Introduction

Pediatric hospitalizations are often a source of anxiety, depression, and stress for parents (^{Compas et al., 2014}; ^{Doupnik et al., 2017}; ^{Craig et al., 2019}; ^{Barreto & Boeckel, 2019}; ^{Bedford & Bench, 2019}). These responses are heightened when hospitalizations occur during childhood. In addition to changing the family’s routine, childhood hospitalizations may also affect child development (^{Gomes et al., 2016}). The parents’ emotional health is also associated with their children’s emotional well-being, and a child’s recovery may be negatively or positively influenced by the parents’ stress level (^{Compas et al., 2012}).

^{Crepaldi (2006)} and ^{Simões et al. (2020)} state that an illness harms a child because, in addition to disrupting their lives in general, it possibly affects their development, formal education, as well as social and familial relations. Additionally, a child’s psychological condition may be harmed due to anguish, fear, and pain elicited by the medical procedures performed during the hospitalization. Depending on how a child experiences a hospitalization, their emotional well-being may worsen due to being separated from their home and family members (^{Crepaldi, 2006}; ^{Freitas et al., 2021}).

According to the Coping Motivational Theory (CMT), coping with stress is a regulatory response that involves behavior, emotions, and motivational orientation. The objective of the regulatory response is to deal with stressors, which can be seen as a threat or challenge imposed on three basic psychological needs - autonomy, competence, and relationship (^{Compas et al., 2012}; ^{Doupnik et al., 2017}; ^{Craig et al., 2019}). The CMT explains that coping is a developmental process. Hence, a coping repertoire increases as individuals develop, whether through trial and error or by mimicking their peers and caregivers, adaptive and maladaptive coping strategies (^{Skinner & Zimmer-Gembeck, 2016}). Thus, psychological instruments are needed to assess coping strategies according to age groups and specific stressors.

Identifying coping strategies used by parents/caregivers in a hospitalization context may significantly contribute to developing individualized assessments and interventions focusing on this population’s main difficulties. As such, a better understanding of coping styles is essential to designing more effective interventions (^{Compas et al., 2017}; ^{Enumo et al., 2019}). To this end, it has been proposed that observing the parents’ emotional responses to a child’s hospitalization may enable health workers to alleviate the stress caused by such an experience on the child by promoting adaptive coping strategies by the parents of hospitalized children (^{Craig et al., 2019}; ^{Barreto & Boeckel, 2019}).

Several instruments address coping strategies among children within a hospital setting. In Brazil, several instruments assess coping strategies, including the Escala de Coping da Hospitalização (COPE-H) [Hospitalization Coping Scale (COPE-H)], which can be used in children and caregivers (^{Garioli, 2016}). More recently, an instrument called the Coping da Hospitalização, Adoecimento e Tratamento [Coping Hospitalization Scale (COPHAT)] was developed to assess the overall context of treatment and illness including post-discharge among children, adolescents, and their parents and caregivers (^{Amaral, 2019}). The latest version of the scale is the COPHAT-P, which consists of 35 items and was developed using the traditional paper-and-pencil format.

The present study aimed to validate an online version of the COPHAT-P to be used outside of a hospital setting. We hypothesize that: (i) A four-factor solution, like the original COPHAT-P, will be found for the online version; (ii) The items of the online version of the COPHAT-P will present high internal consistency, (iii) the online version of the COPHAT-P total score will be positively correlated with the COPE-H; (iv) Emotional problems scores would be directly proportional to COPHAT-P scores.

Method

Results

Table 1 shows the mean score obtained from the online version of the COPHAT-P compared to different sociodemographic characteristics. Most participants were married women, employed, and from southeast Brazil. Additionally, most reported a religious affiliation and higher education.

Regarding emotional problems, most participants reported moderate levels of stress and depression and high anxiety levels during their child’s hospitalization. An ANOVA suggested differences between the score obtained in the online version of the COPHAT-P for only the emotional aspects related to their child’s hospitalization. Participants reporting high levels of anxiety, depression, or stress scored significantly higher in the COPHAT-P than those reporting few symptoms (p<0.001).

