.3
175
Vol. 13 No. 3

Discussion
The management of diabetes care failed to
meet most of the required standards set forth for
good diabetes management in PCUs, although
care-giving standards have been recommended to
assure individuals with diabetes receive quality
care.
22, 28
One-third of those with diabetes had foot
examinations once a year, while 11% had neurological
examinations every visit, in accord with the
standards. These results are similar to previous
studies, in Thailand, wherein low rates of preventive
care have been found among diabetics.
29
The
findings, of this study, are similar to those of Dunn
and Pickering,
30
Chin and colleagues,
31
Grant
32
and
Saaddine and colleagues,
33
who found few creatinine
and cholesterol tests, as well as foot and eye
examinations, were performed in primary care.
Figure 1 Relationships among the structure of primary care units, diabetes care process and diabetes
outcomes
Table 2 (continued)
Quality of Factors Standard PCUs met
Care standard
n %
Coordination A referral system for emergency cases 198 66.0
A counseling system 180 60.0
Patient information was referred 176 58.7
Less than 60 minutes in transportation to refer 167 55.7
Care Glycemic Fasting plasma glucose < 126 mg% 8,227 42.98
Outcome Control (n= 19,141)
s........ . r...., c... u...
,:: .+ .........
o...... c... r...
,.a ,...+.+ . ,.,.. +...... ....
o...... c... o....
,o.,.... ..... .... . :-s
s...... o......,
, ,...+.+ . ,.,.. ...... +......,
c.+......
,- ,...+.+ . ,.,.. ..+......
c......., . c...
,- ,...+.+ . ,.,.. ........, . ....
.:
..-
.::
.::-
..
.a
..aa
...
.a
.. r......._
, ..+ ......... ........_
r......,
,-: ..+ ......... .......,
s......_
,.- ..+ ......... ....
......_
, ..+ ......... ......._
176


The lack of suggested preventive care
practice may be due to the shortage of available
staffs in the PCUs. Since health care reform was
instituted, the number of PCU staff positions has
not increased; however, diabetes care has been
extended to the PCUs. Thus, nurses have had to
provide care, in the PCUs, be proactive in their
communities and perform tasks beyond the role of
nursing (i.e. general management and coordination
with the community). This, in turn, has lead to
nurses experiencing increased workloads.
Although an average of 64 diabetics/per
day comes to the PCUs for care, there only are one
to two health care providers available to deliver
care. Thus, the nurses often are unable to provide
preventive care for all with diabetes. These
findings are congruent with those of previous
studies, in Thailand, which have found the lack of
staffs in the PCUs leads to a work overload for the
nurses.
34, 35
The findings also are consistent with
those of Davidson, Ansari and Karlan,
36
and
Render and colleagues,
37
who revealed staff
shortages to be associated with poor diabetes control.
In Thailand, an individual with diabetes,
whether it is controlled or not, is scheduled to visit
a PCU every four to six weeks. The frequency of
the visits is slightly higher than recommended by
the American Diabetes Association (ADA).
22, 28
However, the guidelines for quality practice
recommends diabetics, with poor metabolic control,
visit a PCU every one to two weeks.
22, 28
Unfortunately, in this study, this action was not
being carried out. It appears the standards for
diabetes care were not being done, due to the lack
of adequate staff and the presence of a local
organizational network.
Findings, of this study, reveal the staff
shortages resulted in inadequate service delivery,
especially in terms of improper preventive care
(see Figure 1). However, given those limitations,
it appears the health care providers provided proper
health promotion and continuity of care, and
achieved good care outcomes. This may have been
due to the available network, wherein the health
care providers had good relationships with health
volunteers who helped them connect with the
community.
The health volunteers also helped the health
care providers with home visits and communication,
which facilitated continuity of care, as well as the
transfer of those with diabetes from the community
to the PCUs. The findings demonstrated the
increased role of volunteers, within the health care
system, was the result of the primary health
care project
38
launched in the late 20
th
century,
wherein local people were encouraged to become
involved in the health care system within their
community. Finding that the involvement of
the volunteers had a positive impact on the health
care being delivered is congruent with
Chuengsatiansups
39
research, which suggested that
health volunteers are an extremely valuable health
resource.
Similar to Chuangs
40
findings, almost half
of the diabetics utilizing the PCUs reached the
desired level of glycemic control. When compared
with the glycemic control rates found in
studies conducted in Western countries,
33-35
the
glycemic control rate found, in this study, was
slightly higher. However, compared to the
glycemic control rate found by Nitiyanant and
colleagues,
29
the glycemic control rate, found in
this study, was considerable higher. The fact the
glycemic control rate, found in this study, was
higher than that in other studies,
41
conducted in
Thailand, may have been due to differences in
the setting, as well as to the condition
of those utilizing the specific health care
institution. For example, in Thailand, those
attending tertiary care facilities usually have more
severe cases of diabetes than do those receiving
care at a PCU.
177
Vol. 13 No. 3

The fact that a high glycemic control rate
was found, in this study, may reflect the efficiency
and effectiveness of the system and the staff
members in the PCUs. The majority of health care
providers were nurses and able to provide, within
the primary care concept, diabetes care in the
PCUs. Even though the existing work overload
brought about improper service delivery, the
glycemic control rate was compatible with rates
found in Western countries. This suggests the
primary care provided, by nurses, reduced costs,
increased access to appropriate medical services for
the population being served and did not reduce the
quality of care being delivered.
The findings were consistent with those of
prior studies which have suggest the structure of an
organization has an important affect on health care
performance and outcome.
29-31
These results
also support Donabedians
19
model, a well
accepted method for setting standards in hospitals,
which proposes that structures affect care
processes, which in turn, affect care outcomes. The
relationships among PCU structure, diabetes care
processes and care outcomes, in this study, support
the application of Donabedians framework within
the primary care settings in Thailand.
Limitations
One cannot apply the findings of this study
without examining its limitations. Data were obtained
exclusively from providers working within PCUs
and did not address information from individuals
with diabetes or their families. Furthermore,
quality of care was assessed in terms of technical
quality and did not include amenities or the
interpersonal domain.
Implications
Based upon the studys findings, the
following recommendations are suggested:
(1) The shortage of nurses working in PCUs,
as well as nurses current work overload need to be
addressed.
(2) Nurses need to enhance the assistance
of health care volunteers by providing them
appropriate training. In addition, nurses continually
need to foster relationships with key community
leaders for the purpose of strengthening the
organizational network.
(3) The standards of diabetes care, practiced
in PCUs, should be refined to better address the
level of quality care.
Acknowledgements
The primary investigator expresses gratitude,
for support of this study, to the Commission of
Higher Education, the Thai Ministry of Education;
and, the Thai Council of Nursing and Midwifery.
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29. Nitiyanant W, Chetthakul T, Sang-A-kad P, Therakiatkumjorn
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Jin L, et al. Am J Public Health. 2000; 90(3): 43134.
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36. Davidson MB, Ansari A, Karlan VJ. Effect of a nurse-
directed diabetes disease management program on urgent
care/emergency room visits and hospitalizations in a minority
population. Diabetes Care. 2007; 30(2): 224-7.
37. Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk
Van JT, Assendelft WJ. Interventions to improve the
management of diabetes in primary care, outpatient, and
community settings: A systematic review. Diabetes
Care. 2001; 24(10): 1821-33.
38. Wibulpolprasert S. Thailand Health Profile, 2005-
2008. Nonthaburi: Veteran Press; 2008.
39. Chuengsatiansup K. Health Volunteers in the context of
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Health Systems Research Institute; 2006.
40. Chuang S, Huang B, Tai T. The status of diabetes
control in Asia: A cross-sectional survey of 317
patients with diabetes mellitus in 1998. Diabet Med.
2002; 19(12): 978-85.
41. Rawdaree P, Ngarmukos C, Deerochanawong C,
Suwanwalaikorn S, Chetthakul T, Krittiyawong. Thailand
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180


, , , , Noel Chrisman

:

300
6 19,141
9
24

82

43
(r = 0.337)
(r = 0.116)

2009; 13(3) 167 - 180
:
:, RN, PhD Candidate,

E-mail: rukchanok.koshakri @gmail.com
, RN, PhD,

, RN, PhD,

, MD, FRCST,

Noel Chrisman, PhD, Professor, School of Nursing, University of
Washington, USA.
181
Nopporn Vongsirimas et al.

Vol. 13 No. 3

Relationship among Maternal Depressive Symptoms, Gender

DifferencesandDepressiveSymptomsinThaiAdolescents
Nopporn Vongsirimas, Yajai Sitthimongkol, Linda S. Beeber, Nonglak Wiratchai, Sopin Sangon
Abstract: To examine the pattern of relationships among factors related to depressive
symptoms in adolescents of mothers with depressive symptoms, the structural
equation model of adolescent depressive symptoms was tested. The conceptual
framework, for this study, drew on the Interpersonal Theory of Depression. Through
use of stratified sampling, 460 Thai adolescents, and respective mother, were selected
for participation. All adolescents completed the: Demographic Data Questionnaire;
Center for Epidemiologic Studies Depression Scale; Rosenbergs Self-esteem Scale;
Multidimensional Scale of Perceived Social Support; Maternal Supportive Behaviors
Questionnaire; Negative Event Scale; and, Parental Bonding Instrument. Each mother
completed the: Demographic Data Questionnaire; and, Center for Epidemiologic
Studies Depression Scale. Data were analyzed using LISREL. A goodness of fit was
obtained with the model. The adolescents depressive symptoms accounted for over
60% of the variance.
A strong effect of maternal depressive symptoms on depressive symptoms
among Thai adolescents, as well as on mediation by intervening variables, was
found. The results also enhanced understanding of how to develop and target nursing
interventions to prevent development of depressive symptoms, and optimize mental
health, among Thai adolescents, when their mother suffers from depressive symptoms.
Thai J Nurs Res 2009; 13(3) 181 - 198
Keywords: adolescent depressive symptoms, social support, self-esteem
Introduction
TheWorldHealthOrganization(WHO)has
estimated that 121 million people suffer from
depression, a major cause (60%) of suicide.
1
In
addition,depressionhasbeenprojectedtocomprise,
by2020,thelargestdiseaseburden,ofallhealth
conditions among women, and to rank second in
thetotalyearlydisability-adjustedlifeexpectation.
1

Depression and depressive symptoms, historically,
Correspondence to: Nopporn Vongsirimas, RN, PhD. Candidate,
Faculty of Nursing, Mahidol University, Bangkok, Thailand. E-mail:
nsncr@mahidol.ac.th
YajaiSitthimongkol, RN, PhD. Associate Professor, Faculty of Nursing,
Mahidol University, Bangkok, Thailand.
Linda S. Beeber, RN, PhD, FAAN. Professor, School of Nursing
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
NonglakWiratchai, PhD. Professor Emeritus, Chulalongkorn University,
Bangkok, Thailand.
Sopin Sangon, PhD, Assistant Professor, Department of Nursing,
Faculty of Medicine Ramathibodi Hospital, Mahidol University,
Bangkok, Thailand.
182
Relationship among Maternal Depressive Symptoms, Gender Differences and Depressive Symptoms

havebeenconsidereddisordersthatafflictmiddle-
aged and older persons.
2
Depression refers to a
diagnostic term that meets set criteria in the
DiagnosticandStatisticManualofMentalDisorder
(DSM-IV),
3
whiledepressivesymptomsaredefined
as a spectrum of cognitive, affective, behavioral
and somatic phenomena that accompany an
unremitting sad mood (p. 154).
4
Adolescents
andyoungadults,however,havebeennotedtobe
increasinglydepressedandtoseektreatment.
2
Prior
studies have found an increase in the onset of
depressive symptoms among individuals 15 to 19
years of age.
2
In the United States of America
(USA), the prevalence rate of adolescent major
depressive disorder (MDD) is estimated to range
from 15% to 20%,
5
while the prevalence rate of
depressivesymptomsisknowntobecloseto30%.
5
In Thailand, the incidence rate of MDD, among

Thai adolescents, ranges from 5% to 8%,
6
while
theprevalencerateofdepressivesymptomsranges
from20%to67%.
7-9
ReviewofLiterature
Depressive symptoms are known to be
predictors of depression, with 25% of adolescents
experiencingaMDDwithinoneyearofdeveloping
depressive symptoms.
10
A diagnosis of depression
duringadolescencehasbeenshowntobeapredictor
of a recurrence of depression during adulthood.
10
In addition, the occurrence of a MDD during

adolescence,whencomparedtothatonchildhood-
onset MDD, has been found to indicate a poorer
prognosis.
6
Reviewoftheliteraturerevealsanumberof
factors,whichincreaseadolescentsrisksofdeveloping
depressive symptoms, have been investigated,
including whether their mother has depressive
symptoms.
10, 11
In particular, adolescent offspring
of mothers with depressive symptoms have been
found to be twice as likely to develop a major
depression, or dysthymic disorder, compared to
adolescents of mothers who never have been
depressed.
12
Not surprisingly, mothers with depressive
symptoms have been recognized to experience
difficultiescarryingoutparentalresponsibilities,lack
maternalconfidenceandpresentwithhostility,
11,13
aswellashavedifficultydealingwithinterpersonal
relations with their adolescent child.
13
Mothers
who suffer from depression, also may appear
unavailable, or insensitive, to their adolescent
11
andbelessable,comparedtomotherswhoarenot
depressed,toprovideappropriateguidanceandrule
enforcement.
12
Adolescents living in such an
environmenthaveexpressedbeingresentfuloftheir
poorlyfunctioningmother.
13
Yet adolescents who receive sufficient

maternalwarmthandsupport,fromtheirsymptomatic
mothers, appear less likely to develop depressive
symptoms.
13, 14
This may be due to the fact that,
when their mothers are impaired and unable to
provide needed warmth and support, their fathers,
grandparents,orconcernedfriendsorrelativesstep
inandprovideforthem.Thus,itappearsthepower
of warm and supportive parenting is a critical
factor in decreasing the likelihood of development
of depressive symptoms among adolescents of
motherswhoaredepressed.
13
Self-esteem also appears to be a protective

factor in decreasing the likelihood of adolescents
developingdepressivesymptoms.Thosewithahigh
level,comparedtothosewithalowlevel,ofself-
esteemhavebeenfoundtosufferfewerdepressive
symptomswhenfacingsimilarstressfulsituations.
15
However, in order to optimize resistance to

depressive symptoms, ones self-esteem has been
showntoneedmediationbysocialsupport.
15,16
Although a number of studies, in Thailand,
haveexaminedtherelationshipoflifestress,social
support, self-esteem and depressive symptoms
among adolescents, none could be located which
183

Vol. 13 No. 3

havepredictedanypatternofassociationsamongthe
various factors.
8
Furthermore, no studies could be
located, in English language or Thai language
publications, which have investigating depressive
symptoms among Thai adolescents, in relation to
theirmothershavingdepressivesymptoms.
Therefore,thisstudysoughtto:1)explorethe
relationshipsandfactorsassociatedwithdepressive
symptomsamongThaiadolescentsofmotherswith
depressivesymptoms;and,2)test,inat-riskadolescents,
the meditational roles of life stress, social support
and self-esteem associated with maternal depressive
symptomsandadolescentdepressivesymptoms.
ConceptualFramework
The conceptual framework, for this study,
drewontheInterpersonalTheoryofDepression.
16,17
The assumptions underlying the theory, proposed

bySullivan,
18
aretherearetwobasichumanneeds:
biological and psychological. Both of these needs
aremetbyhavinganinterpersonalrelationwith
a significant other. Such interaction is dynamic
andacknowledgesbothindividualsbiologicaland
psychologicalneeds.
AccordingtoSullivan,withouthavinginterpersonal
relations with a significant other, one may not be
abletosatisfyhis/herbasichumanneeds.
18
Inthe
InterpersonalTheoryofDepression,
16,17
anxiety
referstoaninsecurefeeling,oremotionaldiscomfort,
thatderivesfromthepersonnotsatisfyinghis/her
basicneeds.Self-esteemreferstoafeelingthat
emergesfromonehavingapositiveself-evaluation,
which is obtained from having an interpersonal
relation with a significant other and perceiving a
positive evaluation from his/her significant other.
The positive evaluation one receives from a
significantotherconstitutesemotionalsupport,
which is an important support that can be gained
by having an interpersonal relation, or role
relation,withonessignificantother.
19
Thus,fromthisperspective,theinterpersonal
relation process, or interaction, between a mother
and her children, might influence the childrens
anxietyandself-esteem.Inotherwords,themental
health of the mother may have an impact on the
mentalhealthofherchildren.
Methods
Thisstudyusedacross-sectional,correlational
research design. Causal effects were examined via
investigationofadolescentsexperiencesofliving,
based on lifetime retrospective ratings, with their
depressedmothers.
Setting and Participants: Fifteen high
schools were randomly selected from 103 high
schoolsinBangkok,Thailand.Astratifiedsampling
techniquewasusedtoobtain460adolescentswho
were15to19yearsofage,abletoreadandwrite
in Thai and residing with their biological mother,
who could read, write and score 16 or higher on
theCES-Dscale.
Inthisstudy,thetermadolescentsrefersto
late adolescence, which is classified from a
psychosocial perspective as one 15-19 years of
age and enrolled in a high school, including a
Mathayom 4-6 (level of high school which
includesgrades10to12).Thestudyssamplesize
was based upon Hair and colleagues
20
suggestion
that a ratio of 10 respondents per each estimated
parameterbeconsideredappropriateforcalculation
of a structural equation procedure. Therefore, the
minimum sample size was set at 460, since the
studyincluded46estimatedparameters.
The adolescent subjects ranged in age from
15 to 19 years, with an average age of 16.53
(SD=1.00).Almostthree-fourths(74%)ofthem
hadadailyallowanceof51-100baht/day(mean
=86.63;SD=31.55).
Morethanhalf(53.9%)ofthemotherswere
in the age range of 41 to 50 years, with a mean
184

ageof43.55(SD=5.38).Almostone-thirdofthem
had a family income of 5,001to10,000 baht/
month (mean = 17,782.19; SD = 41,107.68).
Most(79%)weremarried,buthadaninsufficient
familyincome(55.2%).Almosthalf(44.8%)of
themothersonlyhadaprimaryeducation.
Procedure and Ethical Considerations:Permission
to conduct this study was obtained from the
Human Rights Related to Human Experimentation
andEthicsCommittee,oftheprimaryresearchers
university, and the School Board Committee of
eachofthe15schools,wheredatawerecollected
from November 2007 to March 2008. Once
approval to conduct the study was obtained, the
primary researcher approached the teachers, who
served as counselors, within each of the schools.
Theseteacherswereresponsiblefornon-academic
issues(i.e.socialsupport)andabletoprovidepractical
suggestionsandassistancepriortoandduringdata
gathering. In addition, the teachers facilitated the
researchers access to the students for the purpose
ofdatagathering.
Atotalof4,261adolescentswereapproached,
in their respective classrooms, and told about the:
studyspurposeandprocedure;issuesofconfidentiality
andanonymity;and,theirrighttowithdrawatany
timewithoutrepercussions.Eachwasgivenapacket,
to take home to their mother, which contained a
letter(explainingthestudy,issuesofconfidentiality
and anonymity, and the right to withdraw, at any
time,withoutnegativerepercussions),alongwitha
consent form to sign, and the Demographic Data
Questionnaire for Mothers and the Center for
EpidemiologicStudiesDepressionScale(CES-D)to
complete.Theletterrequestedeachmothertocomplete
the enclosed instruments, sign the consent form,
placeallcompleteddocumentsbackintothepacket
envelope and return the packet, with the enclosed
documents, to the primary investigator the next
day,viatheiradolescent.Atotalof1,758completed
packetswerereturned,fora41.26%returnrate.
Uponreceiptofthemotherssignedconsent
forms and their completed CES-D, code numbers
wereplacedontheCES-Ds.Eachstudentthenwas
administered, in a class room, the: Demographic
Data Questionnaire for Adolescents; Center for
EpidemiologicStudiesDepressionScale(CES-D);
Negative Event Scale (NES); Parental Bonding
Instrument(PBI);MultidimensionalScaleofPerceived
Social Support (MSPSS); Maternal Supportive
Behaviors Questionnaire (MSBQ) and Rosenberg
Self-EsteemScale(RSE).
Directionsforcompletionofthequestionnaires
were provided, as well as responses to questions
that arose during the administration process. Prior
toadministrationofthequestionnaires,thestudents
were informed their respective mother had given
writtenapprovalforthemtoparticipate.However,
they were asked to sign an assent form if they
desiredtotakepartinthestudy,andremindedthey
had the right to withdraw, at any time, without
negativerepercussions.Nonewithdrewfromthestudy.
Codenumberswereplacedoneachadolescents
completed questionnaires to facilitate matching
with their respective mothers completed CES-D.
Only questionnaires of those, whose mother
obtained a CES-D score of 16 or greater, were
placedintotheanalysisprocess.Allcodenumbers
wereremovedfromthequestionnairesimmediately
aftercompletionoftheCES-Dscreeningprocess.
Four hundred ninety-four of the CES-D
Scales indicated the responder had depressive
symptoms(CES-D16).However,32respondents
did not live in the same household as their
biologicaladolescentandtwomadeerrorsanswering
the questionnaires. Thus, 34 questionnaires were
excluded,leavingatotalof460viablequestionnaires.
Instruments:Eightinstrumentswereusedto
collect data from each adolescent and mother.
Theyincludedthe:DemographicDataQuestionnaire
for Mothers; Demographic Data Questionnaire for
Adolescents; Center for Epidemiologic Studies
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Vol. 13 No. 3

