A cross-sectional study on posttraumatic growth and influencing factors among parents of premature infants

Abstract

Objective

Preterm birth is a significant public health concern that negatively affects parents’ mental health. Posttraumatic growth (PTG) is a positive response to trauma that can effectively help parents cope with the stress of preterm birth. However, few studies have investigated PTG among parents with preterm infants. This study aimed to examine the level and influencing factors of PTG among parents with preterm infants and to explore its relationship with social support coping styles.

Methods

A cross-sectional study was conducted among 160 parents of premature infants in a hospital in Shenzhen, China, from May 2022 to August 2022. Parents’ demographic information and birth-related characteristics were collected through a self-designed general information questionnaire. PTG was assessed using the Chinese version of the Posttraumatic Growth Inventory (PTGI). Social support and coping style were measured using the Social Support Scale(SSS) and the Ways of Coping Questionnaire(WCQ). Pearson correlation analysis was used to investigate the relationship between PTGI and WCQ and SSS .A stepwise multiple linear regression analysis was performed to explore independent influencing factors of PTG.

Results

The parents had an average PTG score of 66.41 ± 10.37, with 81.11% having a low and medium level of PTG. The total score of coping style of parents of premature infants was (34.28 ± 4.97) points, which was in the middle and upper level; the total score of social support of parents of premature infants was (14.28 ± 4.97) points, which was in the middle level. In addition, older gestational age at birth (B = 2.396, P < 0.001) ,higher Apgar score at 5 min at birth (B = 2.117, P = 0.023), positive coping style (B = 0.850, P < 0.001), and higher social support score (B = 1.978, P < 0.001) were associated with higher PTG scores.

Conclusion

Parents of preterm infants have low to medium levels of PTG, indicating much room for improvement. Older gestational age, higher Apgar score at five minutes at birth, positive coping styles, and high levels of social support were associated with higher PTG levels. Our findings provide helpful guidance for the development of effective and targeted intervention programs to improve parents’ PTG and well-being.

Introduction

Preterm birth, defined as newborns born before 37 weeks of gestation or less than 259 days from the first day of a woman’s last menstrual period, is a significant public health problem [1]. A recent systematic analysis of 679 data points from 103 countries and areas reported that 13·4 million infants were born preterm in 2020, accounting for 9·9% of all births [1]. Preterm birth disproportionally affects low-and middle-income countries, with Asia and sub-Saharan Africa accounting for approximately 65% of all preterm births globally in 2020 [1]. Preterm birth is the leading cause of under-5-year mortality, accounting for 17.7% of all deaths and 46.0% of neonatal deaths worldwide [2]. For those surviving preterm infants, preterm birth can negatively affect their physiological, neurological, cognitive, behavioral, and psychosocial development, and the adverse impacts can persist throughout childhood and into adulthood [3,4,5].

Preterm birth not only results in poor health outcomes for preterm infants themselves but also causes considerable stress and challenges among parents who are the primary caregivers of preterm infants [6, 7]. Most preterm infants require admission to Neonatal Intensive Care units (NICUs), and the intense treatments, extended hospital stay, and uncertainty about survival may cause significant distress among parents [8]. For most parents, preterm birth is a highly traumatic event that can lead to a wide range of negative emotions, such as guilt, vulnerability, depression, anxiety, and even posttraumatic stress disorder (PTSD) [9]. If parents can not make positive adjustments and adaptation, it will not only impair their health but also negatively affect their parenting skills and quality of care, further aggravating the health of premature infants [10].

