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A comparison of preadmission preparation programmes for children undergoing Day Care Surgery Harper, Jeanine M. 1990

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, A Comparison of Preadmission Preparation Programmes for Children Undergoing Day Care Surgery by Jeanine M. Harper B.F.A., University of Victoria, 1974 M.A, University of British Columbia, 1981 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF EDUCATION in THE FACULTY OF GRADUATE STUDIES (Educational Psychology)  We accept this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA April 1990 © Jeanine M. Harper  In  presenting this thesis in partial  degree at the  fulfilment  of  the  requirements  for an advanced  University of British Columbia, I agree that the Library shall make it  freely available for reference and study. I further agree that permission for extensive copying of  this thesis for scholarly purposes may be granted by the head of my  department  or  by  his  or  her  representatives.  It  is  understood  that  copying or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department of  £  MJA^  dxJ-J^Cyt-ay  The University of British Columbia Vancouver, Canada  Date  DE-6  (2/88)  He*  Q -  ;  /990.  ^^ycAsTt^*^/  ABSTRACT  This study was an outcome oriented experiment considering the effects of Preadmission Preparation on 110 children between the ages of 5 and 12 years entering B.C.'s Children's Hospital for Day Care Surgery. Preadmission Preparation has been shown to reduce negative reactions to hospitalization on children having inpatient surgery. To date, no one has found Preadmission Preparation to be of benefit to children having Day Care Surgery. The study considered effects of attention only; general Preparation; Hospital Tours; Instructional Approaches (Modeling and Rehearsal-Instruction); and Modes of Preparation (Print and Audio-Visual). Additionally, the interaction of experimental factors of preparation programmes with individual characteristics of the children (age, gender, position in sibling structure, socio-economic status, verbal ability, health locus of control, trait anxiety, previous hospitalizations, chronic conditions, and stressful life events) were examined. Measures used as outcomes were: Hospital Behaviour Questionnaire, Observation Rating Scale, and Children's State Anxiety Inventory (Spielberger, et al., 1973). These instruments gave 8 different variables. For the repeated measures aspect of the design, data were collected one week and immediately prior to preparation and immediately prior to and six weeks following surgery. Children who received attention only (the experimental control group) were found to react differently than children who received no attention on only one variable. Although Tours alone were found to reduce negative reactions to day care surgery, Preparation in general (regardless of Approach or Mode) was not found to be effective, and in some cases increased negative reactions. Children receiving Rehearsal-Instruction approach programmes had lower verbal and overall observed anxiety prior to surgery than those receiving Modeling programmes. However, they also had higher dependent anxiety following discharge. The Audio-Visual programme reduced negative behaviours on more dependent variables than the Print programme.  Rehearsal-Instruclion/Print and Rehearsal-Insiruction/Audio-Visual each reduced different negative reactions. Of the 10 individual characteristics of children considered in this study, 5 did not interact with the Programme variables on more than 2 dependent variables or had insufficient cell sizes and were not interpreted. Girls appeared to both benefit from and be more negatively affected by preparation than boys, whose reactions to day care surgery were less affected by preparation. Preparation programmes were particularly effective in reducing negative reactions in children from lower socio-economic families and tours were particularly effective for children with chronic conditions. Children with more external health locus of control benefited most from Modeling or Rehearsal-Instruction programmes with no Tour. Children with high and low trait anxiety reacted differently to preparation, with different effects observed on different measures and for different programme conditions. It was noted that dependent measures did not react in similar ways, nor consistently throughout the study. Limitations of a clinical study with extensive analyses is discussed. Further investigations of measures used to evaluate reactions to day care surgery is warranted. Clinical discussion and further research of programme facets and individual characteristics of children is recommended.  iii  TABLE OF CONTENTS Abstract  ii  Table of Contents  iv  List of Tables  '.  List of Figures  .-  ix  ;  xiii  Acknowledgements  xviii  Chapter I - Introduction and Review of the Literature  1  Introduction  1  Review of the Literature  2  Pediatric Day Care Surgery  2  Reactions of Children to Hospitalization  ,  10  Long Term Effects  10  Short Term Effects  13  Reactions of Children to Day Care Surgery  19  Summary of Effects of Hospitalization  20  Factors Influencing Reaction to Hospitalization  21  Preadmission Preparation  23  Approaches to Preparation  24  Mode of Presentation  31  Other Facets of Preparation Programmes  32  Factors influencing the Effectiveness of Preparation Programmes  34  Preparation for Day Care Surgery  35  Summary  36  Chapter II - Rationale and Research Questions  37  Rationale for the Study  37  Research Questions  41  iv  Question 1: Attention Effects  41  Question 2: Effect of Programme  42  Question 3: Effect of Tour  ,.'  :  42  Question 4: Effect of Instructional Approach  42  Question 5: Effect of Mode of Presentation  42  Question 6: Interaction Effects  43  Question 7: Effect of Individual Characteristics  43  Definitions of Terms  44  Chapter in - Methods  46  Design of the Study  46  The Subjects.  46  The Design  48  Experimental Conditions  48  Control Conditions  50  Variables Held Constant Among the Experimental Conditions  51  Moderating Variables  51  Descriptive Variables  52  Dependent Variables  52  Procedures  53  Context of the Study  53  Staffing  54  Development of Programme Packages  54  Development of Instrument Packages and Protocols  56  v  Enrolment of the Study Surgeons  57  Data Collection  57  Data Processing  58  Instrumentation  ,  59  Created Instruments  59  Adapted Instruments  62  Published and Unpublished Tests  63  Data Analysis  67  Descriptive Analyses  67  Analyses of the Research Questions: Programme Variables  68  Exploratory Analases: Individual Characteristics as Moderators  69  Chapter IV-Results  74  Descriptive Analyses  74  A. Description of the Moderating Variables  74  B.Description of the Dependent Variables  77  C. Relationships Among Descriptive Variables  78  D. Relationships Among Moderating Variables  82  Cluster 1: Biodemographic Characteristics and Blocking Variables  82  Cluster 2: Family Characteristics  84  Cluster 3:Children's Personality Characteristics  85  Cluster 4: Personal History  87  Analyses of the Research Questions: Programme Variables  88  Question 1: Attention Effects  88  Questions 2 and 3: Effects of Programmes and Tour  90  vi  Summary of Questions 2 and 3  103  Questions 4,5, and 6: Facets of Preparation Programmes  104  Summary of Questions 4,5, and 6  115  ,'.  Main Effects of Agegroup and Gender  116  Exploratory Analyses of Individual Characteristics  118  Cluster 2: Characteristics of the Family  118  Cluster 3: Children's Personality Characteristics  124  Cluster 4: Child's Personal History  145  Summary of Question 7  149  Chapter V - Discussion  157  Description of the Sample  157  Question 1: Attention Effects  158  Question 2: Effects of Programme  159  Question 3: Effects of Tour  160  Question 4: Effects of Approach  161  Question 5: Effects of Mode  162  Question 6: Effects of Interactions  162  Question 7: Effects of Individual Characteristics  164  Measures of Reactions to Day Care Surgery  168  Clinical Impactions  170  Limitations of the study  172  Summary  173  Recommendations for Further Research  175  Reference  179  Appendix A  186  Table of contents for Appendix A  187  vn  Appendix B Table of contents for Appendix B  218 :  219  Appendix C  229  Table of contents for Appendix C  230  Appendix D  256  Table of contents for Appendix D  257  Appendix E: Instruments  262  Table of contents for Appendix E  263  viii  LIST OF TABLES  TABLE  PAGE  TABLE 1 ... Composition of Hospital Behaviour Questionnaire Item Factors (Pattern Matrix): Varimax Rotation of Principal Components Analysis (N=200)  64  TABLE 1 Frequency Distributions for Categorical Independent Variables  75  TABLE 3 Summary of Statistics and Tests of Normality for the Continuous Moderating Variables  76  TABLE 4 ; J Internal Consistency Coefficients for Child and Parent trait Anxiety and Health Locus of Control  76  TABLE 5 Summary Statistics, Reliabilities and Normality Tests for Continuous Outcome Variables  77  TABLE 6 Inter-Rater Reliabilites for Observation Scales  78  TABLE 7 Marital Status of Parents  78  TABLE 8 Measures of association for Agegroup and Gender with Marital Status  78  TABLE 9 Gender of Child by Marital Status of Parents  79  TABLE 10 Frequency of Number in Household  79  TABLE 11 79 Summary of Analysis of Variance for Number in Household with Age Group, Gender, and Programme TABLE 12 Ethnic Background of Mothers and Fathers  80  TABLE 13 Ethnic Background of Families  81  TABLE 14 Activity Level Within Identified Ethnic Communities  81  T A B L E 15 Summary of Analysis of Variance for Parent's Ethnic Background with Socio-economic Status (SES) and Number in House (House); and Natural Log of Age (LAge) with Number of Languages Spoken by the Child (Lang).  81  ix  T A B L E 16 Average Number in Household for each Ethnic Group of Fathers T A B L E 17 Number of Languages Spoken by Children  '.  .,  T A B L E 18 : Breakdown of the Sample and Programme Cells by the Blocking Factors  82  82  ...83  T A B L E 19 Descriptive Statistics for the Study Sample (Aug 15,1983-June 1,1984) and a Hospital Population (Dec 1,1983 - May 31,1984) on Surgical Category, Age Group and Gender.  84  T A B L E 20 Measures of Association for Agegroup (Age), Gender, and Surgical Category (SURCAT).  84  T A B L E 21 : .' Measures of Association for AgeGroup (Age) and Gender with Position of Child in Family Structure  85  T A B L E 22 ., Summary of Analysis of Variance for Socio-Economic Status (SES) and Age, Gender, and Position in Family Structure  85  T A B L E 23 Frequencies of Position in Sibling Structure (Position) and Age  85  TABLE 24 Summary of Analyses of Variance for Children's Personality Characteristics (Verbal Ability, Health L O C , Tr. Anxiety) and Blocking Variables (Agegroup, Gender, Surcat)  86  TABLE 25 Mean Health Locus of Control Scores for Each Age Group  86  T A B L E 26 Correlation Among Children's Personality Characteristics  86  TABLE 27 Summary of Relationships Among Chronic Conditions, Previous Experience, Age, and Gender  86  T A B L E 28 Summary of Analysis of Variance for Blocking and Child History Variables  87  TABLE 29 Obtained and Expected Frequencies for Previous Experience by Gender  87  T A B L E 30 Means for Group x Gender on the Children's State Anxiety Scale  89  TABLE 31 Means for Control Groups on the Non-Verbal Observation Scale  90  TABLE 32 Mean Scores for Programme x Gender on HBQ Factor 2 and HBQ Total Score  92  x  TABLE 33 Mean Scores for Programme on HBQ Factor 1: Contentiousness, HBQ Factor 2: Dependent Anxiety, and Verbal Observation Scale.  93  T A B L E 34 : Mean Scores for Tour x Gender on HBQ Factor 2: Dependent Anxiety and Children's State Anxiety  95  TABLE 35 Mean Scores for Tour on Observation Rating, Verbal and Non-Verbal Scales.  97  TABLE 36 ; Mean Scores on Programme x Tour x Agegroup on the Verbal Observation Scale  :  99  TABLE 37 Mean Scores on Programme x Tour x Gender on HBQ Factor 2: Dependent Anxiety  100  TABLE 38 Mean Scores on Programme x Tour on Observation Rating, Verbal and Non-Verbal Scales  101  TABLE 39 Mean Score on Approach x Gender on HBQ Factor 4: Appetite Disturbance  105  TABLE 40 Mean Scores for Verbal and Rating Scales of the Observation Scales and HBQ Factor 2 (Dependent Anxiety) for Instructional Approach  107  TABLE 41 Mean Scores for Factors 2,3, and 4 on Mode of Presentation  108  TABLE 42... Approach x Mode x Agegroup on Observation Rating Scale  110  TABLE 43 Mean Scores for Approach x Mode on Observation Rating Scale and Observation Verbal Scale TABLE 44 Mean Scores for Approach x Mode on State Anxiety  Ill  112  TABLE 45 113 Mean Scores for Approach x Tour onObservation Verbal Scale, and Children's State Anxiety Inventory. TABLE 46 Mean Scores for Age Groups on HBQ Sleep Disturbance and Appetite Disturbance and Children's State Anxiety  117  T A B L E 47 Summary Statistics of Regression Lines of Z Scores of Residuals on SES by Approach by Mode  120  TABLE 48 Summary Statistics of Regression Line of Z Scores of Residuals on Programme x SES  122  xi  T A B L E 49 ..... Summary Statistics for Regression Line of Z Scores of Residuals on Trait Anxiety x Approach x Tour on HBQ Factor 2: Dependent Anxiety  125  T A B L E 50 , Summary Statistics for Regression Line of Z Scores of Residuals on Trait Anxiety x Approach x Tour  127  T A B L E 51 ; Summary Statistics for Regression Line of Z Scores of Residuals on Trait Anxiety x Mode xTour  130  TABLE 52 Summary Statistics for Regression Line of Z Scores of Residuals on Health Locus of Control x Approach x Tour  133  T A B L E 53 '. '. Summary Statistics for Regression Line of Z Scores of Residuals on Health Locus of Control x Mode x Tour  135  T A B L E 54 Summary Statistics for Regression Line of Z Scores of Residuals on Health Locus of Control x Approach x Mode  137  TABLE 55 Summary Statistics for Regression Line of Z Scores of Residuals on Health Locus of Control by Programme by Tour  139  TABLE 56 Summary Statistics for Regression Line of Z Scores of Residuals on Health Locus of Control by Tour  141  TABLE 57 Summary Statistics for Regression Line of Z Scores of Residuals on Verbal Ability by Mode  143  T A B L E 58 Summary Statistics for Regression Line of Z Scores of Residuals on Tour by Verbal Ability  144  TABLE 59 Cell Frequencies for Previous Experience x Programme x Tour  146  TABLE 60 Mean Z Score Residuals for HBQ Factor 1: Contentiousness on Previous Experience by Approach  147  TABLE 61 147 Mean Z Score Residuals for HBQ Factor 4: Appetite Disturbance on Previous Experience by Approach T A B L E 62 Mean Z Score Residuals Observation Verbal Scale on Chronic Conditions ( C Q by Approach  148  TABLE 63 Mean Z Score Residuals for Observation Non-Verbal Scale on Chronic Conditions (CC) by Approach by Tour  148  xii  LIST OF FIGURES  FIGURE  PAGE  FIGURE 1 Location of Study Area FIGURE 2 Experimental and Control Variables  47  ....  50  FIGURE 3 ., Dependent Variables: The Instruments Used and the Occasions of their Use.  53  FIGURE 4 ; Instruments and the Variables Measured.  51  '.  FIGURE 5 Mean State Anxiety Scores on 2 Occasions for Control Groups x Gender  89  FIGURE 6 Significant Terms in the MANOVA Analyses Performed for Questions 2 and 3 and the Affected Scales (Variables)  92  FIGURE 7 Mean HBQ: Factor 2 Scores on 2 Occasions for Programme x Gender  93  FIGURE 8 Mean HBQ: Factor 1 Scores on 2 Occasions for Programme  94  FIGURE 9 Mean HBQ: Factor 2 Scores on 2 Occasions for Programme  94  FIGURE 10 Mean Verbal Observation Scores on 2 Occasions for Programme  95  FIGURE 11 Mean HBQ: Factor 2 Scores on 2 Occasions for Tour x Gender  96  FIGURE 12 Mean Children's State Anxiety Scores on 3 Occasions for Tour x Gender  96  FIGURE 13 Mean Observation Rating Scale Scores on 2 Occasions for Tour  97  FIGURE 14 Mean Verbal Observation Scores on 2 Occasions for Tour  98  FIGURE 15 Mean Non-Verbal Observation Scores on 2 Occasions for Tour  98  FIGURE 16 Mean Verbal Observation Scale Scores on 2 Occasions for Programme x Tour x Agegroup  99  xiii  FIGURE 17 ! Mean HBQ: Factor 2 Scores on 2 Occasions for Programme x Tour x Gender  100  FIGURE 18 , Mean Observation Raring Scale Scores on 2 Occasions for Programme x Tour  101  FIGURE 19 Mean Verbal Observation Scale Scores on 2 Occasions for Programme x Tour  102  FIGURE 20 Mean Non-Verbal Observation Scale Scores on 2 Occasions for Programme x Tour  102  FIGURE 21 Significant Terms in the M A N O V A Analyses Performed for Questions 4,5, and 6  105  FIGURE 22 '. Mean HBQ: Factor 4 Scores on 2 Occasions for Approach x Gender  106  FIGURE 23 Mean Observation Rating Scale Scores on 2 Occasions for Approach  107  FIGURE 24 Mean Verbal Observation Scale Scores on 2 Occasions for Approach  107  FIGURE 25 Mean HBQ: Factor 2 Scores on 2 Occasions for Approach  108  FIGURE 26 Mean HBQ: Factor 2 Scores on 2 Occasions for Mode  109  FIGURE 27 Mean HBQ: Factor 3 Scores on 2 Occasions for Mode  109  FIGURE 28 Mean HBQ: Factor 4 Scores on 2 Occasions for Mode  109  FIGURE 29 Mean Observation Rating Scale Scores on 2 Occasions for Approach x Mode x Age Group  110  ;  FIGURE 30 Mean Observation Rating Scale Scores on 2 Occasions for Approach x Mode  Ill  FIGURE 31 Mean Verbal Observation Scale Scores on 2 Occasions for Approach x Mode  112  FIGURE 32 Mean Children's State Anxiety Scores on 3 Occasions for Approach x Mode  113  FIGURE 33 Mean Verbal Observation Scale Scores on 2 Occasions for Approach x Tour  114  FIGURE 34 Mean Children's State Anxiety Scores on 3 Occasions for Approach x Tour  114  xiv  FIGURE 35 :. Mean Children's State Anxiety Scores on 3 Occasions for Age Group  117  FIGURE 36 Summary of Dependent Variables showing Significant Effects of Multiple Regression Analysis of Cluster 2: Family Characteristics  119  FIGURE 37 Mean Z Score Residuals for HBQ Factor on SES xApproach x Mode  120  FIGURE 38 , ". Mean Z Score Residuals for Observation Non-Verbal on SES x Approach x Mode  121  FIGURE 39 Mean Z Score Residuals for State Anxiety at Follow-Up on SES x Approach x Mode  121  FIGURE 40 '. '. Mean Z Score Residuals for HBQ Factor 2 on SES x Programme  123  FIGURE 41 '. Mean Z Score Residuals for Non-Verbal Observation Scale on SES x Programme  123  FIGURE 42 ..• Mean Z Score Residuals for Children's State Anxiety Inventory on SES x Programme  124  FIGURE 43 Summary of Significant F Values for Effects of Multiple Regression Analyses of Cluster 3: Personality Characteristics  125  FIGURE 44 .' Mean Z Score Residuals for HBQ Factor 2 on Trait Anxiety x Approach x Tour  126  FIGURE 45 Mean Z Score Residuals for Observation Rating Scale on Trait Anxiety x Approach x Tour  127  FIGURE 46 Mean Z Score Residuals for Verbal Observation Scale on Trait Anxiety x Approach x Tour  128  FIGURE 47 Mean Z Score Residuals for Non-Verbal Observation Scale on Trait Anxiety x Approach x Tour  128  FIGURE 48 Mean Z Score Residuals for State Anxiety Inventory at 6 Week Follow-up on Trait Anxiety x Approach x Tour  129  FIGURE 49 Mean Z Score Residuals for HBQ Factor 2 on Trait Anxiety x Mode x Tour  131  FIGURE 50 Mean Z Score Residuals for HBQ Factor 3 on Trait Anxiety x Mode x Tour  131  FIGURE 51 Mean Z Score Residuals for Verbal Observation Scale on Trait Anxiety x Mode x Tour  132  xv  FIGURE 52 Mean Z Score Residuals for Observation Non-Verbal Scale on Trait Anxiety x Mode x Tour  132  FIGURE 53 Mean Z Score Residuals for HBQ Factor 3 on Health Locus of Control x Approach x Tour  134  FIGURE 54 Mean Z Score Residuals for Children's State Anxiety at 6 Week Follow-up on Health Locus of Control x Approach x Tour  134  FIGURE 55 '. Mean Z Score Residuals for HBQ Factor 4 on Health Locus of Control x Mode x Tour  136  FIGURE 56 Mean Z Score Residuals for Children's State Anxiety at 6 Week Follow-up on Health Locus of Control x Mode x Tour  136  FIGURE 57 Mean Z Score Residuals for HBQ Factor 2 on Health Locus of Control x Approach x Mode  138  FIGURE 58 Mean Z Score Residuals for Observation Non-Verbal Scale on Health Locus of Control x Programme x Tour  138  FIGURE 59 140 Mean Z Score Residuals for Observation Verbal Scale on Health Locus of Control x Programme x Tour FIGURE 60 Mean Z Score Residuals for Children's State Anxiety at Pre-Surgery on Health Locus of Control x Programme x Tour  140  FIGURE 61 Mean Z Score Residuals for Observation Non-Verbal Scale on Health Locus of Control x Tour  141  FIGURE 62 Mean Z Score Residuals for Children's State Anxiety at 6 Week Follow-up on Health Locus of Control x Tour  142  FIGURE 63 Mean Z Score Residuals for HBQ Factor 4 on Verbal Ability x Mode  143  FIGURE 64 Mean Z Score Residuals for Observation Non-Verbal Scale on Verbal Ability x Mode  144  FIGURE 65 Mean Z Score Residuals for HBQ Factor 4 on Verbal Ability x Tour  144  FIGURE 66 Mean Z Score Residuals for Observation Non-Verbal Scale on Verbal Ability x Tour  145  FIGURE 67 Summary of Significant F Values for Effects of Multiple Regression Analyses of Cluster 4: Personal History  146  xvi  FIGURE 68 1 Summary of the Relationship of Higher Socio-Economic Status and Approach and Mode  150  FIGURE 69 Summary of the Relationship of Higher Socio-Economic Status and Programme  150  FIGURE 70 Relationship between more Internal Health Locus of Control and Approach and Tour  151  FIGURE 71 Relationship between more Internal Health Locus of Control and Mode and Tour  152  FIGURE 72 Summary of the Relationship of Internal Health Locus of Control and Mode and Approach  153  FIGURE 73 •. J Summary of the Relationship of Internal Health Locus of Control and Programme and Tour  153  FIGURE 74 Summary of the Relationship of Internal Health Locus of Control and Tour  154  FIGURE 75 Relationship of Higher Trait Anxiety scores and Approach and Tour  155  FIGURE 76 Summary of Effects of Trait Anxiety on Mode and Tour  155  FIGURE 77 Number of Significant Effects for each Dependent Variable used in the ANOVAs (Questions 2,3,4,5, & 6)  169  xvii  ACKNOWLEDGEMENTS  I would like to acknowledge the assistance of my committee; Dr. Robinson, whose generosity provided the opportunity to do this study and who taught me professionalism; Dr. Oldridge, who taught me clinical skills and the value of laughter; and Dr. Conry, who guided me through the research study and taught me patience. I would like to thank them for their support and encouragement throughout the various stages of the research project.  The Day Care Surgery Unit staff at B.C.'s Children's Hospital, particularly Mrs. Laird, accommodated our study very graciously. I would also like to thank the children and their families who participated in the study, particularly Drew and Eileen, who were in the video tapes and photographs.  The assistance of the "PPP" staff, Marg Francis, Donna Schmirler, Pat Palulis, Gail Matiaszow, Maureen Oliver, and Gisella Theurer was invaluable. Sally Gardner and the Audio-Visual Department of the Faculty of Education, U.B.C. demonstrated endless patience in the production of the video-tapes and booklets.  My professional colleagues and friends, particularly those at the Child Development Programme at Sunny Hill Hospital for Children, could not have been more supportive and encouraging during thefinalstages of this ordeal.  My debt of gratitiude is deepest to my friends and family, whose good wishes carried me through and who were always there when I needed them. This was particulary true of my parents, Dr. and Mrs. Reginald Harper, my sons, Ian and Graham, and my husband, Lcs Linfoot, whom I acknowledge as a true partner in this endeavor.  xviii  CHAPTER I  INTRODUCTION AND REVIEW OF THE LITERATURE  Introduction  Over the past twenty-five years many changes have occurred in the practice of Pediatric Medicine. Two of these changes are the increased use of Day Care Surgery and the development of psychosocial programmes, in particular Preadmission Preparation Programmes. The purpose of this study was to examine the effects of the interaction of these two practices on children. Since the 1940s, physicians and other professionals have been concerned about the potential negative psychological impact of hospitalization and surgery (Spence,1947). This negative impact may include anxiety and upset behaviour following the hospitalization. One answer to this concern regarding the effects of hospitalization on children is to keep them out of hospital as much as possible. When surgery is required, Day Care Surgery, or the practice of admitting children to hospital, performing the surgery and discharging them all on the same day, reduces the length of time a child must be hospitalized. (There are other benefits to Day Care Surgery which will be discussed later). Another attempt to reduce the psychological impact of hospitalization is psychosocial programmes provided by the hospital, particularly Preadmission Preparation. The purpose of these programmes is to inform children ahead of time of what they will experience and what they may feel. Some programmes also provide professionals with an opportunity to discuss the feelings of the children and offer suggestions as to how to cope with the experience and their reaction to it. The benefit of these programmes for children admitted for inpatient surgery has been described in the research literature. Can a Preadmission Preparation programme assist children to cope with the stress of Day Care Surgery or is Preadmission Preparation unnecessary for children admitted for this type of care? Are there benefits just from receiving the extended attention associated with participating in a research project, regardless of whether or not actual preparation is obtained? If preparation is useful, what approach to preparation and what mode of delivery are best able to assist children to cope with the day care surgery experience? These are the questions addressed by this study.  1  Review of the Literature  This review of the literature consists of three principal sections: Pediatric Day Care Surgery, Reactions of Children to Hospitalization and Preadmission Preparation. Because of the breadth of the topics covered, the most recent studies, which most closely relate to the development of the research questions, are examined in the greatest depth. Paediatric Dav Care Surgery. In this section, the recent (past 15 — 20 years) upsurge in use of Pediatric Day Care Surgery is examined. The reasons for this trend are considered and, in particular, the literature pertinent to psycho-social benefits of this admission protocol are described. Technical discussions of surgical and anaesthetic techniques, which are indeed germane to the arguments for the increased use of day care surgery, are beyond the scope of this presentation and, therefore, not included. Reactions of Children to Hospitalization. The research literature which describes children's reaction to hospitalization is described. Limitations of this research are discussed, with specific reference to generalizability to the current population and to day care surgery. Preadmission Preparation . The role of Preadmission Preparation in reducing negative reactions to hospitalization is examined. Recent research has begun to examine facets of these programmes, attempting to describe the most effective ways to prepare children for elective surgical admissions. Studies which examine methods (approaches), modes of presentation, timing, and other aspects will be reviewed.  