Depression scale (CES-D); Negative Event Scale
(NES); Parental Bonding Instrument (PBI);
MultidimensionalScaleofPerceivedSocialSupport
(MSPSS);MaternalSupportiveBehaviorsQuestionnaire
(MSBQ);and,RosenbergsSelf-esteemScale(RSE).
WiththeexceptionoftheDemographicData
QuestionnairesandtheMSBQ,bothofwhichwere
constructed, in Thai, by the primary investigator,
the instruments were translated from English into
Thai, by prior researchers,
9, 21
and then back-
translatedintoEnglish.Theback-translatedEnglish
version was compared with the original English
version of each instrument for the purpose of
assuring no change in meaning occurred in the
content.Eachinstrumentwasreviewedbyfiveexperts
(twopsychiatrists,twopsychologistsandanursing
instructor)andpilot-testedtodeterminetheinstruments
internalreliability,clarityandcomprehensiveness.
Thepilot-testwasaccomplishedthroughuse
of31Thaiadolescentsandtheirrespectivemother
with depressive symptoms, whose characteristics
were similar to the study sample and independent
of the intended study sample. The procedure used
to conduct the pilot study was identical to the
intendedstudy.Thepilotstudyinternalreliabilities,
foradolescents,were:CES-D(0.87)NES(0.94),
PBI (0.89), MSBQ (0.86), MSPSS (0.79) and
RSE(0.88).ThereliabilityoftheCES-D,formothers,
was0.74.
The Center for Epidemiologic Studies
DepressionScale(CES-D)
22
isaself-administered
20itemquestionnairedesignedtomeasuredepressive
symptoms by ascertaining the level of depressive
symptoms a subject has experienced over the
previousweek,includingthecurrentday.Thescale
consists of four major depressive symptoms: 7
itemsfordepressedaffect(items3,6,9,10,14,
17, 18); 4 items for positive affect (items 4, 8,
12,16);7itemsforsomaticandretardedactivity
(items1,2,5,7,11,13,20);and,2itemsfor
interpersonal relationships (items 15, 19). The
possible responses, for each of the 20 items,
rangesfrom0=rarelyornoneofthetimeto3=
mostorallofthetime.Thescorefromeachofthe
20 items is summed to produce an overall total
score,whichcanrangefrom0to60.Higherscores
indicate greater depressive symptom severity.
A score between 0 and 15 suggests that no
depressionispresent,whilescoresatorabove16
areindicativeofclinicallysignificantsymptomatology.
There is a linear relationship between increasing
score values and the likelihood of a diagnosis of
majordepressivedisorder.
22
Inpopulationscreening,
thecut-offscoreof16hasshownhighsensitivity
rangingfrom86%to100%,anddeterminedtobe
the best cut-off score in detecting depressive
symptoms among a variety of populations across
cultures.
23
In addition, a longitudinal study found
that adolescents, with an initial CES-D score of
16, developed moderate/severe depressive symptoms
at follow-up. This finding confirmed a high
sensitivity of the CES-D scale at the score of
16.
24
A cut-off score of 16 for the CES-D has
been used among researchers in the area of
depressive symptoms in adolescences of depressed
mothers.
25
TheCES-Dalsohasbeenshowntobe
a valid instrument across racial and culturally
diverse groups.
23
It takes approximately 10 to 15
minutestocomplete.Thealphareliabilitycoefficient
of the instrument, for this study, was 0.87 for
adolescentsand0.74formothers.
The Negative Event Scale (NES)
26
is a
self-administered questionnaire that measures
perceived life stressors commonly experienced by
adolescents. The 42 item scale consists of 10
subscalesaddressingproblemswith:1)friends;2)
boy/girlfriend;3)money;4)courses;5)teacher;6)
parents or parents-in-law; 7) other students; 8)
relatives;9)health;and,10)academiclimitations
andcourseinterest.Therespondentisasked,Last
month,howmuchhassledidyouexperience?for
eachofthe42negativelifeevents.Eacheventis
186

scored using a 6-point Likert-like scale: 0 = did
not occur; 1 = event occurred but there was no
hassle; 2 = event occurred along with a little
hassle;3=eventoccurredalongwithsomewhatof
a hassle; 4 = event occurred along with a lot of
hassle;and,5=eventoccurredalongwithextreme
hassle. A total score is obtained by summing
acrossall42items,whichcanproducearangeof
scores from 0 to 210. It takes approximately 10
minutes to complete the scale. The NES has
demonstratedexcellentconstructvalidityandreliability
with Thai adolescents (r = 0.98).
9
The reliability
oftheinstrument,forthisstudy,was0.94.
TheParentalBondingInstrument(PBI)
27
is
a 25-item self-rating scale designed to measure
perceivedrelationshipsandexperiences,withparents,
based upon the childs memory of his/her parents
duringthefirst16yearsoflife.Forthisstudyonly
maternal bonding was measured. The PBI is
composedof2subscales:evaluatingcare(12items)
andevaluatingoverprotection(13items).Eachitem,
which assesses the parent in question, is rated by
the respondent on a four-point Likert-type scale
(0=veryunliketo3=verylike).Thetotalscore
for each of the two dimensions (care and
overprotection) is created by summing items that
address the respective dimension. The possible
rangeofscoresforthecaredimensionis0to36,
while the range of scores for the overprotection
dimension is 0 to 39. High scores on the care
dimension represent the adolescents perception of
caringandaffectionateparenting,whilehighscores
on the overprotection dimension represents the
adolescents perception of overprotective parenting.
27
Lowscoresonthecaredimensionandhighscores
on the overprotection dimension are considered to
besuggestiveofariskfordepressivesymptoms.
28
ThePBIshowsexcellentconstructandconvergent
validity, as well as reliability with a range from
.91 to .99.
1
In addition, it has demonstrated
stabilityovera20-yearperiod.
28
Charoensuk
9
translatedthePBIfromEnglish
into Thai, but added 5 items, in order to increase
the instruments reliability in a Thai adolescent
population.Twoitemswereaddedtocaring(#26
and #27), while three items were added to the
overprotection dimension (#28, #29 and #30).
Thus, the Thai version of the PBI consists of 14
items for parental care and 16 items for parental
overprotection.LiketheoriginalEnglishversionof
the PBI, items are scored on the same four-point
Likert-like scale (0 = very unlikely to 3 = very
likely), and total scores for each dimension are
obtained by summing the score for items in each
respectivedimension.Scoresforthecaredimension
can range from 0 to 42, while scores for the
overprotectiondimensioncanrangefrom0to48.
Interpretation of the scores is the same as the
original English version of the PBI. Alpha
coefficients found, by Charoensuk,
9
for the Thai
versionofthePBIwere.88forcaringand.78for
overprotection.
In this study, prior to data analysis, the
scoring method for the caring component was
reverse,sothathighnumericalvaluesofthecaring
dimension of the instrument conceptually fit with
highnumericalvaluesoftheoverprotectiondimension
(a negative concept). As a result, high scores
indicated low levels of caring and affectionate
parenting, rather than high levels of caring
and affectionate parenting. The scoring for the
overprotectiondimensionofthescaleremainedthe
same and was not reversed. The scale can be
completedinapproximately5to10minutes.The
alphacoefficientfortheinstrument,forthisstudy,
was0.87.
TheMaternalSupportiveBehaviorsQuestionnaire
(MSBQ) was a modification, by the primary
researcher, of the Inventory Social Supportive
Behaviors (ISSB)
29
instrument. The purpose of
both the ISSB and the MSBQ is to measure the
quantity of support adolescents received over the
187

Vol. 13 No. 3

past four weeks from a significant person, with
whom they have had a personal relationship. For
the MSBQ, the significant person is the mother.
Permission to modify the MSBQ was obtained
fromDr.ManualBerrera(personalcommunication,
May23,2007),anauthoroftheISSB.Although
the ISSB has been modified, translated into Thai
andusedonaThaiadolescentpopulation,
22
based
upon the evaluation, by the primary researchers
instrument evaluators, of the Thai version of the
ISSB,itwasdeterminedbesttomodifytheoriginal
ISSB and, thereby, create the MSBQ. The
instrument evaluators indicated the contexts and
conditionsgiveninmanyitems,oftheThaiversion
oftheISSB,didnotfittheThaiculture.
In the ISSB, received support is defined as
assistance received in three forms: 1) being there
(physically,emotionallyandspiritually);2)giving
help; and, 3) giving information and advice.
29
Moreover, the framework of question asking was
developed for use in adolescents who also were
targetsubjectsinthisstudy.TocreatetheMSBQ,
via modification of the ISSB, seven items were
deletedfromtheISSB(i.e.,items1,3,13,17,22,
34,38,and40)andthecontent/conditionsstated
in the remaining items were changed to more
accurately reflect the Thai culture. However, the
conceptualframeworkfortheISSBsthreesupport
forms and their related questions were maintained
intheMSBQ.Sincetherequiredresponsesforthe
ISSB questions were based upon the frequency of
occurrenceofsupport,whichcannotbeappropriately
applied in the Thai culture, the MSBQ item
responseswerechangedtoanagree/disagreeformat.
The created, self-administered MSBQ,
contains33itemsthatwereansweredona4-point
ratingscale(1=definitelydisagree;2=somewhat
disagree;3=somewhatagree;and,4=definitely
agree). Higher scores indicate higher support
received from mothers. It takes about 15- 20
minutestocompletetheinstrument.Aftercontent
validationbytheexperts,thescalewasconsidered
acceptable for use with adolescents having a
mother with depressive symptoms, with a scale-
level CVI of 0.85. The alphas coefficient for the
instrument,inthisstudy,was.96.
The Multidimensional Scale of Perceived
SocialSupport(MSPSS)
30
isa12-iteminstrument
designedtomeasuretheperceivedamountofsocial
support one receives from three separate sources:
family, friends and significant others. Each of the
three sources of social support is assessed using
fourrespectivequestions.Examplesoftwoquestions
are:Thereisaspecialpersonwhoisaroundwhen
Iaminneed;and,Myfamilyreallytriestohelp
me.Theinstrumentutilizesa7-pointLikert-like
responseformat(1=verystronglydisagreeto7=
verystronglyagree).Ascoreforeachofthethree
subscales is obtained by summing across the
respective items. A total score is obtained by
summing across all 12 items.
30
Scores for each
subscale range from 4 to 28, with higher scores
indicating a higher level of perceived social
supportreceivedfromtherespectivesubscale(i.e.,
family,friendsandsignificantother),whereaslow
scoressuggestdecreasedlevelsofperceivedsocial
support. It takes approximately 3 minutes to
complete.TheMSPSShasbeenusedextensivelyand
has demonstrated sound psychometric properties.
31
IthasbeenusedinThailandtomeasureperceived
social support in adolescents, with a reliability of
0.89.
7
Inthisstudy,thereliabilityfortheMSPSS
was0.89.
The Rosenberg Self-Esteem Scale (RSE)
32
isa10-item,self-administeredinstrumentdeveloped
for the purpose of measuring adolescents global
feelingsofself-worthorself-acceptance.Thescale
consists of 2 dimensions: a feeling of self-worth
and self-respect; and, a feeling of competence and
ability.Feelingsofself-worthandself-acceptance
aremeasuredusingeightitems,whilecompetence
andabilityareassessedusingtwoitems.Examples
188

of one question from each of the two dimensions
ofthescaleare:IfeelthatIamapersonofworth
atleastonanequalplanewithothers;and,Iam
able to do things as well as most other people.
For each of the 10 items, a participant rates how
muchhe/shehasvaluedhimself/herselfinthelast
month on a scale of 1 = strongly disagree to
4 = strongly agree. The higher the score, the
higher ones self-assessed self-esteem. It takes
approximately5minutestocomplete.Reliabilityof
the scale has been found to range from .77 to .88.
32
ThereliabilityoftheRSE,forthisstudy,was.78.
Results
Data analysis, using structural equation
modeling (SEM), validated the causal model of
adolescent depressive symptoms, while employing
LISRELrevealedasignificantfitwithchi-square=
251.462;df=217;p-value=0.054;RMSEA=
.019,GFI=.964;AGFI=.927,asdisplayedin
Figure 1.Thecorrelationmatrixoflatentvariables
is shown in Table 1. The paths in the model
consisted of factor loadings and effects between
variablesinthemodel(seeTable 2 & 3).Everyfactor
loading of indicators, measuring the seven latent
variables,weresignificantat0.01(seeTable 3).
Findings from structural equation modeling
showed maternal depressive symptoms had a
significant, positive, indirect effect on adolescent
depressivesymptoms(.095;p<.01),viaperceived
life stress, perceived maternal parenting, maternal
support, support from others and self-esteem.
Gender had a significant, positive, indirect effect
onadolescentdepressivesymptoms(.086;p<.05),
via perceived life stress, perceived maternal
parenting, maternal support, support from others
andself-esteem.
Perceivedlifestresshadasignificant,positive,
total effect on adolescent depressive symptoms
(.281;p<.01),whichwasbothasignificant,positive,
directeffect(.161;p<.01)andanindirecteffect
(.120, p <.01), via maternal support, support
from others and self-esteem. Perceived maternal
parenting had a significant positive total effect on
adolescent depressive symptoms (.471; p <.01),
whichwasbothasignificant,positive,directeffect
(.163,p<.05)andanindirecteffect(.308,p<.01),
viamaternalsupport,supportfromothersandself-
esteem.Maternalsupporthadasignificant,negative,
total effect on adolescent depressive symptoms
(-.096; p <.01), which was decomposed into a
negative, non-significant, direct effect and a
significant,negative,indirecteffect(-.032;p<.01),
via self-esteem, indicating that maternal support
had the mediating effect through self-esteem on
adolescent depressive symptoms. Support from
others had a significant, negative, total effect on
adolescentdepressivesymptoms(-.187;p<.01),
which was decomposed into a negative, non-
significant,directeffectandasignificant,negative,
indirecteffect(-.138,p<.05),viaself-esteem,
indicating that support from others had the
mediatingeffectthroughself-esteemonadolescent
depressive symptoms. Self-esteem not only had a
significant, negative, direct effect on adolescent
depressive symptoms (-.601; p <.01), but also
had the greatest effect on adolescent depressive
symptoms in the model. The LISREL model fit
very well to the empirical data and explained
61.5% of variance of depressive symptoms in
adolescentsofmotherswithdepressivesymptoms.
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Vol. 13 No. 3

Table 1 Correlationmatrixofthestudyvariables(n=460)
MoDe Gen PLS Ppar Msup Osup Selfest AdoDe
MoDe 1.000
Gen 0.006 1.000
PLS 0.166** 0.109* 1.000
Ppar 0.186**0.089 0.317** 1.000
Msup -0.061 -0.067 -0.212** -0.541** 1.000
Osup -0.068 0.042 -0.173** -0.370** 0.548** 1.000
Selfest -0.090 -0.025 -0.298** -0.321** 0.308** 0.360** 1.000
AdoDe 0.194** 0.087 0.462** 0.410** -0.341** -0.397** -0.506** 1.000
*p<.05;**p<.01
MoDe = MaternalDepressiveSymptoms Gen =Gender
PLS = PerceivedLifeStress PPar =PerceivedMaternalParenting
Msup = MaternalSupport Osup =SupportfromOthers
Selfest = Self-esteem AdoDe =AdolescentDepressiveSymptoms
Observed b SE t SC R
2
variables
MaternalDepressiveSymptoms(MDS)
mds1 0.320 0.017 18.808 0.787 0.619
mds2 0.387 0.021 18.375 0.776 0.602
mds3 0.406 0.021 18.931 0.789 0.623
mds4 0.492 0.026 18.735 0.786 0.617
Gender
female 0.361 0.020 18.378 0.778 0.606
PerceivedLifeStress(LS)
ls1 0.747 - - 0.780 0.608
ls2 0.900 0.066 13.679 0.772 0.597
ls3 0.907 0.066 13.838 0.777 0.603
ls4 0.934 0.067 14.012 0.778 0.605
ls5 0.760 0.055 13.891 0.781 0.610
ls6 0.796 0.064 12.508 0.694 0.620
ls7 0.643 0.044 14.586 0.778 0.605
ls8 0.688 0.049 14.003 0.782 0.612
ls9 0.738 0.053 13.998 0.776 0.602
ls10 0.842 0.057 14.785 0.779 0.607
Table 2 validationresultsofthecausalmodelofadolescentdepressivesymptoms
190