While numerous studies have predominantly focused on the adverse psychological effects of preterm birth on parents, a growing body of research has endeavored to explore their positive psychological reactions to trauma-posttraumatic growth (PTG) [11]. PTG refers to a subjective perception of positive changes and the process of positive transformation after encountering trauma, mainly including five domains: relating to others, new possibilities, personal strength, spiritual change, and appreciation of life [12, 13]. Unlike negative psychology, which only focuses on the negative emotions encountered by individuals during traumatic events, PTG focuses on the positive responses to trauma from the perspective of positive psychology [13]. Parents of premature infants are a vulnerable group to traumatic negative emotions due to hospitalization, anxiety about the infants’ health, and lack of parenting experience [14, 15]. PTG can allow parents to re-evaluate premature birth events actively, re-examine the meaning of life, and grow in reflection by initiating psychological compensation mechanisms and rationalization [14, 15].

However, most parent PTG studies were focused on children with severe diseases, such as cancer [16], autism [17], and other intellectual and developmental disorders [18], and limited evidence exists on PTG in parents of premature infants. Therefore, we conducted the current study to explore the levels and influencing factors of PTG among parents of preterm infants in the NICU. Our findings would offer deeper insights into parents’ positive transformation in the face of preterm birth. A better understanding of PTG is crucial to designing effective and targeted interventions to make full use of the positive factors to improve the family care ability, which would ultimately improve the health of premature infants.

Methods

Study design, participants, and procedure

A cross-sectional study was conducted among parents of preterm infants in a tertiary pediatric specialized hospital in Shenzhen from May 2022 to August 2022. A convenience sampling method was used to continuously select fathers or mothers of premature infants who were hospitalized and discharged from the NICU. Inclusion criteria for the participants included: (1) fathers or mothers of live-birth premature infants admitted to NICU for treatment with a gestational age greater than 28 weeks and less than 37 weeks; (2) age ≥ 18 years; (3) with normal listening, reading, writing, and comprehension abilities to complete the questionnaire survey; (4) voluntary participated in this study and signed informed consent. Exclusion criteria included: (1) parents who gave up treatment for the premature infants and the infants died eventually; (2) with a history of severe physical or mental illness; (3) currently receiving psychotherapy; (4) having encountered other major stressful events within one year, such as the death of a loved one. All the subjects voluntarily participated in the study and signed the informed consent form. This study was approved by the hospital ethics committee (Approval No.: 20221067) and complies with the ethical principles of the Declaration of Helsinki. All 160 parents of preterm infants who participated in this study signed an informed consent form for this study and agreed to use their completed information for research and publication.

Theoretical basis

The theoretical basis used in this study is stress theory, which refers to the action “process” that individuals finally show by psychophysiological reactions through the influence or mediation of intermediate factors such as cognition, coping, social support, and personality characteristics under stress [19]. In this study, it is hypothesized that preterm birth and hospitalization experience are important independent variables stressors for parents, and dependent variable stress response is regulated through mediating variables such as social support and coping styles as well as general data, and parents of preterm infants experience increased post-traumatic growth and proactive coping with life when regulating forward. Negative regulation will be manifested as parental post-traumatic stress disorder, depression, anxiety, affecting the family care of premature infants.

Measurement

General information questionnaire

A self-designed general information questionnaire was developed based on a literature review for the current study. The questionnaire collects information on the parents’ social demographic characteristics, including age, sex, education, monthly household income, religious belief, number of children, medical health insurance, history of genetic diseases and other significant diseases. In addition, the questionnaire collects birth-related information, including pregnancy method, gestational age at birth, twin or multiple pregnancy, mode of delivery, Apgar score at 5 min, disease category, and length of hospital stay. The general information questionnaire form used in this study was designed by the investigator according to the objectives of this study and is detailed in the attachment.

Posttraumatic growth inventory (PTGI)

The PTGI was used to assess parents’ positive changes and growth in dealing with stressful experiences related to preterm infants. The PTGI was initially designed and developed by American scholar Tedeschil [12] in 1996 with a total of 21 items. For this study, we used and Chinese version of PTGI (C-PTGI) revised by Wang et al. [20], which includes 20 items under five dimensions: personal strength, relationship with others, self-transformation, new possibility, and life perception. Each item is rated on a six-point Likert scale ranging from 0 “no such change was felt at all” to 5 “a lot of such changes.” The total score ranges from 0 to 105, with a higher score indicating more positive changes and growth. The C-PTGI score was further categorized into low (< 60), medium (60–65), and high (≥ 66) levels of PTG. The C-PTGI demonstrated good internal consistency in the present study with a Cronbach’s alpha coefficient of 0.83.