Paediatric Dav Care Surgery. Day care (or outpatient) surgery is the performance of surgical procedures requiring a general anaesthetic on an ambulatory basis. More specifically, patients are admitted to the hospital one or two hours before surgery and are discharged to their home when they recover from the anaesthetic, usually three to six hours following the surgery. Day care surgery is generally handled from an organized Day Care Unit programme which may consist of a separate unit or dedicated beds and dedicated staff. Generally, the same surgical suites are used as for inpatient surgery and the same protocols for care are followed, although in the United States free standing "surgi-centres" are emerging (Shah, 1980). This practice requires that preliminary laboratory work be completed before the children's admission and that the parents and/or patients understand and be able to manage the pre-anaesthetic requirements (fasting, bathing, etc.) and the post operative care.  2  The history of modern surgery is one of continually developing safer and more effective surgical procedures. This has been accomplished by controlling the environment in which the procedures are performed as well as in advancing specific surgical and anaesthetic techniques. In Day Care Surgery, medical staff relinquish some control of the environment and thereby increase certain risks. The patient is not captive on the day proceeding surgery to ensure that laboratory work is completed and that reports are available to anaesthetists and surgeons. Diet becomes the responsibility of the patient or guardian. Recovery activity and vital signs are not monitored by medical personnel, beyond the few hours immediately following surgery. Historically, most surgery was performed on an outpatient basis. But with the increased number of hospital beds and the increased attention to antiseptic conditions and other environmental controls, more and more surgery was performed on an inpatient basis. However, J. H. Nicoll argued, in 1909, that the benefits of outpatient surgery for children might outweigh the potential risks. He claimed that on the basis of almost 9,000 operations performed safely on an outpatient basis, that the economic benefits to the hospital were considerable and that the children rested and ate much better at home with their mothers than in the hospital. It was not until the 1960s that the issue was again raised (Bergman, Shroud & Oppe\ 1965; Lawrie, 1964 ) and at this time the concept of day care surgery began to gain in popularity with physicians, hospitals, patients and their families. In Winnipeg's Children's Hospital, proportions of surgery performed on a day care basis have increased from 26 percent in 1971 (Tisdale, 1972) to 43 percent in 1981 (Postuma & Ferguson, 1982). In British Columbia, in 1968,7.4 percent of all surgery was done on a day care basis; by 1974, the proportion had increased to 22.1 percent (Shah & Robinson, 1977). By the 1987/1988 fiscal year, 46 percent of surgery performed on patients 15 years of age and younger was in Day Care Surgery units (W. E. Selwood, Institutional Services, Ministry of Health, B.C., personal communication to G. C. Robinson, February, 1989). Indications are that this trend will continue. More and more procedures are being identified as safe to perform on a day care basis (Lawrie, 1964; Shah, Robinson, Kinnis, & Davenport, 1972). In this way adenotonsillectomies (Segal, Berger, Basker, & Marshak, 1983) and orchiopexy (Caldamone & Rabinowitz, 1982) have come to be accepted as suitable for day care admission in some hospitals. Other criteria for day care surgery candidacy are also changing (such as age, length of anaesthetic, etc.) as research and experience justify the inclusion of more and more patients and procedures (Johnson, 1983; Mcrridy, 1982). Finally, it has been observed  3  that specific surgeons tend to designate types of procedures as inpatient admissions, while others perform the same procedures on an outpatient basis (Evans & Robinson, 1980; Heasman, 1964). As more surgeons who are accustomed to day care surgery practices enter the hospitals, and those not accustomed to the concept retire, a further increase in the number of surgical cases performed on a day care basis may be anticipated. Shah (1980) suggested that the reasons that the Day Care Surgery concept took hold in the 1960s and early 1970s in Canada were: (1) psychological from the point of view of both parents and children, (2) economic, and (3) political. A further advantage of Day Care Surgery over inpatient surgery may be: (4) reduced incidence of cross-infection. These four issues will be discussed below in reverse sequence.  Risk of cross-infection. Lawrie (1964), in his report on five years of his surgical day care programme, commented, "In good children's hospitals, 14% of the children were in hospital for illnesses acquired after admission." (p.1289). He suggested that cross-infection occurred less frequently in the day care patients, but did not provide any figures. He reported no chest complication or operauon-wound infections in his day care surgery patients. In the only quasi-experimental study conducted on the effects of day care vs. inpatient paediatric surgery (Shah et al., 1972), incidence of cross-infection was not included as a variable, although other complications were included. Therefore, no real data was found to suggest that incidence of cross-infection is reduced in children having day-care, rather than inpatient, surgery. Political incentives. In 1977, the Federal Government, under its cost-sharing of universal medical coverage programme, provided new incentives to the provinces to promote alternatives to inpatient care, day care surgery as one aspect (Shah, 1980). As health care costs rose and demand for hospital beds increased, waiting lists for elective surgery grew. Day care surgery has been viewed by surgeons as a method of reducing waiting lists, thereby increasing productivity. Reductions in waiting time for surgery and concern for the psychological health of their children (see below) have led parents to also support day care surgery surgery facilities (Shah, 1980; Shah, Papageorgis, Robinson, Kinnis, & Israels, 1969). Economic considerations. With a child in the hospital for six to eight hours rather than 2 or 3 days, there is a financial saving per case. Shah (1980) suggested that the same procedure performed in day care  4  surgery costs one third as much when performed as inpatient surgery. Davenport, Shah, and Robinson (1971) noted that by decreasing the pressure on accute care beds, fewer hospital beds may be required additionally in the future, thereby reducing capital costs. Evans and Robinson (1980) in a careful analysis of the economics of day care services suggested that the cost-savings per "episode" could be as high as 70% if the child was cared for through day care rather than inpatient surgery. However,, they also noted that the total number of surgical procedures performed rose during the time period examined, indicating that day care became an "add-on" rather than a substitute service and that, therefore, total medical costs actualjy rose over the time period rather than falling as a result of the implementation of day care protocols. They further suggested that this concern should be re-examined as time goes on and the use of day care surgery for specific patients and procedures stabilizes. Evans and Robinson (1980) also suggested that the cost to parents of day care surgery cannot be prohibitive as most parents, having a choice, choose this form of treatment for their child. In an attempt to compare actual cost to parents of day care surgery vs. inpatient surgery, Stanwick, Peabody, Postuma, and Home (1982) asked 164 parents to examine their actual costs, including lost wages, transportation, babysitting, etc. They concluded that day care was less costly for bom local and regional families than inpatient surgical care. Psychological considerations — Parental attitudes and concerns. Several surveys and one quasi-experimental study of parental attitudes to day care surgery were located in the literature. At the Health Centre for Children in Vancouver in 1967, parents of 611 children who would have been eligible for Medical or Surgical Day Care if available, were interviewed after their child's discharge from an inpatient admission (Shah, et al., 1969). Forty-eight percent of parents with children 0—5 years of age, 47 percent of parents with children 6—11 years, and 28.6 percent of parents with children 12—18 years favoured day care over inpatient services. Place of residence and educational level also made significant differences to the choice of day care, with more parents living outside of Greater Vancouver than within the city and those with higher education levels preferring day care to traditional inpatient care if both were available and acceptable to their physicians. Most parents claimed that both they and their child felt anxious during their child's hospitalization. They also agreed that children often enjoy their time in hospital.  5  Parents who would have chosen day care, if available, felt more strongly than parents who chose conventional care that their child felt belter in the parents' presence, that they would prefer their child to be at home, and that their child also would prefer to be at home. Parents who chose conventional care were more likely than those who chose day care to feel that their child was safer in the hospital and that it would be difficult to arrange for their child's home care. In a Vancouver survey of 20 mothers with children in a day care surgery unit, Smith (1970) found that 18, or 90 percent, were satisfied with the information and assistance they received and would be happy to have their child have day care surgery again. Two mothers felt overwhelmed by their responsibilities and would have preferred their child remain in hospital for a few days. Although 18 mothers were satisfied with the experience, 14 mothers required assistance and expressed concerns regarding the obtaining of information they desired about the operation and anaesthetic. Glen, El-Shafi, and Klippel (1980) had response from 220 parents (of 431) to a mailed questionnaire. Ninety-four percent claimed they would choose day care over inpatient surgery on another occasion. Of the 12 parents who would not choose day care, their reasons were: -feelings of helplessness and apprehension (6); -overwhelmed by combined responsibility of other children (3); -too far from hospital in event of emergency (1); and -lack of insurance coverage (2). Reasons why parents would choose day care were not given in the research report. Complaints by parents and potential solutions and the researchers' concern that only 77 percent of the parents reported they clearly understood all instructions and information provided were discussed. In Jamaica, 100 parents and guardians were surveyed by Venugopal and Carpenter (1986) on their reaction to day care surgery. Despite adverse socio-economic conditions (single parents, unemployment, no assistance, no transportation) 96 parents would accept this condition of admission again and would recommend it to others. Twelve parents found their child difficult to manage in the post-operative period. Shah, et al. (1972), in the only experimental study found on this topic, considered parental attitudes, as well as medical complications in day care surgery. Children, who had been randomly assigned to day care or  6  conventional inpatient care prior to surgery, were matched for surgical procedure, age, gender, and occupational level of parent. Thus, two groups of 116 parents each, were formed. Parents of children who had day care surgery were more likely than those whose children had inpatient surgery to feel that they would have no difficulty caring for their child after surgery and that their child would be more happy at home during recovery. Of those in the day care group, 78.4 percent preferred day care and 21.5 percent would choose inpatient care. Parents of children who had inpatient surgery were more likely than those whose children had day care surgery to feel anxious if they would have to care for their child at home and that their child was more comfortable and safer in the hospital. Of the inpatient group, 66.4 percent preferred that type of care, with 33.6 percent preferring day care. In Shah et al.'s study (1972), children in the day care surgery group were visited each day at home by a nurse. Parents of these children found the visits reassuring and helpful. They felt a visit on the evening of the surgery to be very important, and continued visits of value. Parents of children in the inpatient group, who had not experienced the day care surgery process and were speculating, rated these visits as less important than did the parents who had actually experienced day care surgery and the visits. Parents from both groups who would have chosen day care, most often gave reasons of psychological benefit to the child, while parents who would have chosen inpatient care, regardless of actual assignment, gave their own anxiety and the presumption of better care of their child by the hospital than by themselves as their main reasons. It is interesting to note that of 350 children eligible for inclusion in this study, 7 were excluded either pre- or post-operativcly by the surgeons or anaesthetists as ineligible for day care surgery because of the mothers' anxiety or inability to care for their children. Psychological considerations - Children's reactions to day care surgery. Each journal article describing the benefits of day care surgery, lists psychological benefits to the child as one of the important criteria. For example: Many young children are very unhappy in hospital, and on their return home are disturbed — and disturbing — for some days or weeks. In contrast, the child who goes home on the same day does not suffer these effects of separation. (Lawrie, 1964, p. 1289)  7  and: The child's separation from his parents and home are minimized so that behavioural disturbances associated with separation and hospitalization are reduced. (Johnson, 1983, p.553) The studies reviewed above indicate that parents have the perception that the children were happier at home. Psychological reactions to inpatient hospitalization and comparisons with day care surgery samples will be discussed in a following section. Other aspects of Dav Care Surgery Programmes. Day Care Surgery Programmes have gained tremendous popularity in the last twenty years, as noted earlier. During these same twenty years other paediatric issues have gained wide public and professional attention, notably,-the psychosocial effects of hospitalization and surgery on children and their families (to be discussed later). Also, Day Care Surgery units tend to have small, constant staffs (five day weeks, maximum two daily shifts) and be in close contact with anaesthetists and surgeons. Day Care Surgery programmes have developed components, not found in inpatient programmes, which are considered to be psychologically supportive. In a study conducted in Vancouver and reviewed above (Shah et al., 1972), a nurse visited the families on the evening of the surgery and daily for several days thereafter. An article concerning a programme in Winnipeg (Tisdale, 1972) described a nurse visiting the home in the week prior to surgery to assess the children's health status, perform routine tests, and give information and reassurance to the children and families. She again visited the families on the day following the surgery, when she assessed the children's progress, reassured the parents, and provided any necessary medical assistance. In Santa Rosa, California (Brown & Peak, 1984), preparation for both children and parents began when the family arrived at the unit prior to surgery and continued throughout their stay. Written instructions in postoperative care were provided the parents and a follow-up phone call was made the day after surgery. In Dallas (Kirkpatrick, 1984), a Nurse-Practitioner was assigned to the Unit. Her responsibilities included obtaining a health history, evaluating laboratory results, pre-operative teaching, and assessing the children's candidacy for day care surgery. At McMaster University (Rigg, Dunn & Cameron, 1980) in the week prior to surgery, families attended an assessment clinic where medical histories were taken and pre-operative teaching occured through a slide/tape  8  presentation and individual discussion. The children, with assistance, were allowed to choose their own method of anaesthetic induction. A specially trained volunteer stayed with the family on the day of surgery. Pre-medication did not often occur and parents accompanied their children to the operating theatre, remaining until the children were under anaesthetic. Parents were also encouraged to be in the recovery room and participate in their children's care until discharged. No post-discharge follow-up was noted. Twenty-seven parents were surveyed and indicated a positive response to the programme. Day Care Surgery Units appear to be the venue where pre-medication is often abandoned and parents are permitted to be present during the anaesthetic induction. Kay (1982) notes: We also demonstrated a close correlation between the degree of disturbed behaviour after the return home,... Children who became disturbed during induction of anaesthesia showed signs of psychological disturbance afterwards; the greater the upset, the greater the effect. We consequently routinely invited and advised the mother's presence at induction in all our subsequent practice, which has so far not produced any difficulties. ( p.80)  Disadvantages of Day Care Surgery. Only one article was found which discussed disadvantages of day care surgery. Hatch (1983) lists potential disadvantages as: 1) less time for establishing rapport with patients; 2) reduced time for post-operative observation and evaluation; and 3) the increase in day care surgery may not be balanced by a reduction in inpatient surgery but, rather, create an increase in the total number of surgeries performed. The first criticism may be partially answered by the acceptance of pre-admission, as well as pre-operative, teaching as part of the Day Care Surgery protocol (Johnson, 1983; Rigg, et al., 1980). The second criticism is felt to be medically answered by the studies supporting the safety of day care surgery for particular operations (e.g., Caldamone, 1982; Heasman, 1964; Merridy, 1982). Psychologically, however, little supporting evidence has been produced (see below). The third comment is also acknowledged in the study by Evans and Robinson (1980) discussed above and may be considered valid. It appears, then, that Day Care Surgery for children is a medically and economically (individually) valid option for performing surgery on children and is more likely to increase than decrease in use over the coming years. Therefore, it is important to consider the actual psychological effects of this surgical protocol on children and their families.  9  Reactions of Children to Hospitalization The negative psychological reactions of children have been reported and studied since the 1940s (Spence, 1947). These effects have been reported as changes in personality and behaviour during the hospitalization and also as behavioural disturbances following discharge which may last for many years. Studies examining these reactions will be discussed under the following headings: long term effects, short term effects including both post-hospitalization and immediate in-hospital behavioural disturbances, comparisons of effects on inpatient and day care surgery groups, and factors influcncingeffects. The gencralizability of early research to the present population will be considered throughout. Long Term Effects Four studies examined the long term effects of hospitalization. Three of these studies took data from major longitudinal developmental studies, not specifically designed to answer questions on effects of hospitalization. The data collected for these studies spanned over twenty years. Each study used different measures, and each measured their "effects" at different ages. All the studies were retrospective and correlational in nature. One of the better known studies on the effects of hospitalization was reported by Douglas in 1975. The data from this study formed part of a major longitudinal study containing a sample of approximately one quarter of the children born in Great Britain in the first week of March, 1946. This particular study examined the 1,199 admissions to hospital of 958 children before March 1,1951. The conditions of the hospitalization for these children differed greatly from what we would expect today: 10% went to adult wards, 47% had no visitors allowed; only 16% were allowed visitors other than their parents. Only three mothers stayed in the hospital with their children. Thirty-six children had tuberculosis and spent 4,000 (combined) days in hospital. The average length of stay was 21.3 days and the median was 8.5 days. Twenty per cent of the children were readmitted before the age of 5. In this correlational study, five ratings of behavioural adjustment were made; namely: parent's rating of child's behaviour upon returning home from hospital; teacher's rating of child's behaviour at ages 13 and 15 years; scores on a standardized reading test; delinquent behaviour between the ages of 8 and 17 years; and frequent job changes of those who left school. Douglas found a number of descriptive variables upon which his  10  sample of hospitalized children differed from the larger study sample; the children were more likely to be boys with physical disabilities, readmitted after age 5 years, who came from large families, and whose parents were manual workers who took little interest in the child's school work. Analysis did not reveal any significant interaction between these descriptive variables and the behaviour ratings. On the behavioural adjustment rating made on the child's return from hospital, 10% of the children were considered improved, 68% were considered to be the same, and 22% had deteriorated in the opinion of their mothers. On the adolescent ratings, hospitalization for longer than one week or more than once before the age of five was associated with poor reading scores and a behaviour rating of troublesome by teachers. If the children had been readmitted after age five, they were also more likely to be considered delinquent and to display job instability. Douglas (1975) found a curvilinear relationship between behavioural ratings and age of single admission longer than one week. Children whose admission occurred before 6 months of age showed similar behaviour ratings as those with no admissions. Children up to 2 years of age showed greatest vulnerability, with risk dropping off for those children whose admissions were at ages 4 to 5 years. For those whose single admission was less than one week, a similar pattern occurred except for a second peak of behavioural disturbance for those whose admission occurred in theirfifthyear. Children admitted for surgical procedures were less likely to receive poor behavioural ratings than those admitted for other reasons. Douglas (1975) looked for a relationship between immediate post-hospital adjustment and later behavioural problems. He found a significant relationship between mother's assessment of post-hospitalization behaviour and teacher's ratings of behavioural problems in adolescence. However, no relationship was found between mother's ratings and the other adolescent ratings. Douglas concluded: It seems that absence of disturbed behaviour on returning home does not imply freedom from the longer term effects of hospital admission, (p.466) Quinton and Rutter (1976) proposed to replicate Douglas'findings.They also used data from a preexisting longitudinal study. A sample of 399 children was randomly selected from screened populations of all children who were 10 years old on the Isle of Wight in 1969 and who were 10 years old in an inner-city borough  11  of London in 1970. Details of hospital admissions (1959 — 1970) were collected through retrospective interviews with the mothers. Measures of behavioural deviance at 10 years of age were measured by questionnaires completed by teachers and an interview with the mothers. On the basis of these measures, children were considered to be: normal, have an emotional disorder, or have a conduct disorder. The parent interview also yielded a measure of "psychosocial disadvantage or family adversity", i.e., an index of descriptive variables placing the child at risk for behavioural or psychiatric disturbance. Quinton and Rutter (1976).found that emotional disturbance was related to two or more hospital admissions, at least one occurring before the child's fifth birthday. This relationship was stronger for children with high psychosocial disadvantage scores than for those with low psychosocial disadvantage scores. They also found an association between single admissions of more than four weeks duration and later conduct disorders. In general, this study confirms the finding of Douglas' study (1975) in a population hospitalizedfifteenyears later. Shannon, Ferguson, and Dimond (1984) also look data from a major longitudinal study: The Christchurch Child Development Study. From the 1,265 children included in the birth cohort, complete data on hospitalization were obtained on 1,048. Sixty-six per cent of the admissions were to the same hospital, which had 24 hour parent visitation rights and "liberal provisions for living-in mothers" (p.816). Unfortunately, the birth year of the children is not provided in the research report. The children's behaviour was assessed at 6 years of age with the same questionnaire used by Quinton and Rutter (1976) for both mothers and teachers. Hospital admissions for thefirstfiveyears were considered to be total days hospitalized, rather than the number of admissions or the duration of the single admissions. Shannon and his colleagues (1984) found a significant relationship between number of hospitalized days and behavioural disturbance at age 6 years. However, they felt that this relationship was explained by other stressful life events and the social position of the family; these being highly correlated with number of hospitalization days. They concluded that with improved hospital conditions over the past twenty years, hospitalization was no longer related to later behavioural disturbance. Superficially, one might conclude that with the change in hospital policies over the past twenty years, hospitalization no longer poses the threat it once did. However, it should be noted that the ages at which behavi-  12  oural disturbance was measured varied greatly among the studies: 6 years of age for Shannon et al.'s study (1984), 10 years for Quinton and Ruttcr's (1976), and 13 and 15 years for Douglas' study (1975). The conduct disorders noted by Quinton and Rutter (1976) are more likely to be observed in older children than in younger children, and Douglas (1975) warned that early post-hospitalization reaction was not associated with later behavioural problems. Pilowsky, Bassett, Begg, and Thomas (1982) considered the relationship of childhood hospitalization to chronic pain in adults. In a correlational retrospective study, they found that 114 subjects from a pain clinic, with no somatic explanation for their pain, were more likely to have been hospitalized in their school-aged years than the 61 subjects attending a rheumatology clinic. Fifty-three subjects from a psychiatric clinic with depressive illnesses were more likely to have been hospitalized at an earlier age (pre-school) man subjects in the other two groups. The authors suggest that separation from parents in the early years prior to the development of sufficient linguistic skills may be a factor contributing to the depressive reactions in later life. They further speculate that prolonged hospitalization in the school-age years may influence the development of "abnormal and inappropriate use of illness behaviour as a coping strategy in later life" (p.83).  