PRELIMINARY

A. Background

Children aged 3 to 6 years are called preschool children. At preschool age children will begin to
enjoy playing outside the home (1). Children will begin to make friends, even families will invite
children to walk out of the house like garden (2). Children at preschool age have very rapid gross
motor activity styles (1). At this age children will really like to play like throwing a ball, riding a
bicycle, riding a building on the field (2). Children who are too active will increase the risk of injury
(1). Pre-school age children will also decrease their appetite (1). The child will also choose the food
consumed by him (1). Children will also like to eat less nutritious foods (1). This sometimes makes
the child's condition decline so that he will experience hospitalization.

Hospitalization can be caused by the child's body feeling unable to withstand the pain so the
child must be treated in hospital (3). Hospitalization is needed for the healing process (3). When
hospitalized, children will try to adapt to new and unfamiliar environmental conditions (3). The child
health figures in Indonesia based on the 2001-2005 National Defense Survey (Susenas) states that in
2005 the morbidity rate of 0-21 years in urban areas according to age group is as follows: age 0-4
years by 25.84%, ages 5- 12 years as much as 14.91%, ages 13-15 years around 9.1%, aged 16-21
years amounted to 8.13% (4). Age-related pains of children 0-21 years if calculated from the total
population is 14.44% (4).

The numbers above show that many children have been hospitalized. The results of research
from Utami (5) the impact of hospitalization on children is the development of long-term emotional
disorders. Emotional disorders are related to the length and number of hospital admissions, and the
type of procedures undertaken at the hospital (6). Repeated hospitalization and a stay of more than
4 weeks can result in future disruptions. Developmental disorders are one of the impacts the
negative (5). In a previous study by Murtutik (7) states that more often children undergoing
hospitalization are at high risk of experiencing disruption in gross motor development in children.
Not only disturbs gross motor skills in children, children will also feel anxiety.

Hospitality that occurs in children, will have an impact on parents. The work of parents will be
disrupted, one of them must wait for their children, so that the role of parents will also be disrupted
(8). Children who are not treated will get the impact with the lack of attention given (8). But the
obvious impact on parents is anxiety. Parents will feel anxious about the development of their
child's health, medication, regulations, conditions in the hospital, and the cost of care (3). Long
hospital treatment will result in increased parental anxiety, which is needed nurse support in giving
attitude to parents. A caring nurse will reduce the level of anxiety in the parents themselves (9). If
changes in attitudes towards parents can be read by children this will affect the child's healing
process. Hospitalization also causes anxiety and stress at all age levels in children (3). The cause of
anxiety itself is influenced by many factors, both from the factors of officers (nurses, doctors and
other health workers), the new environment and family who accompany during treatment (3).
Anxiety that lasts a long time will result in somatic systems whose physical basis cannot be found
and also causes the individual to think too much or pay attention to himself, and in dealing with
something the child is unable to relax (10). Anxiety about ability and achievement can cause a child
to become perfectionistic and obsessive, tendencies that can interfere with the actual performance
and social development of the child (10). The duration of the child's healing process, influenced by
the type of illness suffered by children.
 Diseases in children can be divided into two namely acute disease and chronic disease. Acute
illness is a sudden illness, in a short time, and sometimes will indicate that there is a serious disorder
(1). The morbidity rate of children with acute illnesses such as pneumonia in Central Java Province in
2012 was 24.74%, whereas with cases of diarrhea the morbidity rate of children in Central Java
Province was 42.66%. The morbidity rate of children with DHF in Central Java Province in 2012 was
19.29 / 100000 population (11). Acute diseases commonly suffered by children are diarrhea, dbd,
pneumonia, electrolyte disturbances, urinary tract infections.

