key: cord-0882669-x7oi5mrl
authors: Gerçeker, Gülçin Özalp; Özdemir, Emine Zahide; Özdemir, Bilge; Bektaş, Murat
title: Development of the parental attitude scale-protecting children during COVID-19 and the relationship between parental attitudes and fear of COVID-19
date: 2021-09-08
journal: J Pediatr Nurs
DOI: 10.1016/j.pedn.2021.09.007
sha: a1c8079bfecf5f100fc4024501d21b9e68643b95
doc_id: 882669
cord_uid: x7oi5mrl

BACKGROUND: During the COVID-19 pandemic, parents and children have experienced stress and fear, and the attitudes of parents toward COVID-19 need to be explored. PURPOSE: This study aimed to develop the Parental Attitude Scale-Protecting Children during COVID-19 (PAS-CV19S) and assess its psychometric properties. This study also aimed to determine the relationship between parental attitudes about COVID-19 and fear of COVID-19. DESIGN AND METHODS: In this methodological and correlational study, parents of children ages 6 to 18 years old were included (N = 402). The PAS-CV19S was developed for this study. The study collected data using an online sociodemographic form, a fear of COVID-19 scale, and the PAS-CV19S. The Cronbach alpha coefficient, confirmatory factor analysis, and explanatory factor analysis were used to assess the validity and reliability of PAS-CV19S. Pearson correlation analysis was used to examine the relationship between the fear of COVID-19 scale and the PAS-CV19S. RESULTS: The PAS-CV19S is a valid and reliable scale consisting of three factors (general health, mental health, and preventive behaviors) as subdimensions. The Cronbach alpha of the PAS-CV19S overall was 0.90; the Cronbach alphas for the general health, mental health, and preventive behaviors subdimensions were 0.78, 0.80, and 0.92, respectively. There was a significant negative correlation between fear of COVID-19 and the mental health subdimension. CONCLUSION AND PRACTICE IMPLICATIONS: This study sheds light on parental attitudes about protecting their children from COVID-19. The fear of COVID-19 of parents did not affect attitudes other than mental health. Parental concerns and attitudes about COVID-19 need to be discussed to protect children.

Coronaviruses represent a large group of viruses that cause a range of illnesses. The novel coronavirus disease of 2019 (COVID-19) appeared in December 2019 in Wuhan, China, and was seen in Turkey as of March 10, 2020 (Republic of Turkey Ministry, 2020). More than 11 million cases of COVID-19 have been reported, including more than 2.5 million deaths globally. In Turkey, more than 2.6 million cases of COVID-19 have been confirmed, with more than 28,000 deaths (WHO Coronavirus Disease Dashboard, 2021) . Face-to-face training in schools was suspended as of March 12, 2020, in Turkey (Seker et al., 2020) . According to 2019 data from the Ministry of Education in Turkey, 18 million preschool, primary, secondary, and high school students were affected (Republic of Turkey Ministry of National Education, 2019); since the March lockdown, these students have stayed in their homes. Schools play an important role in social communication for students with their friends and teachers. Also, students who need counseling can access counseling more easily through schools (Wang et al., 2020a) . Because of the epidemic, the daily routines of children have been disturbed, and their access to educational resources has been limited (Lee, 2020) .

In addition to the school closings, changes in curfew have affected children's routines. During the epidemic, children are restricted to their homes without engaging in activities in open areas and without adequate communication with their peers, and these changes may have negative effects on their health (Wang et al., 2020b) . The quarantine process is a major concern of COVID-19 because of the uncertainty about the individual and environmental effects (Brooks et al., 2020) . Children adapt J o u r n a l P r e -p r o o f to the emotional state of adults. Unexplainable behavior in adults is perceived by children as a threat and can cause anxiety (Dalton et al., 2019) . Children and adolescents may exhibit extroverted behaviors (anger, uneasiness) because of their anxiety (Dalton et al., 2020) . Studies on the psychosocial effects of the pandemic are being carried out in children and young people as well as the adults (Cao et al., 2020; Wang et al., 2020b) . In studies was expression most children have experienced anxiety, depression, and fear during COVID-19 (Chang et al., 2020; Liu et al., 2020) .

Fear is known to be associated with other psychological disorders, such as anxiety and depression. Fear has caused substantial negative impacts on people's quality of life during previous epidemics (Huang & Zhao, 2020) . This is strongly intertwined with social isolation and anxiety, especially during the pandemic (Santini et al., 2020) . Parents continued to work (remotely or not) while looking after children, with no clarity about how long the situation would last. For many people, it has been frightening to keep children busy and safe at home. These difficulties are even greater for crowded households. Furthermore, violence against children may increase during school closures. Parents and children can and have experienced stress and fear during the pandemic (Cluver et al., 2020).