Short Term Effects Short term effects of hospitalization can be observed during the actual hospital stay and in the weeks and months following discharge. Studies reviewed in this section varied on the criteria chosen for determining immediate and post-hospitalization psychological adjustment and on the age group chosen for their samples. Jessner, Blom, and Waldfogel (1952) used psychiatric interviews to examine the emotional response of 143 children between the ages of 2 and 14 years to a brief hospitalization for tonsillectomy and adenoidectomy. They claimed that the foci of anxiety were: separation from parents, exposure to the strange hospital surrounding, the anaesthetic, the operation, and needles. In children over 7 years of age, the greatest fear was of the operation itself. The majority of the children in the study were judged to have been able to master the experience, but 25 were judged to be severely negatively affected. The authors comment: The effectiveness with which the child can use his defenses is influenced by the extent to which adults comprehend that even such a minor surgical procedure has a great emotional impact, (p. 168)  13  Another of the earliest studies examining the effects of hospitalization was conducted by Prugh, Staub, Sands, Kirschbaum, and Lenihan (1953). Subjects were two groups of 50 children between the ages of 2 and 12 years admitted for medical diagnosis and treatment for at least 48 hours, with an average stay of seven days. The First group had "traditional care" with parents permitted a weekly two hour visiting period. The second group participated in an experimental programme, including daily parental visits, early mobilization, special play programme, and preparation and support for procedures. Assessment consisted of psychiatric interviews with parent and child over a period of six months to a year following discharge. Degree of reaction was considered severe if negative changes persisted beyond three months, moderate if changes had disappeared after three months, and mild if reactions were observed only during the hospitalization. Parent's and child's adjustment to the actual hospitalization was also considered, as well as degree of stress experienced (e.g., a general anaesthetic was considered a severe stress while x-rays and blood tests were considered minimally stressful). All children expressed some negative reactions during the hospitalization with 92% of thefirst,or control, group and 68% of the second, or experimental, group showing moderate or severe reactions. Negative reactions three months following discharge were reported in 58% of controls and 44% of experimentals. Prugh et al. noted: There was not always a clear-cut correlation between the child's adjustment on the ward and the total reaction; some children who appeared to adjust relatively successfully while in the hospital ehibited disturbances in behavior of a more crippling character following discharge than did others who had been completely incapable, while on the ward, of handling the anxiety aroused by the current experience, (p.81) Other factors which were observed to be related to immediate and post-hospital negative reactions were: 1) age: younger children demonstrated greater disturbance than older children with more than 40% of the under 4 year olds still showing disturbances at three months; 2) parents' adjustment to the hospitalization: parents who handled their own anxiety had children who also managed more easily; and 3) prc-hospital personality: a more limited capacity for adaptation was related to greater difficulties in adapting to the hospitalization. This study not only pointed out the negative impact of hospitalization on children, but also demonstrated that this negative impact could be reduced by changing the way in which children were treated before and during their hospital stay.  14  McKee (1963) found no relationship between negative behavioural changes and hospitalization for tonsillectomy and adenoideclomy. In a group of 413 children, aged 2 to 15 years, 231 children had their surgery, while the other 182 had their surgery deferred for two years. During that two years, McKee found no significant differences in "emotional upset" between the two groups except for thefirstfew weeks following surgery, and enuresis up to six months following hospitalization in the group which had surgery. Vernon, Schulman and Foley (1966) developed a study to consider the relationship among behaviours indicative of post-hospitalizauon upset. Subjects were 387 children between the ages of 1 month and 16 years whose parents returned a mailed questionnaire. The average age of the children was 5 V years. Their length of 2  stay ranged from overnight to over a month with an average length of 8.8 days. The children were hospitalized for a variety of reasons, both medical and surgical. Vernon and his colleagues' Posthospitalization Behaviour Questionnaire (PBQ) was factor analyzed. Children, whose hospitalization lasted for two to three weeks, were given higher ratings by their parents on scales of aggression, apathy, and sleep disturbance than those children with shorter hospitalizations. Children between the ages of 6 months and 4 years were more likely to obtain higher scores, particularly on the Separation Anxiety Factor. Children from the lowest of three socio-economic groups were rated by their parents as improving their behaviour. Birth order, degree of pain, and history of previous hospitalizations were not found to be significantly related to scores on the PBQ. Sipowicz and Vernon (1965) compared the behaviour of 24 pairs of twins on the PBQ following the hospitalization of one twin. In three pairs, the behaviour of the twins did not differ. In 16 pairs the hospitalized twin was the more upset; in five pairs the home twin was rated by the mother as exhibiting more negative behavioural changes. The authors note that conclusions from this study on the effects of hospitalization depend upon the assumption that the hospitalization of one twin docs not create a stress for the other twin. Dearden (1970) attempted to determine the degree of post-hospitalization upset over a seven month period in 36 children aged 4 years, hospitalized for tonsillectomy and adenoidectomy, and to determine predictors of upset before the admissions. The children and their mothers were interviewed one week before admission, and two weeks, two months, and six months following discharge by a psychiatrist or sociologist. As well, mothers rated their children's behaviour, and a rating scale was used to assess the children's behaviour during a structured play setting. All the children were observed to experience post-hospitalization behavioural disturbance  15  in the two weeks following discharge; 19 of 36 had recovered by six months; 10 had not yet recovered; and 7 were disturbed before hospitalization and continued to be so six months after surgery. Dearden identified the following characteristics as being associated with post-hospitalization behavioural distress: mothers with very high or very low anxiety levels, boys from permissive homes, children with minimal prior experience separating from their parents (even for a few hours), only children, and those who were generally verbally and/or behaviourally inhibited and overtly aggressive. Astin (1977) questioned whether number, type, or intensity of fears would differ between hospitalized and non-hospitalized children. Subjects for this study were twenty-five 10 to 12 year olds. On a 71 item fear checklist, no difference was found between the groups on number of fears, but hospitalized children claimed to have more intense fears. Their fears centred upon the home and drugs more often than did those of their nonhospitalized counterparts. Sides (1977) attempted to predict the post-hospital ization behavioural adjustment of 145 children between 1 month and 15 years of age. He used two scales: the PBQ developed by Vemon, et al. (1966) and another standardized behaviour checklist, The Missouri Child Behavior Checklist (Sines, Pauker, Sines & Owen.1969) (MCBC). Using multiple regression, he found that age of the child, maternal anxiety level and number of previous hospitalizations would predict post-hospital behavioural upset two weeks following discharge. Age was found to be negatively related to the PBQ scores, with older children rated by their parents as demonstrating fewer negative behavioural changes. Changes in behaviour occured in 78.05% of the children under the age of 5 years and 52.78% of the children 5 years and older. Maternal anxiety, as measured by the State Trait Anxiety Inventory (Spiclbergcr, Gorsuch, & Lushcne, 1968) (S-TAI), was found to be positively related to PBQ scores in the children. Sides perceived a negative relationship between previous hospitalization and behavioural disturbance: i.e., the more previous hospitalizations, the fewer behavioural problems noted by the parent. In a further analysis, excluding children under 2 years of age, he determined that duration of hospital stay was positively correlated to post-hospital ization behavioural problems; i.e., the longer the stay, the more the behavioural problems. These results arc similar to those reported by Vernon, et al. (1966) described above. Shade-Zcldow (1977) found similar results in her study of 75 children aged 3 to 15 years hospitalized in a paediatric unit of a general hospital. A modification of a standardized behaviour checklist was used to measure  16  in-hospital and post-hospital adjustment. "Length of hospitalization predicted hospital adjustment, above and beyond the contribution of age. Children hospitalized for longer periods of time displayed more aggressive behaviour"(p.5376-B). Previous hospitalizations were not shown to be significantly related to adjustment In a study of adaptation to the actual hospitalization, O'Donnel (1978) observed that children with previous hospitalization experience were rated as more co-operative by the nurses than those with no hospitalization experience. Nurses also rated as more co-operative those children whose parents did not visit at all or who visited extensively (two or three hours of daily visiting associated with the worst behaviour problems). Subjects for his study were thirty 5 to 11 year olds. Reasons for their hospitalization were not given. Pill (1979) reported a sociological study of fourty-four children between ages of 1 and 11 years, admitted to an orthopaedic ward in Great Britain. The children were categorized according to the length and recurrence of their hospitalizations and the severity of their orthopaedic impairment Those children with frequent admissions were also severely to moderately impaired. Their behaviour was considered disturbed both in the hospital and after discharge. The author considered this behaviour to be due to lack of control and difficulty in creating and sustaining interactions. These children had learned deviant ways of getting attention from hospital staff and family and used these methods with varying degrees of success. This hypothesis was supported by the findings of Pilowsky et al. (1982) discussed above. Most of the frequent admissions had been for less than 48 hours for plaster change. The very young children were reported to be clinging and difficult to handle after discharge. Pill believed this to be due to lack of mobility and poor communication skills. Both those children with some and those with no previous hospital experience interacted well with other patients and hospital staff during hospitalization. They learned "legitimate" ways to get attention, such as asking for a bedpan, using the nurses'firstnames, etc. These children tended to be older and less severely impaired than those in other categories. After discharge the children with no previous hospitalizations were reported to exhibit more general anxiety, apathy, or sleep disturbance. Those with some previous experience were more likely to exhibit aggressive behaviour. Separation anxiety was more common in those whose behaviour had been disturbed after previous hospitalizations than in those who had demonstrated no behaviour changes in the past. Irwin and Kovacs (1979) compared the drawings and stories of thirty 6 to 12 year olds admitted for orthopaedic surgery to those of thirty control subjects of the same age who had no history of hospitalizations.  17  They found that the hospitalized group were more fearful and dependent and were less able to make use of coping mechanisms. The hospitalized group also appeared to need to know why they were having surgery and to discuss their situation. Simons, Bradshaw, and Silva (1980) decided to look at the effects of hospitalization on the children in their longitudinal developmental study. Two hundred and sixty-eight children or 21% of a cohort sample of city children had experienced hospital admission by the lime they were 5 years old. At the fifth birthday, mothers were asked about the hospitalizations, including reasons, duration, and behavioural changes in such areas as eating, sleeping, toilet training, and.independence following discharge. Of the sample, 67 (7%) were admitted twice, 21 (2%) three times, 6 (0.6%) four times, and 4 (0.4%) more than four times. In duration, 46% of the admissions were for one or two nights, 39% of the children stayed three to seven nights, and 15% stayed longer than seven nights. Eleven percent of the parents roomed in, 56% had extended contact with their child, and 33% visited daily. Although a significant relationship was found between behavioural disturbance and hospitalization, no relationship with duration or number of admissions was found.This study should be regarded with caution, as the reliability of the dependent measure, parents' recall of behaviour change after an admission occurring up to five years earlier, cannot be evaluated. Bolig (1981) considered the relationship among personality factors and response to hospitalization. Her sample contained 46 children, aged 3 V to 6 V years, hospitalized for illness or medical diagnostic procedures. 2  2  The variables of interest were cognitive style, locus of control, and anxiety level. Children with previous hospital experience were found to be less anxious on discharge than those with no previous experience. Children tended to maintain their locus of control throughout the hospitalization, except those admitted for treatment of a chronic illness. These children were found to become more external as their hospitalization progressed. Riffee (1981) found that children in the 9 to 12 year age range who were hospitalized for surgery had significantly lower self-esteem scores than those hospitalized for other medical reasons or those not hospitalized at all. The three groups contained between twenty-five and twenty-eight children each and were administered the Coopersmith Self-Esteem Inventory (Coopersmith, 1967) on the day of admission (for the two hospitalized groups) and one month later. Peer/social and school subscalcs showed specific effects among the three groups, with the surgical group obtaining the lowest mean score.  18  Reactions of Children to Day Care Surgery Three studies were found which contained samples of children hospitalized for day-care surgery. Davenport and Werry (1970) examined the post-hospital behaviour of 145 children (100 hospitalized for tonsillectomies and adenoidectomies, 45 hospitalized for dental, eye, or other ENT surgical procedures) and 145 controls (95 controls were siblings of the hospitalized group) living in Vancouver, B.C. and Urbana Illinois. The Vancouver children (n=95) were hospitalized for two nights; die Urbana children (n=50) were admitted to a day care unit. Davenport and Werry compared these children on factor scores of the PBQ as factor analyzed by Vernon et al. (1966) and administered pre- and two weeks posusurgcry. They found a significant difference between the Vancouver (48 hour admission) group and the Urbana (Day Care Admission) group on Factor I, labelled General Anxiety and Regression, with the Vancouver group receiving higher scores. Since this analysis included both controls and hospitalized subjects, no conclusion as regards the differential effects of day care and short stay admission surgery can be drawn. Davenport and Werry also found a significant Treatment x Time interaction on Factor IV, labelled Eating Disturbances, with the hospitalized group showing greater improvement (lower scores) than the control group. The use of siblings as a control for hospitalized children may be questioned. Thompson (1985) reports a study utilizing sibling control as evidence to support the hypothesis that hospitalization may also have negative psychological impact on the siblings of child patients. Craft and Craft (1989) found that siblings do experience stress during a hospitalization and that parents do not always perceive the siblings' stress. Teichman, Ben Rafael, and Lcrman (1986) compared the influences of trait anxiety, maternal state anxiety, on day care and inpatient surgical experience on fourty-four children from 6 to 12 years of age in Israel. The instruments used were Hebrew versions of the State-Trait Anxiety Inventory (Spielberger et al., 1968) and the State-Trait Anxiety Inventory for Children (Spielberger, Auerbach, Wadsworth, Dunn, & Taulbee, 1973). The authors found that in the inpatient group, level of trait anxiety and the children's perception of the mothers' anxiety were directly related to the children's state anxiety. However, in the day care group, even high trait anxiety children, who perceived their mothers as low-anxious, achieved low state anxiety scores. No main effect for type of hospital experience (day care versus inpatient) was found and it was concluded that the interaction of personality traits and the mother's anxiety and ability to cope interacted with the hospital experience to affect the  19  children's anxiety level. The authors stressed that day care surgery docs not necessarily presuppose a belter adjustment to the hospital experience than inpatient surgery. One study, reported in two articles (Campbell, Scaifc, & Johnstone, 1988; Scaife & Campbell, 1988), was found comparing the psychological effects on children of day care and inpatient surgery. In the Campbell, Scaife and Johnstone article (1988), the results of a questionnaire to parents were reported. In 58 children randomly assigned to day care (n=35) and inpatient (n=23) groups, significantly fewer children in the day care group were reported to require a lot of extra attention from their parents in the week following discharge. In the Scaife and Campbell report (1988), further data was provided for 49 subjects (day care n=30, inpatient n=19).Medical outcomes were considered to be similar, with complications as likely to occur after 24 hours following surgery (after inpatient discharge) as before. Few differences were found between the two groups on the behavioural rating scale. However, parents of the inpatient group were more likely than parents in the day care group to.perceivc their children as continuing to be affected by the surgical experience three months following discharge. No difference was found between the two groups on parental anxiety or convenience of the hospital stay to the parents. Summary of Effects of Hospitalization From the longitudinal studies reviewed, it may be concluded that repeated and extended hospitalization may be related to behavioural disturbances, including school and job related difficulties, into adolescence and abnormal illness behaviour in adults. In Douglas' study (1975), even those children with single admissions of less than a week showed a pattern of disturbed behaviour related to age, with children hospitalized at 5 years of age and under 2 years of age receiving higher behavioural disturbance ratings than children of other ages. Those children undergoing surgical procedures had lower scores than those admitted for other reasons, but retained the same age pattern. Some studies of immediate and short-term effects have documented the changes in children's behaviour during hospitalization (e.g., Astin, 1977; O'Donnell, 1978). More studies have examined the behavioural changes in children following the hospitalization with different effects seen in different age groups (e.g., Jessner et al., 1952; Vernon et al.,1966). Maternal anxiety and prior hospital experience were observed to affect children's reactions to hospitalization (Sides, 1977), although these relationships were not observed in other studies (e.g., Vemon etal., 1966).  20  Two studies were found that did not support the concept that hospitalization can negatively affect children (McKee, 1963; Davenport & Werry, 1970). The sample of one of these studies was partially composed of children admitted to a Day Care Surgery Unit. The relationship of immediate, short-, and long-term effects of hospitalization is not clear. Both Douglas (1975) and Prugh et al. (1953) noted that they did not find a clear relationship between immediate reactions and later behavioural disturbances. Jessner et al. (1952) warned that lack of evidence of anxiety during the hospitalization may be "prognostically a bad sign" (p.168). The differences in when and how negative reactions occur and the value we should place on these reactions (perceiving them as a healthy release of stress or as a negative symptom to be eliminated) must be considered. In comparing children hospitalized using a day care admission procedure, no support has been provide for the notion that day care surgery has "psychological benefits" (see p. 10). No difference was found between day care and inpatient children on measures of state anxiety during the hospitalization (Teichman et al., 1986) or on post-discharge behavioural ratings (Scaifc & Campbell, 1988). Factors Influencing Reaction to Hospitalization It appears that children react differently to hospitalization and many studies have attempted to determine which characteristics of the children and/or their families may influence how they respond. The following discussion brings together the studies reviewed in the preceding sections which comment upon particular characteristics of the child and family. Age. Most studies have found evidence to suggest that younger children show greater evidence of behavioural disturbance following surgery and hospitalization (e.g., Prugh et al., 1953; Sides, 1977). Vernon et al. (1966) reported that younger children were more likely to demonstrate evidence of separation anxiety in the weeks following discharge. In considering long-term effects, adults with depressive illnesses were more likely to have been hospitalized as pre-schoolers, adults with chronic pain were more likely to have been hospitalized as school aged children (Pilowsky et al., 1982). Gender. Little evidence has been presented to suggest that boys and girls react differently to hospitalization. However, boys from permissive families were observed to be more vulnerable to the hospitalization experience than those from more authoritarian homes or girls (Dearden, 1970).  21  Previous Hospitalization Experience. Some studies have not found a significant relationship between previous hospital experience and in-hospital or post-hospital upset (Shade-Zeldow, 1977; Simmons et al., 1980; Vemon et al., 1966). Other studies have found children who have been previously hospitalized to be less anxious (Bolig, 1981) and more co-operative (O'Donnell, 1978). Pill (1979) found mixed effects with children with no previous experience exhibiting more general anxieties, apathy, and sleep disturbance while those with some previous experience exhibiting more aggression following discharge. Sides (1977) noted that children with previous hospitalization experience had fewer behaviour disturbances following discharge than those without experience. Length of Hospitalization. Longer hospital admissions are perceived as having greater negative effects (Douglas, 1975; Quinton & Rutter, 1976; Shade-Zeldow, 1977; Sides, 1977) than shorter admissions. These effects include increased aggression, apathy, and sleep disturbance following discharge (Vernon et al., 1966). Only one study (Simmons, et al., 1980), using retrospective data, found no evidence to support the hypothesis that behavioural upset following discharge was related to duration of the stay. The hospitalizations upon which these studies are based span over twenty-five years. The context of these hospitalizations, including reasons for hospitalization, standard practices (such as confinement to bed, prohibition of visitors, etc.), and the general environment, is an uncontrolled factor in comparing these studies. Recent studies comparing inpatient and day care admissions have found no differences between the groups on measures of in-hospital state anxiety (Teichman et al., 1986) or post-hospital behavioural disturbance (Scaife & Campbell, 1988). Prehospital Personality Adjustment Prugh et al. (1953) identified children's personality and their ability to adapt as a significant factor in the reaction to hospitalization. Dearden (1970) noted that those children who were rated as disturbed before hospitalization continued to be afterwards. She also suggested that children who were more behaviourally inhibited and those who were more aggressive prior to hospitalization were more likely to be rated as more negatively affected by the experience. Pill (1979) noted that children who were considered "disturbed" before surgery were more likely to express separation anxiety later on. The personality characteristics considered significant by Bolig(1981) were locus of control and general anxiety level. Teichman et al. (1986) found that, in general, higher levels of trait anxiety were related to higher levels of state anxiety. However, they also noted that interaction between individual characteristics might change the relationship.  22  Verbal Ability. Linguistic skills have also been considered a factor influencing the effect of hospitalization on children. Both Pill (1979) and Pillowsky et al.(1982) commented that children who were able to verbalize their needs and to obtain attention thhrough legitimate verbal interaction were more easily able to adapt to the hospital environment. Dearden (1970) noted that children who were "verbally inhibited" were more likely to have difficulty adapting to their hospitalization. Maternal Anxiety. This was considered by Sides (1977) to be one of the most important factors in the prediction of post-hospital behavioural adjustment. Prugh et al. (1953) added that the way in which parents managed their anxiety was also a critical influence. Dearden (1970) identified both extremes of high anxious and low anxious mothers as associated with negative reactions to hospitalization in their children. Teichman et al. (1986) also noted this relationship. Other Factors. Socio-economic status was negatively correlated to negative reactions by Quinton & Rutter (1976) and Shannon et al. (1984) but Vernon et al. (1966) found no relationship between these variables. Nor was any relationship found with birth order. However, Dearden (1970) perceived only children to be more vulnerable than those with siblings. Vernon et al. (1966) also did notfinda significant relationship between posthospital behavioural disturbance and degree of pain associated with surgery. Shannon et al. (1984) described other life stresses as a strong contributing factor to the way children responded to a hospitalization.  Preadmission Preparation Preadmission preparation is becoming an accepted part of the inpatient hospitalization regime of children and their families. It is recommended by the American Academy of Pediatrics (1971), The Association for the Care of Children's Health (1979), the Canadian Commission for the International Year of the Child (1979), and the Canadian Institute for Child Health (1979). A survey of Candian hospitals, in the late 1970s, with more than 20 paediatric beds (Alcock, 1977; Post, 1979) indicated that the availability of preadmission preparation programmes varied among provinces from a high of 86% (Alberta) to a low of 13% (Saskatchewan). By 1980, in the United States, preadmission preparation programmes were in use in more than half of paediatric hospitals responding to Peterson and Ridley-Johnson's survey (1980). Melamed and Siegel (1980) reported that 70% of non-chronic care paediatric hospitals provide preparation.  