PerceivedMaternalParenting
par-nc 0.358 - - 0.750 0.562
par-o 0.348 0.026 13.358 0.780 0.609
MaternalSupport(MS)
ms1 0.287 0.045 6.361 0.798 0.636
ms2 0.254 0.040 6.297 0.776 0.603
ms3 0.252 0.040 6.300 0.784 0.614
SupportfromOthers(OS)
os1 1.019 - - 0.784 0.615
os2 0.957 0.060 15.963 0.790 0.625
os3 0.920 0.060 15.280 0.779 0.606
Self-esteem(SE)
se1 0.312 - - 0.784 0.615
se2 0.414 0.023 18.405 0.795 0.623
AdolescentDepressiveSymptoms(ADS)
ads1 0.260 - - 0.600 0.360
ads2 0.335 0.024 14.205 0.655 0.429
ads3 0.308 0.032 9.595 0.623 0.388
ads4 0.378 0.036 10.626 0.699 0.488
2
=251.462,df=217,p-value=.0542,RMSEA=.019,GFI=0.964,AGFI=0.927
Note:b=EstimatedParameter;SD=StandardError;t=t-value;
R
2
=ConstructReliability;SC=CompletelyStandardizedValueofFactorLoading
mds1=somaticandretardactivity par-nc=perceivednotcaring
mds2=depressedaffect par-o=perceivedoverprotection
mds3=positiveaffect ms1=emotionalandphysicalsupport
mds4=interpersonalrelationship ms2=givinghelp
Fem=female ms3=givinginformationandguidance
ls=problemswithfriends os1=significantothers
ls2=problemswithboy/girlfriends os2=family
ls3=problemswithmoney os3=friends
ls4=problemswithcourses se1=feelingofselfvalueandselfrespect
ls5=problemswithteacher se2=feelingofcompetenceandability
ls6=problemswithparents ads1=somaticandretardactivity
ls7=problemswithotherstudents ads2=depressedaffect
ls8=problemswithrelative/s ads3=positiveaffect
ls9=healthproblems ads4=interpersonalrelationship
ls10=academiclimitations&courseinterest
Table 2 (continued)

Observed b SE t SC R
2
variables
191

Vol. 13 No. 3

Causal EffectedVariables
Variables PLS PPar
DE IE TE DE IE TE
MoDe 0.116** - 0.116** 0.132** - 0.132**
(0.029) (0.029) (-0.036) (-0.036)

Gen 0.098* - 0.098* 0.123* - 0.123*
(0.045) (0.045) (0.057) (0.057)
StructuralEquationFit R
2
=.021 R
2
=.030
Variables Msup Osup
DE IE TE DE IE TE
MoDe -0.006 -0.107* -0.113* - -0.074** -0.074**
(-) (0.062) (0.062) (0.021) (0.021)

Gen - -0.099* -0.099* - -0.068* -0.068*
(-0.082) (-0.082) (0.031) (0.031)

PLS -0.013 - -0.013 -0.025 - -0.025
(0.049) (0.049) (0.032) (0.032)

PPar -0.798** - -0.798** -0.536** - -0.536**
(0.311) (0.311) (0.071) (0.071)
StructuralEquationFitR
2
=.638 R
2
=.288
Variabales Selfest AdoDe
DE IE TE DE IE TE
MoDe - -0.074** -0.074** - 0.095** 0.095**
(0.018) (0.018) (0.022) (0.022)

Gen - -0.066* -0.066* - 0.086* 0.086*
(0.025) (0.025) (0.031) (0.031)

PLS -0.190** -0.006 -0.196** 0.161** 0.120** 0.281**
(0.039) (0.008) (0.040) (0.040) (0.030) (0.044)

PPar -0.218** -0.165** -0.384** 0.163* 0.308** 0.471**
(0.067) (0.035) (0.060) (0.082) (0.059) (0.070)

Table 3 Standardizeddirecteffect,indirecteffect,totaleffectoflatentvariablesinthemodel(n=460)
192

Msup 0.053 - 0.053 -0.064 -0.032** -0.096**
(-) (-) (-) (0.003) (0.003)

Osup 0.229** - 0.229** -0.050 -0.138** -0.187*
(0.060) (0.060) (0.072) (0.042) (0.073)

Selfest - - - -0.601** - -0.601**
(0.087) (0.087)
StructuralEquationFitR
2
=.228 R
2
=.615
*p< .05;**p<.01
Note:ThevaluesinthetableareStandardizedValues.ThevaluesintheparenthesisareStandardError.
DE=DirectEffect PLS=PerceivedLifeStress
IE=IndirectEffect PPar=PerceivedMaternalParenting
TE=TotalEffect Msup=MaternalSupport
MoDe=MaternalDepressiveSymptoms Osup=SupportfromOthers
Gen=Gender Selfest=Self-esteem
Table 3 (continued)
Variabales Selfest AdoDe
DE IE TE DE IE TE
Figure 1Validationresultsoftheadolescentdepressivesymptomsmodel
193

Vol. 13 No. 3

Discussion
The interpersonal theory of depression
frameworkwasusedtopredictrelationshipsamong
thefactorsrelatedtodepressivesymptomsinThai
adolescents of mothers with depressive symptoms.
The findings identified the effect of maternal
depressive symptoms on depressive symptoms in
Thai adolescents. This relationship was mediated
by intervening variables, including: perceived life
stress; perceived maternal parenting; maternal
support; support from others; and, self-esteem.
The results are congruent with previous findings
whichhaveshownmaternaldepressivesymptomsdo
notdirectlyimpactadolescentsdepressivesymptoms,
butareinfluencedbymediatingvariables.
2
Theeffectofmaternaldepressivesymptoms
onadolescentsdepressivesymptomswasshownto
be mediated through: life stress (perceived life
stress and perceived maternal parenting); social
support(maternalsupportandsupportfromothers);
and, self-esteem. In addition, social support
(maternal support and support from others) was
found to have a mediating effect on adolescents
depressive symptoms through self-esteem. These
findings are congruent with prior research, which
hasrevealedinterpersonalrelationshipswithsignificant
others, in providing support and protecting self-
esteem, are significant protective factors in the
developmentofdepressivesymptoms.
15,16
Inaddition,
self-esteem has been shown to mediate the
relationship of social support and depression, and
social support has been found to be an important
resistance factor, regarding depressive symptoms,
but only in combination with self-esteem.
15,16
However, providing social support, without self-

esteem enhancement, has not been found to be
effective and might even place one at risk for
diminishedself-esteem.
16
Thus,thetestmodelfor
Thai adolescents, in this study, supports previous
findingswhichshowculturalandracialdifferences
are not strong enough to make a difference in the
wayself-esteemmediatesdepressivesymptoms.
15
The findings reveal depressive symptoms in
their respective mother, not only led to increasing
perceived life stress among adolescents, but also
lead to increasing perceived impaired parenting
behaviors (not caring and overprotective) from
Figure 1(continued)
mds1=somaticandretardactivity par-nc=perceivednotcaring
mds2=depressedaffect par-o=perceivedoverprotection
mds3=positiveaffect ms1=emotionalandphysicalsupport
mds4=interpersonalrelationship ms2=givinghelp
Fem=female ms3=givinginformationandguidance
ls1=problemswithfriends os1=significantothers
ls2=problemswithboy/girlfriends os2=family
ls3=problemswithmoney os3=friends
ls4=problemswithcourses se1=feelingofselfvalueandselfrespect
ls5=problemswithteacher se2=feelingofcompetenceandability
ls6=problemswithparents ads1=somaticandretardactivity
ls7=problemswithotherstudents ads2=depressedaffect
ls8=problemswithrelative/s ads3=positiveaffect
ls9=healthproblems ads4=interpersonalrelationship
ls10=academiclimitations&courseinterest
194

them.Inotherwords,Thaiadolescentsofdepressed
motherswerefoundtoencounterstressfulparenting,
fromtheirdepressedmother,aswellasexperience
stressful events in their own lives. These findings
arecongruentwithpriorstudies,whereinlifestress
for adolescents of depressed mothers has been
shown to consist of two domains: 1) stress from
being parented by the depressed mothers; and, 2)
stressfromthestressfuleventsintheirownlive.
11
Moreover, this study found that gender had

amediatingeffectthroughperceivedlifestressand
perceived maternal parenting on the adolescents
depressivesymptoms,indicatingthegirlsweremore
sensitivetothiseffectthantheboys.Perceivedlife
stressandperceivedmaternalparentingwerefound
to be associated with depressive symptoms in the
boysandthegirls,butwasslightlystrongerinthe
girls than in the boys. This finding is congruent
with recent research which has documented Thai
cultureplaysanimportantroleonparentalrearing
practices and a childs gender.
33
In addition, Thai
parentsareknowntoexercisemorecontrolovertheir
daughters than their sons.
33
Differences in child
rearingpracticeshasbeenshowntohaveasignificant
impactontheperceivedlifestressandmentalhealth
ofThaichildren.
34
Thesefindingsalsoarecongruent
withpriorfindingswhichhaverevealedadolescent
girlsexperiencehigherlevelsofinterpersonalstress
than do adolescent boys.
35
The higher levels of
interpersonalstress,inturn,helpsexplainthehigher
ratesofdepressivesymptomsinadolescentgirls,in
that exposure to episodic interpersonal stressors is
an important factor regarding the development of
depressivesymptomsinadolescents.
35,36
Thefindingsalsosuggestthatperceivedlife
stress has both a significant, positive, direct and
indirecteffectonadolescentsdepressivesymptoms.
Thosewhohadhighlevelsofperceivedlifestress,
directlyandindirectly,alsohadanincreaseintheir
depressivesymptoms.Thisfindingiscongruentwith
previousresearch,whichhasindicatedthatadolescents
whoareexposedtohighlevelsofstress,particularly
interpersonal stressors, are more likely to develop
depressivesymptomsthanadolescentswhoareexposed
tohighlevelsofstress,butnotinaninterpersonalcontext.
35
In addition, impaired parenting (not caring

and over protection) from ones mother could,
directly and indirectly, increase an adolescents
depressive symptoms. Adolescents, in this study,
who received impaired parenting (not caring and
overprotection)fromtheirrespectivemother,were
lesslikelytoreceivesupportfromtheirmotherand
others. The lack of perceived support may have
decreasedtheadolescentsself-esteemandprecipitated
their depressive symptoms. However, impaired
parenting from their respective mother also was
found to directly decrease the adolescents self-
esteem and increase their depressive symptoms.
The findings, of this study, are congruent with
priorfindings,whichimplyperceivedlackofmaternal
care is associated with a diagnosis of depression
amongadolescents,
37
andsupportpreviousfindings
which suggest deficits in parental support can
predictfutureincreasesindepressivesymptoms,and
theonsetofmajordepression,amongadolescents.
37
Thesefindingsalsosuggestthatthecombination
of having a depressed mother and a high level of
life stress (perceived life stress and perceived
maternal parenting) may lead an adolescent to
perceivelesssocialsupport,and,thus,adecreased
self-esteem.Inotherwords,adolescentsofdepressed
mothers, who have high levels of life stress, may
not perceive support from either their respective
mother, or others, and be unable to develop their
own self-esteem. On the other hand, if such
adolescents perceive receive social support, their
self-esteemmaynotbeaffectedwhenexperiencing
stress. These findings are supported by the
interpersonal theory of depression that purposes
adolescentsneedsupportprovidedbytheirsignificant
other, so that they can gain self-esteem. This
theoretical foundation also is supported by prior
195

Vol. 13 No. 3

researchwhichrevealstheemotionalsupportaThai
studentreceivesfromasignificantother,specifically
a parent, is the significant factor in the prediction
ofthedevelopmentoftheadolescentsself-esteem.
38
These findings also are congruent with previous

findingswhichshowpeerandparentalsupporthasan
effectonadolescentsself-esteem,butdosoindependently.
In addition, peer support has been found to have
more effect when maternal support is low, but
minimaleffectwhenmaternalsupportishigh.
39
The applicability of the interpersonal theory

ofdepressiontoThaimaternal-adolescentdepressed
populations(atheoryinwhichself-esteemmediates
the intimate relationship quality with a significant
personhavingdepressivesymptoms)appearstobe
validatedbythefindingsofthisstudy.Havingapoor,
interpersonal,relationshipwithamothercouldcause
chronicanxietyandbeconceptualizedasastressor.
Thisstudyalsoextendstheunderstandingof
social support in the context of adolescents of
motherswithdepressivesymptoms.Priorresearch
regarding social support has not distinguished
maternalsupportfromthesupportofothers.Inthis
study, besides others social support, maternal
supportwasexplicitlyidentified.Theresultsrevealed
thatmaternalsupportandsupportfromotherswere
key factors influencing adolescents self-esteem.
Thus,eithersupportfromonesrespectivemother,
who has depressive symptoms, or from others,
could attenuate the impact of maternal depressive
symptomsonanadolescentsself-esteem.
StudyLimitationsandRecommendations
forFutureResearch
Allstudieshavelimitationandthisstudyis
no exception. Firstly, the sample was limited to
highschooladolescentsinBangkok.Therefore,the
findings are not generalizable to the entire Thai
adolescent population, or to adolescents whose
respectivemotherdoesnothavedepressivesymptoms.
Secondly,thesampleconsistedentirelyofadolescence.
Itispossiblethattherelationshipbetweenmaternal
depressive symptoms and the course of depressive
symptoms, in adolescents, might differ between
individuals with pre-pubertal versus post-pubertal
depressivesymptomsonset.
40
Based on the causal model, developed in
thisstudy,apotentialfuturedirectionforresearch
couldbetotestthecausalmodelinothersamples,
i.e.Thaivocationalandcollegestudents.Giventhe
susceptibility of girls to impaired mothering, a
study regarding the development, implementation
andevaluationofmentalhealthprogramsfocusing
onadolescentfemalesmightbeinorder.
ImplicationsforNursingPractice
Theresultsrevealthathavingamotherwith
depressive symptoms is a sign of risk for depressive
symptomsinanadolescent.Nurses,bothinhospital
andcommunitysettings,needtodetectearlydepressive
symptoms in adolescents, and provide appropriate
preventive interventions. Mothers diagnosed with
depressionshouldbeimmediatelyassessedfortheir
ability to take care of their children, and their
interpersonal relationships with family members,
whichmightcreatestress.Childrenofdepressedwomen
need regular monitoring for risk of developing
problematic behaviors and depressive symptoms. They
needtobeprovidedwithageappropriateinformation
regarding stress management options. In the
community, specifically in the schools, effective
screeningforat-riskadolescentsisneeded.
Psychiatric-mental health nurses need to
assist teachers in developing the ability to assess
andidentifyadolescentsofmotherswithdepressive
symptoms,andthoseatriskforimpairededucational,
social, and emotional functioning. School-based
interventions,designedtoimprovematernalparenting
andenhancesocialsupport,aswellasprotectself-
196

esteem in adolescents of mothers with depressive
symptoms,needtobeinitiated.Suchinterventions
would strengthen the family-school relationship,
whereby schools could become more involved in
thewell-beingoftheirstudents,andparentscould
gainsocialsupportandgreaterinvolvementwithin
themultiplecontextsandneedsoftheirchildren.
Currently all high schools, in Bangkok, are
runbytheMinistryofEducationandhaveinstituted
the student caring system. Teachers are in the
bestplacetoidentifyandscreenstudentswhomay
beatrisk.However,questionnaires,currentlybeing
used, are not designed to screen for depressive
symptoms,ortoscreenadolescentsforthesignsof
riskfordepressivesymptoms.Thus,effectivescreening
instruments and interventions for adolescents with
symptomaticparentsareneededinThailand.
Acknowledgements
This research was financial supported by:
the Commission of Higher Education, Ministry of
Education, Thailand; the Thai Council of Nursing
and Midwifery; and, the Faculty of Graduate
Studies, Mahidol University. The authors also
thank Professor Eleanor Holroyd and Associate
ProfessorJarruwatCharoensukfortheirsuggestions
in the preparation and editing of the initial
submissionofthismanuscript.
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198

:, RN, Ph.D. Candidate

E-mail: nsncr@mahidol.ac.th
, RN, PhD.

Linda S. Beeber, RN, PhD, FAAN. Professor, School of Nursing
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
, PhD.

, RN, PhD.

, , Linda S. Beeber, ,
:

Interpersonal Theory of Depression
460

60 %

2009; 13(3) 181 - 198
:

199
Vol. 13 No. 3
VishudaCharoenkitkarnetal.
Cognitive Performance after a Transient Ischemic Attack:

Attention,WorkingMemory,andLearningandMemory
Vishuda Charoenkitkarn, Saipin Kasemkitwattana, Barbara Therrien, Orapan Thosingha,
Thavatchai Vorapongsathorn
Abstract: This prospective study aimed to explore the three main areas of cognitive
function (attention; working memory; and, learning and memory) among individuals
who had experienced a transient ischemic attack (TIA). Convenience sampling was
used to recruit 52 individuals, who had experienced a TIA, from outpatient and
emergency departments in three tertiary hospitals, in Bangkok, and one tertiary
hospital in Ayutthaya province, Thailand; as well as 52 persons, who had experienced
minor surgery and served as matched control subjects, from the outpatient
department at a tertiary hospital in Thailand. Subjects were assessed, 3, 10 and 30
days after experiencing a TIA or having minor surgery, using the Necker Cube Pattern
Control Test, Trial Making A Test, Digit Span Forward and Backward Test, Barratt
Impulsiveness Scale, Irritability Assessment Scale, Digit Symbol Substitution Test, and
Hopkins Verbal Learning Test. A repeated-measures-within-and-across-subjects design
was used to analyze the results.
Findings indicate that those who had a TIA continued to experience attention,
working memory, and learning and memory changes, but not irritability changes, for
over 30 days after symptom occurrence. Three days after symptom occurrence, those
who had a TIA showed less ability in the 3 main cognitive performances than did the
control group. Their performance ability became worse at day 10, but improved at
day 30. All performances among those with a TIA were lower than the control group,
at all three time points. Thus, nurses should be concerned about the cognitive ability of
those who have had a TIA, as well as their respective families, and provide information
to both about the effects of a TIA, particularly 10 days after symptom occurrence.
ThaiJNursRes2009; 13(3) 199 - 215
KeyWords: attention, cognitive performance, learning and memory, transient
ischemic attack, working memory.
Introduction
Individuals who have experienced a transient
ischemic attack (TIA) are at risk of a future
stroke.
1,2
One of the most common causes of TIA,
or ischemic stroke, is atherosclerosis, which usually
occurs in one of the internal carotid arteries.
3
Prior
studies have suggested that blockage of the internal
carotid arteries may be a major risk factor for
Correspondence: Vishuda Charoenkitkarn, RN, PhD candidate,
Faculty of Nursing, Mahidol University, Bangkok, Thailand.
E-mailcharoenkitkarn@yahoo.com
Saipin Kasemkitwattana, RN, DNSc. Associate Professor, School
of Nursing, Mae Fah Luang University, Chiang Rai, Thailand.
Barbara Therrien, RN, PhD, FAAN. Associate Professor, School
of Nursing, University of Michigan, Ann Arbor, Michigan, USA.
Orapan Thosingha, RN, DNSc. Assistant Professor, Faculty of
Nursing, Mahidol University, Bangkok, Thailand.
ThavatchaiVorapongsathorn, Ph.D. (Research Design & Statistics
in Education), Associate Professor, Faculty of Public Health, Mahidol
University, Bangkok, Thailand.
200
CognitivePerformanceafteraTransientIschemicAttack:Attention,WorkingMemory
ThaiJNursResJuly-September2009
cognitive impairment.
2,4
The carotid arteries supply
blood to the anterior two-thirds of the brain
(prefrontal cortex, and lateral and temporal lobes).
3