Regarding internal consistency (Table 2), results showed the sample’s good adequacy (KMO=0.836) and a high level of reliability (α=0.94). Item 2 obtained the highest mean score (2.827), while item 16 obtained the lowest mean (0.602) among all 35 items.

We detected that the CFA indicated unsatisfactory goodness of fit: CFI=0.662; TLI=0.634; RMSEA=0.111 (95%CI=0.103 -0.119). The EFA indicated a three-factor solution (Table 3). All items presented factor loading above 0.3 and were considered in the COPHAT-P final version. Factor 1 (Hospitalization) was composed of 16 items and explained 21.7% of the variance. Factor 2 (Expectations for returning to school) was composed of 10 items and explained 14.7% of the variance. Factor 3 (Understanding the disease and treatment) was composed of 9 items and explained 10% of the variance. Thus, the final model explained 46.4% of the variance.

Table 4 presents Spearman’s correlations with the COPE-H and the emotional and sociodemographic variables regarding convergent validity. Only the COPE-H dimension 2 (Adaptive Coping) was not correlated with the online version of the COPHAT-P total score. Regarding emotional aspects, the online version of the COPHAT-P was significantly correlated with all variables, especially with the perception of depression (rho coefficient ρ=0.520). Length of hospitalization (in days) and the number of hospitalizations were the only two sociodemographic variables that significantly correlated with the online version of the COPHAT-P total score.

Figure 1A represents the clustering of items (nodes) based on the three factors identified in the EFA. Factor 1 (Hospitalization) presented the highest frequency of strong partial correlations among the items. Items 13-18 presented the strongest correlation in the entire network (r=0.479), followed by items 17-27 (r=0.351). Strong partial correlations were identified in Factor 2 (Expectations for returning to school) between items 30-31 (r=0.337) and 29-30 (r=0.298). Factor 3 (Understanding the disease and treatment) presented the lowest strong partial correlations between the items. Regarding centrality levels (Figure 1B), items 5 and 25 had the highest values in the three measures considered (i.e., Betweenness, Closeness, and Degree).

Legend: Blue nodes represent Factor 1) Hospitalization; Green nodes represent Factor 2) Expectations for returning to school; and red nodes represent Factor 3) Understanding of the disease and treatment.

Figure 1 1A Gaussian Graphic Model According to the COPHAT-P 35 Items. The Green Edges Represent Positive Correlations, and the Red Edges Represent Negative Correlations. Tick Edges Indicate Strong Correlations, and Thin Edges Represent Weak Correlations. 1B. Representation of the Factors of the Three Levels of Centrality Considered in this Study 

Discussion

The present study aimed to assess the reliability and validity of an online version of the Coping Scale of Hospitalization, Illness and Treatment - parents version (COPHAT-P). The main results indicated that COPHAT-P is an instrument with reliable psychometric properties that can be completed in an online format. The EFA indicated a three-factor solution: (i) Hospitalization; (ii) Expectations for returning to school; (iii) understanding of the disease and treatment. All the items presented factor loading above 0.3 and were kept in this version.

In this study, the scale’s items were grouped into three factors: Factor 1, “Hospitalization,” was comprised of 16 items addressing the period of hospitalization and coping strategies, for instance, item 2: “My child gets anxious when s/he is about to be hospitalized.” Factor 2, “Expectations for returning to school,” comprised ten items addressing expectations about the child going back to school, for instance, item 20: “My child is afraid of going back to school.” Factor 3, “Understanding the disease and treatment,” comprised nine items addressing the individuals’ level of understanding concerning the disease and treatment, for instance, item 6: “My child has doubts about how the treatment works.”