23  The purpose of preadmission preparation programmes is to alleviate some of the stress of hospitalization and thereby reduce the negative sequelae which may result. Hospitalization is considered to be a naturally stressful experience (Ack, 1983; Menke, 1981). Much has changed since the 1950s when Spence (1947), Robertson and Bowlby (Bowlby, Robertson, & Roscnbluth, 1952; Robertson , 1958) and Prugh (Prugh et al., 1953) examined the depression and negative behaviour changes which occured during and following the hospitalization of young children. Unlimited visiting hours for parents, increased parental involvement in the physical as well as psychological care of the child, changes to the environment, more play facilities, and staff with training in psycho-social support have all helped to alleviate .the strain of coming to a strange place where strange people do strange and often painful things to others. Preparation programmes are designed to take some of the "strangeness" out. Before the child enters the hospital, he is given the opportunity to find out what is happening and why, what the hospital is like, and who will be there. Research on preparation for hospitalization has been in the literature since 1952 (Jessner, et al., 1952). Thompson claims that preparation "has received more research attention in recent years than any other topics" included in his book Psychosocial Research on Pediatric Hospitalization and Health Care (Thompson, 1985, p.237). Indeed, Siegel, in his reviewof preparation literature (1976), has also noted: there appears to be a universal agreement about the necessity for such preparation to reduce the possible stress produced by hospitalization, surgery, and other medical procedures, (p.26)  Approaches to Preparation Preadmission preparation programmes vary in content and style from hospital to hospital. They vary in form from hospital "parties" to tours of the paediatric wards, to colouring books, to slides, video-tapes, and films, to booklets, to discussion groups, to medical play. Some programmes make use of commercially prepared materials, others use materials specifically designed for a particular hospital. Most programmes contain a mixture of these elements. Melamcd, Robbins and Fernandez (1982) suggest that preadmission preparation programmes have developed from the practical experience of the particular clinicians involved in preparation. However, as this field has gained more research attention, specific approaches to preparation have been identified as achieving the desired effects: decreasing negative reactions to hospitalization and surgery. However,  24  other approaches without research support continue to be used by clinicians. Each approach provides information to familiarize children with the experience they arc about to undergo and the feelings they may have. However, the manner in which this information is delivered differs according to the approach taken. Two broadly defined approaches were identified in the early (1970s) research as effective means of preparing children for hospitalization. For the purposes of this discussion, the approaches are called Modeling and Rehearsal/Instruction. A third approach, the Hospital Tour, continues to be widely used (Azarnoff & Woody, 1981) but has not been as well validated by the research literature. The research literature discussing these three general approaches and comparisons among them will be described below.  Rehearsal-Instruction. This approach includes two phases: 1) providing information on the coming events and sensations and instructions on how to cope with these occurences and 2) encouragement to rehearse these events and the coping techniques for these events. Rehearsal of upcoming stressful events has been considered one method of coping with or reducing the anxiety associated with the events (Cohen & Lazarus, 1973). Bernstein and Miechenbaum (1979) observed that children who chose to play with hospital related toys prior to their surgery (rehearsing the events to come) were less anxious than other children after their surgery. Wolfer and Visintaincr (1975,1979) and Visintaincr and Wolfer ( 1975) examined the effects of giving information and encouraging rehearsal in their preparation programmes. Children were first provided with information about potentially stressful events such as injections and anaesthesia, and instruction on how to cope with the events and, secondly, were encouraged to rehearse die events to become familiar with the coping procedures. In theirfirststudy, Visintaincr and Wolfer (1975) compared a programme, comprised of information and rehearsal and primary nursing care, which occurcd periodically throughout the hospitalization, to three other conditions: (a) a single session preadmission preparation comprised of information and rehearsal and routine nursing care; (b) primary nursing care with periodic support but no preparation (information and rehearsal); and (c) a control group receiving no programme and only routine nursing care. Eighty children between the ages of 3 and 14 years, hospitalized for elective surgery, were measured on: (a) co-operation and upset during specific procedures; (b) physiological measures such as recovery room medication, ease of fluid intake, and time to first  25  voiding; and (c) post-hospital behaviour. As well, parents were asked to rate their own anxiety and satisfaction after the hospitalization. Visintainer and Wolfer (1975) found the combined periodic programme was more effective than the single session programme on seven of their eleven measures, suggesting that spaced preparation and support may have some advantages over the isolated preparation programme. They also found that periodic supportive care only was no more effective than the control treatment on most measures and argued that delivery of information is a critical component in a preparation programme, even for younger children (aged 3 to 6 years). In a more recent study, Wolfer and Visintainer (1979) further examined facets of information/rehearsal by comparing home preparation by means of a booklet with in-hospital preparation conducted by a nurse. A sample of 163 children aged 3 to 12 years was chosen, and measures used were similar to those in the 1975 study. No significant differences on outcome measures were found between the group of children who used the home preparation and the hospital preparation group. Crocker (1980), in a study examining the effectiveness of an in-hospital pre-operative preparation programme including information given through discussion and a video tape and rehearsal through structured and free play, found no significant differences between the experimental and control groups on physiological measures such as changes in temperature, pulse or respiration or in post-operative recovery (eg., fever or vomiting, behaviour changes). Prepared children were more likely to vomit, but less likely to have raised blood pressure, in the immediate post-operative recovery period than children who did not attend the programme. Anecdotal comments, however, indicated a positive response to the preparation programme.  Modeling. This approach to preparation uses one child's experience in coping with the hospitalization experience as a model for other children. It is based upon the theoretical research of Bandura, Grusic and Menlove (1967), who reported that fears and avoidance behaviours in children could be reduced by having them watch other children perform the desired behaviour. Although Bandura and Menlove (1968) found that live models were more effective than filmed models in extinguishing avoidance behaviour, filmed modeling continues to be a popular approach to reducing medical and dental stress (Siegel, 1976; Thelcn, Fry, Fchrcnbach & Fraulschi, 1979).  26  The more similar the model is to the subject, the greater the effect of the programme seems to be. Kazdin (1974), working with adults, and Kornhabcr and Schroeder (1975), working with children, both found that models similar in age and gender to the subjects had the greater effect in the cases of both coping and mastery models. Meichcnbaum (1971) found coping models to have a significantly greater effect in reducing avoidance behaviour in adults than did mastery models. Thclcn et al., (1979) concluded, in their review of the literature on therapeutic video-tape and film modeling, that to be of greatest effect the model should be of peer age or younger and provide a coping, rather than a mastery model. They also described narration as an effective element of film and video modeling, especially if the narration expressed the model's self-verbalization of thoughts, feelings, and coping techniques during treatment. Multiple models have been shown to be more effective than one model in reducing avoidance behaviour (Bandura & Menlove, 1968). One might add this variable to Thelen et al.'s list. Film modeling has been used successfully to change the behaviour of young children during dental treatment. White, Akers, Green and Yates (1974) found watching a model receive treatment to be more effective than simply watching the dentist manipulate the equipment. Melamed, Weinstein, Hawes and Katin-Borland (1975) found a significant difference in the behaviour of 5 to 9 year olds after viewing afilmedmodel. Although the sample was very small (n=15), the groups were matched for age, gender, race, initial fears, and even parent's and dentist's anxiety levels. Similar results were obtained by Melamed, Hawes, Heiby and Glick (1975), again with a small sample (n=16) and a large age spread (5 to 11 years). These results were not confirmed by Klorman, Hilpert, Michael, LaGama and Sveun (1980), who compared groups watching afilmedmastery model, a filmed coping model, and a control film. Although the group viewing the coping model obtained lower scores on a behaviour profile rating, there were no significant differences found among the three groups. The sample was larger in this study than in the two previously mentioned (n=60). Measurement in this study consisted of behavioural observation only and did not include any physiological response measures. This may have affected the results of the study. Vemon (1973) and Vernon and Bailey (1974) have usedfilmedmodeling in preparing children for anaesthetic induction. In the second study, thirty-eight children between the ages of 4 and 9 were compared on a behavioural rating scale while waiting to enter the operating room, while being prepared for induction, and  27  during induction. Those in the experimental preparation group were perceived as less anxious by the anaesthetist during the first two phases than the control group, but no significant difference was observed between the two groups during the induction. The success of the preparation may have been limited for two possible reasons. The first may have been that the film was of a mock-up, rather than a real induction, and the children acting as models did not react naturally. The second weakness may have been the measurement instrument, a seven point scale on which the children were rated by the anaesthetists. Multiple, less subjective, measures may have been more successful in detecting differences. In preparing children for hospitalization, Melamcd and Siegel (1975,1980) used as their treatment programme a film depicting the experiences of a 7 year old boy during his hospitalization. In one study (Melamed & Siegel, 1975), this film treatment was compared to a control treatment, the viewing of a film unrelated to the hospital experience. Thirty subjects were assigned to each treatment They were matched for age, gender, race, type of operation and previous hospitalization. Outcomes were assessed by both measures of trait anxiety and state anxiety, using self-report, behavioural and physiological measures. The film modeling treatment was shown to be significantly more effective than the control treatment in reducing both anxiety measured by the state anxiety measures [Palmar Sweat Index (Thomson & Sutarman, 1953), Hospital Fears Rating Scale (Melamed & Siegel, 1975)] and post-hospital behavioural problem measures [Behaviour Problem Checklist (Peterson, 1961)]. It is interesting to note that both groups also received in-hospital pre-operative preparation from the Child Life worker and anesthesiologist, suggesting that the modeling preparation programme contributed to further reduce the children's anxiety beyond the pre-operative preparation. No attempt was made to match the children for prehospitalization personality. They also did not include parents in their treatment programmes, a variable considered by Crocker (1980) and Thompson and Stanford (1981) to affect the strength of treatment  Hospital Tours. The tour approach to preparation combines information given by the tour leader with a chance to see the physical environment where the child will be. Tours of the paediatric ward, laboratory, and (occasionally) surgical suite appear to be one of the most widely used methods of preparation for elective surgery (Peterson & Ridley-Johnson, 1980; Post, 1979) and are widely endorsed by professionals in this field (Association for the Care of Children in Hospital, B.C. Affiliate, 1980; Canadian Institute for Child Health 1979; Thompson & Stanford, 1981). 28  Little research has been done on the tour approach to preparation. Sauer (1968) compared 50 children who participated in a weekly tour programme to 50 children who did not. No attempt was made to match the control and experimental groups. Nurses rated the children as easy or difficult to manage. The results were that 14% of the experimental group and 53% of the control group were considered difficult to manage. All children were invited to attend the programme. Reasons why the control children did not attend were not discussed and fundamental differences between the groups may have existed/This study has many limitations, including the lack of data comparing the groups and the unsophisticated measuring device (nurses' ratings). Azarnoff, Bourque, Green.and Rakow (1975), in a well controlled study, compared a tour programme to a booklet preparation and a control (no preparation). These treatments occured immediately preceding the admission. One hundred and twenty-eight children between the ages of 4 and 11 were assessed on three measures: Post-hospital Behaviour Questionnaire (Vernon et al., 1966), human figure drawing, and a Non-verbal Semantic Differential (Bentler & Lavoie, 1972). The interpretation of the data is not clear, but the authors conclude that "tours are more effective than booklets for certain children and parents, and it (sic) is usually better than no intervention" (p.57).  Comparison of Instructional Approaches. Other studies have attempted to compare the effects of different preparation approaches. Ferguson (1979) compared a modeling video-tape treatment and a preadmission visit from a nurse who supplied information and emotional support. She found significant interaction effects with age on the Hospital Fears Rating Scale (Melamed & Siegel, 1975) and Post-Hospital Behaviour Questionnaire (Vemon, et al., 1966); younger children (aged 3 to 4 years) responded more positively to the video-tape and older children (6 to 7 years) equally well to the visit and the tape. The media factor in this study (mode of presentation) was confounded by the variable time of preparation; the home visit occurred one week in advance of admission, while the video-tape was shown upon admission. Harper (M.A. thesis, 1981) compared the effects of a tour programme to an audio-video-tape modeling programme, both occuring one week prior to admission. No significant difference between the treatment approaches was found on the Post-Hospital Behaviour Questionnaire (Vemon et al., 1966) or the Hospiuil Fears Rating Scale (Melamed & Siegel, 1975) in 30 children hospitalized for elective surgery requiring two nights in the hospital.  29  Peterson and Shigetomi (1981) compared the effectiveness of three approaches: (a) information presented through a puppet show and tour, (b) modeling presented in a film created for another hospital in 1975, and (c) instruction in coping techniques, including rehearsal, presented by an experimenter. Experimental conditions included various combinations of these approaches, including one group which received all three. No significant differences were found among the groups for pulse rate or temperature, a behaviour checklist completed by nurses, parents and observers, the Faces Scale (Venham, Bengston & Cipes, 1977) or Hospital Fears Rating Scale (Melamed & Siegel, 1975). However, differences among the groups were found on a number of behavioural Likert-type rating scales, fluid and food consumption, and time tofirstvoiding. They concluded that the instruction in arid rehearsal of coping techniques was the single most effective instructional approach to preparation, but that a combination of approaches was even more effective. Mode of presentation was not considered in this complex and detailed study. Length of preparation (combination preparations took longer than single approach preparations) may also have been a factor in the effectiveness of combination approach programmes. The effectiveness of a hospital tour was compared with (a) a programme including puppet modeling and tour and (b) a programme including puppet modeling and tour and coping skillls instruction and rehearsal by Peterson, Ridley-Johnson, Tracy and Mullins (1984). Forty-one children aged 2 to 10 years who were hospitalized for less than 24 hours for oral or plastic surgery received their preparation after admission on the night before surgery. No differences between genders was observed. Children who only received a tour were rated as more anxious and less co-operative before and after surgery than those in the other groups. Parents in this group also rated themselves as more anxious than those in the other two groups. Following discharge, children in the tour only group were more likely to become upset when doctors or hospitals were mentioned. No significant differences were observed between groups receiving tour, coping instruction, rehearsal, and modeling and the group receiving tour and modeling only. The issue of length of treatment is discussed and the value of the tour only type programme is questioned. Results were compared to the earlier Peterson and Shigetomi (1981) study, where rehearsal of coping techniques was shown to be more effective than modeling in reducing negative effects of hospitalization. The differences in results may have been affected by the timing of preparation; in the earlier study preparation occurred one week prior to surgery; in the later study, preparation occurred after admission on the night before surgery. 30  Zastowny, Kirschcnbaum and Mcng (1986) compared the effectiveness of what is described as an "information" video, but appears to be more accurately described as a puppet modeling video programme, and tour with (a) the video/tour plus anxiety reduction intervention for parents, and with (b) the video/tour plus instruction for the parents in coping techniques for the children. Thirty-three subjects ranging in age from 6 to 10 years were admitted for a wide range of elective surgical procedures. Preparation occurred in small groups one week prior to surgery. The group whose parents had been instructed in teaching their children coping techniques was observed to be less anxious at stressful times during the hospitalization than the other two groups. No differences were observed on post-hospitalization behaviour or psychological recovery data. The treatments in this study differ widely from those used in other studies, where the focus of preparation is usually the child. In this case the focus of instruction was the parents.  Mode of Presentation Preparation programmes are not unidimensional. As well as an approach to the preparation there must be a mode of delivery. Modeling approach is commonly associated with an audio-visual presentation. Hospital tours and encouraging coping techniques are usually personally presented programmes. When these approaches are compared, the mode of presentation becomes confounded with the approach (Ferguson, 1979; Harper, 1981; Peterson & Shigetomi, 1981). Elkins and Roberts (1983) have discussed this recuning problem. They summarize: Some procedures have not been shown to be more effective than no preparation (treatment group vs. no treatment control group); others have not been compared to other forms of preparation (multi-treatment comparisons). Consequently, one medium cannot be said to be more effective than another or more useful with particular groups of children. Peterson and Brownlcc-Duffcck (in press) present a well-articulated call for more comparative research in this area; preparation media are one area in particular need, (p.284) Audio-Visual. With the research support for the effectiveness of filmed modeling programmes (Melamed & Siegel, 1975,1980), researchers have attempted to examine the effectiveness of other types of preparation through audio-visual media. Twardosz, Borden, Wcddlc and Stevens (1980), in a study of preoperative preparation, compared a class in which demonstrations on a doll, role playing, and encouragement of questions was compared to a video  31  taped presentation of a similar class with materials for play provided. Sixty children between the ages of 3 and 12 years, scheduled for ENT (Ear, Nose & Throat) surgery were observed for signs of anxiety-related behaviour prior to surgery and were rated for co-operation by operating and recovery room nurses. Blood pressure, respiration rate and temperature at various intervals were taken from the chart. Significant differences were found on only two measures: observed anxiety before surgery and blood pressure prior to surgery were higher in the video tape group than in the live presentation group. No significant differences were found between either group and a control group who received individual preparation from a nurse who gave information only and no opportunities to rehearse. Print. In their 1980 survey of paediatric hospitals, Peterson and Ridley-Johnson (1980) found that printed materials were the second most common preparation medium. Lende (1971) compared the effectiveness of three modes of providing information to children: a book, a discussion, and a puppet play. She theorized that the more actively involved in the preparation programme the children became, the more positive would be the effects obtained. However, with her sample of 72 children aged 4,5, & 6 years undergoing surgery for tonsillectomy and adenoidectomy, she obtained no significant results on the Post-Hospital Behaviour Questionnaire (Vernon el al., 1966) and a rating scale of behaviour during the routine laboratory blood test. Azarnoff, Bourque, Green and Rakow (1975) (described above) claimed that tours may be more effective than booklets, but no specific results were reported.  Other Facets of Preparation Programmes As well as instructional approach and mode of presentation, other aspects of the preparation programme must be considered. These include time of preparation and parental presence during preparation. Timing. The question of the best time for preparation was raised by Vernon and Foley in 1965 and was still not answered 11 years later when Siegel (1976) reviewed the more recent literature. Freud (1952) theorized that too lengthy a time between preparation and surgery might create dangerous fantasies, but that too short a time would not allow for the internalization of the material and the preparation of defenses.  32  Time of preparation was a confounding variable in studies by Wolfer and Visintainer (1979) and Ferguson (1979) described above. It is not possible to determine whether the approach, mode of presentation, timing, or the interactions among these variables had the critical effect. However, there is some concensus that young children should not be prepared too far in advance of the hospitalization. Melamed, Myer, Gee and Soul (1976) addressed the issue of timing of preparation using the same battery of measures used in other Melamed studies (sec pages 27-28: Melamed & Siegel, 1975) administered to 48 children between the ages of 4 and 12. Half of the children were prepared with a modeling film 5 to 9 days prior to admission; the others were prepared on the day of admission. Age of the children was also considered. Timing of preparation did not have a significant effect on the self-reported medical fears or on physiological arousal the night prior to surgery. However, when the interraction of time of preparation with the age group of the child was considered, significant effects were observed; with younger children (ages 4 to 7) who viewed the film in the week prior to admission having greater increases in physiological stress throughout the hospitalization, but younger children prepared at admission reporting the greatest medical fears. It is interesting to note the seemingly contradictory conclusion of physiological and self-report measures. Faust and Melamed (1984) found significant differences between children prepared immediately prior ro surgery (at the time of admission) and those prepared the night before surgery (also at the time of admission). Sixty-six children between 4 and 17 years of age (inclusive) were matched on gender, type of surgery, race, and previous experience. Outcome measures were similar to those in other Melamed studies described above with the addition of the Peabody Picture Vocabulary Test (Dunn & Dunn, 1981) and a hospital information test For children admitted on the morning of surgery, the 10 minute slide-tape preparation programme increased physiological arousal, and those who saw the control film reported fewer hospital-related fears. Additionally, children with previous hospitalization experience demonstrated greater physiological arousal after preparation than those children without experience. Parental Presence. Most researchers have included parents in their preparation programmes (e.g., Wolfer & Visintainer, 1975,1979; Ferguson, 1979); and one study (Zaztowny et al., 1986) focused the preparation on the parent, although the children were also present. Researchers have complained that parents did not attend preparation sessions unless specifically requested (Crocker, 1980; Twardosz et al., 1980). Crocker (1980)  33  did not find significant differences between the effects of the programme related to whether or not parents were present and Melamed and Siegel (1975,1980) have successfully prepared children without the parents' presence. However, these authors (Crocker, 1980; Melamed & Siegel, 1980) agree that parental presence is important and should be encouraged.  Factors influencing the Effectiveness of Preparation Programmes Earlier in this chapter characteristics of children and their families, which have been identified as having an effect on children's reactions to hospital ization, were described. Some of these characteristics have also been found to interact with preadmission preparation. Findings from studies, described earlier, which examined these interactions, will be summarized below. Age. As described in the section on Timing of Preparation (see p.42), the interaction of timing with the age of children has been observed in two studies (Melamed et al., 1976; Ferguson, 1979) with younger children appearing to respond better to preparation immediately prior to admission than one week in advance. Older children were reported as having fewer behavioural problems after discharge if they received preparation one week in advance (Melamed et al., 1976). Melamed et al. (1976) also found a main effect of age; with younger children reporting increasing medical fears throughout the hospitalization and the older children reporting decreasing fears. Gender. Gender continues to be included as a variable in preparation research (eg., Peterson & Shigetomi, 1981; Peterson et al., 1984) although only one study was found which reported any significant effect to which it could be related. Melamed et al. (1976) observed that boys prepared one week before admission reported themselves and were rated by observers as being less anxious than girls at admission. Race. Melamed et al. (1976) reported more medical fears before and after preparation in black children than in white. They also observed that white children had significantly lower observed anxiety after preparation than black children. They interpreted this latterfindingas support for the notion that children identify more strongly with a same-race model portrayed in the preparation film than with a different race model. They also noted that socio-economic status (which was not measured) may have contributed to the effect.  34  Prehospitalization Personality. In two studies (Peterson & Shigetomi, 1981; Peterson et a l , 1984) parents rated their child's usual reaction to medical procedures and their child's coping disposition. No significant interactions between these variables and reactions to preparation were observed. However, parent and child coping ressponses were related. Please refer to pp. 29-30 for a description of the study. Previous Hospitalization Experience. Melamed and Siegel (1980), using similar procedures and measures as in previous modeling studies described above (Melamed & Siegel, 1975, see p.27), observed that children with prior experience tended to be more anxious (physiological and self report measures) on the evening before surgery than those with no previous experience and may have benefited less from the preparation. However, both treatment groups showed decreasing levels of physiological, observed behavioural and selfreported anxiety than their control counterparts. In Faust and Mclamed's study (1984), children with previous experience demonstrated greater physiological arousal after preparation than those children without previous experience.  