Ways of coping questionnaire(WCQ)

The WCQ was used to assess the coping style level of parents of preterm infants. The questionnaire was developed by Jie Yanning [21], a Chinese scholar, and consisted of two subscales: positive coping and negative coping, including 20 items. Each item is rated on a 4-point Likert scale and assigned a score of 0, 1, 2, and 3. By using formula standard score (Z score) = (actual score mean - sample mean) ÷ sample standard deviation, the positive coping style and negative coping style scores were transformed into standard scores (Z score), and then using formula coping tendency = positive coping standard score (Z score) - negative coping standard score (Z score), the tester ‘s coping tendency score was obtained. If the coping tendency value is > 0, it means that the coping style of parents of premature infants is positive coping, and the higher the score, the more positive the coping style. If the coping tendency value is < 0, it means that the coping style of parents of premature infants is negative coping, and the lower the score, the more negative the coping style. In this study, the total Cronbach ‘s α coefficient of the scale was 0.85, the Cronbach’ s α coefficient of the positive coping scale was 0.89, and the Cronbach ‘s α coefficient of the negative coping scale was 0.78.

Social support scale(SSS)

The SSS was developed by Xiao Shui [22], a Chinese scholar, to evaluate the degree of social support of subjects from three dimensions: objective support, subjective support, and utilization of support. The scale contains a total of 10 items, with scores ranging from 12 to 66, and the higher the score, the higher the degree of social support of the subject. A total score of 22 or less indicates a low level, 23 to 44 indicates a moderate level, and 45 to 66 indicates a high level. Cronbach ‘s alpha coefficient for this scale was 0.81 in this study.

Statistical methods

Shapiro-Wilk test was used to test the normality of the PTG score, WCQ score and SSS score, which showed a normal distribution and was expressed as mean ± standard deviation. Data were described by frequencies and percentages for categorical variables and means and standard deviations for continuous variables. Pearson correlation analysis was used to investigate the relationship between PTG and WQC and SSS in parents of premature infants. Univariable analysis was performed by independent sample t-tests and one-way analyses of variance to compare PTG scores across various sample characteristics. LSD pairwise comparison was performed for variables with statistical differences among three groups and above. A stepwise multiple linear regression analysis was performed to explore independent influencing factors of PTG, with all variables that were statistically significant in the univariable analysis as the independent variables. In this study, SPSS 25.0 software was used for statistical analysis, and P < 0.05 was considered statistically significant. This study is a cross-sectional study, with the formula N = N = 4U$\:\alpha\:$²S²$\:/\delta\:$², α = 0.05 for the calculation of cross-sectional sample size. Considering 20% inefficiency, the final sample size is 160.

Results

Characteristics of the sample

Table 1 shows the descriptive analysis of the sample characteristics. Among the 160 subjects, 100 (62.50%) were fathers and 60 (37.50%) were mothers. Their age ranged from 20 to 45 years, with an average age of 34.68 ± 5.79. 130 (81.25%) conceived spontaneously, and 30 (18.75%) used assisted reproduction technology such as in vitro fertilization (IVF).

Table 1 Characteristics of the sample (n = 160)

Descriptive analysis of PTG score

Table 2 shows the scores of the total C-PTGI and its five dimensions. For the total scale, the total score was 66.41 ± 10.37, and the mean score was 3.28 ± 0.51. For the five dimensions, the mean score ranged from 2.90 ± 0.79 for new possibility to 3.55 ± 0.77 for self-transformation. The proportions of low, medium, and high levels of PTG were 42.39%, 38.72%, and 18.89%, respectively.

