Post-traumatic growth and influencing factors among parents of premature infants: a cross-sectional study

Study design

A cross-sectional survey was conducted to explore the levels and factors influencing PTG among parents of premature infants in NICUs. This study followed the STROBE checklist for cross-sectional studies. This study was approved by the Medical Ethics Committee of Soochow University Children’s Hospital (2021C5196). The principles of informed consent and confidentiality were adhered to. Prior to the study, the parents of premature infants were informed of the purpose, significance, and precautions of the study, and informed consent was obtained. All questionnaires were anonymous, properly maintained, and used only for this study.

Data collection and participants

This non-experimental investigative study was conducted at an advanced children’s hospital in Suzhou, China. The investigation lasted for eight months, beginning in February 2022. Based on the convenience sampling method, 217 subjects who met the sample scheduling standards were selected and signed informed consent forms were obtained. Premature infants meeting the following criteria were included: (1) gestational age < 37 weeks; (2) parents as the main caregivers; (3) diagnosis of three or more hospital diseases; (4) parents with normal cognitive and understanding abilities; and (5) parents who voluntarily participated in the questionnaire survey and study. We excluded samples from premature infants with congenital malformations or genetic disorders, and from families with major traumatic events within the first month of birth. This study adopted an offline investigation, and 20 samples were selected for pre-investigation in the early stages of testing its feasibility. The contents of the questionnaire were modified and improved, and the survey was conducted on the day the premature infants were discharged. After routine health education, questionnaires were distributed to parents, and informed consent was obtained. The investigator explained the significance and purpose of this study in detail. To ensure the integrity and reliability of the data, investigators checked each item, communicated it in a timely manner with parents, and supplemented missing items. A total of 220 questionnaires were sent out and 217 were effectively received, resulting in an effective participation rate of 98.64%.

Instruments

Based on the purpose of this study, we developed an anonymous questionnaire to collect data through a review of relevant published literature. A pilot study involved pre-surveying 20 parents of preterm infants prior to a formal investigation to determine whether the questions were clear and understandable. The questionnaire included the following: (1) basic information of premature infants: sex, gestational age, birth weight, birth mode, length of hospital stay, etc.; (2) basic information of parents: sex, age, education level, religious belief, average monthly income, payment method, etc.; and (3) basic fertility information: whether the child was an only child, pregnancy, pregnancy complications, etc.

The Post-traumatic Growth Inventory (PTGI) is used to measure the experiences and growth of parents of premature infants after a traumatic event. In this study, the simplified Chinese version of the PTGI revised by Wang et al. (2011) was used, including 20 entries in five dimensions [19]. The index is scored on a six-point Likert scale. From “no such change was felt at all” to “a lot of such changes”, scores were respectively recorded as 0–5 points, with a total score of 0–105 points. Higher scores indicated higher PTG levels. A score of < 60 was considered low level, 60–65 as medium level, and ≥ 66 as high level. The reliability of the scale was good, with a total Cronbach’s α coefficient of 0.874; the Cronbach’s α coefficients of each dimension were 0.611–0.796.

The Chinese Event-Related Rumination Inventory (C-ERRI) was used to evaluate the cognitive processing styles and levels of parents of premature infants experiencing traumatic events. In 2011, Dr. Cann compiled a questionnaire based on PTG theory [20], and in 2013, Dong translated and revised the questionnaire, applying it to patients with accidental trauma [21]. The questionnaire consisted of 20 items in two dimensions (purposeful and intrusive meditation). Using a four-point Likert scale, the occurrence of such thoughts after trauma ranges from “never” to “often” on a scale of 0–3, with a total score of 0–60. The total score was proportional to the rumination level. The Cronbach’s α coefficient of the total scale was 0.92, that of intrusive meditation was 0.93, and that of purposeful meditation was 0.85; this was close to the reliability of the original scale.

The Perceived Social Support Scale (PSSS), developed by Zimet, was used to assess parents’ subjective perceptions and satisfaction with external social support [22]. The scale contains three dimensions and 12 items. Answers are scored on a seven-point Likert scale (1–7), from ” slightly agree” to “strongly agree”, with the total score being 12–84 points. The score obtained is proportional to the level of social support. The Cronbach’s α coefficient of the scale was 0.922, while those for the two dimensions were 0.851 and 0.913, indicating good reliability.

The Family Resilience Assessment Scale (FRAS) evaluates families’ ability to use their own potential and tap surrounding resources in the face of negative events. It was developed by Dr. Sixbey, an American scholar, based on the family resilience model, and has been widely used in research in children with chronic diseases [23]. This scale was Sinicised by Dong [24], after which it contained 44 items in four dimensions: family communication and problem-solving, using social and economic resources, maintaining a positive attitude, and giving significance to adversity. A four-point Likert scale (1–4) was used, ranging from “strongly disagree” to “strongly agree”, with a total score of 44–176; this score correlated positively with the level of family resilience. The Cronbach’s α coefficient of the total scale was 0.96, while that of each dimension was 0.70–0.97, consistent with the original scale.

Data analysis

We used Epidata3.1 to input data, and SPSS26.0 was used for data analysis after a double check. Statistical significance was set at p < 0.05. For sociodemographic data, count data were described statistically as frequencies and percentages. Mean ± standard deviation was used to statistically describe normally distributed measurement data, while median or interquartile spacing was used to statistically describe measurement data not conforming to the normal distribution. Two independent sample t-tests were used for bivariate variables with normal distribution and homogeneity of variance, and a single-factor ANOVA was used for multivariate variables. The Mann–Whitney U test was used for binary variables with non-normal distributions, and the Kruskal–Wallis H test was used for multiple classification variables. In the bivariate analysis, Pearson’s correlation analysis was used to determine the relationship between PTG and rumination, perceived social support, and family resilience for normally distributed data, whereas Spearman’s correlation analysis was used for other cases. A multiple linear regression method was adopted with PTG as the dependent variable and statistically significant indicators in univariate and bivariate correlation analyses as independent variables. Independent variable factors were gradually added to the equation model, and only statistically significant factors were retained to determine the factors influencing PTG and the best model.