Preparation for Dav Care Surgery This chapter has examined the psychological and economic reasons for the expanding use of Day Care Surgery, the study of the reactions of children to hospitalization, and the research basis for preadmission preparation for surgery and hospitalization. No research studies were found which indicated that Day Care Surgery is less stressful for children than Inpatient Surgery. Only one study was found which examined whether preparation could have an effect on the reactions of children to day-care surgery. This will be described below. Abrams (1982) compared a control condition (no treatment at all) to a 6 minute slide-tape with an informational narrative, and a 6 minute slide-tape with a narrative describing sensations and encouraging mastery of the experience. Sixty children between the ages of 4 and 11 were observed and rated by operating and recovery room staff for resistance and anxiety related behaviours and parents were asked to complete the PBQ (Vernon et al., 1966). No significant differences were found among the groups, with less than half of the total sample displaying any resistance behaviour. The strength of a 6 minute treatment programme to affect children's responses and the sensitivity of measures used to potential changes, both positive and negative, may be questioned.  35  Summary In this chapter, the literature which chronicles the increasing use of Day Care Surgery for children was described. Since most of this literature is descriptive, it was presented only to document the increasing use of day care surgery. Political and social/psychological reasons for this phenomenon were discussed and the literature on psychological benefits was described in greater detail. Only one of the studies described was experimental in nature, the rest were surveys and none provided evidence that there are psychological benefits to children from having day care, rather than inpatient, surgery. Studies which examined psychological effects of hospitalization on children and particular factors which may influence these effects were also reviewed. These studies span many years and vary greatly in their designs and methods. For example, some (such as McKec, 1966; Sides, 1977; Vernon et al., 1966) used an experimental design, while others (such as Irwin & Kovacs, 1979; Pilowsky et al., 1982) used a corelational design. Still others (eg.Dearden, 1970; Pill, 1979) used a sociological design. Studies where sufficient description was provided to evaluate the validity of the conclusions were described in greater detail. Other studies, which could not be evaluated, were presented in less detail. Finally, the research literature describing preadmission preparation and its effectiveness in reducing negative psychological effects of hospitalization was reviewed. This topic has recieved a great deal of attention in the past thirty years and only those studies with clearly presented methods were reported here in any detail. As the research literature has progressed, studies have become increasingly sophisticated. It is easy to be critical of the weaknesses in the design of earlier studies in which factors, now known to be influential, were not considered. There was no way of knowing the many confounding variables or the quality of measures which would be identified in later research. It is also easy to be critical of the more detailed and well described studies because the specific aspects of the better described studies can be identified when the design is clearly laid out. The research was presented within its historical context and its contribution to the developing body of literature was emphasized. In the most recent studies, weaknesses or omissions were identified which contributed to the formulation of the present research questions. In the following chapter, this review of the literature on Day Care Surgery for children, effects of hospitalization on children, and Preadmission Preparation will be further summarized, and some of the questions raised by considering the relationships among these topics will be presented.  36  CHAPTER II RATIONALE AND RESEARCH QUESTIONS  The purpose of this chapter is to provide the rationale for the study by summarizing the Review of the Literature, to present the research questions and to provide definitions of certain terms used throughout the study.  Rationale for the Study  Use of Dav Care Surgery. One third to almost one half of the elective surgery performed on children is carried out via Day Care Surgery. Interconnected reasons for this trend to increased use are political, economic, and psychosocial. Governmental incentives have been provided to create alternatives to traditional hospital care which are demonstrably safe, economically valid, and have parental/social support (Shah, 1980). It has been demonstrated that, on a per patient basis, there are economic benefits to both the hospital (Evans & Robinson, 1980; Shah, 1980) and to the parents (Stanwick et al., 1982). Day care surgery has been viewed as a method of increasing productivity by reducing waiting lists and this has led to an increased number of total surgeries performed (Evans & Robinson, 1980). Effects of Hospitalization. The urge to keep children out of hospital as much as possible has a long history. Since the turn of the century, surgeons have remarked that infants and children often do not react well to being hospitalized (Nicoll, 1909). Hospitalization during childhood has been associated with behavioural and personality disturbance in adolescence and adulthood (Douglas, 1975; Pilowsky et al., 1982; Quinton & Rutter, 1976). More immediate sequelae of hospitalization have also been observed. Resistance and anxiety related behaviours have been observed during the hospitalization (Astin, 1977; O'Donnel, 1978; Wolfer & Visintainer, 1975,1976). Children have reported themselves to be anxious and have expressed a feeling of lowered selfesteem during and after their hospitalization (Ferguson, 1979; Riffle, 1981). Negative behavioural effects, such as increased dependency, sleep disturbance, appetite disturbance, and aggression, have been observed in the weeks and months following discharge (Jessner et al., 1952; Vemon et al., 1966). It must be noted that research-  37  ers (Douglas, 1975; Jessner et al., 1952; Prugh et al., 1953) have warned that in-hospital adjustment may not be related to later behavioural adjustment.  Effects of Dav Care Surgery. Parents have felt that day care surgery was less stressful for children than inpatient surgery (Shah et al., 1969,1972). The psychological benefits to children is one of the main arguments for the expanding use of day-care surgery. It has been the hope of proponents of day care surgery that this protocol would eliminate the negative reactions to hospitalization observed in inpatient admissions. Indeed, length of hospitalization does appear to have a positive correlation with later maladaptive behaviour (Douglas, 1975; Shade-Zeldow, 1977; Sides, 1977). However, it has also been noted that the biggest stress associated with the hospitalization is the separation during anaesthetic and surgery (Peterson & Shigetomi, 1983) which still occurs during day care surgery. The interaction of maternal anxiety and children's negative reactions has been observed (Dearden, 1970; Sides, 1977) and Day Care Surgery has been found to be stressful for parents who now have the responsibility for the child's recovery care (Glen, et al., 1980; Smith, 1970). Additionally, new stresses may be added to the child and parent There is less time for establishing rapport (Hatch, 1983). Both parents (Smith, 1970) and professionals (Glen et al., 1980) have expressed their concern about the difficulty in obtaining/understanding instructions. No differences have been observed between day care and inpatient surgical patients on measures of state anxiety during hospitalization (Teichman et al., 1986) or on post-discharge behavioural ratings (Scaife & Campbell, 1988), suggesting that reactions to hospitalization are similar, regardless of whether the children have inpatient or day care surgery.  Preparation Programmes. One of the methods developed for reducing the sequelae of hospitalization in children admitted for inpatient surgery is Preadmission Preparation Programmes. These have been found to increase co-operative behaviour during hospitalization and reduce negative behaviour associated with anxiety following discharge (Ferguson, 1979; Peterson et al., 1981). Two of the approaches to programmes which have been shown to be effective are entitled for this study: Rehearsal-Instruction (Wolfer & Visintainer, 1975,1979) and Modeling (Melamed & Siegel, 1975,1980) programmes. Another popular method without much research support (Harper, 1981; Peterson et al., 1981) is the hospital tour. Comparisons among these methods have been  38  confounded because they have been delivered via different modes of presentation. The audio-visual mode has become associated with modeling programmes (Melamed & Siegel, 1980; Abrams, 1982) and the print mode (one of the most popular modes) (Peterson, et al., 1980) has been used with success in Rehearsal/Instruction and other more informational programmes (Linde, 1981; Wolfer & Visintainer, 1979). The examination of the interaction of Approaches and Modes of preparation has been called for in the literature reviews (Elkins & Roberts, 1983; Melamed et al., 1983). It has been noted that younger children benefit from being prepared shortly before admission, whereas older children can be adequately prepared a week prior to admission (Ferguson, 1979; Melamed et al., 1976). Although no research evidence has been presented, parental presence at preparation is advised (Crocker, 1980; Melamed & Siegel, 1980).  Measuring Reactions to Hospitalization. It was noted from reviewing both the literature describing effects of hospitalization on children and literature on preadmission preparation programmes that many different effects are described and that these effects are not always correlated. In measuring the effects during the hospitalization, four types of measures were used: (l)behavioural observation (e.g., Melamed & Siegel, 1975; Sides, 1977); (2)co-operation rating scales (e.g., O'Donnel, 1978; Wolfer & Visintainer, 1975,1979); (3)physiological measures, such as Palmer Sweat Index (Melamed & Siegel, 1975,1980), muscle tension (Ferguson, 1979), time to first voiding, incidents of vomiting, blood pressure pulse (e.g., Crocker, 1980; Wolfer & Visintainer, 1975, 1979); and (4)self-reported anxiety (e.g.J erguson, 1979; Melamed et al., 1976). For measuring post-hospitaliza7  tion reactions, most studies havereliedupon parent report behavioural rating scales (eg., Peterson & Shigetomi, 1981; Sides, 1977; Vernon, et al., 1976), although some studies have used psychiatric interviews (eg., Dearden, 1970; Jessner, et al., 1952). Most of these studies reported significant findings on only some of their measures. Concern has been expressed that in-hospital and post-hospital adjustment may not be correlated (e.g., Jessner, et al., 1952). The need for multi-dimensional measurement of reactions to hospitalization continues to be recognized (Elkins & Roberts, 1983; Melamed, et al., 1983).  39  Factors Influencing Reaction to Hospitalization and Moderating Effects of Preparation. Several factors were identified as possibly influencing children's reaction to hospitalization preparation . These factors included: 1) age (Sides, 1977; Vernon et al., 1966); 2) previous hospitalization experience (Bolig, 1981; Faust & Melamed, 1984; O'Donnel, 1978; Pill, 1979; Sides, 1977); 3) prehospital personality adjustment including: behavioural adjustment (Dearden, 1970; Pill, 1979); locus of control (Bolig, 1981); general anxiety level (Bolig, 1981); 4) verbal ability (Dearden, 1970; Pill, 1979; Pillowsky et al., 1982); 5) socio-economic status of the family (Quinton & Rutter, 1976; Shannon et al., 1984); 6) birth order (Dearden, 1976; Vernon et al., 1966); and 7) life stresses (Shannon et al., 1984). It was also noted that other individual characteristics of the children and their families had a moderating effect on preparation programmes. These include: 1) gender (Melamed et al., 1976) 2) race (Melamed et al., 1976: confounded with SES); and 3) previous hospitalization experience (Siegel, 1977). It may also be that other individual characteristics of children and their families also influence the effects of preadmission preparation. It should be noted that other studies did not find these characteristics to affect reactions to either hospitalization or preparation. For example, gender was was not found to interact with the experimental variables in studies by Peterson and Shigetomi (1981) and Peterson et al. (1984).  Preadmission Preparation for Dav Care Surgery. Only one study was identified which examined the effectiveness of preparing children for day care surgery (Abrams, 1982). No significant effects were obtained on an anaesthetists rating scale of resistance behaviour. The effectiveness of a 6 minute slide-tape show was not demonstrated.  40  The Questions. If day care surgery is considered a stressful experience for children, and if that stress is manifested in negative reactions during and following the hospitalization similar to those of children undergoing inpatient surgery, can a preadmission preparation programme reduce those negative effects? If so, which approach and mode of preparation are best suited to preparing children for day care surgery? Do characteristics of the children or their families ameliorate the effects of preparation, i.e., is it important to know the individual characteristics of the child in selecting a preadmission preparation programme? Research Questions The Research Questions are described in this section of Chapter II. Definitions of terms used in the study are provided following the research questions. For this research study and the questions asked, the following limitations apply to the use of the word, "children", and the phrase, "reactions to day care surgery": A. "Children" referred to children between 5 years and 12 years of age (inclusive) undergoing day care surgery at B.C's Children's Hospital between August 15,1983, and June 1,1984. B. "Reaction to day care surgery" was defined as follows: 1) self reported anxiety immediately preceding and one month following surgery; 2) observed anxiety immediately prior to surgery; and 3) behavioural changes in the month following surgery.  Question 1: Attention Effects. Do children who receive attention from interviewers prior to their surgery, but no preparation, differ in their reaction to day care surgery from those children who receive no attention from interviewers or preparation? The purpose of this question was to determine whether there was any effect of participating in the research study, which included an in-home interview one week before surgery and a session at the hospital Department of Paediatrics office one to three days before surgery, and discussions of the child's and parents feelings about the scheduled hospitalization regardless of whether any actual preparation instruction took place. It was hypothesized that there would be no difference between the children who received no attention and no preparation prior to surgery and those who received attention but no preparation.  41  Question 2: Effect of Programme Do children who receive a preadmission preparation programme differ in their reaction to day care surgery from those who receive no preparation programme? The purpose of this question was to determine whether the preparation programmes were effective in reducing the negative psychological effects of day care surgery in this population. It was hypothesized that there would be no difference between those children receiving a preparation programme and those children receiving no programme in their reaction to day care surgery.  Question 3: Effect of Tour Do children who receive a tour differ in their reaction to day care surgery from those children who do not receive a tour? The purpose of this question was to determine whether the tour was effective in reducing the negative effects of day care surgery. It was hypothesized that there would be no difference between the two groups in their reactions to day care surgery.  Question 4: Effect of Instructional Approach Do children who receive a modeling approach programme differ in their reaction to day care surgery from those children who receive a rehearsal-instruction approach programme? The purpose of this question was to compare the effectiveness of the two instructional approaches: modeling and rehearsal-instruction. It was hypothesized that there would be no difference between the groups of children receiving the two approaches to preparation programmes.  Question 5: Effect of Mode of Presentation Do children who receive a programme presented through an audio-visual mode differ in their reaction to day care surgery from those children who receive a programme in a print mode? The purpose of this question was to compare two modes of presenting preadmission preparation programmes: print and audio-visual. It was hypothesized that there would be no differences between the groups of children receiving programmes in the two modes of presentation. 42  Question 6: Interaction Effects Are there significant interaction effects on reactions to day care surgery between instructional approach, mode of presentation, and tour? The purpose of this question was to examine the interaction among the aspects of preadmission preparation programmes to consider whether one programme was better than another in reducing negative effects of day care surgery. It was hypothesized that there would be no significant difference among the groups of children receiving specific preadmission preparation programmes.  Question 7: Moderating Effects of Individual Characteristics Do any of the following moderate the effectiveness of any of the preparation programmes in reducing negative reactions to the day care surgery experience? I Biodemographic Characteristics age gender II Family Characteristics position in sibling structure socio-economic status III Personal Characteristics verbal ability health locus of control trait anxiety IV Personal History Characteristics previous hospitalizations chronic conditions stressful life events The purpose of this question was to consider the interaction of some individual characteristics of the children and their families with the preparation programme variables; approach, mode and tour; which might  43  indicate whether children with these individual characteristics respond better to one particular programme than another. Since there was some conflicting evidence reported in the literature on this question the focus of this question must be considered to be exploratory. It was hypothesized that the individual characteristics would not moderate effectiveness of programmes. Definitions of Terms  1. Day Care Surgery — the practice of admitting the patient to a specific unit on the day of surgery, performing the surgery, returning the patient to the unit from the post-operative recovery room, and discharging the patient all on the same day. 2. Preadmission Preparation Programmes — programmes designed to prepare children for the hospital and surgical experience and which occur before the child is admitted to the hospital. These programmes are intended to provide information and emotional support. 3. Facets of Programmes — Each preparation programme is designed in different ways. They must have a mode of presenting material (personal interview, tour, puppet show, book, audio-video tape, etc.). They must also have a theoretical or instructional approach, or style to presenting the material. These elements which comprise a programme are termed the facets. 4. Instructional Approach — the style or theoretical approach used for the preparation programme. The three approaches considered in this study were the Modeling, Rehearsal-Instruction, and Tour. 5. Mode of Presentation — the medium by which the preparation programmes are presented. In this study the modes of presentation were Audio-Visual and Print. 6. Surgical Categories — Surgical procedures were classified by the specialty of the surgeon performing the operation (eg., surgery performed by a general surgeon was classified as a general surgery procedure). Six categories were included in this study: 1) General Surgery — included abdominal surgery (eg., hernia repairs). 2) Ear, Nose, and Throat — surgery performed in this area, including adenoidectomies, myrongotomies and tubes, etc.  44  3) Orthopaedics — surgery involving the bones, including simple fracture reductions, cast changes, and heel cord lengthening. 4) Genito-Urinary — surgery on the genitals or urinary tract, including circumcisions. 5) Plastic — in this study most of this type of surgery centred on the head and neck area, including ears and cleft lip and palate repair. 6) Dental — surgery involving the teeth and gums including extractions and capping of teeth. These definitions refer, in the main, to the experimental and moderator variables described in the "Methods" chapter, which follows..  45  CHAPTER III METHODS  In this chapter the methodology of the study is described. First, the design of the study is presented, including descriptions of the subjects, design factors, and dependent variables. Secondly, the Data Collection and Treatment Procedures are described. Thirdly, the instruments used in the study are described. Finally, the methods of Data Analysis are outlined.  Design of the Study  The Subjects One hundred and ten children were selected from the children receiving treatment in the Day Care Surgery Unit of B.C.'s Children's Hospital between August 15,1983, and June 1,1984. The children included in the study met the following criteria: 1. undergoing a procedure requiring a general anaesthetic in one of six major categories as defined by the specialties of thefifteenparticipating surgeons performing the surgery. The categories were: General; Ear, Nose, & Throat; Genito-Urinary; Orthopaedic; Plastic; & Dental; 2. between 5 and 12 years of age inclusive; 3. lived in the Greater Vancouver area, including West Vancouver, Abbotsford, and Mission (please refer to fig. 1, map of Greater Vancouver); and 4. understood and could verbally respond to questions in English.  Surgical Categories. The Data Analysis and Support Office of the Hospital Programme Branch of the B.C. Ministry of Health was consulted, and a list of surgeons who performed the majority of procedures on children in the 5 to 12 year age group in the Vancouver children's hospitals was generated (W.E.Selwood,Institutional Services, Ministry of Health, B.C., personal communication to G.CRobinson, June 1982). Fifteen of these surgeons agreed to participate in this study and their surgical specialties formed the six categories of surgical procedures.  46  FIGURE 1 Location of Study Area  47  Age Ranee and Language Requirements. These restrictions were placed upon opportunity of children to participate in the study so that the same instruments could be used with all the children. Children needed to be old enough and understand English well enough to be able to comprehend the questions asked of them and give valid responses. Residence. Children in the study lived within the Greater Vancouver Region because budget limitations would not allow interviewers to travel further than this to visit children in their homes.  The Design The study was designed as an outcome oriented experiment with 8 dependent variables, measuring reactions to hospitalization, and 3 independent variables, (facets of preparation programmes). The research questions also required the examination of interactions between moderating variables and preparation variables. The design also incorporated repeated measures requiring multiple analyses of dependent measures collected at two or three times. The design of the study is described in greater detail as the Experimental factors of the study are described. The role of the moderating variables is also explained further. As the dependent variables are described, the repeated measures aspect of the design is explained more fully. Three experimental variables were selected as design factors. These facets of preadmission preparation programmes were Instructional Approach, Mode of Presentation, and Hospital Tour.  Experimental Conditions Instructional Approach: Two levels of Instructional Approach were compared: Modeling and Rehearsal Instruction. Preadmission modeling is exemplified by the film "Ethan Has An Operation", developed by B. Melamed and her colleagues (Melamed & Siegel, 1975; Melamed et al., 1979). This approach displays the thoughts, feelings and behaviours of a model(s) which the subject can imitate. As suggested by the research literature (Siegel, 1976; Elkins & Roberts, 1983), two models were used in each programme (a male eight-year-old Caucasian and a female twelve-year-old Oriental), displaying coping rather than mastery, behaviour.  48  Rehearsal-Instruction programmes have been observed to be effective in studies by Wolfer and Visintainer (1975,1979). This approach teaches the children what they can expect to happen to them when they come to the hospital, what they can do to cope with stressful experiences there, and encourages rehearsal of these coping techniques. In this study, the Rehearsal-Instruction Programmes provided instruction by an adult as well as opportunities to observe children demonstrating the behaviours. A "Hospital Kit" containing surgical and anaesthetic masks, a syringe and identification band was provided to encourage rehearsal of potentially stressful events.  Mode of Presentation: Two levels of Mode of Presentation were used: Audio-Visual and Print. Twenty-minute audio-video-programmes were produced by video-taping the actual hospitalization for surgery of a boy and a girl. In the final tapes the children's comments and adult voice-over narration provided continuity between sections of the tape where live sound was heard. For the print programmes, the same boy and girl as in each video-tape were photographed during their stay; and the black and white photographs were used in twenty-seven page booklets. The text was taken from the dialogue and narration of the video-tapes. The two levels of Instructional Approach were crossed with the two levels of Mode of Presentation to create four distinct programmes: Modeling/Audio-Visual, Modeling/Print, Rehearsal-Instruction/Audio-Visual, and Rehearsal-Instruction/Print (See Figure 2).  The Hospital Tour The tour was designed to approximate the descriptions of such hospitaltoursgiven in the literature (Azarnoff et al., 1975; Sauer, 1968). It included walking through and discussing elements of the Day Care Surgery Unit and the ante-rooms of the Operating Rooms. The impact of the tour varied because some children were given tours on weekends or evenings when the Day Care Surgical Unit and O.R. ante-rooms were empty; while other children saw these areas at a time when the areas were in full use. The former situation provided opportunities to stay as long as the children wished for families to explore and discuss the areas, while the latter situation provided a more realistic view of what would actually be experienced. The tour is described in detail in Appendix A.  49  Control Conditions Since it has not been established that preparation programmes are of benefit to children entering hospital for day care surgery, it was appropriate to compare the experimental variables to a control, or non-preparation, condition. Also, this study involved extensive contact with hospital-related staff for data collection and interviews, which might affect reaction to the actual hospital experience, a potential "Hawthorne effect". Therefore, two control conditions were established. Control Condition A. Children assigned to this condition received no preadmission preparation programme as defined above; but half received a hospital'tour. All measures obtained on the experimental treatment groups were obtained for these children. Control Condition B. A second control group was established which had no contact with the research staff prior to admission to the hospital and, therefore for which no pre-test measures were obtained. Children assigned to Control Condition B received no programme or tour. Figure 2 illustrates the eleven cells resulting from the three experimental and two control variables.  