key: cord-0848807-zlhjnypa authors: Glauberman, Gary; Wong, Daisy Kristina; Qureshi, Kristine title: Experience of parents of preschool children in Hawaii during the COVID‐19 pandemic date: 2022-03-31 journal: Public Health Nurs DOI: 10.1111/phn.13076 sha: 7995a50680757a41c75ac668a10806ab74b10dc8 doc_id: 848807 cord_uid: zlhjnypa OBJECTIVE: The COVID‐19 pandemic has resulted in major disruption to economic, health, education, and social systems. Families with preschool children experienced extraordinary strain during this time. This paper describes a qualitative study examining the experience of parents of preschool children in Hawaii during the COVID‐19 pandemic. SAMPLE: Thirteen (N = 13) parents of preschool children living on the island of Oahu, Hawaii, participated in small group discussions occurring in February and March 2021, approximately 1 year after the start of the pandemic in the state. Discussion transcripts were coded and sorted into themes. RESULTS: Four themes emerged: stressors due to the COVID‐19 pandemic, family coping and resources, meaning of the COVID‐19 crisis to the family, and family adaptation patterns. Themes mapped to the Family Adjustment and Adaptation Response model. CONCLUSION: Families relied on various resources to cope with stressors experienced due to the COVID‐19 pandemic, and adopted new patterns related to seeking healthcare and household emergency preparedness. Findings may inform policies and interventions to support families during the ongoing COVID‐19 pandemic and future public health emergencies. caregiving or education (Gassman-Pines et al., 2020; Weaver & Swank, 2021) . A nationwide survey found that parents with children age 18 or younger experienced worsening mental health, increasing food insecurity, decreased health insurance coverage, and loss of childcare during the pandemic (Patrick et al., 2020) . Half of employed parents with children younger than 12 reported difficulty meeting childcare responsibilities (Pew Research Center, 2020) . Disparities in impact of the pandemic on families with school-age children also occurred, with families of color experiencing more adverse hardships (Chen et al., 2021) . This study examined the experience of parents with preschool children in Hawaii during the COVID-19 pandemic. It sought to bring to light ways that families adapted to various pressures exerted on them and ways they adjusted behaviors related to accessing healthcare services and household emergency preparedness (EP). The Family Adjustment and Adaptation Response (FAAR) model describes how families adapt to major adversities or stressful experiences. FAAR illustrates the process families engage in when facing a crisis, and involves four main constructs: (1) capabilities (resources and coping), (2) demands (stressors and strains), (3) meanings, and (4) family adjustment/adaptation. Family adaptation can be positive, characterized by positive physical/mental health of the family unit, or negative, characterized by an imbalance of family functioning, or the achievement of balance for the family at the price of deterioration of individual family member health (Patterson, 1988 (Patterson, , 2002 . The FAAR model has described family stress and coping during crises such as diagnoses of disability/disease, unemployment, or food insecurity (Inhestern & Bergelt, 2018; Maitoza, 2019; Weiss et al., 2015; Younginer et al., 2015) . Recent studies have used family stress theories to examine family experiences during the COVID-19 pandemic. Such studies have identified significant stressors to families arising from the pandemic, such as physical/mental health concerns, economic stress, marital conflict, and challenges in homeschooling, and provide a basis for interpreting how families coped with these stressors (Weaver & Swank, 2021; Wu & Xu, 2020 ). This study used a qualitative descriptive design. This approach provides a comprehensive, descriptive summary of experiences from the viewpoint of the participants (Sandelowski, 2000) . Data collection occurred via small group discussions held in February and March 2021, 12 months into the COVID-19 pandemic in Hawaii. The study was conducted at this time because some restrictions on gatherings had been lifted and preschools were allowed to reopen with limited occupancy. The study used purposive sampling with snowball technique (Parker et al., 2019) . Five individuals whose children were enrolled in a university daycare center were first invited to participate via email, eight other participants were then referred by the initial participants, for a total of 13 participants. Inclusion criteria included being (1) Demographic data were entered into MS-Excel for descriptive statistics. Qualitative data were analyzed using thematic analysis procedures (Nowell et al., 2017) . First, three researchers concurrently reviewed transcripts independently to familiarize themselves with the data. Each then conducted initial coding. Researchers then gathered to compare codes. Where differences in coding were encountered, they were discussed and mutually resolved. Coded data were then sorted and collated into themes. Themes and subthemes were refined and named to reflect aspects of the data they captured. Researchers then generated a report that provided an account of the data within and across themes. Trustworthiness of the