Impacts that arise in children affected by acute diseases such as acute diarrhea. Children will
become weak when there is an imbalance of intake and output. The child's condition will further
decline if the child refuses to be given care (12). Rejection is one of the reactions of children due to
hospitalization (13). Circumstances like this will make parents worried. Some research also shows
that parents will experience anxiety because the child is suffering from one of the acute illnesses.
Research that shows that children who suffer from acute illnesses, such as the Gurbus study (14)
shows that parents who have children with hearing loss have different levels of anxiety. Anxiety
level of parents before the child is installed hearing aids are higher than when children are hearing
aids after 6 months the level of parental anxiety decreases to a moderate level of anxiety. Research
conducted by Chan (15) states that parents will feel anxious when their child is hospitalized by being
treated in an isolation room. Parents feel that they are very anxious about the condition of their
children who have SARS, in this study children who have SARS are not allowed to be accompanied by
parents, children in isolation care because the disease can be contagious, this affects parental
anxiety. At work parents will not focus on work (15). It was also mentioned that parents will
experience fear, and extreme anxiety when the child experiences treatment in isolation (15).

Chronic illness is a disease that occurs in a long period, recurs, occurs slowly and becomes more
serious (1). The morbidity rate of children with TB in Indonesia is 0.64% with an age range of 0-14
years, the morbidity of leukemia in children as much as 75% of children experience acute
lymphoblastic leukemia. In contrast to acute, chronic conditions are processes that occur slowly,
progressively get worse or become dangerous (1). During this process parents and children will
experience several events that can be traumatic and stressful (6). The type of illness suffered by
children will show different levels of parental anxiety (1). Anxiety level of parents with children with
chronic disease shows moderate anxiety. When the child has experienced treatment, parents will
pay more attention to the care of their children (1). In research conducted by Rani (16) about the
description of anxiety levels of parents in children suffering from leukemia get results that from 30
respondents showed 9 parents whose children suffer from leukemia have mild anxiety, 8 parents
experience moderate anxiety, 8 parents experience severe anxiety, and 2 parents do not experience
significant anxiety.

Anxiety is a condition of subjective anxiety (17). This condition can be felt by everyone.
Anxiety is a normal condition if it is felt not to be excessive (12). Anxious responses themselves can
be categorized into physical responses, cognitive responses and emotional responses. Physical
response is usually indicated by frequent urination, muscle tension, changes in vital signs, frequent
sweating, sleep disturbance, dizziness, frequent pacing, pupillary dilation, back pain (18). Cognitive
responses are usually shown to be a decreased perception of space, more alert, considering the
information obtained, difficult to think, can occur hallucinations (18). Whereas emotional responses
are usually shown with discomfort, irritability, self-confidence faltering, impatience, fear,
withdrawal, denial (18).

Every parent will experience different levels of anxiety, anxiety itself is divided into 4 levels,
namely first mild anxiety anxiety characterized by symptoms such as not being able to sit quietly,
tremors in the hands, pulse and blood pressure increase, more want to immediately resolve the
problem (17 ). Anxiety is being characterized by attention to the important and exclusion of others,
the field of perception is narrowed, and stimuli from the outside are not able to be received, blood
pressure and pulse increase, there are movements that move unreachable, insomnia and sometimes
feel uneasy (18). The level of severe anxiety is characterized by greatly reducing one's perception
land, symptoms that appear at this level are complaining of dizziness, headaches, nausea, unable to
sleep (insomnia), frequent urination, diarrhea, palpitations, narrowed perception land, do not want
to learn effectively , focusing on himself and the desire to eliminate high anxiety, feelings of
helplessness, confusion, disorientation (17). Panic is the last level of anxiety, people who are
panicking are unable to do something even with direction. Signs and symptoms that occur in this
situation are difficulty breathing, dilated pupils, palpitations, pale, diaphoresis, incoherent speech,
unable to respond to simple commands, shouting, screaming, hallucinating and delusional (18).

Anxiety experienced by parents will have an impact on children, children who are hospitalized
will feel more afraid to see their parents looking worried. According to Wong (13) feelings that arise
in children are anxiety, anger, sadness, fear and guilt. These feelings often arise due to facing
something new and have never been experienced before, feeling uncomfortable and insecure,
feeling of losing something that is usually experienced, and something that is felt painful (6). In
Sari's research (19) states that there is a relationship between the level of anxiety of parents with
hospitalization. The results of this study indicate the second highest level of anxiety is moderate
level of anxiety (19). In the study also mentioned that the relationship between parent and child
anxiety occurs not absolute due to genetic factors, but more through factors that affect parents feel
the level of anxiety growing (19). According to Mariyam research (9), the factors that influence
parental anxiety are age, gender, education status, economic level, level of knowledge of children's
illnesses. Parents who do not understand the illness experienced by their children will feel excessive
anxiety (9). It was stated that knowledge of a child's illness is one of the factors that causes parents
to feel anxiety. In other studies investigated by Rinaldi showed that knowledge about illness is
related to parental anxiety levels (20). The results of the study showed that parents' knowledge was
lacking produce a higher level of anxiety (20). In this study the most anxiety level experienced by
parents is a high level of anxiety with a low level of knowledge, while a severe level of anxiety with a
high level of knowledge medium (20).