FIGURE 2 Experimental and Control Variables Programme  Tour  Control Conditions A A B  Yes No No  Experimental Conditions Modeling/Audio-Visual Modeling/Audio-Visual Modeling/Print Modeling/Print  Yes No Yes No  Rehearsal-Instrucuon/Audio-Visual Rehearsal-Instrucuon/Audio-Visual Rehearsal-Instruction/Print Rehearsal-Instruction/Print  Yes No Yes No  50  Variables Held Constant Among the Experimental Conditions As described in Figure 2, combinations of the Design Factors and Control Conditions were combined to create treatment "packages". Other programme variables, which might affect the strength of the programmes were monitored for consistency amongst the treatment "packages". Content of programmes was standardized throughout all treatment packages. Topics covered, information provided, and time (number of pages) allotted to each topic were held constant in each treatment. Length of programme was standardized to 45 minutes, regardless of the preparation "packages" assigned. Video-tapes required 20 minutes for viewing. This same amount of time was used to present the booklets page by page to ensure exposure to content However, children were allowed to take the booklets home. The tour was allotted 15 minutes. The remaining time was used for answering questions or for conversation unrelated to the forthcoming hospitalization. Timing of programme delivery. All families received their programmes one to three days before surgery. Attractiveness of programmes. The same children were used as models in all four programmes. In Modeling, the same adult, a professional T.V. announcer, was used for the voice-over narration as was used for the Instruction in the Rehearsal/Instruction approach. Booklets were formatted in the same shape as a television screen. The video tapes were created in full colour. Unfortunately, cost precluded the use of full colour photographs in the booklets and two-colour printing was used.  Moderating Variables It has been suggested that characteristics of the children, their families, and the hospital experience may affect the child's reaction to hospitalization and surgery and may also affect the response to preadmission preparation (Melamed & Siegel, 1980). Since the research is inconsistent and sparse on the effects of individual child characteristics, a number of characteristics were chosen for exploratory analysis to promote further research. . Therefore, 10 variables were selected to act as moderating variables. These variables were grouped into 4 clusters because of the relatively small sample size. Each cluster and the variables of which it is comprised are described below. Cluster 1: Biodemographic Characteristics of the Child: This cluster was made up of two variables: age and gender. These variables served as blocking variables in the design. An attempt was made to ensure that treatment cells were balanced for age group and gender across conditions.  In this study, age was used as a  categorical variable at two levels: younger children (5 to 8 years inclusive) and older children (9 to 12 years inclusive). Gender is a categorical variable at two levels: male and female. 51  Cluster 2: Personality Characteristics of the Child: This cluster consisted of three variables: Verbal Ability. Trait Anxiety, and Health Locus of Control. It was hypothesized that the children's facility to understand and use the language of the personnel in the hospital, their general trait anxiety level, and also their concept of the controlling factors in the hospitalization, their surgery and recovery might affect the children's response to the hospital environment and also the treatment programme. It was suggested that different instructional approaches or modes of delivery of preadmission preparation might be more effective for certain types of children. Cluster 3: Characteristics of the Family: It has been suggested that children from different family backgrounds may respond differently to hospitalization. The two variables chosen for this study were socio-economic status of the family and position in the sibling structure, i.e. whether the child was a youngest child or only child. Cluster 4: Child's Personal History Characteristics: Three variables were selected for this cluster the presence of chronic conditions, the numbers of previous hospital experiences, and the amount of stress in the child's life in the preceding six months.  Descriptive Variables Other data were collected in order to describe the families and to compare the experimental groups on variables which might have a potentially confounding effect.These variables were not used in the experimental analysis. These variables were: Surgical Category, Marital Status of Parents, Number in Household, Ethnicity of Families, and Number of Languages Spoken by Child.  Dependent Variables It has been noted that sequelae from hospitalization may demonstrate themselves in one or more of several ways: in reaction to the actual event, in post-hospitalization behavioural upset, in prolonged recovery periods, or physical and psychological side effects (Vernon & Foley, 1965; Prugh et al., 1953). In several reviews of the preadmission preparation research (Elkins & Roberts, 1983; Siegel, 1976; Melamed et al., 1982) particular emphasis has been placed on the need for multi-modal methods for measuring anxiety and reaction to hospitalization. Therefore, a series of dependent variables were identified which propose to measure varying negative reactions to hospitalization. Figure 3 lists the dependent variables, the instruments used to measure them and the occasions upon which they were used. A more detailed discussion will follow in the Instruments Section.  52  FIGURE 3 Dependent Variables: The Instruments Used and the Occasions of their Use. Variables  Instruments .  Occasions*  A. Child's Reaction to Hospitalization Experience 1.  Self-reported anxiety prior to surgery and following discharge  Children's State Anxiety Inventory (Spielberger et al., 1973)  2,3,4  2.  Observed anxiety prior to surgery  Observation Rating Scale  2,3  B. Child's Post Hospitalization Behavioural Adjustment 3.  Parent-reported behaviour rating scales  *Occasions:  1 2 3 4  Visit 1 Visit 2 Visit 3 Visit 4  Hospital Behaviour Questionnaire (adapted from Vernon, et al., 1966)  1,4  5-10 days prior to surgery 1-3 days prior to surgery 1 hour prior to surgery 6 weeks following surgery  Procedures  This study was part of a major research project entitled: The Vancouver Preadmission Preparation Project, funded by National Health and Welfare; principal investigator: Dr. Geoffry C. Robinson. As such, the protocal for the procedures followed that of the major research project, with the addition of the Control Group A sample selection and enrollment in the study. Context of the Study The study was planned to be conducted at B.C.'s Children's Hospital, an amalgamation of services from two separate facilities: the Health Centre for Children of the Vancouver General Hospital, and Vancouver Children's Hospital. The new hospital was opened in the Spring of 1982.  53  Staffing Interviewers. Three graduate students in Clinical and Educational Psychology were hired to act as interviewers. An orientation to the study and the hospital was provided. They were then trained in the use of all interviews and instruments.  Experimenters. Two research assistants were hired to present the intervention preparation programmes. One was a graduate student in Educational Psychology who had collaborated in the submission of the research proposal and developed the preparation packages. Before the commencement of the project, she had had no experience with B.C.'s Children's Hospital. The second was a Nursing administrator who was the project's main liaison with the hospital during the development of the preparations. She had worked as a supervisor in B.C.'s Children's Hospital for one year preceding her appointment to the project. When this second individual was unable to continue with the project, a third individual, with a background in Counselling Psychology, was hired. She had no previous experience working in B.C.'s Children's Hospital. The experimenters were provided with manuals (see Appendix A) which described the specific protocols for each preparation package and were trained to present all preparation programmes and the tour. Frequent procedural reviews were conducted to maintain consistency amongst the Experimenters.  Office Manager. An office manager coordinated the activities of the interviewers and experimenters, received the names of potential subjects from doctors' offices and hospitals (see below) and assigned these children to preparation programme cells. These procedures were all verified prior to commencement of the data collection in order to ensure that random assignment conditions would be met and that interviewers would remain blind to the preparation programme condition of the children. Development of Programme Packages Liaison was established with the Assistant Director of Nursing responsible for education and research and with the Head of the Department of Anaesthesia. Content of the programmes was established in the following manner: 1.  Members of the Nursing Department described a typical child's experience to the experimenter.  54  2.  The experimenter created a "script" of events.  3.  Staff from each area in the hospital were asked to evaluate the script in two ways: a. look for omissions, errors or other content concerns (e.g., one person used the phrase "a mosquito  bite"  to describe the insertion of an intravenous needle and other staff objected to this phrase —  therefore it was  not used); and  b. weight the relative importance of information, i.e., how much time (or how many pages) should be allotted to each topic (eg. admission, examination, transportation to surgery, anaesthetic, etc.). 4.  The information presented was revised and pages or time to be allotted per topic were equalized amongst the programmes. Subjects for the audio-video taping and photgraphs were recommended by surgeons. Each potential child  and parent was asked if he/she would be willing to participate in the project Parents were then visited by project staff to explain what their participation would entail. Several days were allowed for consideration of the request before a decision to participate and signed consents were obtained. Two children and their families were selected: 1.  an 8-year-old Caucasian male admitted to the day care surgery unit for a hernia repair; and  2.  a 12-year-old Oriental female admitted as an admit-day-of-surgery patient for repair of a perforated ear  drum.  Audio-Video Tapes. A freelance consultant was hired to act as Director of the video-tapes. Technical services were provided by the Audio-Visual Department of the Faculty of Education at the University of British Columbia. The children were followed throughout their hospitalization, from the time they entered the lobby until they were anaesthetized. They were again photographed at intervals from the post-anaesthetic recovery period through to their discharge. Hospital staff had been well briefed and parents of the children in nearby beds were also informed of what was occurring. Few special arrangements were made to accommodate the taping. A bed against a wall was reserved for the child, and the nurses and anaesthetist assigned to the children were preselected. Otherwise, staff were instructed to simply proceed with their normal routine.  55  One month after surgery, the video crew visited the children and their parents in their homes to obtain footage of the children's preparations for and recovery from the hospitalization. An interview with the children and their parents was also conducted to obtain their comments on the hospitalization experience. Scripting of the audio-video tapes was then completed. A professional broadcaster was hired to narrate the tapes, and editing proceeded.  Booklets. Still photographs were taken during the audio-video taping. Text for the booklets was taken from the script of the audio-video tapes. Photographs were chosen, text was typeset and the booklets were printed.  Tours.  The tours were developed to conform to the descriptions of hospital tours found in the literature  (Azarnoff et al., 1975; Peterson & Ridley-Johnson, 1980) and to contain the same general information as was found in the audio-video tapes and booklets. However, much less detail was included in the tours than in other treatment conditions. An outline of the tours is contained in Appendix A.  Development of Instrument Packages and Protocols Each instrument wasreviewedand revised to conform to a consistent format Permission was obtained to adapt published tests to this design. (See Appendix D for the letter of permission.)  The Background Interview and behavioural questionnaire were pilot tested for both length and acceptability of questions. Finalrevisionsto the instrument packages were then made, printing of all instruments completed, and four instrument packages (one for each data collection observation) assembled. Specific protocols were developed for each staff role. Telephone and personal interview scripts were pilot tested and revised before being included in a manual for the staff. Coding manuals were also developed. These procedural manuals are included in Appendix A. The coding manual is contained in Appendix E.  56  Enrolment of the Study Surgeons The 15 study surgeons selected through analysis of B.CMinistry of Health data (see p. 46) were presented with a description of the study, detailing their role. Their approval and agreement to participate was obtained (see Appendix D for letters of consent) The office staff of these surgeons was invited to attend a presentation at B.C.'s Children's Hospital which described the study and gave them the opportunity to view the preparation programme packages. Their role in recommending children and their parents for the study was explained. Specific materials were prepared for the use of the surgeons' office staff, such as a card with a photograph from the booklet which outlined the criteria for entry into the study.  Data Collection Subjects in the treatment and Control A conditions were identified by the 15 study surgeons and their offices, and letters outlining the study (see Appendix D) were distributed to families meeting the participatory requirements of the study. The names of the families were then sent to the project office manager. After a 3-month trial period, however, it was ascertained that many potential subjects were not being referred. Subsequently, potential subjects were identified through the computing services of the Admitting Department of the hospital as well as by surgeon referrals. These patients were mailed the letter describing the study. Approximately 10 days before surgery, the parents were telephoned by one of the project interviewers. A standardized interview (see Appendix A) was conducted to describe the study, obtain verbal consent to participate, and schedule the first home interview. At the first observation, a home visit which took place at least 5 days (but not more than 10 days) prior to the scheduled surgery, written consent (see Appendix D) was obtained from the parent and verbal consent was obtained from the child. Measures of all moderating variables were obtained. Also, an appointment for the second observation was made. The second observation took place at the hospital 1 to 3 days prior to the scheduled surgery and immediately prior to conducting the preparation programme. All family members were invited to the visit. Any of the family who attended were met in the lobby of the hospital by the interviewer. They were taken to the second floor 57  Project Office in the University of B.C. Department of Paediatrics, where they were introduced to one of the experimenters. While the interviewer made behavioural observations of the child, the experimenter interviewed the parent and child. The experimenter then excused herself, while the interviewer completed the State Anxiety Questionnaires with the parent and child. The experimenter returned and the interviewer then left the office area, after confirming her pre-surgery visit to the child. The treatment package was then administered. The treatment consisted of viewing the video-tape, or reading the booklet through, and/or taking the family on a tour of the day-care Unit. An attempt was made to keep each treatment and control session to the same length, 45 minutes. The experimenter visited with the control families but did not deliberately discuss the hospitalization. However, each family was given an opportunity to ask any questions regarding their child's stay. At the end of the session, the experimenter escorted the family back to the first floor lobby. The third observation by the interviewer consisted of a visit to the child at his hospital bed approximately one hour before the scheduled surgery to make behavioural observations and to administer the State Anxiety Questionnaire. On several occasions children were already sedated or had already been taken to the surgical suite. Therefore, data were missing for this observation in some cases. The fourth observation occurred in the child's home approximately 6 weeks following the surgery. At these times, outcome measures were collected (see Figure 2).  Subjects for Control Condition B were identified by the Day Care Surgery Unit staff upon the children's entry into the Unit prior to surgery. The interviewer approached each family with a letter describing the study and obtained written consent at that time (see Appendix D). Verbal consent was obtained from the child. Behavioural observations were made. After the child had been taken to the surgical suite, the interviewer obtained data used as descriptive variables. The interviewer followed the protocol for the fourth observation as described above to collect the sixweek follow-up data.  Data Processing As instruments were returned to the Project Office by the interviewers, they were checked for identification numbers and coding completeness. Interview packages were then separated into instrument files and sent to a 58  data processor for entry of coded data into computer disk files. Instrument files were returned to the Project Office, where instruments were re-sorted into subject files. Completeness and accuracy of each subject file was verified, as were the instrument files created on the computer.  Instrumentation Some instruments were created for this study, others were adapted from other sources. Published and unpublished tests were also used. This section identifies the dependent, descriptive, and moderating variables of interest and the instruments used as their operational definitions. Figure 4 lists these instruments and variables. Following is a more complete description of each instrument and its use in the study.  Created Instruments 1. Background Interview. The Background Interview was designed to obtain a variety of information on the child's personal, social and medical background. Questions were asked by the interviewer in a conversational format, although the interview schedule was highly structured. Responses were probed until the scoring criteria outlined in the Interviewing Manual and Coding Manual were realized. Although the child and both parents may have been included in the interview, one parent — usually the mother — was selected as the "respondent" and her (or his) answers were recorded. Appendix A contains a copy of the Interviewing Manual and Appendix E contains a copy of the Instrument and the Coding Manual.  Nine variables were obtained from the Background Interview. a. Age. The child's date of birth was obtained. For use in analysis, age was calculated as of the date of surgery. Age was used as a categorical variable (under 9 years of age, or 9 years of age and older) to assign patients to treatment conditions and in the data analysis. b. Gender. The child's gender was recorded and used as a categorical variable: male or female. c.  Surgical Category. Each child's surgery was classified according to the surgical specialty of the surgeon. These categories were: (1) General; (2) Ear, Nose and Throat; (3) Orthopaedics; (4) Genito-Urinary; (5) Dental; and (6) Plastic. 59  d. Previous hospitalizations. If the parent did not express certainty, the child's physician's and/or hospital records were consulted. However, some uncertainty as to the reliability of this data persisted. Therefore, a categorical variable was structured: no previous hospital experience or some previous admissions. e. Chronic handicaps and conditions: All conditionsreportedby the parent were recorded. However, there appeared to be no method of evaluating the severity of these conditions. Therefore, a dichotomous variable was created: some or no chronic conditions or handicaps. f. Ethnic background. The Ethnic background of both the mother and father were obtained. Those parents identifying themselves as having a background other than simply Canadian, were asked how active they were within that ethnic community. This variable was used for descriptive purposes only. g. Marital status. This variable was also used to describe the sample. A categorical variable was created: parents were married (to each other), separated, divorced or "other". h. Position in sibling structure. A dichotomous variable was created: youngest and only children in one category, all other sibling patterns in the alternate category. i. Number in household. A count was taken of the number of people, other than the subject, living in the household. This continuous variable was used for descriptive purposes, j. Socio-economic status. The Blishen Scale (Blishen and McRoberts, 1976) was used to assign a value to the socio-economic status of the occupation for each parent or other adult contributing to the family's income. For the analysis, only one value was used per family. If both parents worked full time, the higher value was assigned, otherwise the value for the occupation of the parent who worked full time was used.  60  FIGURE 4 Instruments and the Variables Measured. A. Created Instruments Variable 1. Background Interview  Variables  a. Age b. Gender c. Surgical Category d. Previous hospitalizations e. Chronic handicaps and conditions f. Ethnic background g. Marital status of parents h. Position in sibling structure i. Number in household j. Socio-economic status  Type of  moderator . moderator descriptive moderator moderator descriptive descriptive moderator descriptive moderator  B. Adapted Instruments 2. Observation Rating Scale 3. Hospital Behaviour Questionnaire (four factoranalytically derived scales)  k. Observed anxiety 1.. Parent-reported behaviour  dependent dependent  m. Language ability level  moderator  n. Locus of control (internal vs. external) o. Amount of stress in child's life p. Self-reported usual anxiety level q. Self-reported state anxiety  moderator  C. Published and Unpublished Tests 4 . Peabody Picture Vocabulary Test - Revised 5. Health Locus of Control 6. Life Events Scale 7. State Trait Anxiety Inventory for Children  61  moderator moderator dependent  Adapted Instruments 2. Observation Rating Scale. This instrument was adapted from two sources. The behaviour checklists were adapted from the Observer Rating Scale of Anxiety developed by Melamed  and her colleagues and used in several studies evaluating preadmission preparation programmes  (Melamed  and Siegel, 1975; Melamed et al., 1978). The child was observed for three one-minute periods  and a point given for each negative item observed and each positive item not observed. The scale was modified by creating explicit behavioural definitions for each item, and by developing a Coding Manual (see Appendix E). The scale was change from 26 to 25 items. Those items that could not be behaviourally defined were deleted and additional items were created by splitting items into two behavioural categories. For example, "scans examiner's face for approval" was deleted, "frowning" and "appears in pain" were changed to "lip or face contortions" and "verbal expression of pain". Scoring was also modified. Negative items observed scored one point. Positive items observed scored a negative point, i.e., they were subtracted from the score. Finally, the checklist was divided into two scales, a Verbal Scale and a Non-Verbal Scale. The Rating Scale was adapted from an instrument developed by Wolfer and Visintainer for their studies of hospitalized children (1975,1979). Five Likert-type rating scales were combined to create a single score rating the child's degree of upset, cooperation, muscle tension, etc. Inter-raterreliabilityfor the Verbal, Non-Verbal and Rating Scales was established prior to commencement of data collection through observation of children video-taped and on the ward. Throughout the data collection period interviewers would periodically observe children in pairs enabling consistency to be maintained throughout the long data collection period. Internal consistency estimates were calculated for each section of the Observation Rating Scale at each administration.  3. Hospital Behaviour Questionnaire. This instrument was adapted from the Posthospital Behavior Questionnaire by Vemon et al. (1966) which has seen frequent use in studies of hospitalized children (e.g., Ferguson, 1979; Vemon, 1973). This 27-item scale was modified in the response it asked from parent-raters. Instead of indicating whether the child's behaviour had changed since the hospitalization, the parent rated how often  62  each behaviour occured (every day, twice a week, once a week, etc.). The instrument was administered prior to, as well as post-hospitalizarJon. Although the Posthospital Behaviour Questionnaire is often used so as to yield only a single total score, prior research (Vernon et al., 1966) has suggested that its 27 items may represent several distinct factors or scales. The revised questionnaire was factor analysed for the Vancouver Preadmission Preparation Programmes Study (Conry, Harper, and Robinson, 1986). The Varirriax annalysis with orthogonal rotation yielded four factors.The resulting pattern of factor coefficients is displayed in Table 1. The factors; labelled Contentiousness, Dependent Anxiety, Sleep Disturbance, and Appetite Disturbance; had principal loadings on (correlations with) 8,7,6 and 6 items respectively. Factor score co-efficients were derived and applied to yield standardized factor scores on the four factors. These coefficients were applied to the item responses obtained in this study. These four factor scores were used in this study. Internal consistency reliabilities were computed for the Pre-test administration of this instrument in the Preadmission Preparation Programme Study (Conry, et al., 1986). These were reported as .79, .71, .73, and .55 for each factor scale.  Published and Unpublished Tests 4. Peabodv Picture Vocabulary Test - Revised (Dunn and Dunn, 1981). This well known test of receptive vocabulary was used as a measure of language ability level. Standard scores, calculated following the instructions in the Manual, were used in the analyses. Split-half reliabilities are reported in the Manual for each age group as ranging from .67 to .88 for Form L. Median test-retest reliability for the alternate forms of the test werereportedas .82 for immediate retest and .78 for retest after one year or more. Correlations with the earlier version of the PPVT arereportedas ranging from 0.50 to 0.87. Other validity studies are not reported in the Manual.  