These areas control not only motor and sensory
function, but also are associated with higher brain
functions, such as thoughts and actions. Humans
are able to attend to and analyze sensory data,
perform memory functions, learn new information,
form thoughts, solve problem and make decisions.
Therefore, a TIA may produce changes in cognitive
functions, which are more difficult to characterize
than motor or sensory loss.
Clearly, cognitive difficulties may negatively
impact ones learning, understanding, and adoption
of new health behaviors. However, previous
investigations of cognitive function, among individuals
who have experienced a TIA, have found conflicting
results.
5-10
Thus, before developing and implementing
presumed effective health education programs to
prevent strokes, it is important to identify ones
level of cognitive function, including attention,
working memory, and learning and memory.
Programs may need to be tailored to account for the
persons existing cognitive abilities or disabilities.
For example, if a person cannot pay attention to
the information being transmitted, he/she will not
learn and remember.
11, 12
In other words, if people
cannot use the information they receive, they cannot
change their behavior.
LiteratureReview
Despite the short duration of TIA symptoms,
and absence of residual disability, those who have
experienced a TIA require an active approach,
because the risk of future events remains high. The
highest risk is within the first 30 days.
1,2
A study of
patients presenting to an emergency department,
within 24 hours after a TIA, reported a 5.3% risk
of stroke at two days,
13
a 8 % risk at seven days,
and a 12 % risk at one-month.
1
In an attempt to
prevent a recurrent stroke, national stroke guidelines
recommend symptom management within the first
48 hours, after the onset of symptoms, and referral
to a neurological specialist within 7 to 10 days.
13,14

Treatment should include 300 mgs of aspirin,
along with a 4-week intake of all other medications
prescribed by the neurological specialist.
14
In
addition, health information needs to be provided each
time the patient interfaces with a health care provider.
Nurses usually provide a psychosocial
supportive role to individuals who have experienced
a TIA. The main aspects of providing support
include directing patients to key services, and giving
appropriate and accurate information regarding
treatment and lifestyle changes for the purpose of
preventing future strokes.
14
Therefore, effective
communication between patients and nurses is
essential, especially within the first month post-
TIA. Nurses are aware, from practical experience,
that non-adherence to health care regimens is a
major factor in the recurrence of strokes.
15,16
One
seldom explored, yet potentially powerful explanation
for why patients encounter difficulties in making
lifestyle changes and adhering to treatment regimes,
could be subtle or overlooked changes in patients
cognition, or actual cognitive impairment. Problems
within the brain of a person who has had a TIA
may affect his/her ability to select, attend to, learn
and/or remember information. Some cerebrovascular
lesions are clinically silent or cause disorders in
function so mild that the effect is hardly noticeable
to the patient.
17
Regarding the pathology of TIAs, one of the
most common causes is atherosclerosis, which usually
occurs in the internal carotid arteries.
3
These two
arteries supply blood to the prefrontal cortex (the
anterior part of the frontal lobes of the brain) and the
hippocampus (a structure located inside the medial
temporal lobe of the cerebral cortex).
3
When blood
flow through one, or both, of the internal carotid
arteries is impeded, cerebral ischemia occurs.
201
Vol. 13 No. 3
Animal models have provided clues to the

nature of cognitive function impairment secondary
to a cerebral ischemia. Cerebral ischemia, lasting
at least 5 minutes in rats, has been found to be
related directly to the extent of damage in the
hippocampus.
18
The pyramid CA1 cells, in the
hippocampus, are known to be very susceptible to
ischemia.
18
The hippocampus area of the brain
plays an important role in both learning and
memory processing. Research has shown that an
ischemic event in the rodent brain leads to
selective loss of pyramidal CA1 cells of the
hippocampus, which slowly occurs over a two to
three day period, with almost total destruction of
the cells after four days.
6
The cellular damage has
been found to be present after a recovery period of
one week.
19
Tanaka and colleagues
7
found, in
Wistra rats, that cholinergic activity (an index of
transmitter activity associated with learning and
memory) in the frontal cortex markedly decreased
3 weeks after an ischemic event, but was restored
six weeks later. The prefrontal cortex is another
area significantly impacted by a TIA.
2,3
This area
of the brain is associated with cognitive functions,
such as attention, working memory and executive
attention (the main component of both attention
and working memory).
20,21
The findings of the
aforementioned studies suggest that, in animal
models, cognitive function may change, anywhere
from a few days to nine weeks, after TIA
symptoms occur.
Evidence suggests that cognitive problems
are experienced, among humans, after a TIA occurs.
Attention, working memory, and learning and
memory are three main cognitive functions associated
with the prefrontal cortex and hippocampus.
5
Prior
studies have confirmed that attention, working
memory, and learning and memory impairment
occur after one experiences TIA symptoms.
8,9
In
contrast, Sinatra and colleagues
10
found individuals
who had experienced TIA symptoms did not have
poorer performance in all verbal tests, than did
those who had not experienced a TIA. However,
the tests were administered one to three months
after the occurrence of the last ischemic event.
Frontal lobe dysfunction, accompanying carotid
stenosis, has been found to be associated with
potential attention and working memory difficulties.
For example, Rao and colleagues
22
found two
measures of frontal lobe function (verbal fluency
and behavioral control) to be independent predictors
of global cognitive impairment among individuals
who have experienced a TIA. Moreover, Sachdev
and colleagues
23
found cognitive deficits among
individuals who had experienced a TIA to be
characterized by disturbances of frontal functioning,
but with less verbal memory impairment. As a whole,
prior investigations have revealed conflicting
findings regarding cognitive functioning among
individuals who have experienced a TIA. Cognitive
function may be affected by the time of measurement
and the various tests administered. However, they
indicate cognitive function changes, within a
month, after a TIA event occurs. Clearly cognitive
difficulties would impact negatively the learning,
understanding and adoption of new health behaviors.
Thus, based upon the need to prevent a
recurrent stroke, during the first month after a TIA
event, and due to the conflicting findings regarding
cognitive function, the aim of this study was to
explore the three main areas of cognitive performance
(attention, working memory, and learning and
memory) 3, 10, and 30 days after TIA symptom
occurrence.
Method
Design: A repeated measures, within-and-
across subjects, design, using case-control technique,
was utilized to exam the pattern of cognitive
performance of individuals, who had experienced a
TIA, 3, 10, and 30 days after TIA symptom
202
occurrence. Matched control subjects, after experiencing
minor surgery, also were tested at the same
intervals. Cognitive function has been studied
primarily in Western cultures and, thus, norms may
not be representative of Eastern cultures. The case-
control study approach was used to obtain an index
of normal cognitive function in a different culture.
Samplesize
Sample size was calculated using the formula
for ANOVA,
24
yielding 52 subjects, who had
experienced a TIA, and 52 control participants,
who had experienced minor surgery, with a
statistical power of 0.80, an effect size of 0.25
and a significance level of 0.05. The total sample
size was 104 persons.
Sample
After institutional ethics committee approval
was granted, from the main authors academic
institution and from all hospital settings involved in
the study, subjects for both the TIA group and the
minor surgery group were recruited. A convenience
sample of 52 individuals who had experienced a
TIA was drawn from the list of patients who were
admitted through the outpatient and emergency
departments of three tertiary hospitals in Bangkok
and one tertiary hospital in Ayutthaya province,
Thailand. Selection criteria, included individuals
who had experienced a TIA and were: (a) at least
24 years old; (b) able to read and write Thai; (c)
able to take and respond to tests and questions; (d)
without hearing loss, eye problems, history of
substance abuse or dependency, diagnosis of cancer,
HIV/AIDS, head injury, attention deficit hyperactivity
disorder or any known neurological disorder other
than a TIA; (d) not currently on prescription
medications known to alter cognitive processing;
(e) not depressed; and, (f) willing to participate in
the study. A volunteer registered nurse, from each
outpatient and emergency department, was asked to
assist the primary investigator in recruiting potential
subjects for the TIA group. This was accomplished
by the volunteer nurse identifying potential subjects,
via their chief complaint, and then confirming, with
a neurologist, their diagnosis of TIA and adherence
to the selection criteria. Once potential subjects
were identified, the volunteer nurses explained: the
objective of the study; what the subjects involvement
would entail; that anonymity and confidentiality
would be maintained; and, that the subject had the
right to withdraw at any time, without negative
repercussions. Potential subjects consenting to take
part in the study were asked to sign a consent form
and to provide their telephone number so that they
could be contacted by the primary investigator.
After receiving a subjects consent to participate,
the researcher called the subjects for the purpose of
setting up an appointment to introduce herself and
to arrange for the three administrations of the research
instruments.
Fifty-two individuals, who had undergone
minor surgery (i.e. any surgical procedure that did
not involve anesthesia or respiratory assistance, such
as excision of a scar or suturing of a minor wound),
but had no known hypertension, diabetes, vascular
disease or history of a TIA or stroke, were recruited
for the control group. Potential subjects were
identified by way of their patient record, while
they were being seen in an outpatient department
of one of the selected hospitals. Each potential
subject was demographically (age, gender and
educational level) matched with a subject in the
TIA group. Once potential control subjects were
identified, the primary investigator provided them
the same information subjects in the TIA group
received. Those consenting to participate were
asked to sign a consent form and appointments were
made with them for the purpose of administering
the three rounds of the research instruments.
203
Vol. 13 No. 3
Four subjects, who had experienced a TIA, had
a stroke within 30 days of their initial symptoms.
They and their four matching control subjects were
removed from the study. As a result, four more
individuals, who had experienced a TIA, as well as
four matching control subjects, who had experienced
minor surgery, were recruited and participated in the
study. Thus, the attrition rate for the study was 7.69%
Instruments
A Demographic Data Questionnaire was used
to obtain subjects demographic characteristics,
while their cognitive performance (attention, working
memory, and learning and memory) was evaluated
via eight different measures. Their cognitive
performance assessment included the: Necker Cube
Pattern Control Test (NCPCT); Digit Span Forward
Test (DSFT ; Trail Making A Test (TMAT);
Barratt Impulsiveness Scale (BIS); Visual Analogue
Scale (VAS); Digit Symbol Substitution Test
(DSST); Digit Span Backward Test (DSBT) and,
Hopkins Verbal Learning Test-revised (HVLT-R).
The researcher developed Demographic Data
Questionnaire obtained information on all subjects
regarding their gender, age and educational level.
Data obtained on those who had experienced a TIA,
included their TIA symptoms, length of symptoms
and illness history.
Attention, the first component of cognitive
performance, was assessed via five tests that
measured distractibility, impulsivity and irritability.
Distractibility was measured using the NCPCT,
DSFT and TMAT. Impulsivity was assessed using
the BIS, while irritability was measured by way of
the VAS. The NCPCT was developed as a direct
test of ones attentional capacity (ability to
inhibit a competing pattern stimulus) by using a
cube with a width and length of 2 centimeters each
and a depth of 1 centimeter.
25, 26
Subjects may see
the cube pattern in two different views, one when
looking at the foreground and the other when
reversing to the background of the cube. To maintain
one pattern, subjects have to mentally inhibit the
alternative pattern. There are two assessment
components to the NCPCT, for: 1) establishing a
baseline of passive attention; and, 2) measurement
of controlling, or effortful, attention.
In the first component, the subject is tested
in two 30-second sessions (T1 and T2). The subject
is asked to passively look at the cube. Each time
the cube reverses or flips, the subject taps the
researchers hand. The researcher counts the number
of flips that occur.
In the second component, the subject is tested
in the two more 30-second sessions (T3 and T4).
The subject is asked to try to keep the cube from
flipping. Whenever, the cube reverses or flips, the
subject also taps the researchers hand. The
numbers of flips that occur are counted. The values
obtained from session T1 and session T4 are
discarded. The value obtained in session T2 is
subtracted from the value obtained in session T3,
with the results being divided by the value obtained
in session T2. This results is then multiplied by
100 for a percentage score [(T3-T2)/T2 x100].
The result was defined as the persons attentional
capacity. TIA subjects who had a significantly
higher mean NCPCT score than their matched
control were determined to have distractibility
The DSFT examines verbal recall; attention
capacity and working memory by having subjects
retain a verbally stated series of numbers, and then
repeated back in the correct order.
27
The number of
digits in the sequence increases, with each successful
repetition, until 9 digits are successfully repeated,
or until the person fails, at a given sequence, after
two attempts. The score is the highest number of
digits successfully completed. Scoring is expressed
in the form of a digit. Each item is scored 0, 1, or 2,
with: 2 = passes both trials; 1 = passes only one
trial; and, 0 = fails both trials. TIA subjects who
204
had significantly lower mean scores than their
matched control were considered to have attention
impairment and distraction.
28

Attention and concentration abilities, including
visual-motor, conceptual tracking and sequencing
skills, were measured by the TMAT.
29
This instrument
is a timed (minutes) paper and pencil test, which
consists of 25 encircled numbers randomly scattered
over an 8x11 paper. Subjects are instructed to
connect, in order, the series of numbers without
lifting his/her pencil from the paper. TIA subjects,
who spent significantly more time to complete the
test than their matched control, were determined to
have poorer attention and concentration abilities.
Impulsivity was measured by the Barratt
Impulsiveness Scale (BIS) short form,
30
which
consists of 15 items with a 3 factor structure: poor-
planning (5 items), motor impulsivity (5 items)
and attention impulsivity (5 items). Since it originally
was used with students, slight modifications of the
situation in the questionnaire were made for this
study. Each of two original questions on attention
impulsivity was replaced by a more relevant question,
as follows:

The scores of the items of the BIS were rated
on a 4-point Likert-type scale (1= rarely/never to
4=almost always). TIA subjects who had significantly
higher scores, than their matched control, were
considered to have high impulsivity.
Irritability was measured, using a Visual-
Analogue Scale (VAS).
25
Subjects were asked to
respond to two mood state items (patience and
annoyance), which assess how they usually feel
and how they currently feel. The four questions
asked were:
1. How patient am I with others usually?
2. How patient am I with others right now?
3. How easily annoyed or irritated am I
usually?
4. How easily annoyed or irritated am I
with others right now?
For each of the four questions, subjects are
asked to place a mark on a 100 mm line which
has, at one end, not at all, and, extremely so,
at the other end. For each of the two mood states,
the placement of the mark on the 100 mm line, for
the usually response, was compared to the placement
of the mark, for the right now response. The distance,
in millimeters, was measured between the two
marks. The larger the distance between the two
marks, the greater the presence of irritability. TIA
subjects who had significantly higher scores, on the
difference between the usual and right now
responses for the two mood states (patience and
annoyance), than their matched controls, were
considered to have higher irritability.
Working memory, the second component of
cognitive performance, was assessed by way of the
Digit Symbol Substitution Test (DSST) and Digit
Span Backward Test (DSBT). The DSST is used
to identify cognitive and cerebral dysfunction. This
tool requires complex visual scanning and tracking
perception, motor speed, and memory.
31
The test
consists of rows containing small blank squares, each
paired with a randomly assigned number from one
to nine. Above the rows is a printed key that pairs
each number with a different symbol. The subject
is required to scan the numbers and fill in the
blank space with the symbols corresponding
to each number, as rapidly as possible, within
90 seconds. The number of correctly matched
symbols and numbers that are recorded, within
Original: I am restless at lectures and talks. New: I am restless when listening to long talks.
Original: I squirm at plays or lectures New: I squirm when listening to long talks.
205
Vol. 13 No. 3
90 seconds, are counted. TIA subjects who had a
significantly lower score, than their matched
control, were considered to have a working
memory deficit.
The Digit Span Backward Test (DSBT)
measures working memory, which involves both
the storage and manipulation of information.
27

Subjects are asked to repeat digits backwards after
they are verbally stated by the researcher. The
number of digits, in a sequence, increase, with each
successful repetition, until 9 digits are successfully
repeated, or until the subject fails at a given
sequence, after two attempts. The score is the
highest number of digits completed. Scoring is
expressed in the form of a digit. Each item is
scored 0, 1, or 2, with: 2 = passes both trials; 1 =
one trial is passed; and, 0 points = both trials are
failed. TIA subjects who had significantly lower
mean scores, than their matched control subject,
were considered to have working memory
impairment.
Learning and Memory, the third component
of cognitive performance, was assessed using the
Hopkins Verbal Learning Test-R (HVLT-R).
32