The results of observations made at the time of the practice of children's stases found that there
were 15 parents who experienced mild anxiety with children suffering from acute illness. The results
obtained at the time of the interview with the parents, the parents said that they were worried
about their child's condition now. There are 6 people who experience moderate anxiety by saying
that they feel often sweating, frequent urination, chest palpitations, fear of the child's current
condition. 6 parents who said they had moderate anxiety with children diagnosed with acute
diarrhea, dengue fever, typoid, pneumonia, hypovolemic shock, asthma. Then there are 2 parents
who experience severe anxiety with the symptoms that parents often cry to find the condition of
their children who are getting worse day by day. His child was diagnosed with nephrotic syndrome
and dengue fever with degree 3. 2 This parent is less cooperative with actions taken to his child,
such as refusing when the nurse to inject drugs to his child.

B. Problem Formulation

Hospital is an event that has a truamic impact on children and parents. This traumatic situation
causes children and parents to experience anxiety, which is because the child is undergoing
hospitalization. The impact of hospitalization for children is overwhelming, the child's emotions will
be disturbed by the separation he experienced during hospitalization, emotional disturbances are
related to the length and number of hospital admissions, and the types of procedures undertaken in
hospitals. Repeated hospitalisation and a stay of more than 4 weeks can result in disruption in the
future.

This impact is what sometimes makes parents experience anxiety. Not only is emotional
development disrupted but physical development will also be disrupted. Sometimes parents will
feel their children are weaker than other children. Parents will experience anxiety when their
children are hospitalized. Parents are sometimes afraid of their child's declining condition and even
the emotional impact of children will be noticed by parents. Parents will show signs of anxiety such
as appearing gloomier, easily offended, appearing agitated, angry, and regretting the cause of
hospitalization experienced by children. The level of anxiety in parents will vary with the symptoms
that occur in children. Sometimes there are severe anxiety because they do not know the actual
condition of the child who is undergoing hospitalization. The situation of children with chronic and
acute illness will vary. The level of anxiety in parents whose children experience hospitalization
during acute and chronic conditions will also be different. The worsening situation sometimes
makes parents feel worried about their child's condition, this will worsen the atmosphere of
hospitalization. Children will feel uncomfortable with the conditions of their parents. From the
description of the background and the problems that occur, researchers want to know the difference
in the level of anxiety of parents in children who are hospitalized with acute illness and chronic
disease.

C. Research Objectives

1. General Purpose

Identifying differences in the level of parental anxiety in children who are hospitalized with acute
illness and chronic disease

2. Special Purpose

a. Identifying parental characteristics

b. Identifying parental anxiety in children who are hospitalized with acute illness

c. Identifying parents' anxiety in children who are hospitalized with chronic diseases

d. Analyzing differences in the level of anxiety of parents in children who are hospitalized with
acute illness and chronic disease

D. Research Benefits

1. For the Nursing Professional

The results of this study can be used as additional information for the nursing profession in terms of
knowing the level of anxiety in parents which can sometimes affect children's anxiety so that it can
inhibit the child's healing process.

2. For Hospitals
 The results of this study can provide information for hospitals. This research can also be used as a
source of knowledge that parents also experience anxiety when the child is hospitalized. So that
nurses can give attention or care to parents. Nurses are also able to provide an explanation of the
child's actual condition by using good communication so that parental anxiety does not increase.

3. For the Community

The results of this study can be used for new knowledge for the community about the level of
anxiety of parents. Society to know that parents also experience anxiety when the child is
hospitalized.