63  TABLE 1 Composition of Hospital Behaviour Questionnaire Item Factors (Pattern Matrix): Varimax Rotation of Principal Components Analysis (N=200)* 1  Descriptors: Factors/Items  I  CONTENTIOUSNESS 25. Disobedient 15. Doesn't talk 26. Breaks things 14. Temper tantrums 18. Attention seeking 10. Needs help doing things 16. Upset with mention of doctors 6. Disinterested in goings on II.  DEPENDENT ANXIETY 5. Afraid to leave house 12. Avoids new things 9. Upset when left alone 13. • Can't decide 17. Follows parent around 3. Lies about doing nothing 8. Bites nails SLEEP 19. 1. 20. 22. 23. 7.  DISTURBANCE Afraid of dark Fuss at bedtime Bad dreams Can't get to sleep Shy with strangers Wets bed  APPETITE DISTURBANCE 24. Poor appetite 27. Sucks thumb 2. Fusses over eating 11. Disinterested in play 4. Needs pacifier 21. Irregular bowels Factor variance:  1 2 3  Factor Loadings II III IV 2  3  69 66 56 52 47 44 27 ' 22  07 09 02 -07 26 43 21 18  31 -02 13 32 23 -09 17 -21  20 01 03 15 -02 24 -04 19  18 15 -19 24 31 32 08  76 65 60 50 43 42 20  -05 12 19 10 07 -26 -17  09 -02 28 03 36 -15 -05  01 24 11 18 01 08  35 -01 01 -01 33 -06  65 64 61 49 43 20  -01 06 04 -07 -05 -12  01 22 06 39 -05 24  06 -03 -01 19 24 00  10 -10 40 06 -07 -21  75 52 50 -41 38 32  2.76  2.69  2.42  1.93  Loadings rounded to 2 significant figures; decimals omitted. Items ranked within factor clusters by magnitude of principal loading. Brief "key word" item descriptions included here; see Appendix E for complete Hospital Behaviour Questionnaire items. *From Conry, et al. (1986)  64  5. Children's Health Questionnaire was the title used in this study for the Children's Health Locus of Control Scale (Parcel & Meyer, 1978). This scale contains twenty items. Each item consists of a statement to which the child responds true or false. Six items have an internal control positive response (e.g. I can do many things to fight illness; There are things I can do to have healthy teeth.) The rest have an external control positive response (e.g. People who never get sick are just plain lucky; Other people must tell me what to do when I feel sick). All items were read to the children to eliminate variation due to reading ability. "Internal" items were scored positive, and "external" items were scored negative. Total scores were used in the analysis. A reliability and validity study was conducted by the authors, using a sample of 140 children in grades 3 through 5. (The original instrument was developed with children in grades 2 through 6.) Internal consistency (Kuder-Richardson) was reported as r = .72 and r = .75 for two administrations six weeks apart. Test-retest reliability was reported as r = .62. Construct validity was assessed by correlating scores with those on the Nowicki-Strickland Children's Locus of Control Scale (Nowicki & Strickland, 1973). They hypothesized that the scores would be related but not highly correlated for the specific health and more general locus of control scales. They report "a significant but not high correlation" (p. 156) and suggest that further studies are needed. 6. Life Events Scale was the title given to the Social Readjustment Rating Scales developed by Coddington (1972). The purpose of these scales is to record the positive and negative life events requiring adaptation and readjustment by the child and occurring in a specified time period. Each event is assigned a value of life change units, reflecting the relative stress imposed by the event The child's score is the sum of the life change units for the events he/she has experienced. In a study of over 3500 healthy children living in Ohio, Coddington found life change scores to be correlated with age (older children experiencing greater stress than younger children) but not with gender, race or socio-economic status. He suggests that hospitalized children may have experienced greater life stresses than children not experiencing hospitalization and recommends further study of this possibility. For this study, the time period referred to in administration of the Life Events Scale was six months. The scale used was that designed for elementary school-aged children. One item was added to the scale to cover the area between "jail sentence of parent for 30 days or less" and "jail sentence of parent for one year or 65  more" and an average of the two existing life change units was used as the value for the life change units on the new item. Items were grouped by topic (i.e., all items pertaining to parents were grouped together, all items pertaining to health and physical abilities were grouped together, etc.) Examples of items are "beginning a new school year", "change in parents' financial status" and "discovery of being an adopted child". 7. State-Trait Anxiety Inventory for Children. Self-reported state and trait anxiety were measured using this instrument which was developed by Spielberger in collaboration with Edwards, Lushine, Mpntouri and Platzek (1973). The inventory is composed of two 20-item scales: the first 20 items are designed to measure trait anxiety (how you generally feel); and the other 20 items are designed to measure state anxiety (how you feel right now). For the purpose of this study, permission was obtained from the publisher to reproduce the Inventory as two separate instruments (see Appendix D). Trait anxiety items were placed on the "How I Usually Feel" instrument. Examples of trait items are "I feel like crying" and "I am shy". Each item was scored on a 3-point scale using the choices "hardly ever", "sometimes" or "often". The instrument was administered verbally to all children to minimize the effects of reading ability on the results. State anxiety items were placed on the "How I Feel Now" instrument Each item was scored on a 3-point scale using the modifiers "very" and "not" to describe each adjective. Examples of items are "I feel very nice/ nice/ not nice" and "I feel very upset/upset/not upset". This instrument was also administered verbally to all the children. Reliabilities published in the manual for the state anxiety scale are: (a) internal consistency: .82 for males and .87 for females; and (b) test-retest reliability: .31 for males and .47 for females. For the trait anxiety scale, reliabilities werereportedas: (a) internal consistency: .78 for males and .81 for females; and (b) test-retest reliability: .65 for males and .71 for females. Validity studies of the scales have also beenreportedin the manual. Evidence of construct validity of the state scale isreportedwhere scores on each item were higher during stressful situations than in non-stressful situations. Concurrent validity of the Trait Anxiety Scale has been indicated byreportsof correlations of .75 with the Children's Manifest Anxiety Scale (Castaneda, McCandless & Palermo, 1956) and .63 with the  66  General Anxiety Scale for Children (Sarason, Davidson, Lighthall, Waite, & Ruebush, 1960). For this study, on each of the two instruments (State or "How I Feel Now", and Trait or "How I Usually . Feel"), scores for each item were added to obtain a single score.  Data Analysis Data analysis was divided into three main sections; Descriptive Analyses, Analyses of the Research Questions on Programme Variables and Exploratory Analyses of Individual Characteristics. These will be discussed below.  Descriptive Analysis Preliminary data analyses were conducted to provide a description of the sample and to describe, within the clusters, relationships among the moderating variables. Descriptive Variables: Frequency distributions were calculated for those variables which were collected only for descriptive purposes. Appropriate measures of association were calculated among these variables. These measures included Chi-Square and Kendall's Tau for correlations between categorical variables, and analysis of variance for relationships between categorical and continuous variables. Dependent Variables: Summary statistics were also computed for the continuous dependent variables. Internal consistency reliabilities for each administration of each appropriate instrument were calculated using the LERTAP computer programme (Nelson, 1974). Interrater reliabilities were computed for the Observation Scales. Moderating Variables: For the categorical variables, frequency distributions were prepared. For the continuous variables, summary statistics (mean, standard deviation, range, etc), including tests of normality of distribution, were computed. Relationships Among Moderating Variables. The relationships between age and gender and each of the moderating variables were explored. Also, the relationships among the moderating variables in each cluster were examined. The specific analyses performed varied, depending upon the type of variables included. For categorical variables, Chi-squared and Kendall's Tau statistics were calculated; for continuous variables, Pearson correlations were calculated; and for analyses combining a continuous and categorical variable, analyses of variance were performed.  67  Descriptive statistics were obtained from the hospital on the age, gender, and surgical category of patients during a one year period overlapping the data collection period.  Analysis of the Research Questions: Programme Variables Analyses varied depending upon the nature of the research question and the dependent variables used. Therefore, the analyses for each question will be discussed separately below. These analyses considered the main hypotheses of the study, concerning the Programme variables.  Question 1: Attention Effects. The purpose of this question was to evaluate the effect of extra individual attention (but no preparation) on children. To answer this question the design included a group (Control Group B) which received no interviews or observations prior to their hospitalization. Consquently, no pre-test data were collected for these children and the analyses of the data differ somewhat from that used in other questions. Two types of analyses were used: 1. Analyses of Variance (ANOVA) were used to evaluate the effects of attention on those continuous dependent variables administered only once. These were: Hospital Behaviour Questionnaire, (4 factor scores), and Observation Scales (3 scores). 2. Multivariate Analysis of Variance (MANOVA) was used for the Children's State Anxiety Inventory, a continuous variable administered twice; before surgery and at the 6 week follow up visit As well as the Group A (attention) versus Group B (no attention) contrast; age and gender were also entered into the analyses. Their interactions with the attention effect were examined.  Questions 2 and 3: Programme vs. No Programme and Effect of Hospital Tour. MANOVAs were used to evaluate the effects of treatment and tour on the dependent variables which were part of the repeated measures design of the study (pre- and post -occasions). These measures included reported behaviours, self reported anxiety levels and observed behaviours. As well as the treatment vs. no treatment and the tour vs. no tour contrasts examined, other variables were entered into the analysis. These were: age group and gender. Only the interaction of these variables with  68  treatment and tour were considered in this question. The main effects of the moderating variables and their interaction with each other are reported within Research questions 4-6.  Questions 4.5 and 6: Facets of Preparation. The interactions of Approach, Mode, and Tour were examined using MANOVAs for the dependent variables administered on two or three occasions. These measures were: Hospital Behaviour Questionnaire (4 factor scores), Observation Scale (3 scales) and the Child State Anxiety Inventory. Main effects of each analysis were considered in questions 4 and 5. The interactions among the design factors were addressed in question 6. As mentioned above, the interactions with age and gender were also considered. Exploratory Analyses: Individual Characteristics as Moderators. The purpose of this question was to determine whether children's or families' characteristics interacted with experimental independent variables (preparation programme or no programme, instructional approach, mode of presentation, and hospital tour) to affect children's responses to hospitalization and surgery. The ten characteristics, or moderating variables, were chosen for this exploratory analysis and were grouped into four clusters of related variables (see Design: Moderating Variables, p.51). Cluster 1, the Biodemographic Characteristics, Age and Gender, were examined within the MANOVAs described above for Questions 2 through 6. For analysis of the other clusters, a structured multiple regresion equation was produced. Independent variables and their interactions were entered into the equation in order of most likely "pre-existing" effects. For example, verbal ability was entered before trait anxiety in Cluster 2 because of the supposition that a child's verbal ability has developed over a longer period of time than the child's trait anxiety. This approach is the same as that proposed for analysis by Cronbach and Snow (1977). Within this model, each test of effects has been corrected for "overlap" of all sources of variance entered earlier into the equation. For analyses in this study, the general order of entry in the regression equations was: First, the individual difference variables in the "cluster"; Second, the treatment or independent variables and interactions among them; and 69  Third, the interactions between the individual difference "moderators" and the treatment variables. The order of entry of the moderator variables within their respective clusters was: Cluster 2 1. Verbal Ability 2.Trait Anxiety 3. Health Locus of Control Cluster 3 l.Socio-Economic Status 2P6siton in the sibling structure Cluster 4 1.Chronic Conditions 2Previous Hospitalizations 3life Stress At this stage the full regression model included significance tests of individual differences and treatment main effects. Only the significance tests of the interactions between these two categories were relevant to Research Question 7. Therefore, tables in Appendix C refer only to these interaction terms. Each equation had as many as thirty independent variables, twenty-one of which were interaction terms of interest. Such an equation of interest was developed for each of eight dependent variables. When testing such a large number of effects for signifi-  cance, it is necessary to adopt a criterion forjudging when an interaction has had a true significant effect. When an interaction term was significant in analysis of two or more dependent variables, it was deemed worthy of closer inspection and further analyses were conducted. This second stage analysis also used a regression approach. Its purpose was to generate accurately the information required to portray the results found to be significant in the regression analysis described above. To accomplish this, a "reduced model" regression analysis was preformed, where the model included all terms that had been in the first model except the term found to be significant, the lower-order terms involved in the significant one, and higher order interactions. For example, if the following equation had been tested for significance in the first model:  70  Y= Yj+ U.+X +X +P + T + P T + X P + X T + X P + X T + X P T A  0  A  A  Q  Q  A  +X PT+£, 0  where Y is the dependent variable (eg. State Anxiety),  Yl is the pre-test of the dependent variable X is the effect of the "age" individual difference variable, A  X is the effect of the "gender" individual difference variable, Q  P is the effect of the "Programme" experimental variable, T is the effect of the "Tour" experimental variable, P T is the interaction effect of Programme and Tour, and X P through X P T are the interactions between individual difference variables and experimenA  G  tal factors, and the [X TJ interaction had proven significant, the "reduced" model constructed for the second stage A  analysis would be: _ Y=Y,+  n+x + x + p+e . A  0  This equation was then applied to the full sample: its residuals included the variance associated with the [X T] term found to be significant in the initial analysis, as well as the variance associated with the main effect of A  tour rrj. The effects of prior terms in the initial equation were removed and the residuals were not contaminated by variance from those (five, in this example) sources. The next step was to standardize the residuals as T scores (mean=50, standard deviation=10) so that portrayals of significant interactions in the results were on a common scale. Then, two simple regression equations were generated, one for each experimental group (Tour and No Tour in this example). For the example provided here, the structure of this equation would be: Y=  [i + A + £ ,  where Y is the standardized residual score on the dependent variable, A is age, and E is error of estimate. 71  Finally, these two lines were plotted on the same graph to portray the differences proven significant in the first-stage analysis. When an interaction is significant in thefirst-stageanalysis, the plot resulting from the secondstage analysis displays regression lines, the slopes of which vary significantly. In the example fabricated here, the graph portraying the results might have the following appearance:  MeanT  • Tour  scores  • No Tour  for State Anxiety  y Younger  Older Age  This would indicate that older children within the Tour group were more anxious than younger children in the same group and that there was no relationship between age and anxiety for children who received No Tour. In summary, all significant interactions between individual difference measures and experimental preparation factors were elaborated and interpreted with a four-step follow-up analysis: 1. A "reduced model" regression analysis was applied to the full sample in the case of each significant interaction; 2. The residuals for the reduced model analysis were standardized; 3. A simple regression equation was generated for each level (or combination of levels) of the experimen tal factor(s) involved in the significant interaction, predicting the residual dependent variable for the interaction; and 4. The simple regression lines were plotted on the same graph to permit comparison of the slopes of the different groups and to permit interpretation of the meaning of the interaction.  72  In these exploratory analyses, a comparatively large number of variables was assessed and, therfore, the number of analyses was large. Because of the relatively small sample size, the variables were dealt with in small groups and individually. Results of these analyses are reported in the final section of Chapter IV. For all seven research questions, results of statistical analyses were considered to be significant at the .05 level of confidence.  73  CHAPTER IV RESULTS  The results of analyses are reported in three main sections. First, descriptive analyses were conducted to describe the sample and examine the relationships among variables used in this study. The second section is entitled Analyses of the Research Questions for Programme Variables and reports the results of the analyses as they relate to each of the six research questions. The final section, Exploratory Analyses of Individual Characteristics, reports the results of the regression analyses.  Descriptive Analyses This section of the results is divided into four groups of analyses: A. Description of the Moderating Variables; B. Description of the Dependent Variables; C. Relationships among the Descriptive Variables; and D. Relationships among the Moderating Variables. These four topics will be discussed below.  A. Description of the Moderating Variables Preliminary analyses of the blocking and moderating variables differed, depending on whether they were continuous or categorical variables as described in Chapter 3.  Categorical Variables: A frequency distribution was prepared for each variable. Table 2 gives the frequencies and percent of sample used for each variable.  1. Age Groups: More "young" children than "older" children were found to be in the sample. This trend is consistent with that in the general hospital population. (See description of Hospital sample, p.83 for further discussion). The variable was used in the original form. 2. Gender: More boys than girls were found in the sample. This trend is also consistent with the hospital sample (see p.84). (Comparisons with other variables are found in the analyses described in C and D of this section.)  74  . TABLE 2 Frequency Distributions for Categorical Moderating Variables Categories Age Groups Under 9 Over 9 Total  Original N  %  80  72.7  20.  212  110  100  74 26 110  67.3 32.7 100  Gender Male Female Total  Previous Hospital Experience Some 87 None 21 Missing Data 2 Total 110  100  Chronic Conditions Some None Total  61 49 110  55.5 44.5 100  Position in Sibling Structure Youngest or Only 50 Other 6J2 Total 110  45.5 54£ 100  79.1 19.1  1A  3. Previous Hospital Experience: Most of the children in the sample (79.1%) had been hospitalized at least once before. 4. Chronic Conditions: Over half of the children (55.5%) were felt by their parents to have some chronic condition. 5. Position in Sibling Structure: Just under half of the children (45.5%) were the youngest or only child in their family.  75  Continuous Variables: Table 3 presents the summary statistics for continuous moderator variables (stressful life events, verbal ability, trait anxiety, health locus of control, and socio-economic status) including tests of normality of distribution. Multiple item tests of personality trait measures were examined for internal consistency. Hoyt estimates of reliability are reported in Table 4 for Child Trait Anxiety and Health Locus of Control. Both were considered sufficiently reliable. It should be noted that the sample size for Health Locus of Control was reduced from the 91 cases expected. Children who did not complete the forms were below six and a half years of age and the Interviewers judged that the children did not sufficiently understand the questions to respond reliably.  TABLE 3 Summary of Statistics and Tests of Normality for the Continuous Moderating Variables VARIABLE  N  M  SD  MIN  MAX  K-S  P  109  144.09  102.83  0  434  1.20  0.11  Verbal Ability  91  96.78  19.15  40  137  0.85  0.46  Trait Anxiety  88  35.59  7.34  21  55  0.60  0.86  Health Locus of Control  80  30.80  3.84  23  38  0.94  0.34  Socio-economic Status  98  52.20  14.57  18  74 .  1.27  0.08  Stressful Events  TABLE 4 Internal Consistency Coefficients for Child Trait Anxiety and Health Locus of Control VARIABLE  N  Child's Trait Anxiety Health Locus of Control  88 80  Number of Items 20 20  76  Hoyt's R 0.84 0.77  B.Description of the Dependent Variables Preliminary analyses of these variables included tests of reliability and normality.  Continuous Variables: Summary statistics for these variables are reported in Table 5. Also, in this table are reported the internal consistency reliabilities (Hoyt's R) and the test for conformity to the normal distribution (KS). Very few of the tests and subtests were normally distributed for this sample. However, transformation was not considered appropriate because they were used as outcome measures. Reliabilities ranged from 0.54 (Observation Verbal Scale) to 0.91 (Child's State Anxiety prior to surgery).  TABLE 5 Summary Statistics, Reliabilities and Normality Tests for Continuous Outcome Variables Variables  N  Hospital Behaviour Questionnaire Contentiousness-Pre 109 Post 110 Dependent Anxiety-Pre 109 Post 110 Sleep Disturbance-Pre 109 Post 110 Appetite Disturbance-Pre 109 Post 110 Child's State Anxietv-Pre 90 During 101 Post 107 Observation Rating Scale Pre 91 During 109 Observation Verbal Scale 91 Pre During 109 Observation Nonverbal Scale Pre 91 During 109  X  S.D.  Min  Max  K-S  P  8 8 7 7 6 6 6 6 20 20 20  49.87 51.14 49.91 51.45 50.55 49.20 50.28 49.34 33.04 34.13 29.73  10.02 9.98 10.09 9.94 10.35 10.01 11.04 10.02 5.23 6.24 4.60  32.87 35.44 17.43 24.65 23.55 27.50 32.61 27.48 21 21 20  87.77 90.35 66.84 74.12 93.22 88.20 84.15 79.42 49 59 43  1.58 0.88 1.03 1.34 1.24 1.29 1.53 1.13 1.70 1.99 1.53  0.01 0.42 0.24 0.05 0.10 0.07 0.02 0.16 0.01 0.00 0.02  0.85 0.91 0.87  5 5  9.67 7.39  3.07 2.50  5 5  15 18  1.42 2.59  0.04 0.00  0.78 0.75  27 27  7.90 5.38  3.03 1.96  1 2  15 11  1.00 0.01 1.34 0.06  0.76 0.54  48 48  8.62 6.89  3.16 3.16  0 0  16 16  1.15 1.15  0.14 0.14  0.69 0.69  Items  Hoyt'sR  * * * * * * *  •Reliabilities not computed for this sample. See Instrumentation Section for explanation.  Interater reliabilities were calculated for the Observation Scales. Correlations between scores of pairs of observers on 35 occasions were used to calculate the reliabilities reported in Table 6.  77  TABLE 6 Inter-Rater Reliabilites for Observation Scales Scales  N-  R  Rating Scale Verbal Scale Non-Verbal Scale  35 35 35  G.78 0.65 0.82  2  C. Relationships Among Descriptive Variables: Several variables were collected for descriptive purposes only. These variables describe the families from which the subjects came and were correlated with some of the moderating variables used in the study in order to describe the sample. 1. Marital Status: Most of the children were from two-parent families. Families where the parents were married accounted for 81.8% of the sample (see Table 7). Table 8 describes the relationship between marital status of parents and age and gender of child. There was a significant relationship between marital status of parents and gender of child. Table 9 shows the expected and obtained frequencies for marital status of parents by gender of child. Slightly more boys had married parents and more girls lived with parents in situations not described as married, separated, or divorced than would have occured by chance.  