Table 2 Each scale and its dimension score (n = 160)

Descriptive analysis of coping style score

Table 2 shows the scores of the total WCQ and its two dimensions. For the total scale, the total score was 34.28 ± 4.97 points, and the mean score was 1.71 ± 0.24. For the two dimensions the score of positive coping dimension was 1.92 ± 0.51 and the score of negative coping dimension was 1.41 ± 0.81.98(61.25%) parents of preterm infants had positive coping tendency and 52 (38.75%) had negative coping tendency in their coping styles. See Table 3 for details.

Table 3 Coping tendency (n = 160

Descriptive analysis of social support score

Table 2 shows the scores of the total SSS and its three dimensions. For the total scale, the total score was 34.66 ± 12.09, and the mean score was 3.46 ± 1.21. For the three dimensions, the mean score ranged from 2.46 ± 0.82 for Utilization Dimension of support to 4.82 ± 1.64 for Subjective support.

Pearson correlation analysis of PTG, social support and coping style

The results showed that there was a significant positive correlation between the total PTG score and the dimensions of support utilization (r = 0.723, P < 0.01), objective support (r = 0.682, P < 0.01), subjective support (r = 0.778, P < 0.01), and positive coping dimension of coping style (r = 0.657, P < 0.01) of social support. The total PTG score was significantly negatively correlated with the negative coping dimension of coping style (r = 0.789, P < 0.01). See Table 4 for details.

Table 4 Pearson correlation analysis of posttraumatic growth, social support and coping style

Univariable analysis of PTG

Table 5 shows the comparison of PTG scores by different sample characteristics. The results showed significant differences in PTG scores by sex, age, education level, history of significant diseases, monthly household income, gestational age at birth, twin or multiple pregnancy, and Apgar score at 5 min at birth (P < 0.05).

Table 5 Comparison of PTG scores by different sample characteristics (n = 160)

Multivariable analysis of PTG score

Multiple linear stepwise regression analysis was performed with statistically significant variables (P < 0.05) in univariate analysis as independent variables and PTG total score as the dependent variable. We set the entry level α = 0.05 and exclusion level α = 0.10, and the independent variable assignments are shown in Appendix 1.

Table 6 shows the results of the regression model. The results showed that Variance inflation factor (VIF) = 1.986 ~ 4.328, all < 5, tolerance = 0.321 ~ 0.689, all > 0.2, indicating that there was no multicollinearity between the variables. The Durbin-Waston (DW) test value was 1.764, indicating that the data met mutual independence. Residual analysis was performed on the fitted model and residuals followed a normal distribution.Two variables remained significant in the final model: gestational age at birth (B = 2.396, P < 0.001), Apgar score at 5 min at birth (B = 2.117, P = 0.023) ,coping style (B = 0.850, P < 0.001) and social support (B = 1.978, P < 0.001). The model was statistically significant at F = 28.642, P < 0.001, with adjusted R² = 0.679, indicating that the above variables explained 67.9% of the variation in the dependent variable.

Table 6 Multiple linear regression analysis of PTG

Discussion

Summary of the findings

This cross-sectional study examined the level of PTG and its influencing factors among parents of premature infants admitted to NICUs in Shenzhen, China. Specifically, we explored the impact of parents’ socio-demographic characteristics and birth-related clinical characteristics on parents’ PTG. Our results showed that the parents had a medium-to-low level of PTG, with an average score of 66.41 ± 10.37. In addition, older gestational age, higher Apgar score at five minutes at birth, positive coping styles, and high levels of social support were associated with higher PTG levels.These findings broaden our understanding of PTG among the less studied parents of preterm infants and carry significant clinical implications in guiding future effective intervention programs.