study was enhanced through various elements related to credibility, dependability, confirmability, and transferability (Lincoln & Guba, 1985; Nowell et al., 2017) . Credibility was supported through inclusion of diverse participants and use of a flexible question guide allowing participant-driven discussion. Dependability was ensured through regular research team meetings to discuss emerging findings and study processes. Confirmability was supported by having each researcher independently conduct initial coding transcripts and peer-debriefing to assure emerging themes were supported by data. Transferability was supported with strategies including purposeful sampling according to the study criteria, and by providing a description of the context of participants' experiences. All participants were females with ages ranging from 36 to 55 years. Five (38%) participants identified as Japanese, one (8%) as Filipino, two (15%) as Caucasian, two (15%) as Chinese, and three (23%) as "Other" (Taiwanese, Thai, Mixed). One participant (8%) had an associate's degree, three (23%) had a bachelor's degree, and nine (69%) had graduate degrees. Participant characteristics (N = 13) are summarized in Table 2. 3.1.2 Healthcare-seeking behaviors and household EP Level of household EP before the COVID-19 pandemic (on a scale of 0-10) Mid (4-6) 3 (46) High (7-10) 4 (31) Mid ( Adapting to a new normal Adaptations to healthcare-seeking behaviors Household emergency preparedness adaptations participants (n = 10, 77%) had not received any EP training. Most participants (n = 9, 69%) had at least one household member considered an essential worker. Participants rated their household's EP currently and before the pandemic (where 0 = completely unprepared and 10 = extremely well prepared). The median rating before the pandemic was 5.0, compared to the median rating of 6.0 at the time of the study. Four overarching themes emerged from the qualitative data: (1) stressors due to the COVID-19 pandemic, (2) family coping and resources, (3) meaning of the COVID-19 crisis to the family, and (4) family adaptation patterns. Table 4 summarizes themes and categories, which mapped to the domains of the adaptation phase of the FAAR model (Patterson, 2002) . Participants expressed feeling overwhelmed with the number of demands placed on them daily. Demands were related to shifts in employment, childcare, and routine household responsibilities. Participants experienced shifts in employment that were stressful, including increases in hours or responsibilities, decreases in income, working from home, or losing employment. One participant stated: Participants reflected on new routines and patterns they had adopted. They discussed feelings about their 'new normal,' and also described changes to practices related to seeking healthcare services and preparing for emergencies. When asked what plans their family had if someone were infected with COVID-19, participants provided a range of responses. One participant said, "The plan is to. . . reduce your exposure and don't get sick. When someone gets sick, then deal with it." Some participants explained that they had family discussions about the challenges of quarantining in their homes. The most common barrier described was a small living space. A participant who lived in a one-bedroom apartment said, "If one of us has COVID-19, how could we quarantine ourselves. . . ? I don't have a solution that could work well in our home." All participants had either started the COVID-19 vaccination series or had expressed intent to get vaccinated. Two participants were pregnant, and expressed concern about vaccine safety for pregnant women. This study sought to bring to light the experiences of parents of preschool children in Hawaii during the COVID-19 pandemic. Discussion of this study's findings is organized according to the domains of the FAAR model. The COVID-19 pandemic and public health policies enacted to mitigate the spread of disease resulted in a crisis state for some families with preschool children. Parents felt overwhelmed by stress resulting from multiple demands confronting them all at once. Chief among these were major changes to employment. Stressful changes to the work environment experienced by participants in this study reflected trends in the state. One-third of Hawaii residents experienced reduced work hours, 20% had lost jobs, and 11.2% The COVID-19 pandemic has been a period of high uncertainty, especially for mothers of young and adolescent children, who have had to spend extra time, energy, and resources to manage uncertainties to ensure their family members' safety (Walker et al., 2021) . Participants experienced high levels of uncertainty throughout the rapidly evolving pandemic, resulting in a strain on their mental health. Disconnection from extended family members, friends, spiritual communities, and other communal networks, may also have contributed to the mental health strain described among participants. Increased levels of mental distress have been reported among parents in the US (Patrick et al., 2020) . Hawaii residents have also reported experiencing anxiety, depression, or other negative feelings as a result of the COVID-19 pandemic (Buenconsejo-Lum et al., 2021) . While the long-term impact on mental health of the COVID-19 pandemic has yet to be fully understood, it is