According to the COPHAT-P items, having a child hospitalized is a highly stressful experience for parents, regardless of the severity or length of hospitalization, even after hospital discharge (^{Bedford & Bench, 2019}). Therefore, future interventions to identify families at high risk of experiencing mental health difficulties can guide health services more appropriately (^{Silva, 2018}). Additionally, the emotional aspects of hospitalized children are related to having their daily routine interrupted, including not being able to attend school, feeling bad for being hospitalized, having doubts about the disease and therapy (^{Compas et al., 2014}; ^{Crepaldi, 2006}; ^{Freitas et al., 2021}; ^{Simões et al., 2020}).

The network analysis showed a similar distribution, with three clusters. Note that items 5 - “My child thinks it will be difficult to catch up with the school’s workload,” and 25 - “My child thinks it will be difficult to do everything the teacher will ask” presented the highest centrality measures. This suggests that parents become very concerned with their children’s academic studies during hospitalizations. Children and adolescents are entitled to receive psycho-pedagogical support when in hospital, and the activities should be adapted to their developmental stage (^{Smerdel & Murgo, 2018}). However, attending school also provides social-related factors beyond formal education, which may be associated with the parents’ uncertainties concerning their children’s education.

Additionally, the strong connection found between item 9 - “It is hard for my child to accept the changes taking place in his/her body because of the treatment.” with items 8 - “My child hinders the treatment” and 24 - “My child has difficulty depending on others” is noteworthy because these items belong to different factors. The same results are also found with item 16 - “The staff hides from my child the reason for his/her treatment,” which was positioned close to “Hospitalization.” However, this item belongs to the “Understanding of the disease and treatment” factor. These results indicate that knowledge concerning the disease and therapy may support treatment adherence and help children accept the necessary medical procedures for their illness. A psychologist may support this process by providing health education and psychoeducation (^{Joo et al., 2017}; ^{Stein et al., 2019}) regarding disease illness and therapy.

Assisting the parents/caregivers is also vital and can help them relate with the hospitalized child or adolescent. A systematic literature review reports that psychological interventions conducted among parents can improve psychological control, which benefits their children’s hospitalization (^{Law et al., 2019}).

Note that basic psychological needs are involved in this process. The items highlighted in the network analysis show that there was a relevant impact on autonomy and competence. When these aspects are not adequately addressed, individuals may perceive stressors as threats and adopt maladaptive coping strategies (^{Skinner & Zimmer-Gembeck, 2016}). Therefore, assessing this process is crucial to intervene in the context of hospitalizations appropriately.

Regarding the convergent validity of the online version of the COPHAT-P, based on the COPE-H-Caregiver, the results showed the COPE-H-Caregiver Factor 2 (Maladaptive Coping) was not correlated to the online version of the COPHAT-P. This finding was expected because these scale items were designed to identify the intensity of maladaptive coping. The parents’ perceptions regarding depression, length of hospitalization, and the number of times their children were hospitalized were positively correlated with the online version of the COPHAT-P. These results are in line with other studies reporting that a child’s hospitalization can be a source of anxiety, depression, and stress for parents (^{Compas et al., 2014}; ^{Doupnik et al., 2017}; ^{Craig et al., 2019}; ^{Barreto & Boeckel, 2019}; ^{Bedford & Bench, 2019}).

Studies addressing coping strategies report relevant information for psychological assessment and intervention. In methodological terms, this study advances toward what Skinner and Zimmer- Gembeck (2016) proposed to conduct studies addressing coping from a developmental perspective. In this sense, the online version of the COPHAT-P can support understanding regarding the coping process and the development of interventions to decrease maladaptive coping strategies and improve parents’ quality of life facing a child’s hospitalization.

This study’s limitations include the fact that a convenience sample composed of a small number of participants was used, restricting the instrument’s external validity. Additionally, due to a lack of valid instruments in Brazil, the online version of the COPHAT-P convergent validity was verified based on a single instrument (COPE-H). Lastly, a test-retest was not conducted to identify the temporal stability of data distribution.

Conclusion

In summary, this study’s results showed that the online version of COPHAT-P demonstrated good validity indexes and is a useful tool that can be used in the future to assess the coping strategies adopted by parents facing the hospitalization of a child. It is quick and easy to use and can be used by health workers to design therapeutic interventions or preventive measures directed to this population.