The level of PTG

Our study showed that only less than one-fifth (18.89%) of parents had a high level of PTG, while over 80% had a low-to-medium level of PTG, indicating much room for improvement in parents’ PTG. The average PTG score in our study was 66.41 ± 10.37, which was lower than that reported in a Chinese sample by Pang [23] but higher than that reported in a Korean sample by Lee et al. [15]. The different PTG levels between our study and other studies may be related to the sample. Pang’s [23]study selected parents of general preterm infants, while our study selected parents of preterm infants admitted to the NICU who had a more severe condition and a worse prognosis than general preterm infants. Therefore, parents in our study were more negatively affected by preterm events and had a lower PTG score. In contrast, most of the children in Lee et al.‘s [15]study were critically ill premature infants transferred from various hospitals in this city, with higher severity of illness, longer hospital stay, and greater risk of complications, which may contribute to more parental concern and lower PTG.

Wu et al. [24]showed that nearly 50% of people who suffered traumatic experiences could experience more than moderate PTG, and higher PTG is associated with more positive changes. Premature delivery, as a sudden stress event, may put parents under significant stress. However, most families focus on the condition, disease development, care, and prognosis of premature infants after birth and may ignore the psychological feelings of their parents, who receive less support. Our findings suggest that continuous care and support still need to be provided to the parents to improve their PTG and reduce psychological distress. It is recommended that nursing staff integrate the existing nursing resources and provide parents of premature infants with relevant information about the condition, care methods, and disease prognosis [25]. In addition, educational support and psychological intervention are also needed to effectively improve parents’ PTG levels and promote their mental health.

Influencing factors of PTG

Univariate analysis in this study showed that parents’ PTG scores varied significantly by sex, age, education level, history of significant diseases, monthly family income, gestational age at birth of preterm infants, twin or multiple pregnancies, and Apgar score at 5 min of birth. Further multiple regression analysis excluding the interaction between the factors identified two significant influencing factors of PTG: gestational age at birth and Apgar score at 5 min at birth.

Gestational age

Our study showed that older gestational age was associated with higher PTG in parents of preterm infants, which is consistent with the study by Aftyka et al. [26]. The reasons may be that children with smaller gestational age are more severely ill, are more likely to have a variety of complications, and thus have a worse prognosis. Therefore, their parents may have more concerns about the condition and prognosis of premature infants, which may lead to more negative emotions and lower PTG levels than parents of children with older gestational age. This suggests that nursing staff should provide more targeted educational guidance and nursing knowledge for parents of premature infants with a young gestational age. In addition, nurses should encourage parents to integrate and use social resources actively and in multiple ways to acquire disease-related knowledge. These approaches can deepen their understanding of the diseases and prognosis, enhance confidence in care, and perceive premature delivery events more positively, ultimately promoting psychological transformation and PTG.

Apgar score at 5 min at birth

Apgar score at 5 min refers to the score derived from the assessment of neonatal asphyxia by five signs: skin color, heart beat rate, respiration, muscle tone, and movement and reflexes in the fifth minute after birth in preterm infants. An Apgar score < 7 indicates mild asphyxia and an Apgar score < 4 indicates severe asphyxia [27]. Our study showed that a higher Apgar score at 5 min at birth was associated with higher PTG in parents of preterm infants. Parents’ PTG scores in our study were lower than the normal PTG level of parents with full-term infants [28]. The Apgar score reflects the condition of premature infants, with a lower score indicating a more severe condition and a worse prognosis of premature infants [27]. Therefore, parents of premature infants with low Apgar scores are more likely to have concerns and worries about the conditions of their children and develop negative emotions and low PTG. It is suggested that medical staff should take appropriate intervention measures for parents according to the conditions of premature infants. Nurses should encourage parents to participate in the care of premature infants actively and consciously adjust to mental and psychological pressure [29]. These approaches can help maintain emotional stability, reduce anxiety levels, and maintain physical and mental health.