This tests examines three aspects of learning and
memory: total recall, retention and recognition.
The HVLT-R tasks include three learning trials
(T1, T2 & T3), one 20-25 minute delayed recall
trial (T4), and one yes/no delayed recognition
trial (T5). The latter trial (T5) consists of a
randomized list that includes the 12 target words
and 12 non-target words, six of which are drawn
from the same semantic categories as the target
words. Raw scores are derived for total recall,
delayed recall, retention (% retained), and a
recognition discrimination index. The scores are
measured as follow: 1) Total Recall = Trial 1 +
Trial 2 + Trial 3; 2) Percent retained = (Trial 4 /
Trial 3) x 100; and 3) Recognition = number of
hits of the T5 recognition trail / 12. TIA subjects
who had significantly lower scores, than their
matched control, were considered to have learning
and memory deficits.
Since all instruments, except the Demographic
Data Questionnaire, were written in English, they
required translation into Thai and then back
translation into English. The back translated
English version of each instrument was compared
to its original English version to make certain that
no changes in meaning occurred. Permission to use
and translate each of the copyrighted instruments
was obtained prior to them being translated
and used.
Instruments validity and reliability: The
primary researcher was trained in the use of the
instruments by Dr. Barbara Therrien, School of
Nursing, University of Michigan and Dr. Bruno
Giordani, Director, Neuropsychology Section,
Department of Psychiatry, University of Michigan,
USA. Content validity of all instruments in Thai
version was tested by four experts who were two
psychologists, one medical doctor, and one neurologist.
Face validity was assessed by administering the
instruments to ten Thai elderly, who were not part
of the study, for the purpose of evaluating cultural
appropriateness, language, level of readability and
clarity of instructions. Instrument items and
instructions were revised accordingly, based upon
feedback from the ten Thai elders. All instruments
were pilot tested on 20 individuals, who met the
studys inclusion criteria, but would not be part of
the study. Based upon the pilot study data, test-
retest reliability was assessed on the: NCPT,
DSFT, DSBT, TMAT, DSST and HVLT-R. The BIS
and VAS were tested by way of Cronbachs alpha.
The reliabilities for all instruments were acceptable
(r = .812 to .985).
206
Procedure
Each subject in both groups (TIA and matched
control) was administered the battery of tests, by
the primary researcher, in his/her respective home,
on three separate occasions. Test administration
occurred for those in the TIA group 3, 10 and 30
days after experiencing symptoms, while his/her
matched control was administered the tests 3, 10 and
30 days after having minor surgery. The test
environment was free of distractions (music, noise,
people, or outside view) during the testing process. It
took subjects approximately 50 minutes to complete
all tests.
Results
No significant differences were found among
the demographics between those who had experienced
a TIA and those who had experienced minor surgery.
The majority were middle-aged males, with a low
level of education (see Table 1). Among those
who had experienced a TIA, it was their first TIA
episode. All of them had a history of hypertension
and most (n =52; 100%) encountered physical
weakness and difficulty speaking (n = 29;
55.70%) after experiencing their TIA. Their
symptom duration ranged from 5 to 120 minutes,
with a mean of 20 minutes (see Table 2).
Gender
- Male 31 59.60 31 59.60
- Female 21 40.40 21 40.40
Age (years)
< 40 2 3.80 2 3.80
40-49 19 36.50 19 36.50
50-59 21 40.40 21 40.40
60-70 10 19.20 10 19.20
Average Mean=52.52 ( SD=7.97), Mean=52.52 (SD=8.00),
Min-max = 37-69 years Min-max=37-68 years
Education
- Illiterate 7 13.46 7 13.46
- < Elementary school 7 13.46 7 13.46
- Elementary school 12 23.08 12 23.08
- Secondary school 8 15.38 8 15.38
- High school / Vocational school 6 11.54 6 11.54
- Diploma Degree / Vocational school 6 11.54 6 11.54
- Bachelors or Higher Degree 6 11.54 6 11.54
Table 1 Demographic characteristics of the sample
Demographics TIA Control
n % N %
207
Vol. 13 No. 3
Symptoms
- weakness on left side 4 7.70
- weakness on right side 11 21.20
- speech difficulty 8 15.40
- weakness on left side & speech difficulty 2 3.80
- weakness on right side & speech difficulty 27 51.90
Duration of Symptoms (minutes)
<10 1 1.90
10-59 48 92.30
>59 3 5.80
Average Mean=20 SD=20.627 Min=5; Max=120
Personal Illness History
- Hypertension 26 50.00
- Hypertension & diabetes mellitus 12 23.10
- Hypertension & hyperlipidemia 6 11.50
- Hypertension, diabetes mellitus & hyperlipidemia 8 15.40
Table 2 Characteristics Related to Health Status (n = 52)
TIA
Demographics
N %
All variables met the assumptions underlying
statistical testing for two-way analysis of variance
(ANOVA) repeated with one factor. Results of the
Necker Cube Pattern Control Test (NCPCT), Trail
Making A Test (TMAT), Digit Span Forward Test
(DSFT), Barretts Impulsiveness Scale (BIS),
Digit Span Backward Test (DSBT), Digit Symbol
Substitution Test (DSST) and Hopkins Verbal
Learning Test-revised (HVLT-R) showed a
similar pattern. The main effect of time points and
group, as well as the interaction effect of group by
time points, were significant (p<.05; .01; .001).
These findings imply that those who had
experienced a TIA, as well as those who had
minor surgery, had a different degree of attention,
working memory, and learning and memory at
each of the three time points (see Table 3).
Comparing mean scores of all tests performed
revealed that those who had experienced a TIA
displayed poorer performance than did those who
had minor surgery, with respect to attention,
working memory, and learning and memory at
each of the three time points. Individuals who
experienced a TIA also were found to have a
similar pattern of impairment, which indicated
some degree of impairment three days after TIA
symptom occurrence. The mean scores of all tests
showed increased impairment, among those who
experienced a TIA, 10 days after they had TIA
symptom occurrence. In contrast, the battery of test
scores showed a change towards improvement 10 to
30 days after TIA symptoms occurred. However,
those who experienced a TIA still exhibited poorer
performance in cognitive performance than did
those who had minor surgery (see Figure 1).
208
Attention
NCPCT
TIA -52.2315.03 -48.7412.80 -55.9712.36 13.09*** 10.90*** 12.02***
Control -59.9912.01 -60.8410.75 -60.7311.06
Trail Making a Test
TIA 59.831.92 63.062.05 57.352.02 12.77** 45.90*** 52.66***
Control 51.501.39 51.501.40 51.541.39
DSFT
TIA 11.881.82 10.961.77 12.461.82 11.45** 47.319*** 30.90***
Control 12.820.24 12.810.24 12.981.82
Barretts Impulsivity
TIA 27.100.50 27.350.48 26.760.52 27.65*** 13.19*** 4.37*
Control 23.270.50 24.750.48 22.980.52
Irritability
TIA 5.380.57 5.190.57 4.810.55 5.35* 1.06
ns
1.13
ns
Control 3.650.57 3.070.52 3.560.55
Irritability
TIA 5.480.50 4.710.50 4.330.47 4.43* 2.85
ns
0.56
ns
Control 3.650.62 3.460.61 3.170.59
WorkingMemory
DSBT
TIA 6.920.25 5.830.24 7.130.27 15.74*** 32.61*** 55.22***
Control 7.980.24 8.060.25 7.850.25
DSST
a
TIA 34.581.36 32.521.34 35.401.34 16.97*** 92.91*** 59.43***
Control 41.501.13 41.231.13 41.541.15
Learning&Memory
HVLT -R
- Total Recall
TIA 20.540.71 19.100.40 22.060.64 11.27** 32.30*** 30.30***
Control 23.170.53 23.370.52 23.400.52
- Retained
TIA 104.692.39 96.552.62 114.201.38 60.55*** 12.98*** 10.76***
Control 122.641.53 117.131.53 118.381.39
- Recognition
TIA 1.710.02 1.630.02 1.740.02 22.33*** 58.53*** 41.04***
Control 1.780.02 1.770.02 1.800.02
*p<.05,; **p<.01; ***p<.001
Table 3 Repeated measures ANOVA for TIA group and matched control group
3 days 10 days 30 days Group Time Group x Time
MeanSD MeanSD MeanSD F F F
209
Vol. 13 No. 3
Figure1 Comparison of the mean scores of the NCPCT, DSFT, TMAT, DSBT, DSST, and HVLT-R
The irritability score of those who
experienced a TIA did not show, over the 30 day
period, the same pattern of change as the other test
scores. However, the mean irritability scores of
those who had experienced a TIA suggested they
were more irritable, at all three time points, than
were those who had experienced minor surgery.
Discussion
The results provided evidence that compromised
cognitive performance (attention, working memory,
learning and memory) occur after a TIA. Most
subjects presented with weakness and speech
difficulties, which may have occurred secondary to
a disturbance in their frontal lobe, and the lateral
surfaces of their temporal and parietal lobes, due to
ischemia.
3,34
Thus, their symptoms may have
contributed to their brain function.
210
Furthermore, the mean duration of TIA
symptoms was 20 minutes, providing an indication
of the extent of possible CA1 cell damage, in the
hippocampus, and deficits in spatial learning.
Confirmation of CA1 cell loss has been conducted,
in rats, when ischemia has occurred for 5 and 10
minutes.
17
The fact that those who had experienced
a TIA had ischemia for approximately 20 minute
helps explain why their cognitive performance was
worse than those who had minor surgery. In
addition, results of this study are supported by
prior findings,
35, 36
which show that persons with
an obstructed carotid artery, who have experienced
a TIA, can have lasting cognitive impairment,
which affects their attention, memory and learning,
despite recovery of their focal neurological deficits,
such as weakness or speech difficulties.
Attention: Anatomical studies on attention
impairment have cited findings regarding prefrontal
and parietal lobe damage.
20
This study found impaired
performance, at all three time points, when using
measures of distractibility and impulsivity, two of
the indicators of attention impairment. Attention is
essential for effective functioning, since it is necessary
for learning needed information.
Distraction manifests as failure to inhibit
competing demands or loss of focus, while impulsivity
is related to the loss of inhibition in the behavioral
dimension. In this study, results from the BIS
showed the same pattern as those of the
distractibility tests (NCPCT, DSFT, TMAT). These
results corroborate other studies, which concluded
there are real attention deficits among individuals
who have experienced a TIA.
22, 23
In contrast, individuals
who have experienced a TIA have been found to
not necessarily show worse performance than those
who have not experienced a TIA.
10
However, this
was found through the use of dissimilar tests from
this study and without matched controls, based on
gender and education.
In this study, an increase in distractibility and
impulsivity was found between days 3 and 10, and
beginning improvement of cognitive function was
noted between days 10 to 30. This may be related
to the fact that body weakness is present when
prefrontal and parietal lobes are damaged.
20
In
addition, brain cells are known to remain damaged
one week post-TIA symptoms.
18
Another explanation
for the worsening of attention capacity, at day 10,
is that environmental and life demands may be
increasing at that time, since subjects were trying
to return to their normal life activities. It is likely
that these demands overwhelmed their attention
capacity, since their brain cells still were compromised.
Beginning improvement of cognitive function may
have been noted between days 10 to 30, since
neurological recovery is known to generally occur
during the first few weeks to months, post attack.
37

The fact that attention deficit was still found at day
30, among those who had experienced a TIA,
most likely is related to the fact that, in Wistar
rats, an increase in choline acetyltransferase activity
in the frontal cortex and hippocampus, caused by
hypofusion of cerebral blood flow in the forebrain,
results in behavior deficits.
7

Although the results of the irritability testing
(VAS) did not show the same pattern as found with
distraction or impulsivity, those who had experienced
a TIA showed more irritability than did the
controls at all three times of measurement. This
may be because the irritability test was not sensitive
enough, or the irritability change was too small, to
detect the change. It is possible, also, the irritability
test failed to adequately capture irritability, due to
no specific situation being provided, or the subjects
could not feel a change in their irritability.
Working memory: Results suggest those
who had experienced a TIA had working memory
impairment, as measured by the DSBT and the
DSST. A consistent pattern of change in their
working memory was found, over the three time
periods, similar to the distraction and impulsivity
211
Vol. 13 No. 3
testing. One component of the working memory
model is the central executive function, which is an
attentional control system in the attention model.
Executive function has been shown to be responsible
for directing attention to relevant information,
suppressing irrelevant information and inappropriate
actions, and coordinating cognitive processes, when
there is more than one task to be done at the same
time.
21
In this study, those who had experienced a
TIA were found to have attention deficit. Thus,
they had deficiencies in their working memory and
were not able to manipulate all the information
they received.
Another possible explanation of the finding
is there is a relationship between the frontal lobes
and working memory. Prior studies have shown the
frontal lobes play an important role in working
memory.
38
Electrophysiological recordings have
demonstrated that some neurons, in the frontal
lobes, fire only during the delay period of a working
memory task.
39
Impairment of working memory
means that information cannot be acquired, manipulated
or used in a normal manner, significantly impacting
what and how much one can learn and remember.
Learning and Memory: Learning and memory
performance (assessed by the HVLT-R) of those
who had experienced a TIA were lower than that
of their matched controls. Thus, the pattern of
learning and memory of those who had experienced
a TIA appeared to be similar to the pattern of
attention and working memory.
Impaired learning is known to be associated
with ischemic damage to the temporal lobe,
especially the hippocampus, which is supplied with
blood by the internal carotid arteries. It has been
found that CA1 cells, in the hippocampus of
animals, are sensitive to ischemia and related to
learning and memory.
18
In addition, attention is
needed to focus on the target of information before
manipulating it by working memory. The working
memory then manipulates the information and
transfers it to long term memory. These three main
concepts appear to work together as a network.
Thus, either attention or working memory deficits
could influence ones ability to learn and remember,
and have an indirect relationship with other
cognitive impairments on learning. It is likely that
the explanation, regarding the learning and memory
deficits of those who have experienced a TIA,
involves a combination of the above.
The pattern of change also may be explained
by the delayed death of CA1 cells, after a carotid
occlusion, in the hippocampus. Animal studies have
revealed that after an ischemic event of at least 5
minutes, the cells change very slowly after two
days; but are almost totally destroyed within four
days.
18
Therefore, those who have experience at
TIA, at day three, may show less ability in
learning and memory than they had pre-TIA, due
to the decreased number of functioning CA1 cells.
It also is possible that the destruction of CA1 cells
continued, which may account for the worsening of
learning and memory at day ten post-TIA.
In contrast, test scores, of those who had
experienced a TIA, showed improvement, between
day 10 and day 30. This may be related to the
fact that the activity of the enzyme, choline
acetyltransferase, has been found to be restored, in
sham-operated rats, six weeks after a carotid
ligation.
7
In addition, choline acetyltransferase
dysfunction has been shown to be correlated with
discrimination learning disabilities in hypoperfused
rats.
7
Even though improvement was noted, among
those who had experienced a TIA, at day ten, such
an explanation may explain why their HVLT-R
means scores, at day 30, were poorer than
the HVLT-R means scores of their matched
control. Prior research also found that individuals
who had experienced a TIA subjects showed
significant differences in their cognitive impairment,
when compared to persons who had not
experienced a TIA.
23

212
Conclusions,Recommendationsand
Limitations
This study found that impairment of
attention, working memory, and learning and
memory, but not irritability, occurred in the first
few days after the presentation of TIA symptoms.
The impairments were found to worsen, by day
ten, but improved between day 10 and 30.
However, it is not clear if there was continual
regression before recovery, or if recovery had
begun earlier than the tenth day. Regardless, nurses
need to assess the ability of those who have
experienced a TIA to receive information,
particularly 10 days after their initial symptom
occurrence. Further research is needed to measure
cognitive performance at different times, i.e. at
days 3, 5, 10, 15, 20 and 30 to help clarify the
impairment pattern.
Moreover, the findings show that those who
experienced a TIA may have had cognitive
impairment before testing. Their cognitive impairment
may have occurred before the presentation of their
TIA symptoms. Since to demonstrate the effect of
cognitive impairment, the relationship between
cognitive impairment and an individuals ability to
learn and remember are required, comparison of
cognitive performance, among those who have TIA
symptoms and individuals who do not have TIA
symptoms should be explored.
Although irritability among those who had
experienced a TIA did not change within 30 days
of their occurrence of symptoms, they were found
to have more irritability than their matched
controls, at all three times of measurement. Even
though the instrument used to measure irritability
had a high reliability, the individual items used
within the instrument need to be further examined,
since it is possible they were not sufficiently
sensitive to detect changes in the subjects
irritability. In addition, the use of qualitative
questions, in future studies, may be needed to
enhance measurement and interpretation of
irritability.
Finally, the primary researcher, who had
been trained to administer all the tools used, as well
as to score and measure the results, did so solely by
herself. Therefore, unintentional biases in the
measurement and reporting of data may have
occurred.
ImplicationsforNursingPractice
The findings may stimulate nurses and other
health care providers to consider patients ability to
think, receive information, and learn, particularly
10 days after having experienced the occurrence of
TIA symptoms. If any information is to be given,
during this time, families or relatives probably
are the key persons to help those who have
experienced a TIA receive suggestions and instructions
from nurses and other health care providers.
Moreover, individuals who have experienced a TIA
should be cautioned to think before they act,
especially since impulsivity often leads to falls,
accidents and mistakes.
Furthermore, nurses should implement
therapies to help those who have experienced a
TIA deal with their cognitive changes. Examples of
restorative techniques, which may assist to improve
learning and memory, include: using vivid pictures
to capture attention; limiting competing stimuli
(TV); doing one task at a time; speaking slowly;
using short sentences during instructions to
facilitate working memory; putting important pieces
of information first and last during short instruction
periods; and, building in repetition and demonstration
of tasks.
25, 40
213
Vol. 13 No. 3
Acknowledgements
The lead author wishes to thank the Faculty
of Nursing, Mahidol University and the Commission
of Higher Education for their scholarship, as well
as the Thailand Nursing Council for Nursing and
Midwifery for the grant which supported this study.
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:, RN, PhD candidate,

E-mail charoenkitkarn@yahoo.com
, RN, DNSc.

Barbara Therrien, RN, PhD, FAAN. Associate Professor, School
of Nursing, University of Michigan, Ann Arbor, Michigan, USA.
, RN, DNSc.

, Ph.D.

:
, , Barbara Therrien, ,

: (prospective study)
3 (attention) (working memory)
(learning and memory) (TIA)
(convenient sampling) 52
4
() 52
1
Necker Cube Pattern Control, Trial A, Digit Span Forward,
Barratt Impulsiveness Scale, Irritability Assessment Scale, Digit Symbol Substitution, Digit Span
Backward, Hopkins Verbal Learning 3
3,10 30

30
3 3
(Irritability) 10
30 3 TIA

10

2009; 13(3) 199 - 215
:

216
Participative Model of Child Protection in Northern Thailand


ParticipativeModelofChildProtectioninNorthernThailand
Naruemon Auemaneekul, Wilawan Senaratana, Yuwayong Juntarawijit, Kasara Sripichyakan,
Barbara J. Ensign
Abstract: This community-based, participatory research was undertaken with the aim
to develop a model for promoting child protection in Northern Thailand. Semi-
structured interviews, focus group discussions, participant activities and observations,
group meetings and brainstorming were conducted among children, parents, villagers
and key community leaders of one rural community in Chiang Mai province,
Thailand. Content analysis was utilized for analyzing qualitative data.
The model demonstrated three levels of protective factors for child protection.
At the individual level, both children and parents needed to be equipped with the
skills and knowledge of child protection. At the family level, the focus was on
promoting family warmth and applying sufficient economy. At the community level,
the emphasis was on promoting public awareness, encouraging a child protection
network, and developing a community child protection master plan. Community
mobilization supported the sense of belonging and sustainability of the project.
The participation evaluation indicated change outcomes in terms of more
network interest, raising public awareness, improving capacity, disseminating
knowledge, and committing and implementing community child protection policy.
The study outlines implications for nursing research, education and practice regarding
child protection. Culturally appropriate activities and programs also were encouraged.
Thai J Nurs Res 2009; 13(3) 216 - 226
Keywords: child protection, participative model, Northern Thailand
Background and Significance
Children have rights to special protection
because of their powerlessness against maltreatment.
The United Nations (UN) Convention on the
Rights of the Child (CRC), to which Thailand
became a signatory, addresses survival, protection,
development and participation rights.
1
Child protection
refers to protecting children from violence,
exploitation, abuse and neglect.
1, 2
Violations of
childrens rights to protection are massive, under-
recognized and underreported obstacles to child
survival and development. According to the World
Health Organizations (WHO) Global Burden of
Correspondence to: Naruemon Auemaneekul, RN, PhD Candidate
Faculty of Nursing, Chiang Mai University, Thailand. E-mail:
phnaruemon@staff2.mahidol.ac.th
Wilawan Senaratana, RN, MPH. Associate Professor, Department
of Public Health Nursing, Faculty of Nursing, Chiang Mai University,
Thailand.
YuwayongJuntarawijit, RN, DrPH. Assistant Professor, Department
of Public Health Nursing, Faculty of Nursing, Chiang Mai University,
Thailand.
KasaraSripichyakan, RN, PhD. Associate Professor, Department of
Pediatric Nursing, Faculty of Nursing, Chiang Mai University, Thailand.
BarbaraJ.Ensign, RN, DrPH. Associate Professor, Department of
Psychosocial & Community Health, School of Nursing, University
of Washington, Seattle, WA, USA.