important that nurses, healthcare providers and other professionals providing services to families with young children be increasingly sensitive to the immense stress that the pandemic has had on parents, and the strain this may have caused on family relationships. The COVID-19 pandemic did not result in major disruptions to healthcare services and access among participants of this study. Individuals who had delayed routine visits reengaged with healthcare providers once they felt that sufficient safety precautions were in place. Enhanced access to telehealth and shorter wait times were welcomed by participants. Increased use of telemedicine may be one of the positive outcomes of the pandemic, with the highest usage among patients 20-44 years of age (Mann et al., 2020) . Patients consider telemedicine easy to use and as valuable as in-person visits, and without telemedicine visits, they would have missed medical appointments (Smith et al., 2021) . Such qualities will ensure that telemedicine will remain an important means of accessing healthcare, especially for par- Parents of young children experienced a major strain on their mental health during the COVID-19 pandemic. Nurses who care for parents of young children can initiate crisis intervention strategies and make linkages to mental health services to help to protect clients' mental health during extremely stressful situations such as pandemic disease outbreaks or natural disasters. Evidence-based strategies include managing media consumption to minimize exposure to news that elicits distress, accessing information from reliable sources that encourage practical steps parents can take to protect themselves and loved ones, and limiting information seeking to once or twice a day. Also, encouraging parents to help children to find positive ways to express their feelings, and maintaining familiar routines or establishing new ones are also important (Brymer et al., 2020; World Health Organization, 2020) . Nurses can partner with other healthcare providers to encourage greater EP among families with preschool children. Nurses are trusted sources of health and safety information and can leverage such trust to encourage EP behaviors. Providers can assist families in preparing for emergencies by encouraging regular vaccinations, stockpiling emergency supplies, and maintaining a family emergency plan (CDC, 2020). Nurses who work at the systems/policy level can advocate for stronger social safety nets to support parents serving as caregivers for their children. Parents of young children took on a heavy burden of multiple conflicting responsibilities, simultaneously maintaining their households while being responsible for their children's education while schools were closed. Parents also experienced changes in working conditions, including decreases in salary or loss of employment. Such changes impacted parents' ability to provide a safe, nurturing environment for children to grow and develop. This study showed how expanding eligibility to preschool programs enabled parents to continue working and provide income to support their household. Providing expanded social support services to parents of young children can empower families to support themselves, ultimately contributing to the long-term health and wellbeing of family members. This study was limited by its small number of participants, many who had children attending a university-affiliated preschool. The average education level of participants was higher than the general population in the state. The sample's racial/ethnic make-up was diverse but not fully representative of all groups in the state. Participants were females living on Oahu, the island with the highest concentration of health/social services. Future studies can address these limitations by including a larger, more geographically diverse sample with characteristics more representative of the general population. Also, small group discussions were conducted by distance via phone or webconferencing. Results may differ if done in-person. Despite these limitations, this study provides valuable insight into the experience of Hawaii parents with preschool children during the COVID-19 pandemic, and robust evidence to support nursing interventions and programs or policies targeting families with young children during largescale disease outbreaks or other disasters. The COVID-19 pandemic had an immense impact on families with young children. This study uncovered stressors experienced by families of preschool children in Hawaii during the COVID-19 pandemic and ways families adapted to the public health crisis. It is important to understand the unique needs of parents with preschool-aged children, as well as how perceptions regarding vaccines, risk, and emergency preparedness have changed due to the COVID-19 pandemic. Such information can inform public policy and outreach efforts to support families during public health emergencies. The Authors declare that there is no conflict of interest. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: [Sigma Theta Tau International Gamma Psi at-large Chapter] The data that support the findings of this study are available from the corresponding author upon reasonable request. Parent/caregiver guide to helping families cope with the COVID-19 pandemic. 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