Our study showed that gestational age at birth and Apgar score at 5 min are important factors influencing parents’ PTG. Both factors reflect the severity of the disease in premature infants, which will directly affect the treatment and prognosis of premature infants, thus affecting the psychological status of parents. For parents of premature infants, nursing staff can set up transition wards in the NICU to improve parental care of premature infants through a parent-participatory care model [30]. Nurses should also empower parents of premature infants by listening to their demands, encouraging them to ask questions, and responding timely and appropriately. Multiple intervention methods, such as multimedia teaching, on-site demonstrations, seminars, and knowledge testing, are also helpful in reducing the psychological pressure on parents [31]. Additionally, a premature infant care clinic may also help to provide individualized evaluation and guidance for premature infants after discharge.

Coping style

The results of this study showed that the coping style scores of parents of premature infants were in the middle and upper level, indicating that most parents of premature infants took active measures to cope with various difficulties caused by premature delivery and subsequent treatment, could actively cooperate with doctors’ treatment and subsequent growth and development monitoring, and held hope for treatment. A small number of parents were also very depressed about learning that their children were born prematurely and that their children ‘s disease status at the time of admission to the intensive care unit and took negative coping measures such as evasion. In addition, the results of this study showed that mothers of preterm infants had higher scores on the positive coping dimension and lower scores on negative coping than fathers of preterm infants, and mothers of preterm infants had more positive coping styles compared with fathers of preterm infants, which was consistent with Tahmineh [32] et al. The reason for analysis may be that, influenced by traditional concepts, fathers of premature infants less choose to confide in the outside world, lack of relief methods, and more use evasion or transfer of attention to alleviate the pressure caused by premature delivery events. As nursing staff should also pay attention to emotional changes in fathers of premature infants at work, fathers of premature infants can be encouraged to adopt active coping through group cognitive behavioral intervention [33], behavioral therapy [34], etc. At the same time, positive psychological strategies such as role model motivation and peer encouragement can also be used to promote the parents of children to feel positive psychological experience.

Social support

In this study, the social support of premature infants was at a moderate level.Good social support is very important for the physical and mental health of individuals, people usually hope to receive social support in the face of trauma and stress, and social support is conducive to better adaptation of parents of children to dilemmas and then improve the quality of life [35]. Compared with parents of normal full-term infants, parents of premature infants tend to feel helpless early in life, crave identification and support, and have a higher need for social support. Therefore, it is suggested that our nursing staff should pay attention to the psychological changes of parents of premature infants at different stages and develop appropriate interventions according to their different characteristics. At the same time, the results of this study showed that most of the social support of parents of premature infants came from families and relatives and friends, and there were few channels to obtain social support, and the support provided by communities, governments, and charities could not meet the needs of parents of premature infants. These suggest that future nursing workers should provide more channels for parents of premature infants to obtain social support, and actively seek help from families, colleagues, friends and society by constructing mutual assistance groups for patients and peer education support, to meet the needs of parents of premature infants in many aspects [30, 36]. Some premature infants will have a series of problems such as poor prognosis, long rehabilitation time and high cost, which brings great pressure and heavy burden to the parents and families of premature infants. Therefore, it is recommended that the medical security department issue more perfect policies, and at the same time, it can also establish a special fund to implement designated assistance for the families of premature infants, give more policy and economic support to the families of premature infants, and relieve the pressure.

Limitations

Our study has several limitations. First, the cross-sectional study design makes it impossible to establish a causal relationship between PTG and risk factors. Second, participants were recruited using convenient sampling methods, which may limit sample representation. Furthermore, because the rest needs of mothers of premature infants after the end of delivery, the majority of the study subjects investigated in this study were male, and a large sample study with longitudinal design and including more psychosocial variables was needed in the future to obtain a more comprehensive overview of PTG in parents of premature infants, but also to explore that gender would have an impact on the study results under the same number of men and women.

Conclusions

In summary, our study shows that parents of preterm infants admitted to NICU have low to medium levels of PTG, indicating more intervention programs are needed to improve their PTG. Older gestational age, higher Apgar score at five minutes at birth, positive coping styles, and high levels of social support were associated with higher PTG levels. Our findings provide helpful guidance for the development of effective and targeted intervention programs to improve parents’ PTG and well-being.