In one study of Abuhammad (2021), parents had good protection measures about COVID-19 and were satisfied with governmental measures. COVID-19 is not the first virus to threaten humanity and might not be the last. Effective strategies are needed to evaluate and strengthen familial attitudes to protect, care for, and provide for children. When the literature was reviewed, a scale measuring parental attitudes about COVID-19 was not found. Determining the attitudes of parents This study was a methodological, correlational exploration conducted to develop the Parental Attitude Scale-Protecting Children during COVID-19 (PAS-CV19S) and assess its psychometric properties. The relationship between the PAS-CV19S and fear of COVID-19 was evaluated.

Inclusion criteria of the study were: a) being a parent with children aged 6 to 18; b) being Turkish parent; c) having internet access; d) uses social media, and e) literate. The sample included all parents with children between the ages of 6 and 18 between June 15, 2020, and July 3, 2020, who resided in Turkey. GPOWER 3.0 statistical program using, the study was set to 80% power, with low effect size, a 95% confidence interval, and the margin of error was 5% for a 0.05 level of significance.

The required sample size was determined to be 385. A convenience sampling method was applied in this research, and at least 385 parents planned to be included through social media. The study included 402 parents who were matching including criteria between June 15, 2020, and July 3, 2020.

The construct validity analyses were conducted with all 402 parents.

Parents who did not have children between the ages of 6 and 18 years and those who stated that they did not agree to participate in this research on Google forms via social media were not included in the study. Behaviors among parents who have children older than 18 years old could differ, so these parents were not included in the study. anxiety, and depression. The minimum score for each item was 1 (strongly disagree), and the maximum score was 5 (strongly agree). The total score ranged from 7 to 35. A higher score indicated a greater fear of COVID-19. A Turkish validity and reliability study of this scale was performed by Satici et al. (2020) . Scale permission was obtained for use in this study.

This research was carried out using Google forms via social media. The online sociodemographic form, the PAS-CV19S and the fear of COVID-19 scale were shared through the researchers' Facebook, Instagram, and Twitter accounts. When a person who saw the notice clicked on the link, an informed consent form for the research appeared. Any participant who Turkish parent had children ages 6-18 years and who completed the informed consent was able to fill out the data collection forms. The data were collected between June 15, 2020, and July 3, 2020, after the lockdown ended.

Permission was obtained from the Republic of Turkey Ministry of Health and the ethics committee of the university hospital. Statements were taken from the participants of this study to attest that they participated in this study and that they met the criteria of participation in this study. After the participants read about the purpose of the research saw a form with the contact addresses of the researchers, they read the following statement: "I know that I have children between the ages of 6-18, I voluntarily participate in this study and I can stop answering whenever I want. I accept the use of the information I provide in scientific publications." Participants who approved this statement completed the form. Anyone who wanted to leave was able to exit by closing the form. The contact address of the responsible researcher was shared, and detailed information about study was provided so that the participants could call/e-mail.

An average and percentage calculations were used to evaluate descriptive data. The significance level was accepted as p< .05. Shapiro Wilks test was used for normality of scale means. Regarding the PAS-CV19S, it was used the scope validity index for compatibility analysis of expert opinions. Pearson correlation analysis for item-total score analysis of scale and sub-dimensions, Cronbach Alpha coefficient for determining the internal consistency of scale and sub-dimensions, confirmatory factor analysis whether the items and subdimensions explained the original structure of the scale and explanatory factor analysis to determine the item-factor relationship were used. The data were divided into two halves for factor analysis, EFA was performed with one-half of the data, and CFA was performed with the other-half. The relationship between the PAS-CV19S and the fear of COVID-19 Scale and the items mean scores was evaluated by Pearson correlation analysis. SPSS 22.0 (SPSS Inc., Chicago, IL, USA) and LISREL 8.7 analysis programs were used to evaluate the data (Jöreskog and Sörbom,1996) .

Of the 402 parents included in the study, 89.1% (n = 358) were mothers, and parents' mean (±standard deviation) age was 40.24 ± 6.52 years; 72.6% (n = 301) were university or higher-level graduates, and participants had an average two children (mean ± SD = 1.8 ± 0.7; minimum = 1, maximum = 5). Overall, 17.2% of participants (n = 69) had a chronic illness (32.4% had asthma; 22.1%, hypertension; 11.8%, diabetes mellitus; and 33.7%, other). In addition, 8.5% (n = 34) of the children had a chronic illness (47.2% had asthma; 5.6 %, allergy; 5.6%, type 1 diabetes mellitus; 41.6%, other). During the pandemic, 37.8% of participants (n = 152) stated that they were actively working; 5.5% (n = 22) had COVID-19; and 22.6% (n = 91) had been near people who were positive for COVID-19 (Table 1) .