Disease, some 875,000 children and adolescents,
under the age of 18 years, died as result of an
injury or violence in 2002.
3
Most child victims are
abused by their parents.
4

217

Vol. 13 No. 3

Naruemon Auemaneekul et al.
In Thailand, the available statistics of child
victims who need help has been increasing almost
every year.
5, 6
The statistics from the Health Care
Service Development Office, Ministry of Public
Health,
7
revealed, in 2007, there were 19,068
cases of abuse, which involved women and children,
for an average of approximately 52 cases of abuse
daily. Of the child abuse cases reported between
2004 and 2007, the majority involved sexual abuse
(60-70%), followed by physical abuse (20-30%),
mental abuse (3-7%) and neglect (2-4%).
Review of the literature, regarding Western
culture and Thai research, reveals child abuse
prevention research has focused on improving a
protective environment, parenting and childrens
life skills. Most of the studies have used a quasi-
experimental design, when examining families at
risk.
8, 9, 10, 11, 12
Although positive changes have been
reported in most of the studies, limitations in
design, including: small sample sizes, few common
characteristics being evaluated among the studies,
the use of similar methodology, and inadequate
formal and rigorous evaluations have been noted.
Therefore, the design of new studies should take these
limitations into account.
11, 13
In addition, the impact
of the findings from previous studies, on childrens
life skills and knowledge, remains unknown.
14
Prevention is the priority, which also
supports and advocates for mitigating the effects of
abuse. The quasi-experiments and randomized
control trials, which were examined, can neither be
used to confirm nor refute questions about ones
values or beliefs. The content of the studies also
does not indicate how children and parents retained
skills, learned during the studies, or maintain
modified behaviors, if they were not supported
within their own homes or communities. Additionally,
child abuse is a problem, which is influenced by
the norms, customs, values and beliefs of the
people in a specific geographical area. Therefore,
taking cultural and ecological context into account,
encouraging participation from individuals within a
specific community, encouraging general respect for
the rights of the children and raising awareness that
all forms of violence against children are taboo is needed.
Community Based Participatory Research
(CBPR) increasingly has been applied in violence
related fields, especially in child abuse prevention
efforts.
15, 16
All reviewed studies confirmed the CBPR
approach engaged local knowledge, and encouraged
the enhancement of cultural relevance, on the
respective issue under examination.
15, 16, 17, 18
In order
to protect children from being abused, it would be
helpful when trying to understand the perception of
people, in a specific geographical area, regarding
their cultural beliefs on child physical abuse and
corporal punishment, to have accomplished a community
based participatory assessment. This is significant
since the concerns, beliefs, and cultural values and norms,
mentioned by the community members, need to contribute
to the development of proper child protection
programs and activities that fit within the local culture.
Therefore, the purpose of this study was to
develop a child protection model based on the
participation of community members. The following
questions were posed: How does the community
participate in developing a culturally appropriate model
of child protection? What is a culturally appropriate
model of child protection in Northern Thailand?
Method
Community Based Participatory Research
(CBPR) was employed as the research method in
this study. Motivation for this research arose from
expressions of interest and concern regarding the
issue by stakeholders in the Northern Thailand
rural community used as the research setting.
Sample: Participants were: community leaders
(Chief Executive of the Sub-district Administration
Organization [SAO]; Community Abbot; Sub-district
and Village Headman; Assistant Village Headman;
218


Chair of the Public Health Center; and, Director of

the primary school in the community); community
members, including a group of 10-13 year old
children (both low and high risk) and their
parents; local organization personnel, both formal
and informal community leaders; and, other interested
villagers. Also contributing to the study were
volunteers of the Community Network on Child
Protection committee (CNCP); child protection
experts; and, two local research assistants.
Research Instruments: The primary instruments
for data collection were personal interviews
conducted by the primary researcher. In addition,
the primary researcher provided interview guidelines
for focus group discussions, semi-structured
interviews and an observation guide. Tools included
tape cassettes and tape-recorders. Two research
assistants were trained regarding the data collection
procedures, and provided assistance as note takers,
facilitators and co-coordinators for the research
activities, as well as interviews transcribers.
Research Procedure: The research procedure
for model development was based on the concepts
of Community Based Participatory Research (CBPR).
The strategies used involved people, capacity
building, taking culture into account, working
partnerships, power sharing and community change.
The free participation in the model development
process, among the participants, generally, began
with community preparation, problem identification,
capacity building, planning, collaborative community
assessment, and reflection and sharing of the findings.
The desired child protection model was tailored via
validation and review of child protection experts,
and reflection and consensus among community
members. This was followed with planning for
implementation of a policy driven model, including
participative evaluation for project monitoring and
further improvement.
Data Collection: Data were collected via
focus group discussions, semi-structured interviews,
group and public meetings, brainstorming, participative
activities, participative observation and field notes.
The interviews lasted one and a half to two hours
each. During each interview, note taking, clarification
of questions and eliciting of elaboration of responses
was accomplished by the primary researcher and
research assistants. The primary researcher played
the role of facilitator, consultant and participant
observer when conducting group and public meetings,
including group brainstorming sessions. Upon
completion of data collection, the researcher reflected
on the observations, interactions and discussions,
impressions from the field notes, as well as transcribed
the interviews verbatim from the audio tape-recordings.
Trustworthiness: To ensure trustworthiness of
the study, criteria for developing an effective evaluation
of qualitative research was employed.
19, 20, 21

Credibility of the study was established by prolonged
engagement with the participants, triangulation of
information from the multiple data sources, member
checking and use of peer debriefing processes.
Transferability of the study to other contexts was
established by providing a data base with sufficient
information and detailed descriptions of the means
utilized. Dependability and conformability, in this
study, were established by providing enough
information and an audit trail.
Data Analysis: Data analysis of statements
and opinions voiced by the target groups during the
focus groups and semi-structured interviews was
based on content analysis.
22
This process allowed
the researcher to analyze and classify words and/or
statements. Data then were interpreted for the induction
analysis, so as to answer the research questions.
Human Subjects Protection: Prior to
implementation, the study was approved by the
Human Subjects Review Board of the Faculty of
Nursing of the researchers university. Informed
consent was obtained from all participants. Data
collection procedures were designed to cover all
aspects of protecting the human subjects. Participants
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Vol. 13 No. 3

names were not disclosed, and all other information
was kept confidential. The audio-tapes, from the
interviews, were erased, and written transcripts
were destroyed upon completion of the study.
Results
Team building: The study began with
introduction of child abuse issues to the community,
and community discussion was encouraged regarding
the situation, causes and consequences of child
abuse. As a result, community awareness was
raised and a community child protection team,
comprised of volunteers, was established. They
later were named the Community Network on
Child Protection committee (CNCP). A team
building activity then was conducted, to facilitate
community members in getting to know each other
and in learning to work together as a team.
Need identification: The model development
process began with need identification from the
CNCP and other community members. There was
community concern that child abuse causes long-
term negative consequences, both for individual
children and society, as a whole. The CNCP and
other community members, therefore, decided to
instill prevention measures, rather than wait for
serious cases to occur in the community. They equated
protection measures to vaccines for communicable
diseases, and expressed the belief the proverb
spare the rod, spoil the child should be adjusted
and carefully applied for more appropriate child
rearing practices. The participants stated:
Waiting for a case to happen is just
like shutting the stable-door after the
cow has been stolen Voey haey
leaw loom koo ()
Protection is the vaccine Kan pong
kan preab sa muan kan ceet vaccine
()
Problem Identification: The child abuse
situation analysis was suggested and the data
collection methods were raised from individual
observations or what is called detective inquiry
activity. Information was collected from the CNCP
and focus groups, composed of children, parents
and villagers. In addition, semi-structure interviews
were conducted with key informants. Information for
the situation analysis was gathered, by the researcher,
research assistants and volunteers, from the CNCP.
Risk factors, suggesting the need for child
abuse action in the community, included community
conflict, social isolation, communication problems,
pilfering, presence of gangs, broken families,
family violence, alcohol abuse, stress, gambling,
economic problems and materialism. It was
determined that this was an at risk community (see
Figure 1). Despite the presence of these risk factors,
no indication of serious child abuse cases was
found in the community.
Model development: The child protection
concepts, gained during focus group discussions
and semi-structured interviews, were used as the
first draft for the community child protection
model. This was then presented, to the community
members during a public meeting, in order to get
feedback and suggestions. The CNCP was given
the responsibility of revising the model to more
comprehensively reflect the community concerns.
The model then was reviewed by external child
protection experts, and presented to the community
group for consensus. This resulted in the final draft
of the primary prevention model for child protection
in the community.
The child protection model emphasized
participation among local organizations and community
members, in order to protect children from all
kinds of abuse. This included improved surveillance
of children and families at risk. Details of the
community child protection strategies are portrayed
in Figure 2.
220


Figure 1 Problem identification
Figure 2 Primary prevention model for child protection
221

Vol. 13 No. 3

1. Child protection at the individual level:
Protection at the individual level included children
as victims and adults as perpetrators. Protection for
children focused on promotion of protective
factors, in order to reduce triggers and the chance
of a child becoming a victim. This included promoting
the childs social immunity by: increasing awareness
of childrens rights violations; promoting desired
behavior and self-discipline; promotion of their
morals and virtue; and, increasing life skills.
Developing childrens life skills, included: teaching
critical thinking, refusing, avoiding, protecting oneself
from harm and asking for help; and, providing
instructions on how to be safe in risky situations.
For protection from adults being a child
abuser, focus was on placed on helping adults
reduce the chance of their becoming a perpetrator.
This involved adult education about child rights,
child protection laws and the minimum standard
treatment of a child, as stipulated in the ministerial
regulations. In addition, the adults education
involved promoting knowledge, attitudes and skills
on non-violence; positive child discipline; and,
rearing practices. Thus, the promotion of good
relationships, love and bonding between parents
and children was emphasized.
2. Child protection at the family level:
Protection at the family level focused on promoting
happiness and a good environment within the
family, in order to reduce the chance of a child
becoming a victim, due to stress within the family.
Strategies included promoting: warm and healthy
relationships among family members; non-violence in
the family; and, economization, by applying the sufficiency
economy concept initiated by His Majesty the King.
3.Childprotectionatthecommunitylevel:
Protection at the community level focused on
promoting awareness among community leaders and
public education for community members, in order
to continue promotion of child protection as a
system. Creating a protective community environment
for children involved: promoting safe areas and
non-violence; development of a security system;
and, discouraging gambling, and drug and alcohol
use. Additional activities focused on providing
growth opportunities for children, such as sports
and alternative recreation for children and youth.
Finally, a committee was established to develop a
community network on child protection. The committee
organized protection surveillance and coordinated
assistance when required. The development of the
community network involved: arranging continuous
child protection activities; developing sincere involvement
among local organizations; integrating child protection
into local activities; and, promoting social cohesion
and unity in the community. Promoting participation
of a variety of community groups served to build
community strength, and raised consciousness
among community leaders, to be good role models
for non-violent problem-solving.
4.Keyleadersoncommunitychildprotection:
The key leaders on community child protection
were composed of two main sectors, the: SAO and
CNCP. The SAO was the main local organization
to provide budgetary support and integrate other
local resources. The SAO also was set as the key
leader in academic and education support, including
educating community members about child protection
laws. The CNCP was set as the key leader in
coordinating and running child protection activities.
The CNCPs responsibilities included: conducting
child protection surveillance and case reporting
service; running public hearings and consensus;
and, developing and proposing the child protection
plans to the SAO. The proposal to the SAO was
necessary in order to put the plan into local policy
and integrate it with local budgets and other
resources. In addition, this allowed the two groups
to search for and write grant proposals, and run
and evaluate projects together.
5. The community network: The
community child protection network was comprised
222


of local organizations and resources; temple, village
administration team, school, and public health center.
The temple was set as the key leader in applying
dharma doctrine and teaching for family life during
weekends. The village administration team was the
network leader in promoting community awareness
and also serving as a role model for non-violence.
As the school was the community network closest
to the children and their families, it was set as the
leader for surveillance and home visits. The public
health center was considered the leader in mental
health promotion, and promoted stress management
for families and community members and performed
home visits to families considered at risk. The
purpose of the home visits was to reduce the risk
factor of adults becoming perpetrators, by visiting
those who were more likely to abuse children.
6. Collaborative child protection activities:
Some of the activities required the cooperation and
involvement of key leader groups, community network
groups and community members, in order to proceed
and integrate child protection activities with
existing local programs. In addition, some of the
programs offered overlapping services and activities,
i.e. reducing alcohol assumption in the community;
parent education; children and youth education;
local risk area surveillance; promoting positive
recreation activities for children (sports, family
activities); and, promoting sufficiency economy.
Impact of model development: The model
development process brought about change to
promote the protective environment for children in
the community. The community meeting for both
assessment and model reflection showed increasing
community concern and awareness on child abuse
as a public issue. This could be seen with the
presence of interested parties from adjacent
communities and provincial organizations, as well
as from community suggestions, feedback, and
questions posed, by community members, to the
project coordinator. The sub-districts quarterly
journal was utilized to educate community members
on child protection activities. Outreach discussion
regarding networking and policy implementation at
higher levels were supported. The child protection
master plan, to be implemented, was another evidence
of change in the community. The community
members also came up with the vision, mission,
strategies and priority setting for each year.
Discussion
The results showed an acceptance of corporal
punishment, the embed belief of the Thai proverb
of Spare the rod and spoil the child, and a view of
children as a possession among community members.
This supports the findings of Bhikkhu,
23, 26
and
Natamongkonchai et al.
24
who mentioned that corporal
punishment is likely to be acceptable as a normative
belief regarding appropriate parenting behaviors. It
also supports the studies of Wechayachai,
25
Amornvivat
et al.,
26
Phuphabul et al.,
27
and Natamongkonchai
et al.
24
who indicated Thai parents use verbal
aggression, along with physical punishment by spanking,
hitting and pinching, to discipline their child.
When the beliefs mentioned above influenced
the consideration of corporal punishment, as the
common discipline for child rearing practice among
parents, child physical abuse in the community was
not considered as abusive. Even though Thailand
became a signatory to the Convention on the Rights
of the Child (CRC), in 1992, and the Child
Protection Act was enacted in 2003, these
concepts are relatively new for the Thai culture. In
addition, Thais, traditionally, believe that family
violence is a private issue and it is better for others
to stay out of family issues.
28, 29, 30
Thus, others are
reluctant to intervene when child abuse takes place
in the family. Similarly, this study found that the
community viewed spanking or verbal aggression as
the parents right and not an abusive behavior.
Rather, these actions, often, are viewed as way for
223

Vol. 13 No. 3

parents to show love to their children. Physical
aggression becomes abuse when it is unfair, undeserved,
done for no good reason and is excessive.
Abuse was defined in terms of harm done or
maliciousness. Therefore, the model proposed
increasing child protective factors and decreasing
risk or trigger factors at all levels. At the individual
level, protection was focused on increasing child
protection knowledge and skills, in order to
decrease the likelihood of the child becoming a
victim or being the trigger for abusive action.
This is in accordance with Belskys
31
results,
wherein childrens own behavior was found to
elicit or maintain child abuse action.
At the family level, the model focused on
promoting happiness and a good environment
within the family. This included promoting career
and side jobs, thereby applying the concepts of
sufficiency economy. Reducing family stress
would, in turn, reduce the chance of a child becoming
a victim. This was supported by the studies of
Sawyer et al.,
32
Wongsamari,
33
Krongyuth,
34
Katz and
Woodin,
35
and Thyen,
36
who indicated that families,
in which child abuse occurs, have poor relationship
patterns, more conflict and less cohesion. Straus &
Smith
37
mentioned that poverty causes the highest
rate of child abuse. This was supported by the
Transitional Model of Wolfe
38
who pointed out
that child abuse occurs when parents fail to
manage their life stressors.
At the community level, focus was on
promoting public awareness activities and education
on child rights and child protection law. The
expectation was that this would deal with those
parents who believed that family violence is a
private issue. Creating a protective environment for
children in the community and promoting community
coherence in the model would be the significant
protective factors. This idea is supported by
Belsky,
31
who discussed ecology of child abuse and
mentioned that maltreating parents often lack
significant social connections to others in their
neighborhoods and communities. Therefore, community
coherence would help family members contact with
others in the community. This could provide role
models for acceptable parental behavior and
influence parents to conform to a better standard of
the rearing and treatment of their children. It also
might maximize the use of community resources on
child abuse protection and child rearing practices.
The collaborative activities among community
resources on child protection were composed of
two majors sectors: child protection key leaders
and a child protection network. This supported the
idea of capacity-orientation proposed by Kretzmann
and Mcknight
39
who mentioned that connecting local
resources could multiply their power and
effectiveness for the project. This also supported
the concept of a community network for child
protection response proposed by UNICEF.
40
Conclusions and Recommendations
The community child protection model
emphasized the participation of local organizations
and community members in creating child
protective factors from all kinds of abuse.
Community health professionals need to play a role
in identifying and treating victims, as well as
preventing the occurrence of abuse. Prevention
should be implemented in a child-focused, family-
centered, community-based and culturally adapted
manner. Review of the protocol and the role of
community and school health nurses on child
protection should be promoted.
Acknowledgements
The authors would like to express their thanks
to the informants who took time to participate in
this study. Gratitude also is extended to the
Graduate School, Chiang Mai University and the Thai
Nursing Council, for providing funds for this study.
224


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226


:, RN, PhD Candidate

E-mail: phnaruemon@staff2.
mahidol.ac.th
, RN, MPH. -

, RN, DrPH. -

, RN, PhD. -

BarbaraJ.Ensign, RN, DrPH. Associate Professor, Department of
Psychosocial & Community Health, School of Nursing, University
of Washington, Seattle, WA, USA.

, , , , Barbara J. Ensign

:

3

2009; 13(3) 216 - 226
:

227
Vol. 13 No. 3
KallayaWiriyaetal.
BuddhistMothersExperienceofSufferingandHealingAfterthe
AccidentalDeathofaChild
Kallaya Wiriya, Urai Hatthakit, Wantanee Wiroonpanich, Lee Smith-Battle

Abstract: Numerous nursing studies have examined suffering, but none have addressed
the suffering and healing Buddhist mothers experience after the accidental death of a
child. The purpose of this study was to gain understanding of the meaning of suffering
and the practices of healing and suffering, among Buddhist mothers after such a loss.
Buddhist concepts provided the philosophical framework, and Gadamerian hermeneutic
phenomenology provided the methodological framework, for this investigation.
Ten Buddhist mothers were recruited from a government hospital in Songkhla
province, Thailand. In-depth interviews were conducted and data were analyzed
using hermeneutics. Five themes that reflected the meaning of suffering among
Buddhist mothers, after the accidental death of a child, were identified. They
included: the mothers heart was torn into pieces; the mothers body was frozen and
she was uncertain she would survive; happiness in the mothers life was missing; the
mothers anger and rage at self and others; and, the mother worried and wondered
about the next life of her deceased child. The mothers were found to heal their
suffering by: transforming their relationship with the deceased child; elevating the
deceased child to be a very good child capable of going to heaven; making merit in
order to pass the benefit to the deceased child; self-healing through understanding
and mind cultivation; and, seeking support. The findings promote the understanding
of the suffering and coping of Buddhist mothers whose child accidentally died.
ThaiJNursRes2009; 13(3) 227 - 241
KeyWords: death of child, buddhism, suffering, healing, Gadamerian hermeneutic
phenomenology
Introduction
A mother and her child are involved in an
intenselycloserelationshipfrombirthtoadulthood.
1
Thelossofachild,throughdeath,isauniqueand
particularly intense type of grief or suffering, and
may be more severe than other types of
bereavement.
2
The violent or unexpected death of
a child is a traumatic event that can bring
Correspondence to: Kallaya Wiriya, RN, PhD Candidate, Faculty
of Nursing, Prince of Songkla University, Hat Yai, Songkhla,
Thailand. E-mail: kallayawiriya@yahoo.com
UraiHatthakit, RN, PhD. Assistant Professor, Faculty of Nursing,
Prince of Songkla University, Hat Yai, Songkhla, Thailand.
WantaneeWiroonpanich, RN, PhD. Assistant Professor, Faculty of
Nursing, Prince of Songkla University, Hat Yai, Songkhla,
Thailand.
LeeSmith-Battle, RN, DNSc. Professor, School of Nursing, Saint
Louis University, St. Louis, MO, USA
228
BuddhistMothersExperienceofSufferingandHealingAftertheAccidentalDeathofaChild
unimaginable suffering for the family, especially,

forthemother.
Suffering,auniversalhumanexperience,can
bedescribedas:feelingpainordistress;sustaining
injury or loss; being the object of some action;
beingobserved;or,patientlyenduringasituation.
3
Priorstudies,inThailand,haveexaminedBuddhists
suffering regarding: family caregivers of seriously
mentallyillpatients;
4
apalliativemodelforHIV-
infected patients;
5
the use of meditation, as a
healing mode, for HIV-infected patients;
6
factors
related to paraplegic patients;
7
and, tsunami survivors
unexpected loss of family member(s), houses,
possessions and businesses.
8
However, no study
couldbelocatedthatspecificallyexaminedBuddhists
mothers suffering, as a result of the accidental
deathofachild.Thisoversightneededtobeaddressed,
since approximately 95% of the Thai population
areBuddhists.
9
Therefore,thepurposesofthisstudy
weretoinvestigate,usingGadamerianhermeneutic
phenomenology,whatsufferingmeanstoBuddhists
mothers,whohaveexperiencedtheaccidentaldeath
ofachild,andhowtheyattempttohealtheirsuffering.
LiteratureReview
Sufferingisasignificanthumanexperience,
notonlyinnursingandhealthcare,butalsowithin
the Buddhist culture. This literature review
explored the meaning of suffering in general and
the Buddhist concept of suffering, including what
Buddhists view as the causes and alleviation of
suffering.
10,11
Morse
12,13
indicatedthatsufferingrefers
toresponsetoaloss,whichinvolvesanextremely
distressed state, wherein emotions are released.
KahnandSteeves
14,15
suggestthatsufferingmeans
extremediscomfort,includingdispleasureorunpleasant
perceptions. In addition, they described suffering
asanexperiencethataffectsthewholeperson,and
isdefinedintermsofphysical,mentalorspiritual
pain; loss; and, psychological distress. Smith
16
viewed suffering as a spiraling, vicious circle of

physical,psychological,socialandspiritualdistress.
Theimmediateresponsetosuffering,accordingto
Battenfield,
17
may be shock, loss of control, or
having no expression, at all, until one recognizes
what has happened and realizes, in order to get
throughthesituation,onemustcontinuetofunction.
17
These responses also are related to the symptoms

oftraumaticgrief,depressionandanxiety.
18
In Buddhism, the notion of suffering has

been translated to Pali (the ancient scriptural and
liturgical language of Theravada Buddhism) as
dukkha,meaningunsatisfactoriness,
10,11
orbeing
inadequate or unsuitable. Suffering also has been
presented as the result of, or caused by, such
factors as disease, discomfort, disorder, conflict,
difficulties,unfullfillmentand/orpain.
10
Buddha explained everything about life in

terms of causation.
19
Causality (conditionality) is
addressed in the Law of Dependent Origination
(Paticcasamuppada),whichconsistsof12factors:
ignorance(Aviccha);volitionalactionsorkamma-
formations (Sunkhara); consciousness (Vinnana);
mentalandphysicalphenomena(Nama-Rupa);the
six faculties (five physical organs and mind)
(Uttayana);sensorialandmentalcontact(Phussa);
sensation(Vedana);desire;thirst(Tanha);clinging
(Ubbatan);theprocessofbecoming(Pope);birth
(Chatta); decay or death (Jara-marana); and,
associated sorrow, lamentation, pain, suffering,
griefanddespair.
10,20
Thesefactorsarelinkedina
circleofcauseandeffect.Acauseofsufferingmay
begin at any point of Paticcasamuuppada, but
proceedsthroughthecircle.Forexample,whenawife
seesherhusbandwithanotherwoman,thestimuli
initiallyoccursthroughthewomanseyes(ayatana
and pussa). She feels disappointment (vedana)
becauseshelovesherhusbandverymuch(tanha).
Herattachment(ubbatan)toherhusbandleadsher
toattempttokeephimasarefuge(pope).Feelings
ofjealousy,angerorworryoccur(chatta).Thewoman
229
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KallayaWiriyaetal.
suffersbecauseshedoesnotrealizeherdefilement
(aviccha).Shemaycreateseveralnegativethoughts,
suchastheotherwomanisherhusbandsnewgirl
friend(sankhara).Withoutconsciousness(vinnana),
or the right understanding, the woman will suffer
and her suffering will continue in the circle of
Paticcasamuuppada. On the other hand, if the
womanhaswisdom,shecanstopthecircle,atany
point, and her suffering will be alleviated.
21
In
other words, suffering refers to individual experiences
that are extremely uncomfortable and which may
involve physical, mental or spiritual dimensions.
Usuallythephysical,mentalandspiritualdimensions
areinterconnectedwitheachother,dependingupon
theparticulareventandthepersonsresponsetoit.
When a mother has the right understanding
of the nature and occurrence of suffering, she is
able to break the circle of Paticcasamuppada and
stopthesuffering.Healing,ortheendofsuffering,
is a result of right actions based on wisdom or
right understanding. Buddhists are encouraged to
solve problems according to their true sources of
the cause of suffering,
10
and heal their suffering
usingtheirownwisdom.Healingmaybeachieved
throughcognitive,emotiveorbehavioralreactions.
22
Healing is both a process and an outcome. As a

process, healing is: a natural process; occurring
fromwithin;restoringbalancetosystems;capable
of self-diagnosis and repair, without conscious
effort; an individual unique experience; and, an
activeprocessinwhichpersonstakeresponsibility
fortheirownhealth.Asanoutcome,healingrestores
balance,wholeness,relaxationandharmony.
23,24,25,26
Whenindividualsfacesuffering,theyseekwhatever
is fitting in their minds, so they can alleviate or
eliminatethesuffering.Thus,healingiswhatoften
isreferredtoasthebestwaywehavefordealing
withsufferinginourlives.
Thereareseveralwaystohealsuffering,or
dealwithdiscomfort,dependingontheproblem,i.e.
prayer, meditation, therapeutic touch and massage.
27
Hence, healing is completely unique and creative

inmaintainingwellness.
27
InBuddhism,morethan
2500 years ago, Buddha offered a remedy, or
strategy, for healing suffering. This remedy is
called the Middle Way, and can be applied to
theconditionsofcontemporarylife.Itisaprescription
forahappy,well-adjustedlife.
27
TheMiddleWay,
orNobleEightfoldPath,comprisesallthepractical
teachings of Buddhism. It is classified into three
categories;sila, Samadhiandpanna,describedas:
(a)ethicalconduct(Sila),composedofrightspeech,
right action, and right livelihood; (b) mental
discipline (Samadhi), including right effort, right
mindfulness,andrightconcentration,withsuppression
of intellectual activity, development of tranquility
andlossofsensations;and,(c)wisdom(Panna),
or right thought and right understanding. Commonly,
thesetermsarereferredtoasthethreefundamental
exhortations of the Buddha, including: not to do
any evil; to cultivate good; and, to purify the
mind. As described above, purification of the
mind,inordertoachievethefinalgoalofabsolute
freedom, must be completed by wisdom, as a
result of insight, into the Law of Dependent
Origination,andthestateofanatta,ornot-self,or
impersonalityofallphenomena.Havingattainedthis
knowledge,thepersonlivesagoodlife,overcomes
allproblems,bringssufferingtoanend,andenjoys
freedom,peaceandhappinessofthemind,without
resortingtoanyexternalsupernaturalpower.
20,21
Method
Designandanalysis:Gadamerianhermeneutic
phenomenology was used to guide the study.
Gadamerskeyphilosophicalconceptsincludethe:
hermeneutic circle; dialogue; fusion of horizons;
and,prejudice.
28,29
Emphasisisplacedonlanguage
withthebeliefthatlanguageandhistorysupplythe
sharedsphere,inthehermeneuticcircle.Inaddition,
Gadameraddressesunderstandingandinterpreting,
230
within the research process. Understanding, like

conversation,representsarelationshipbetweenthe
researcher and the participants.
30
Interviews and
conversationsarenon-directive,sothatparticipants
are able to tell their stories in the way they wish.
Interpretationoccursbywayofcreatingafusionof
horizons between the researchers original prejudices,
in conversation with the participants understandings.
Prejudicereferstoourpreconceivedunderstandings
thatcomefrompastexperiencesandsocialization.
Gadamer
31
advocatescontinuallystrivingtoidentify
prejudice, which originate from the researchers
historical background, as it relates to the topic at
hand.Inpractice,theresearcheracknowledges,as
much as possible, his/her prejudices, while data
arecollectedandinterpreted.
16
BasedonGadamers
32
philosophical hermeneutics, the following was

accomplished:
1. Audio-taped interviews were transcribed
bytheresearcher.
2.Theresearcherreadandrereadeachtext,
whilelisteningtotherecordings,togainafeelfor
thedata.
3.Themeswereextractedby:reading,word
by word and line by line; under lining and/or
highlighting words; coding words; identifying and
naming themes, which emerge from segments of
thetext;groupingthemes;and,namingthemes,in
relationtopartsandthewhole.
4.Membersoftheresearchteamwereasked,
by the primary researcher, to validate the themes
identified.
5.Theprimaryresearcherlookedforconstitutive
patterns (themes that unified the text). This
involvedthecreative,linguisticandintuitiveprocess
of finding metaphors and images to interpret the
experiencesoftheparticipants.
6.Aninterpretiveaccountwasgeneratedby
writing and rewriting, using the chosen metaphors
asanarrativedevice.
7.Writingandrewritingwasdonetoincorporate
all the interpreted accounts into a synthesized
interpretation.
Setting:ThesettingofthestudywasSongkhla
province,Thailand.TheprovinceofSongkhlawas
selected because of its high incidence of death
amongchildren,resultingespeciallyfromaccidents.
In2000,theprovincereportedthehighestnumber
of deaths throughout Southern Thailand (n =
7,575).
33
Accidentsareaprimarycauseofdisability
in Thailand, with traffic accidents, specifically,
being the leading cause of death. Data, from the
Registration Administration Bureau of Thailand,
33
indicates the highest rate of accidental child death

occursamongthe15-19yearolds,followedbythe
5-9yearoldsandthe10-14yearolds,respectively.
Ethical considerations and identification of
informants: Approval to conduct the study was
obtained from the Research Ethics Committee of
the primary researchers university. In addition,
approval was obtained, from the administrator of
hospitalwheredatawerecollected,forthepurpose
ofaccessingnamesofpotentialinformantswhohad
sustainedtheaccidentaldeathofachild.Inclusion
criteriaforpotentialinformantsconsistedofmothers
who:(a)hada16to18yearoldchild,whodied,
as a result of an accident, within the prior three
monthstotwoyears;(b)wereBuddhist;(c)were
fromSongkhlaprovince;and,(d)werewillingto
takepartinthestudy.
Once names of potential informants were
obtained, community leaders, and members of the
healthstaffatprimarycareunits(PCU),locatedin
the community where the potential informants
lived,wereapproachedandaskedforassistancein
introducing the primary researcher to the potential
informants.Inaddition,potentialparticipantswere
recruited through the snow ball technique. Each
potential informant was told: the purpose of the
study; what was involved; her anonymity and
confidentialitywouldbemaintained;and,shecould
withdraw from the study, at anytime, without
231
Vol. 13 No. 3
KallayaWiriyaetal.
negativerepercussions.Onceapotentialinformant
verballyconsentedtoparticipate,shewasaskedto
sign an informed consent form. A total of 23
potentialinformantnameswereobtained;however,
only10participatedinthestudy.Thereasonsfor
notparticipatingincluded:havingnotime;moving
to another province; unable to be contacted by
telephone, due to an incorrect phone number; or,
notwantingtotalkaboutthedeathofherchild.
Descriptionofinformantsandtheirdeceased
children: The 10 informants ranged in age from
34to54years,withameanof44.2years.Half
(n=5)hadonesurvivingchild,whiletheothers
had two (n=3), three (n=1) or six surviving
children(n=1).Thedeceasedchildrenhaddied4
and17monthspriortotheinformantsenrollment
in the study and ranged from 10 to 18 years of
age,withanaverageof13.9years.Themajority
(n=8)ofthedeceasedchildrenwereboys.The
childrensdeathsweretheresultfroma:motorcycle
accident (n = 6); drowning (n = 2); stab wound
(n=1);or,gunshotwound(n=1).
Data collection: A total of 27 interviews
wereconducted,withhalf(n=5)interviewedthree
times, four interviewed twice and one interviewed
fourtimes. Interviewswerescheduled,aboutone
monthapart,atthemothersconvenience,ineach
respectivehome.Demographicdata(informantsage,
number of living children, length of time since
death of child, age and gender of deceased child,
andtypeofaccidentdeceasedchildhadsustained)
wereobtainedduringthefirstinterview.Theinterview
tookanaverageof1.5hourstocomplete.
To develop dialogue with the mothers,
regarding their feelings of suffering and healing
practices,thefollowingquestions/statements,initially,
were posed: (a) Please tell me about the child
whodied.;(b)Whatwasheorshelike?;and,
(c)Tellmehowyoufeltandwhatyoudidwhen
you were told about the childs death. As the
informants described the nature of their suffering
andhealingprocesses,theresearcherposedprobing
questions/statements, that focused on the content
oftheinformantsdescriptions,suchas:(a)Please
elaborateonthesituationandyourresponsetothe
deathofyourchild;(b)Howdidyoudealwiththe
situation?;and,(c)Howdidyouhealyourself
after the death of your child? This was done to
obtainmorein-depthdescriptionsand,subsequent,
understandingoftheinformantsverbiageregarding
theirsufferingandhealingprocesses.
Duringthesecondinterview,whichtookan
averageof1.5hours,theprimaryresearcherfocused
onspecificpoints(themes)thatemergedfromdata
generated from the first interview. Subsequent
interviews took place until no new data were
generated, and their descriptions of suffering and
healingbecamerepetitive.
Findings
The meaning of suffering: Five themes
emergedasdescriptorsofthemeaningofsuffering
among the bereaved mothers. These themes included
the mothers: (a) heart was torn into pieces; (b)
body was frozen and she was uncertain if she
wouldsurvive;(c)happinessinthelifewasmissing;
(d) anger and rage at self and others; and (e)
worriesandwondersaboutthenextlifeofthedeceased
children.Detailsofeachthemearepresentedwith
illustrativequotestosupporttheirexistence.
Theme 1: The mothers heart was torn
intopieces.Thisthemereferstotheextremepain,
distress,brokennessanddisconnectionthemothers
experiencedwhentheirchilddied.Nopreviouslife
situationappearedtobecomparabletotheirimmense
senseoflossandintensesuffering.Theirstatements
supportedthistheme:
Iwastoldthathehadpassedaway.
He passed away on the way to the
hospital. At that minute, I cried like
myheartwastornintopieces.(M2)
232
Before this, when it happened to my

friend, I saw this thing simply. But
when it happened to me, oh! (Deep
breath)ithurtmebadly.Itslikemy
heartwasbrokeninpieces.Nomatter
howlongittakes...notthislifeorthe
next life, the pain and suffering will
stillbewithme.(M3)
Theme 2: Mothers body was frozen and
shewasuncertainifshewouldsurvive.Thistheme
refers to the mothers feelings of immobilization.
Theirbrainsdidnotfeelliketheywerefunctioning
andtheyindicatedfeeltheydidnothavepowerto
doanything.Themothersdescribedmanyelements
ofphysical,emotionalandembodiedsuffering.This
themeissupportedbytheirstatements:
I was going to faint when I realized
hewasgone.Iwasdownonthefloor
andfeltlikeIhadnoenergyleft.My
braincouldnotfunctionwell.(M5)
I was walking to see what happened,
butallmyenergysuddenlywasgone.
Icouldntwalk,grabbedthetableand
stood there. I did not cry. No tears,
butwasindeepshock.Ididnotcry,
but felt like my body was frozen. I
could not accept it, never thought of
that day before. I was in bed for 3
months, could not get up. When my
body demanded food, I ate very little
tosurvive.(M7)
Theme3:Themothershappinessinthelife
was missing. With the death of their children, the
mothers happiness seemed impossible and future
hopes for their children died. The deaths led to a
collapse of meaning in the mothers lives. A
significant person in their lives had disappeared
andtheirhopesforthedeadchildrenweredashed.
When the children died, the mothers were faced
with great suffering. These mothers grieved the
lossoftheirchildrenwhohadbeengreatcompany,
and contributing members to their respective
families everyday routines and hopes for the
future. These thoughts were noted from their
comments:
I was hoping that he would undergo
an ordination to be a monk. Thus, I
could gain merit from him. But his
age disqualified him; he was just 17.
He would be going back to school.
The school was opening in a month.
His future was going well. He would
haveabrightfuture(M2)
In the past, the four of us (parents
andtwochildren)hadmealstogether.
Nowthereareonlythreeleft.Weuse
to have pleasant meals together, and
were very happy. My tears poured
down just thinking of his condition on
that day. Father, mother, and children
living,eating,andwatchingTVtogether,
this is perfectionI didnt know what
thiswaswhenhewasalive.Whenhe
wasnthere,Irealizedthatsomething
wasmissingfrommylife.(M9)
Theme4:Themothersangerandrageat
selfandothers:Angerandragedirectedatselfand
others, referred to the internal feeling that the
mothersexpressedaboutthemselvesandthosenear
them.Becauseamothersuddenlylostherbeloved
child, she greatly suffered. The women broke
downandcouldnotcontroltheiremotions,sothey
expressed themselves by using unpleasant words
towards others. These actions were reflected in
theirstatements:
233
Vol. 13 No. 3
KallayaWiriyaetal.
My own father passed away a long
timeago,Iworshipedhispictureevery
day. When I went out I asked him to
protect my family. Sometimes I was
infrontofhispictureandcomplained
to him for not helping my son, his
grandson; you know Because my
husband took my son for training to
rideamotorcyclehewasdead.Ioften
blamed my husband for my sons
death.(M3)
I am so mad with the policeman.
Whydidnttheypayattentiontomy
dead childs situation? I spoke to
them with a big mouth when they
came back and asked me some
irrelevantquestions.(M8)
Theme5:Themothersworriedandwondered
about the next life of the deceased children.
Mothers spent considerable time thinking and
worrying about their deceased children. They
wanted to know how their children were faring in
the next life. Most mothers dreamt about their
deceasedchildren.Theycommented:
After 100 days, I dreamt he asked
me to pick him up. Since I had the
samedream,repeatedly,Iwenttosee
amonk.Thethingwashediedonthe
roadandnooneinvitedhissoul/spirit
in, and hes still there and cannot go
anywhere. I asked the monks to pray
at the point where the accident took
place,andtohelptoreleasehissoul/
spirit. Because at his death, his dry
blood was not cleaned, someone told
me to invite monks to release his
spirit. After I did the rite for him I
feltbetter.(M2)
My sister took me to see a fortune
teller, who has so many people
believinginhim.Hesaidnottocry,
whenever you cry, your daughters
spirit is crying next to you. You just
cannot see her. She is even sadder
whensheseesyoucrying.Sheissad
because she cannot take care of you
right now. If I am happy, her spirit is
happytoo.Hesaidthatmydaughters
spiritwaslikeatraveler.Herspiritis
travelinginanotherlife.(M4)
The healing of suffering:Themothers,asa
result of the accidental death of their children,
lookedforcomfortandhealingpracticestoassuage
their intense feelings of loss. Data revealed the
existenceoffourpracticestheused:
1. Transforming the relationship with the
deceasedchild:Mostmothersdescribeddeveloping
arelationshipandconnectionwiththeirdeadchilds
spirits. Since their child was no longer physically
present, the mothers yearned for, and developed
waystospirituallyconnectwiththeirchild.Theystated:
I feel that she stays with us every
day.Iplacerice,water.Idontknow
ifshecaneatornot,butIpreparefor
her every day. [She pointed to her
daughterspictureandashescontainer,
and there was some food in front of
it].Ifeelsheisstillwithmeinthis
house.(M1)
My son always went to the temple
with me. I recently went to temple
and walked with lit candles in hand
andIpreparedflowersandcandlesfor
him. In my mind, I asked him to
comewithme,soIwalkedbymyself
with two sets of flowers, joss sticks
andlitcandles(laughedsoftly).(M7)
234
2. Elevating the deceased child to be a very