Validity analysis: The experts (with Ph.D. degrees in pediatrics, community health, and psychiatric nursing, and with an M.D. in pediatrics) were identified to test the validity of the PAS-CV19S. Each of the 12 experts ranked each item on a 4-point Likert scale (1 = inappropriate, 2 = some change is needed, 3 = appropriate, 4 = very appropriate). The scale consisted of 24 items. The content validity index was 0.98 (range, 0.97-1.00).

Test-retest reliability: The PAS-CV19S was administered to 20 parents 2 weeks later, and there was a statistically significant positive relationship between the test-retest scores (p<0.05).

Internal consistency reliability: The reliability coefficient of the PAS-CV19S was α = 0.90. The reliability coefficients for the subdimensions of general health (eight items), mental health (five items), and precautionary behaviors (11 items) were α = 0.78, α = 0.80, and α = 0.92, respectively.

The overall item score, subdimension item score, and subdimension/the overall item score correlations for the PAS-CV19S are shown in Table 1 . The overall item score correlations ranged from 0.277 to 0.675, and the general health subdimension item score correlations ranged from 0.381 to 0.609. The mental health subdimension item score correlations ranged from 0.411 to 0.637, and those for the precautionary behaviors subdimension ranged from 0.563 to 0.777. Subdimension/total scale score correlations of general health, mental health, and precautionary behaviors were 0.690, 0.715, and 0.738, respectively (p<0.001; Table 2 ). and 26.43% of the total variance; had factor loadings of 0.41-0.71, 0.60-0.69, and 0.59-0.81, respectively (Table 3) .

The confirmatory factor analysis (CFA) results were compatible with those of the EFA and are shown in Figure 2 . The CFA found that the factor loadings of the general health, mental health, and has 24 items. The minimum and maximum scores on this scale are 24 and 120, respectively. As the scores on the PAS-CV19S increase, parental attitudes about general health, mental health, and precautionary behaviors change more with higher scores.

The general health, mental health, and precautionary behaviors subdimensions and the PAS-CV19S total mean scores were 51.0 ± 4.4 (min, 40; max, 55), 32.7 ± 4.1 (min, 18; max, 40), 22.0 ± 2.3 (min, 11; max, 25), and 105.7 ± 8.8 (min, 84; max, 120), respectively.

The mean ± standard deviation scores on the fear of COVID-19 scale were 20.1 ± 5.7 (min, 7; max, 35), mean ± standard deviation scores for individual items were as follows: item 1 ("I am most afraid of coronavirus-19"), 3.5 ± 1.0; item 2 ("It makes me uncomfortable to think about coronavirus-19"), 3.6 ± 1.0; item 3 ("My hands become clammy when I think about coronavirus-19"), 1. .9 ± 0.8; item 4 ("I am afraid of losing my life because of coronavirus-19"), 2.9 ± 1.2; item 5 ("When watching news and stories about COVID-19 on social media, I become nervous or anxious"), 3.5 ± 1.1; item 6 ("I cannot sleep because I'm worried about getting coronavirus-19"), 2.1 ± 1.0; and item 7 ("My heart races or palpitates when I think about getting coronavirus-19"), 2.3 ± 1.1.

The correlation between the total PAS-CV19S score or the general health, mental health, and precautionary behaviors subdimension scores and total fear of COVID-19 scale score were examined.

There was a significant negative correlation between fear of COVID-19 and the mental health subdimension (r = -0.120, p<0.05), but no correlation was found between fear and general health, precautionary behaviors, or PAS-CV19S total score (Table 4 ).

The PAS-CV19S was developed to evaluate parental behaviors related to COVID-19 in an up-to-date, detailed, and easily applicable way. This scale was developed according to institutional guidelines, and it consists of universal items. Researchers can adapt this scale to their communities and use the scale in related studies. The findings of this study show that the scale has a high level of reliability.

Expressions intended to be assessed by the items were measured sufficiently. The total Cronbach alpha value was 0.90, and it was greater than 0.78 for all subdimensions. The Cronbach alpha for the general health subdimension (α = 0.78) was slightly lower than the others. In this study, the subdimension/total scale correlations were statistically significant (p < 0.001) and were greater than 0.69. These findings showed that all items had sufficient correlation with their subdimensions. The items that composed the subdimensions also had a high level of reliability. Furthermore, the scale had high internal consistency (Rattray & Jones, 2007) .