good child capable for going to heaven. Every
mother believed that her deceased child was a
perfectperson.Inparticular,eachmothercompared
thedeceasedchildtotheirotherchildren.Although
the mothers suffered for not being with their
deceased children, they gained comfort from the
beliefthattheirchildrenwerespecialandhadgone
toagoodplace,orheaven.Somestated:
He was a very good boy. Everyone
loved him, such as friends, teachers,
and neighbors. He was a kind boy
helpinghisfather,motherandsisters.
He was friendly and smiled at
everyone My son was innocent. He
was a good boy. He did not do
anything bad. Now he has stopped
doing anything in this world. His
deathhasstoppedallkamma[thePali
term for karma or actions and deeds]
and he will gain merit from previous
meritoriousdeeds.(M3)
The fact that I lost my dad from
cancer and my beloved brother, who
also passed away from his heart
failure, was not comparable with the
factIlostmyson.Itsnotthesameat
all. People liked him despite the fact
that he was drug addicted. He had
good relations with people, and he
loved helping them. If he saw an old
man or lady walking, he would pick
him/heruponhismotorcycleandtake
him/her home. He was good in most
things,exceptforthedrugs.(M5)
3. Making merit in order to pass the
benefitstothedeceasedchild.Eachmothermade
merittobenefitherdeceasedchildandenhanceher
childs chance for rebirth. All of the mothers
poured water and prayed for sending the merit to
the deceased children. They believed that if they
did not pour water, their dead children could not
obtain the merit. The practice of merit was
reflectedintheircomments:
Some said my daughter died from the
accident.Atthetimeherspiritlefther
body, she might not know that shes
deadsoshemightnothavetakenthe
benefitsfromthemeritrightaway.If
wedo49days,whentherewasaday
that her spirit knew that shed died,
she could take the benefits from the
merit. I am not sure if its true or not,
butitmademefeelbettertodoso.After
that,Igaveanothermerit at the 100th
dayaftershepassedaway.(M4)
I did major merit making like
everyone did; during the funeral, at
the 100th day and a week after 100
days, just like the Thai tradition.
Other than that, takbart (alms giving)
intheearlymorningandpouringwater
for his benefitIn the past, I gave
merit and poured water to my dead
ancestors,Ididnotfeelmuchofthis.
But now, I specifically gave the
benefit to my own son, I feel
differently. Like I am suffering, so
whenIgivebenefitstomydeadson,
Ifeelbetter.(M6)
4. Self-healing through understanding and
mindcultivation.ThemotherspracticedBuddhist
actions to gain comfort, cultivate their minds and
relievetheirsuffering,asreflectedintheirstatements:
235
Vol. 13 No. 3
KallayaWiriyaetal.
Frompreaching,lifeislikeacoconut,
if it is raw (young) and healthy, it
doesntfallfromthetree,butwhenit
becomes too ripe (old), it does.
Although, if it is raw bitten by an
animal or insect, it will fall from the
tree too. Like us, youth or the aged
can pass away anytime. It is
uncertain.Ifwecanacceptthistruth,
we can accept its consequence. I
listentopreachingandIunderstandit
soIamresignedtotheresult.(M6)
I usually do meditate at home. And,
my company arranges monthly group
meditation. Monks tell me to let my
mind be free and peaceful. I should
think that there is nothing in my
body.Ishouldnotadheretoanything.
ThenIfeelfree.IfIpurifymymind,
itisgoodforme.(M10)
5.Seekingsupport.Seekingsupportinvolved
reachingouttoothers.Someofthemotherssought
help from a monk by asking him to perform rites
to release their childs spirits; others turned to a
fortune teller to learn about their deceased child.
Theseactionsarereflectedintheirstatements:
Someone told me that we have to do
something to send my sons spirit to
heaven. So I invited an abbot to pray
and perform ritual activities at that
place where the accident occurred. I
prepared 8 kinds of food including
whole fish (composed of head and
tail), candles and joss-sticks, or
aromatic vapors. You know I have
neverdreamtaboutmyson.Hemight
gotoagoodplace.(M3)
My friend asked me to see a fortune
teller. When I asked him about the
illness of my youngest son and how
my dead child was, he said that my
deadchildhadnotcommittedanysin
sohewouldbeok.Hetoldmenotto
worryandtakecareofmyself.(M9)
Discussion
AlltheparticipantswereBuddhist,aswould
beexpectedinThailand,where95%ofthepopulation
isBuddhist.(Thisneedstobedocumented.)Thus,
to understand suffering and ways to overcome it
(healingpractices),onemustexaminetheseconcepts
withinthecontextofBuddhistbeliefs.
Suffering: Suffering is a universal human
experience. The mothers, in this study, certainly
were no exception, as they stated they could not
eat or sleep, felt shock and angry, wept and
worriedaboutthelossofmeaningandlackedhope
fortheirfuture.Theyexperiencedextremephysical,
mental and spiritual distress the first two to three
monthsaftertheirchildrensdeaths.Theirphysical
suffering was expressed by way of crying, not
sleepingwell,notbeingabletoeat,losingweight
andfeelingpowerless,whiletheirmentalsuffering
manifested itself in confusion, anger, sadness,
non-acceptance and worry, and their spiritual
sufferingwasreflectedinfeelingdisconnectedand
tornfromanormallife.
These findings are consistent with previous
research on suffering, wherein suffering has been
presented through sorrow, lamentation, grief and
despair.
10
Suffering also has been recognized as a
universalconcept,involvingemotionalresponseto
a loss,
13, 14
and viewed as extreme discomfort,
experienced through physical, mental or spiritual
responses.
14, 15
These concepts are congruent with
the physical, psychological and spiritual suffering
experiencedbytsunamisurvivors.
8
236
AccordingtoBuddhistbeliefs,sufferingcan
be categorized three ways, including: dukkha-vedana
(feeling of suffering expressed through unpleasant
sensations of pain or numbness); dukkha-laksana
(suffering that involves uncertainty; it occurs,
keepsgoing,anddisappears);and,dukkha-ariyasacca
(suffering as a result of cause and effect).
10, 21, 34
The mothers expressed feelings that their hearts

weretornintopieces,theirbodieswerefrozenand
theyhadnopowertosurviveisrelatedtodukkha-
vedana (feelings of suffering). Dukkha-vedana is
connected to sense-formation through ones body
andmind,orthefiveaggregates,orfiveheaps,of
existence:(1)Rpa- physicalform;(2)Vedana-
feelings or sensations; (3) Senna-ideations; (4)
Sankhara-mentalformationordispositions;and,(5)
Vinnana-consciousness. When sensations (vedana) of
pain, or unpleasantness (a broken heart or frozen
body),arose,theirmindscouldnotstopideations
(sanna)relatedtomemoriesoftheirdeadchildren,
andmentalformations(sankhara)arose.Although
themothersmightimaginehowtheycouldsurvive
without their daughters or sons, without having
consciousness(vinnana),orasenseofwisdom,their
intensesufferingcontinued.
According to Buddhism, not only does the
sensation of pain and unpleasantness (dukkha-
vedena)resultinsuffering,butsodoestheuncertainty
ofbodyandmind.Ifonedoesnotunderstandand
realizethistruth,andremainsattachedtothebody
and mind, he/she will suffer when the body and
mindchange.
Themothers,inthisstudy,couldnotaccept
the death of their children, and the loss of shared
andmeaningfulactivities,i.e.watchingTV,singing
karaoke,havingdinnerandtakingtheirchildrento
school.Theirintensedesiretohavetheirdeceasedchild
withthem,sotheycouldcontinuetoloveandcling
tohim/her,leadthemtobeconvinced,duetothedeath
oftheirchild,theyhadnohappinessandneverwould.
Loveispartofdesireandawishtolovecan
greatly heighten suffering in a human being.
35
Thus, a mothers intense desire to love her child
could become an unhealthy longing, particularly
when faced with suffering, due to the loss of her
child. For example, if one had not experienced
intenseloveofanother,whenthatpersonhasdied,
intense suffering, most likely, would not occur.
Ontheotherhand,ifonehadintenseexpectations
of love, or happiness, and neither occurred as
anticipated, the outcome may be one of suffering.
However,happinessandloveareuncertainties,since
nothing in life is permanent, or stable. All things
changewithtime.ThisisinaccordwiththeBuddhist
beliefofdukkha-laksana(sufferinganduncertainty).
20,21
Inaccordwithdukkha-ariyasacca(suffering
is a result of cause and condition), some of the
mothersfeltanger,andwereenragedwiththemselves
and others, especially during highly emotional
situations.Anger,hatredandill-will(Byapada)are
defilements,andoftenviewedasbademotions,
which are related to the cause of suffering.
34
Unfortunately,ifbademotionsarenotsufficiently
dealtwith,theycanbecomebarrierstomovingon
toaproductiveandhappylife.
Similar to the anger expressed by the
informants, in this study, tsunami survivors were
found to express intense anger, because they did
not have sufficient time, as a result of the
unexpectednessofthedeathsthathadoccurred,to
serve their families.
8
However, the causes of the
unexpected deaths, in this study, were different.
Deaths from the tsunami were the result of a
natural disaster, while deaths, in this study, were
from:motorcycleaccident;drowning;stabwound;
and, gunshot wound. Thus, the mothers felt anger
withthosearoundthem,aswellaswiththemselves,
because they associated their childrens deaths,
either directly or indirectly, with themselves or
others. Those around them, with whom they felt
anger,mayhavebeenthehusbandswhotooktheir
children to where the deaths occurred, or a
237
Vol. 13 No. 3
KallayaWiriyaetal.
policeman who could not arrest the person who
causedthedeathoftheirchild.
Furthermore, some mothers worried and
wondered about the next life for their deceased
children.AccordingtoBuddhistteaching,worryingand
wonderingarepartofdesireorcraving,whichare
causes of suffering related to dukkha-ariyasacca.
20, 21
Desire is related to birth and death, known as the

CycleofExistence,orSamsara. Samsara,orthe
cycleofbirthanddeath,alsoimpliesapluralityof
differentrealmsofexistence,inwhichrebirthtakes
placeaccordingtothenatureofkamma(karma).
20,34
TheLaw of Kammarelatestohowpeopleactand,
thus,goodorbadoutcomes,inlife,arethedirect
resultofonesactions.
34
KammaispartoftheLaw
of Dependent Origination, (Paticcasamuppada)
and is divided into three parts, including: (a)
defilement (kilesa), which involves the tendency
todesire,orcrave,something(tanha);(b)kamma,
which means expression, both good and bad, in
physical actions, wording and mind; and, (c) the
result of kamma, which means the outcome of
everyaction.
10,20,34
Paticcasamuppadadescribesthe
processofkammaandhowitleadstotheresultof
kamma, which brings about the outcome of what
onedoesbyhis/herintentionalmind.
20,34
The mothers beliefs in rebirth appeared to

haveinfluencedtheirthoughtsandactions,relatedto
dealingwiththelossoftheirchildren.Themothers
concerns for the next life depended on the
childrenspreviouskamma.Concernaboutrebirth
causedagreatdealofemotionalworryforsomeof
the mothers. However, most believed their child
had no sin and, therefore, would go to a good
placeforrebirth.
This study revealed the period of intense
sufferingdiffered,onadaily,weeklyandmonthly
basis, among the mothers. During the period of
intense suffering, the mothers were immobilized.
Thereafter,theywereabletoresumelife,buttheir
intensefeelingsarose,asaresultoftheirmemories
of their children. This may have been due to the
attachmentbetweenthemothersandtheirchildren,
the mothers backgrounds and their understanding
ofthetruthoflifeanddeath,relatedtotheBuddhist
conceptofwisdom.
Healing from suffering:Eachmotherworked
to transform her relationship, with her deceased
child, to bring about healing from her suffering.
Oftenthiswasdonebykeepingsomeoftheirchilds
personalpossessions,forthepurposeofremembering
and connecting with them. Remembrance and
connection were done: through dreams; looking at
photos;or,speakingtoothersabouttheirdeceased
child,. This finding is consistent with those of
GudmundsdottirandChesla,
36
whofound,families,
in an attempt to preserve memories of their
deceased children, would create home memorials
displayingpersonaleffects,suchashair.
Most of the mothers regularly engaged in
Buddhist practices, such as going to temple,
makingmerit,givingcharity,listeningtoDhamma
(the gradual instruction of truth taught by the
Buddha)andpreparingfoodforthemonks.These
activities were done for the purposes of: giving
benefits for rebirth to their deceased children;
providing themselves with a peace of mind; and,
developing personal wisdom. Such behaviors are
relatedtothethreefundamentalmodesoftraining:
sila, samadhi and panna.
11,21,37
Aspreviouslydescribed,
sila, or morality, consists of right speech, right
action and right livelihood, while Samadhi, or
mentaldiscipline,iscomposedofrighteffort,right
mindfulness and right concentration. Finally wisdom,
or panna, consists of right thought and right
understanding.
Two of the participants (M5 and M10)
regularlypracticedinsightmeditation,priortoand
aftertheirloss,whileone(M9)startedtomeditate
after she lost her son. Thus, it appeared that how
eachmotherapproachedhealinghersufferingvaried.
For example, one mother (M5) took mind
238
developmentcoursesinSounMok,Surajtaneeprovince,
where the practice of dramma is popular, and
continuedtomeditateonadailybasis.Anothermother
(M10) practiced insight meditation prior to and
after she lost her son. Both of these mothers
understoodtheircircumstancesandreturned,fairly
quickly,toanormalroutine.However,4ofthemothers
(M1, M6, M7 and M9) experienced prolonged
suffering, during the first three months, after the
deathoftheirchild.Theycouldnotworkanddid
not want to do anything, although others returned
toworkaftertheirchildsbodywascremated.
Althoughthemothers,inthisstudy,contended
with their loss, 4 to 17 months, after the event,
they all continued to suffer, in some way. They
could not eliminate, completely, their suffering.
They were sensitive to events that prompted their
feelings of suffering, i.e. when they heard news
related to a persons death or saw their childrens
belongings.Mostmothersdidnotreadnewspapers
in an attempt to avoid bad news. Similar to
Hatthakit and Thaniwathananon findings,
8
wherein
tsunamisurvivorswerenotedtoexperienceemotional
suffering one to one and a half years after the
catastrophicevent,themothers,inthisstudy,showed,
although their physical suffering dissipated, their
emotional suffering remained and they required a
longertimeforrecovery.
Interestingly,asenseofhope,forwhattheir
deceasedchildwouldofferthem,appearedtohave
influenced the mothers level of suffering. For
example, the mothers of deceased sons hoped to
gain merit from their sons ordination as a monk,
while mothers of deceased daughters hoped their
daughterwouldprovidecareforthem,intheirold
age.Thisphenomenonwasreflectedbyonemother
(M1),whosefirstchildwasrapedandsecondchild
wasdisabled.Herhopeinlifewaswithherthird
child,whodiedinanaccident.Thismothersuffered
severely,becauseshefelt,afterthedeathofherthird
child,thatshehadlittlehopeinherlife.However,
thedegreetowhicheachmothersufferedappeared
to depend upon her character, the hope she had
anticipatedherdeceasedchildwouldbringher,and
herin-depthBuddhisthealingpractices.
Implications
The aim of this study was to explore the
meaning of Buddhist mothers suffering and their
healing practices after the accidental death a child
occurred.Thefindingsrevealed:1)lossofachild
leadsamothertoexperiencesuffering;2)suffering
isaprocessofthemind,whichcanleadonetoa
different life; 3) suffering is the embodiment of
physical, mental and spiritual aspects; and, (4)
feelings of suffering and healing practices are
unstableandchangeable.Thefindingscanbeused
tohelpguidenurses,andotherhealthcareproviders,
providingcaretosufferingmothers.Forexample,
establishingsupportgroups,focusedonthehealing
practices used by the women, and providing
information about various meanings of suffering
experienced by such mothers could prove useful,
not only mothers after the accidental death of a
child,buttotheirfamiliesaswell.
LimitationsandRecommendations
All studies have limitations and this study
was no exception. The study was conducted only
withBuddhistmothers,inThailand,whoexperienced
an accidental death of a child. Thus, the findings
may not apply to Thai fathers, to mothers from
other religious beliefs or cultures, or to mothers
whohavelostachildduetoaneventotherthanan
accident. As with any qualitative study, the
researcher had to assume the respondents were
truthful,andhadestablishedatrustingrelationship
withtheinvestigator.
Future studies need to address the meaning
of suffering and healing practices experienced by
239
Vol. 13 No. 3
KallayaWiriyaetal.
mothersandfathersofchildrenwhohavediedasa
result of an acute illness or a chronic illness. In
addition,itwouldbewisetoexaminesufferingand
healing practices among mothers and fathers from
various religious beliefs and cultures, so as to
comparesimilaritiesanddifferencesofresponsesto
thedeathofachild.
Acknowledgements
The primary author would like to thank the
CommissiononHigherEducation,MinistryofEducation,
Thailand,forthescholarshipsupportprovided.
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: , RN, PhD Candidate,
E-mail: kallayawiriya@yahoo.com
, RN, PhD.

, RN, PhD.

Lee SmithBattle, RN, D.N.Sc. Professor of Nursing, Faculty of
Nursing, Saint Louis University. St. Louis, MO, U.S.A.

, , , Lee SmithBattle
:

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; ;

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;
; ;

2009; 13(3) 227 - 241
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Thai Journal of Nursing Research Vol 13 No 3 Jul 92974

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Thai Journal of Nursing Research Vol 13 No 3 Jul 92974

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Vol.13No.

:Shakketefian, EdD, RN, FAAN Professor and Director of

participating patients FPG; (b) structure; and, (c)

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

:, RN, PhD Candidate,

Relationship among Maternal Depressive Symptoms, Gender

In Thailand, the incidence rate of MDD, among

In addition, the occurrence of a MDD during

Yet adolescents who receive sufficient

Self-esteem also appears to be a protective

However, in order to optimize resistance to

The assumptions underlying the theory, proposed

However, providing social support, without self-

Moreover, this study found that gender had

In addition, impaired parenting (not caring

These findings also are congruent with previous

The applicability of the interpersonal theory

:, RN, Ph.D. Candidate

Cognitive Performance after a Transient Ischemic Attack:

Animal models have provided clues to the

:, RN, PhD candidate,

Chair of the Public Health Center; and, Director of

:, RN, PhD Candidate

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

unimaginable suffering for the family, especially,

viewed suffering as a spiraling, vicious circle of

These responses also are related to the symptoms

In Buddhism, the notion of suffering has

Buddha explained everything about life in

Healing is both a process and an outcome. As a

Hence, healing is completely unique and creative

within the research process. Understanding, like

philosophical hermeneutics, the following was

indicates the highest rate of accidental child death

Before this, when it happened to my

2. Elevating the deceased child to be a very

The mothers expressed feelings that their hearts

Desire is related to birth and death, known as the

The mothers beliefs in rebirth appeared to

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