The EFA found that the three factors explained 52.67% of the total variance and had eigenvalues greater than 1.00. These findings suggested that the items on the scale explained variance adequately and provided evidence of its construct validity. The EFA found that the factor loadings of all items on the scale were greater than 0.41. It showed that the items on the scale were at moderate and high levels and that its construct validity was acceptable (De Vellis, 2012). The CFA found that the subdimension factor loadings were greater than 0.35. The GFI, CFI, NFI, and NNFI were all greater than 0.90, and the RMSEA was less than 0.080. These results showed that the data are compatible with the model and confirmed the three-factor structure. These values showed that J o u r n a l P r e -p r o o f the scale has structural validity, that the scale items are adequately represented in subdimensions, and that the tool is valid (De Vellis, 2012; Johnson & Christensen, 2008) . The scale developed in this study, as prepared by current guidelines, has high validity and reliability values. A measurement tool adapted to Turkish culture has not yet been encountered. This scale enabled the determination of the attitudes of parents to protect children from COVID-19. It is a measurement tool that can be easily applied to improve children's health in community-based studies.

The PAS-CV19S scale overall and in subdimension scores were high. These high scores indicated that parents take general health measures to protect their children, are sensitive to protecting their children's mental health, and show precautionary behaviors to avoid COVID-19. In the scale items, the parents scored lower than on the following two items than on other items: "I can protect my child from coronavirus" and "I maintain my child's daily routine." These need to be addressed: parents have felt that they may not be able to protect their children from coronavirus, and they are also aware that their children's daily routines are disrupted. Parents need to build 

During the COVID-19 pandemic, high levels of anxiety in parents have affected the anxiety levels of children (Saddik et al., 2020) . We found average levels of fear. Although the scores of the first, second, and fifth items on the FCV-19S were high, the scores of the other items were low. There was a significant negative correlation between fear of COVID-19 and the mental health subdimension scores of PAS-CV19S. This result suggests that, as the fear of COVID-19 increases, parents are less concerned with protecting their children's mental health.

No correlation was found between fear of COVID-19 and general health or precautionary behaviors subdimensions or between fear of COVID-19 and the PAS-CV19S total score. Parents and children have lived with increased stress and fear during the pandemic (Cluver et al., 2020). The isolation and curfew imposed a complete change of lifestyle, and these measures had the potential to threaten the mental health of children and parents. Numerous mental health threats for all people have been associated with the current pandemic (Fegert et al., 2020) . The long-term consequences of the pandemic should be monitored, and the attitudes of the parents during this process should be observed. In this study, we shed light on parental attitudes about protecting their children during COVID-19 pandemic. Although we did not find a relationship between fear of COVID-19 and parental attitudes, we found a relationship between their attitudes toward protecting their children's mental health and fear of COVID-19. Future studies should focus more on this topic and should handle preventive health behaviors for parents. Effective strategies to support parents and children to cope with the challenges of COVID-19 are needed such as providing instructional materials; links to websites that contain current advisories on COVID-19 safeguards; and access to mental health resources (Clark et al., 2020) . Studies about COVID-19 and its effect on parents of children with chronic and developmental diseases are needed (Narzisi, 2020), in part because parents with children who have chronic diseases will likely experience more fear and anxiety (Senkalfa et al., 2020) .

The general attitudes of parents about protecting children during COVID-19, attitudes about mental health, and precautionary behaviors can be determined by health professionals. During the pandemic, which is predicted to continue in the coming years, health professionals will continue to be called upon to provide anticipatory guidance on COVID-19 protective public health measures to parents and children. In this study, the fear of COVID were evaluated and considered average. Parents may feel unable to protect their children from COVID-19 and may worry about their children's development and education as the daily routines are disrupted. More importantly, parents can project their COVID-19 fears to their children, and the relationship quality between the two generations can change. Health professionals should support parents in matters related to and should approach parents and their children holistically.

There are some difficulties and limitations in this study. The findings of the study cannot be generalized for all parents. Studies with larger sample sizes will be required to define the relationship between fear of COVID-19 and parents' attitudes about protecting children during COVID-19 pandemic.

We developed a valid and reliable measurement tool that measures parental attitudes about protecting children during COVID-19; it consists of three subdimensions: general health, mental health, and precautionary behaviors. This scale can be used in descriptive and experimental studies to determine parental attitudes during COVID-19. It is designed according to national and international guidelines, the scale and its items are universal. Adaptive and comparative studies can also be conducted with this scale for cross-cultural studies. Timely and correct determination of attitudes will make it easier to take protective measures. In this study, the attitude scores of parents were quite high, suggesting that parents take general health measures to protect their children, are sensitive to protecting their children's mental health, and show precautionary behaviors to avoid 

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The authors thanks to all parents in this study.

Gülçin Özalp Gerçeker and Murat Bektaş contributed to the study conception and design.Material preparation were performed by Gülçin Özalp Gerçeker and Emine Zahide Özdemir.

Özdemir. Data analysis were performed by Murat Bektaş. The first draft of the manuscript