TABLE 7 Marital Status of Parents Marital Status  Frequency  Married to each other Separated Divorced Other Total  Percent  90 9 3 & 110  81.8 8.2 2.7 ZI 100  TABLE 8 Measures of association for Agegroup and Gender with Marital Status Variables  N  Age Gender  110 110  Chi-square P 2.86 6.12  Kendall's Tau P  0.58 0.19  0.02 0.14  78  0.38 0.03  Pearson R P 0.00 0.22  0.50 0.01  TABLE 9 Gender of Child by Marital Status of Parents Gender Marital Status  Male  Married Separated Divorced Other  Female  64 (60.5)* 6( 6.1) 1 ( 2.0) 3( 5.4)  26 (29.5) 3 ( 2.9) 2( 1.0) 5( 2.6)  •Frequency (Expected fequency)  2. Number in Household: The frequency distribution of the number in each household is presented in Table 10. The most common family size was four (42.7%), with 79% of the sample having families with three to five members. Table 11 shows the summary of the analyses of variance describing the relationship between number in household and age group and gender. No association was discovered for this sample between number in household and the two blocking variables or the treatment group to which the child was assigned. T A B L E 10 Frequency of Number in Household Number in Household  Frequency  2 3 4 5 6 7 8  Percent  2 16 47 24 6 1 2 12 110  Missing Data Total  1.8 14.5 42.7 21.8 5.5 .9 1.8 10.9 100  TABLE 11 Summary of Analysis of Variance for Number in Household with Age Group, Gender, and Programme  Variables  N  Age Group Gender Programme  98 98 91  Sum of Squares 1.5138 1.1884 10.7261  79  DF  Mean Square  F  P  6 6 9  .2523 1.38 .1981 .89 1.1918 1.05  .23 .51 .41  3. Ethnicity of Families: The ethnic background of the families was examined via a number of questions. Table 12 reports the ethnic background with which each parent identified themselves, while Table 13 describes the ethnic identity of the families. Fifty-eight mothers (52.7%) andfifty-threefathers (48.2%) identified themselves as simply Canadian with no other ethnic identity. Western European, other than Greek or Italian, were the next largest group identified with 16 mothers (14.5%) and 14 fathers (12.7%). As is seen in Table 13, most of the families (80%) were made up of parents with the same ethnic background. Forty-eight families (43.6%) perceived themselves as Canadian without any other ethnic background. Of the remaining families, the question was asked how involved they were within their ethnic community. Table 14 reports the answers of this group. Approximately half (53.9%) and 49%) did not consider themselves to be at all active within their ethnic community. No significant relationship was found between the ethnic backgrounds described by the parents and their socio-econcomic status (Table 15). Nor was any relationship found between the number in the household and the mothers' identified ethnic backgrounds. A significant relationship was found between the number in the household and fathers' identified ethnic background. Table 16 displays the mean number per household in each of the father's ethnic groups. It appears that the Asian Fathers; other than East Indian, Japanese or Chinese; and the Canadian Indian fathers had the largest households, with an average of 6 persons, and the Eastern European  T A B L E 12 Ethnic Background of Mothers and Fathers  Ethnic Background  Mothers Percent Frequency  Canadian Greek Italian Other Western European Eastern European East Indian Chinese Japanese Other Asian Canadian Indian Others Not applicable*0?arent not present) Total  58 2 0 16 7 5 9 1 2 3 6 1 110  52.8 1.8 0 14.5 6.4 4.5 8.2 .9 1.8 2.7 5.5 100  •9  Fathers Frequency Percent 53 3 2 14 5 5 9 1 2 1 9  _£  110  48.3 2.7 1.8 12.7 4.5 4.5 8.2 .9 1.8 .9 8.2 5,5 100  *Not applicable was noted when the parent was not part of the child's life in any way and the parent responding did not feel that the ethnic background affected the childs' life.  80  TABLE 13 Ethnic Background of Families Mothers' Background Can Can 48* (43.6) Greek 0 (0) WJBur 4 (3.6) E.Eur 1 . (.9) E.Indian 0 (0) Chinese 0 (0) Japanese 0 (0) Asian 0 (0) Can Ind 0 (0) Other • 0 (0) N/A 0 (0)  Greek 0 (0) 2 (1.8) 0 (0) 1 (.9) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)  Ital 1 (.9) 0 (0) 1 (-9) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)  Fathers' W.Eur E.Eur 2 1 (1.8) (.9) 0 0 (0) (0) 10 0 (9.1) (0) 1 4 (3.6) (.9) 0 0 (0) (0) 0 0 • (0) (0) 0 0 (0) (0) 0 0 (0) (0) 1 0 (.9) (0) 0 0 (0) (0)) 0 0 (0) (0)  Background E.Ind Chin 0 0 (0) (0) 0 0 (0) (0) 0 0 (0) (0) 0 0 (0) (0) 5 0 (4.5) (0) 0 9 (8.2) (0) 0 0 (0) (0) 0 0 (0) (0) 0 0 (0) (0) 0 0 (0) (0) 0 0 (0) (0))  Jap Asian 0 0 (0) (0) 0 0 (0) (0) 0 0 (0) (0) 0 0 (0) (0) 0 0 (0) (0) 0 0 (0) (0) 1 0 (.9) (0) 2 0 (0) (1.8) 0 0 (0) (0) 0 0 (0) (0) 0 0 (0) (0)  Can Ind 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (.9) 0 (0) 0 (0)  Other 2 (1.8) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 6 (.5) 1 (.9)  •Frequency (Percent of Total)  TABLE 14 Activity Level Within Identified Ethnic Communities  Response  Mother's Frequency Percent  Very active Somewhat active Not at all active Total  5 19 28 52  Father's Frequency Percent  9.6 36.5 53.9 100  6 19 24 49  12.2 38.8 49.0 100  TABLE 15 Summary of Analyses of Variance for Parent's Ethnic Background with Socio-economic Status (SES) and Number in House (House)  Variables  N  Sum of Squares  DF  Mean Square  F  Mother's Ethnic & SES Father's Ethnic & SES Mother's Ethnic & House Father's Ethnic & House  98 98 91 91  1860.8059 3444.7378 17.5647 21.8962  9 11 9 11  206.7562 313.1580 1.95 1.9906  In 1.57 1.85 1.94  81  P ~A1 .12 .07 .04  N/A 4 (3.6) 0 (0) 1 (.9) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (0) 0 (0) 0 (0)  fathers had the smallest households. The number of languages spoken by the children is recorded in Table 17. Most of the children (68.2%) spoke only one language, English.  T A B L E 16 Average Number in Household for each Ethnic Group of Fathers Ethnic Group  N  Canadian Greek Italian West European East European East Indian Chinese Japanese Other Asian Canadian Indian Other  Mean Number  50 3 2 6 . 4 5 7 1 2 1 10  4.3 4.3 4.0 3.8 3.2 4.6 4.7 4.0 6.0 6.0 3.8  T A B L E 17 Number of Languages Spoken by Children Number  Frequency  1 2 3 4 5 6  Percent 68.2 27.3 2.7 .9 0 .9  75 30 3 1 0 1  D. Relationships Among Moderating Variables The relationships among the variables in each cluster of independent variables was examined by computing Pearson R, Chi-Square and other appropriate statistics.  Cluster 1: Biodemographic Characteristics and Blocking Variables Three variables were used as blocking factors in assigning children to treatment conditions as was described in Chapter 3. These were: age group, gender, and surgical category. Thefirsttwo also comprised the  82  first cluster of variables used as moderating variables. Table 18 shows the breakdown of each of these variables for each treatment cell and for the entire sample. Table 19 describes the study sample and a sample of the hospital population on the same variables. Although the actual frequency counts of the two samples were not comparable because the time periods were not the same; a comparison of the percentages shows some discrepancies between the general population and the sample enrolled in the study. In surgical category, the greatest differences were in the Orthopedic group, where far fewer than would be expected were enrolled in the study; and in the Plastic and Dental group, where more children than would have been anticipated were enrolled. In the Agegroup and Gender categories, the trends toward younger children and males was the same, but the discrepancy was more pronounced in the sample than in the population.  The relationships among the variables age, gender, and surgical category are described in Table 20. There does not appear to be a significant relationship among these three variables.  T A B L E 18 Breakdown of the Sample and Programme Cells by the Blocking Factors Programme/ Groups  Age Group <9 >9  M  Gender F  Total Sample  80  30  74  36  46  41  8  15  Rehearsal-Instruction /Print /Audio-visual  11 14  5 2  10 9  6 7  6 6  6 7  2 1  2 2  Modeling /Print /Audio-visual  13 10  4 4  13 13  4 1  9 7  6 6  0 0  2 1  Control A Control B  21 11  7 8  18 11  10 8  11 7  11 5  2 3  4 4  83  Gen/Gu.  Surgical Category ENT Ortho Pi/Dent  TABLE 19 Descriptive Statistics for the Study Sample (Aug 15,1983-June 1,1984) and a Hospital Population Sample (Dec 1,1983 - May 31,1984) Sample Variables  Population  N  %  . N  %  Sureical Category General ENT Orthopedic Genitourinary Plastic and Dental  16 41 8 30 15  14.5 37.3 7.3 27.3 13.6  44 133 143 71 11  10.9 33.1 35.6 17.7 2.7  Age Groups <9 >9  80 30  72.7 27.3  255 147  63.4 36.6  74 26 110  67.3 32.7 100  227  56.5 43.5 100  Gender Male Female Total  m 402  TABLE 20 Measures of Association for Agegroup (Age), Gender, and Surgical Category (SURCAT). Variables Age & Gender Age & SURCAT Gender & SURCAT  N 110 110 110  Chi-square P 0.10 0.76 6.85 0.23 4.44 0.49  Kendal's Tau P 0.05 0.30 0.12 0.09 0.08 0.21  Pearson's R P 0.05 0.13 0.21  0.30 0.08 0.17  Cluster 2: Family Characteristics Socio-economic status (SES) of the families (as computed using the method outlined in the Instrumentation Section) was described on the Blishen Scale (Blishen & McRoberts, 1976). As derived in 1981, this scale has an average, for the Canadian population of 50 and a standard deviation of 10. The Blishen scores for this sample had a mean of 52.20 and a standard deviation of 14.57. The mode was 62.00. The K-S test was used to determine whether the sample was normally distributed on this variable. A score of 1.273 was computed, suggesting that the sample did not deviate significantly from normal (p=0.08). Measures of association were calculated for SES, position in family structure and age and gender. Tables 21 and 22 summarize these tests. Only age and position in family structure were found to be related (p=0.02). Table 23 gives the expected and  84  obtained cell frequencies for each position by age group. It seems logical that the youngest and only position group would have more younger (under 9 years) children than the other position group.  T A B L E 21 Measures of Association for AgeGroup (Age) and Gender with Position of Child in Family Structure (Position) Variables  N  Age & Position Gender & Position  Chi-square  110 110  3.16 0.00  P  Kendall's Tau  0.08 . 1.00  0.19 0.01  P  Pearson's R P  0.02 0.44  0.19 0.01  0.02 0.44  TABLE 22 Summary of Analyses of Variance for Socio-Economic Status (SES) and Age, Gender, and Position in Family Structure (Position) Variables  N  Sum of Squares  DF  Mean Sum of Squares  SES by Agegroup SES by Gender SES by Position  98 98 98  5.8862 8.2439 39.6894  33 33 1  .1784 .2498 39.6894  F  .8348 1.2346 .1855  P  .71 .23 .67  TABLE 23 Frequencies of Position in Sibling Structure (Position) and Age Age Group Position  N  Youngest or Only Other  38 53  <9 41(36.4)* 39(43.6)  >9 9( 3.6) 21(16.4)  *Frequency(Expected Frequency)  Cluster 3:Children's Personality Characteristics Table 24 summarizes the analyses of variance, measuring the degree of association between the children's personality charactertisics and the three blocking variables. Agegroup was found to be significantly related to Health Locus of Control (Health LOC). Older children obtained higher scores than younger children, indicating a greater perception of internal control over health issues. Table 26 lists the mean scores for each age group on this variable. Table 27 gives the correlations among the personality charactertistics. They do not appear to be related in this sample.  85  TABLE 24 Summary of Analyses of Variance for Children's Personality Characteristics (Verbal Ability, Health L O C , Tr. Anxiety) and Blocking Variables (Agegroup, Gender, Surcat) N  Variables  Sum of Squares  Verbal Ability Age Group Gender Surcat  91 91 91  214.63 270.00 2368.30  Health L O C Age Group Gender Surcat  80 80 80  390.30 19.91 78.47  Trait Anxiety Age Group Gender Surcat  88 88 88  101.88 1.04 7.19  DF  Mean Square  F  P  |  214.63 4.04 473.66  .58 .01 1.31  .45 .91 .27  390.30 19.91 26.16  39.18 1.35 1.83  .00 .25 .15  101.88 1.04 2.04  1.91 .02 .04  .17 .89 .99  ; 3  TABLE 25 Mean Health Locus of Control Scores for Each Age Group Age Groups  N  Under 9 Over 9  58 22  SD  Mean 29.44 34.39  3.38 2.46  TABLE 26 Correlation Among Children's Personality Characteristics Variables Verb A B x L O C Verb AB x Tr. Anx LOC x Tr. Anx  N  R  P  80. 88 80  .15 -.16 -.03  .09 .07 .40  TABLE 27 Summary of Relationships Among Chronic Condition (CC), Previous Experience (Prev. Exp.), Age, and Gender Variables CC and Prev. Exp. CC and Age CC and Gender Prev. Exp. and Age Prev. Exp. and Gender  N 109 110 110 109 109  Chi-square 1.60 0.14 0.05 0.59 7.12  P 0.45 1.71 0.83 0.74 0.03  86  Kendall's Tau -0.03 -0.05 -0.04 -0.06 0.22  P 0.40 0.27 0.33 0.28 0.01  Pearson' sR P -0.01 -0.06 -0.04 -0.06 0.20  0.48 0.28 0.34 0.26 0.02  Cluster 4: Personal History The relationships among the categorical variables, chronic conditions, previous experience, agegroup, and gender are summarized in Table 21. There was a significant relationship found between previous experience and gender (p=0.03). Table 28 reports the results of the analyses of variance considering the relationships of stressful life events (satress) and each of the categorical variables from Clusters 1 and 4. No significant relationships were observed. Table 29 shows that more boys and less girls than expected had previous experience with hospitalization.  T A B L E 28 Summary of Analysis of Variance for Blocking and Child History Variables  Variables  N  Gender by L. Events Prev. Exp. by L. Events C.C. by L. Events  109 108 109  Sum of Squares  DF 1 1 1  804.86 9645.16 2091.33  Mean Squares 804.86 4822.58 2091.33  F  P  .08 .45 .20  .72 .64 .66  TABLE 29 Obtained and Expected (*) Cell Frequencies for Previous Experience by Gender Previous Experience Male  Some None  63 (58.3) 10 (14.8)  87  Gender Female 24 12  (28.7) (7.2)  Analyses of the Research Questions on Programme Variables  Analyses which were pertinent to each of the six major research questions will be reported.  Question 1: Attention Effects For these analyses, children who served as control subjects for the Programme questions (Control Group A , n=16) were compared to a group of children who did not receive any pre-Programme attention in the form of interviews or observations (Control Group B, n=21). Because no data were collected prior to the hospitalization, the variables used and the form of the analyses varied from other questions, as described in the data analysis section. There were 8 dependent variables used: Hospital Behaviour Questionnaire (4 factor scores), Observation Scales (3 scores), and Children's State Anxiety Questionnaire. Appendix B, Table 1 summarizes the Analyses of Variance (ANOVA) for this question. Column 1 lists the sources of variance in the ANOVA model. Alternating columns contain the F values for the main effects and each interaction term in the model for each dependent variable used in this analysis. Also included in the table are probabilities of a type 1 error (P) of less than .05. It should be noted that no interactions were calculated where empty cells or a singular matrix occurred. Appendix B, Table 2 summarizes the Multiple Analysis of Variance (MANOVA) used to analyze the Children's State Anxiety Inventory. Column 1 lists the main effects and interaction terms in the model. Column 2 lists the F values at the pre-surgery measurement. Column 4 lists the F values for the change over time from the pre-surgery measurement to the 6-week follow-up measurement Again, the probabilities of type one error less than .05 are recorded in columns 3 and 5 with their associated F values. Of the 8 dependent variables used in the analysis of Question 1, only one significant interaction and one main effect were noted; each on one variable only.  Group x Gender: This interaction was seen on the Children's State Anxiety Inventory, both at the presurgery measurement (p=.01) and at the 6-week follow-up visit (p=.05). (See Appendix B, Table 2). Table 30  88  presents the means for each cell and Figure 5 graphically depicts the relationship between Group and Gender on this variable. Girls who had received the measurement attention prior to hospitalization expressed more anxiety than thosereceivingno attention pre-hpspitalization at the presurgery measurement. It should be remembered that girls in A group had filled out this same questionnaire just a few days earlier, whereas those in B group were completely unfamiliar with it TABLE 30 Means for Group x Gender on the Children's State Anxiety Scale Means Group  N •  Pre Surg  Post Hosp  Group A Male Female  7 8  29.95 46.21  27.80 30.36  Group B Male Female  9 8  35.50 34.23  30.83 28.23  89  Main Effect of Attention (Group'): Again; this effect was observed on only one variable, the NonVerbal Scale of the Observation Rating Scale (p=.04). (See Appendix B, Table 1). Table 31 lists the means for each group on this variable. Those children having no attention prior to the hospital admission demonstrated more anxiety-related non-verbal behaviour than those children who received "measurement attention". TABLE 31 Means for Control Groups on the Non-Verbal Observation Scale  A B  Summary:  Group  N  Means  (Attention) (No Attention)  16 19  6.00 9.00  There appeared to be a difference between those children who had no pre-surgery attention  in the form of interviews at home and in the hospital and those children who formed the control group for the study of preadmission preparation. Girls who had answered the questionnaire before in an interview rated themselves as more anxious prior to surgery than other girls or the boys. This may have been an artifact of their experience with the questionnaire, although boys did not respond in this way. Those children in the no-attention group (B) were observed to display more anxiety-related non-verbal behaviour than their counter-parts. It must be remembered, however, that this was not a blind-rating, as the observers were those interviewers who had recorded the pre-test measures for the group A controls. Therefore, of 8 variables and 6 sources of interaction, only two effects were significant, suggesting minimal effect of pre-test intervention on this sample of children admitted for day-care surgery.  Questions 2 & 3: Effects of Programmes and Tour For these analyses children who had some preadmission preparation, either a programme or a tour, were compared with those children who did not have that type of preparation and with those who had no preparation at all. It did not include those in the control condition B. As well as Programme, the independent variables included in these analyses were Tour, agegroup and gender. The dependent variables for these analyses were: The Hospital Behaviour Questionnaire (4 factor scores); the Observation Rating Scales (3 scores), and the State  90  Anxiety Scale for Children (2 occasions). Although the full models for each of these analyses are reported in Appendix B, only those effects relevant to the research questions will be discussed here; i.e. main effects of Programme and Tour and interactions of Programme and Tour with agegroup and gender. A summary of multivariate and univariate analyses results are presented in Appendix B. Tables 3 to 5 present the F values and significance levels less than .05 for each of the repeated measures terms in the model for the Hospital Behaviour Questionnaire(Table 3), Observation Scales (Table 4), and State Anxiety Scale (Table 5). The top line of each table labels the dependent variables. Each scale heading has two columns. Pre. indicates differences among groups at the pre-test measure, Occas indicates the differences among groups in the change scores over time. The Child State Anxiety Scale (Table 5) contains an additional two columns, indicating the differences among groups at the two post-test measures; immediately prior to surgery (Surg) and six weeks postsurgery (JPosi). On the left hand side of the tables are listed the main effects and interactions among the between subjects factors and Time for the Experimental Variables: Programme, Tour, agegroup and gender. In each case, F values and P values <.05 are recorded. Because of the complexity of the analyses following from the large number of variables, the results will be reported in three sections: 1) Programme and interactions with agegroup and gender; 2) Tour and interactions with agegroup and gender; and 3) Programme by Tour interactions and three-way interactions with agegroup and gender. An overview of the terms in the model and where significant results were found is presented in Figure 6. Following this table, each interaction and main effect which significantly affected any of the dependent variables will be elaborated.  91  FIGURE 6 Significant Terms in the MANOVA Analyses Performed for Questions 2 and 3 and the Affected Scales (Variables) Interactions  1)  Programme x Gender Programme  2)  Tour x Gender  3)  Scales (Dependent Variables)  P  HBQ Factor 2: Dependent Anxiety HBQ Factor 1: Contentiousness HBQ Factor 2: Dependent Anxiety Verbal Observation Scale  .01 .04 .04 .04  HBQ Factor 2: Dependent Anxiety Child State Anxiety - Post Occas. Programme x Tour x Agegroup Verbal Observation Scale Programme x Tour x Gender ' HBQ Factor 2: Dependent Anxiety Programme x Tour Observation Rating Scales Multivariate Rating Scale Verbal Scale Non-Verbal Scale  .03 .05 .02 .04 .00 .00 .00 .00  Programme x Gender Only one variable was observed to be significantly affected by this interaction: HBQ Factor 2: Dependent Anxiety (p=.01). Table 32 gives the mean scores for the groups on the scale; Figure 7 displays the change overtimegraphically. Parents reported more behaviours associated with dependent anxiety at the six week follow-up than prior to the hospitalization, except for the parents of girls who received no Programme; theyreportedfewer behaviours.  T A B L E 32 Mean Scores for Programme x Gender on HBQ Factor 2 and HBQ Total Score  Group Programme/Males /Females No Programme/Males /Females  N  HBQ Factor 2 Pre  44 18 18 10  48.85 49.35 52.44 51.57  92  Post 50.29 54.37 54.77 47.88  FIGURE 7 Mean HBQ: Factor 2 Scores on 2 Occasions for Programme x Gender  PROGRAMME B males 4) females NO PROGRAMME r j males O females  PRE  POST TIME  Main Effect of Programme: The main effect of Programme was observed on three univariate analyses: HBQ Factor 1: Contentiousness (p=.04), HBQ Factor 2: Dependent Anxiety (p=.04) and the Verbal Observation Scale (p=.04). Mean scores for the treated and untreated groups on these three scales are reported in Table 33. Figures 8,9, and 10 depict the relationships graphically. Parents reported more behaviours associated with contentiousness (Figure 8) and dependent anxiety (Figure 9) after the surgery than before surgery for children in the Programme group, while they reported fewer behaviours in the group which did not receive a programme.  TABLE 33 Mean Scores for Programme on HBQ Factor 1: Contentiousness, HBQ Factor 2: Dependent Anxiety, and Verbal Observation Scale.  Group  N  Programme No Programme  62 28  HBQ Factor 1 Pre Post 46.82 51.75  49.75 50.81  93  HBQ Factor 2 Pre Post 49.10 52.33 52.00 51.32  Verbal Scale Pre Surg 7.48 5.64 8.61 5.48  In observation of verbal behaviours associated with anxiety (Figure 10), more such behaviours were served at the pre-test observation in the no-Programme group than in the Programme group, but both groups demonstrated fewer of these behaviours prior to surgery, with a more dramatic decrease observed in the nontreated group. FIGURE 8 Mean HBQ: Factor 1 Scores on 2 Occasions for Programme  52 51  a  50  ee  8 Vi  1  49 48 47 I  46  POST  PRE TIME  94  •  PROGRAMME  •  NO PROGRAMME  FIGURE 10 Mean Verbal Observation Scores on 2 Occasions for Programme  • PROGRAMME •  NO PROGRAMME  TIME  Tour x Gender This interaction was seen to significantly effect Factor 2 of the HBQ: Dependent Anxiety (p=.03) and the follow-up occasion of the Children's State Anxiety Inventory (p=.05). Table 34 presents the means for the groups on these three measures. Figures 11 and 12 are the graphic representations. Girls who received tours were reported by their parents to have fewer behaviours associated with dependent anxiety at the follow-up visit than they did before, while all others increased these behaviours. Girls who received tours also reported less anxiety than the others at the follow-up visit. The smaller number in this cell, compared to the others, should be noted. The drop in State Anxiety scores at the six week follow-up was most dramatic in the boys who received Tours.  T A B L E 34 Mean Scores for Tour x Gender on HBQ Factor 2: Dependent Anxiety and Children's State Anxiety  Group Tour/Male /Female No Tour/Male /Female  N 31 9 31 19  HBQ Factor 2 Pre Post 48.63 52.93 52.65 47.98  51.65 50.70 53.40 51.55  95  N  Child's State Anxiety Surg Pre Post  31 9 31 19  33.44 29.96 31.58 33.02  35.00 28.39 32.08 34.92  28.72 26.00 29.56 30.31  FIGURE 11 Mean HBQ: Factor 2 Scores on 2 Occasions for Tour x Gender 54  —I PRE  1  TIME  POST  FIGURE 12 Mean Children's State Anxiety Scores on 3 Occasions for Tour x Gender  TOUR | male 9 female NOTOUR f~| male Q female  PRE  SURG  96  POST  Main Effects of Tour: Tour was found to. have a main effect on the Multivariate analysis of the Observation Rating Scale (p=.01) with effects observed on the Rating Scale (p=.01), Verbal Scale (p=.01) and NonVerbal Scale (p=.01). Table 35 displays the mean scores and Figures 13,14, and 15 present the graphic representations. On the Rating and Verbal Observation Scales (Figures 13 and 14), groups receiving a tour were observed to express more behaviours associated with anxiety before preparation and admission than the no tour group. However, tour groups were given a similar score to the No/Tour group at the pre-surgery observation; a large drop in scores for the Tour group, a smaller drop for the No/Tour group. In contrast, non-verbal anxiety observations for the No/Tour group were higher than for the Tour group at the pre-admission observation (Figure 15). Again, scores were similar for the two groups at the pre-surgery observation, with children in the Tour condition showing a very small change in scores.  TABLE 35 Mean Scores for Tour on Observation Rating , Verbal and Non-Verbal Scales. Group  Tour No Tour  N  Rating Scale Pre Surg  Verbal Scale Pre Surg  41 49  11.31 8.56  9.51 7.10  7.31 7.01  Non Verbal Scale Pre Surg  5.15 5.37  7.10 9.45  6.82 6.07  FIGURE 13 Mean Observation Rating Scale Scores on 2 Occasions for Tour  12  •  11  o  • NOTOUR  10  tn  z <  TOUR  9 -  7 • I  SURG  PRE TIME  97  FIGURE 14 Mean Verbal Observation Scores on 2 Occasions for Tour 10  9  R  L  •  TOUR  •  NO TOUR I  «s o o (A  55  I  SURG  PRE TIME  FIGURE 15 Mean Non-Verbal Observation Scores on 2 Occasions for Tour 10  CO  w a o u CO  5S <  w  *  I SURG  PRE TIME  98  •  TOUR  •  NO TOUR  Programme x Tour x Agegroup: This interaction was found to significantly affect the Verbal Observation Scale (p=.02). Table 36 presents the mean scores and Figure 16 presents the graphic display of the means on the Verbal Observation Scale. Observation scores (Table 36, Figure 16) of the children's verbal behaviour associated with anxiety were lower at the pre-surgery measurement than at the pre-admission measurement for all groups. However, young children in the No Programme/Tour or Programme/No Tour conditions showed a more dramatic drop than those in the Programme/Tour or No Programme/No Tour conditions. Older children's scores, on the whole, did not decrease as much as did the younger children's scores. Scores of older children showed the greatest decrease under the Tour conditions.  TABLE 36 Mean Scores on Programme x Tour x Agegroup on the Verbal Observation Scale Group Programme/Tour/Younger /Older Programme/No Tour/Younger /Older No Programme/Tour/Younger /Older No Programme/No Tour/Younger /Older  N  Pre  22 7 25 8 8 4 13 3  6.59 9.14 7.60 8.12 12.12 10.75 6.08 7.33  Surg 5.82 6.29 5.00 6.62 4.12 6.50 5.31 6.00  FIGURE 16 Mean Verbal Observation Scale Scores on 2 Occasions for Programme x Tour x Agegroup PROGRAMME/TOUR _ younger •  older  PROG/NO TOUR 0 younger O older NO P R O G R A M M E / T O U R ^ younger / \ older NO PROG/NO TOUR ^younger folder <  I PRE  I SURG  TIME  99  Programme x Tour x Gender: This interaction was observed to significantly affect HBQ Factor 2: Dependent Anxiety (p=.04). Table 37 presents the mean scores while Figure 17 presents the graphic display of the means on HBQ Factor 2.  On the Dependent Anxiety Scale (Table 37, Figure 17), parentsrecordedhigher scores at the 6 week follow-up than at me pre-admission measurement for girls who received a Programme and No Tour and boys who received neither or both Programme and Tour or just a Tour.  TABLE 37 Mean Scores on Programme x Tour x Gender on HBQ Factor 2: Dependent Anxiety N  Group Programme/Tour/Male /Female Programme/No Tour/Male /Female No Programme/Tour/Male /Female No Programme/No Tour/Male /Female  21 7 23 11 10 2 8 8  Pre  Post  47.61 53.68 50.09 45.02 49.65 52.18 55.22 50.95  51.21 52.88 49.36 55.87 52.09 48.53 57.43 47.22  FIGURE 17 Mean HBQ: Factor 2 Scores on 2 Occasions for Programme x Tour x Gender PROGRAMME/ TOUR fg male • female PROGRAMME/ NOTOUR 0 male O female NO PROGRAMME/ TOUR A A  male female  NO PROGRAMME/ NO TOUR  PRE  POST TIME  100  ^  male  ^  female  Programme x Tour This interaction was found to significantly affect the multivariate analyses of the Observation Rating Scales (p=.00). The scales showing significant univariate effects are the Rating Scale (p=.00), Verbal Scale (p=.00), and Non-Verbal Scale (p=.00). Table 38 presents the mean scores for the Programme by Tour interaction for each of these scales while Figures 18,19, and 20 depict these scores graphically. On the Rating Scale of behaviour related to anxiety (Figure 18), rating scores of the children in the No Programme/No Tour condition dropped less from the pre-admission level than scores of those children in any of the Programme conditions. Greatest drops in observed anxiety were in children in the Programme only and Tour only groups. Similarly, on the Verbal behaviour observation scale (Figure 19), scores of children in the No Programme/Tour or Programme/No Tour conditions made the most dramatic drop from pre-admission to presurgery, with the Tour only condition showing the greatest decrease. TABLE 38 Mean Scores on Programme x Tour on Observation Rating, Verbal and Non-Verbal Scales  N  Group Programme/Tour /No Tour No Programme/Tour /No Tour  29 33 12 16  Rating Pre Surg 9.65 10.35 11.70 7.50  7.18 6.26 7.70 6.88  Verbal Pre Surg  Non-Verbal Surg Pre  7.55 8.21 11.40 6.21  9.07 8.60 5.80 10.33  6.29 5.50 4.95 5.00  6.59 5.73 7.95 6.17  FIGURE 18 Mean Observation Rating Scale Scores on 2 Occasions for Programme x Tour 12  it  2 «  io  o u  Vi  z  1  PRE  SURG  TIME  101  •  PROG/TOUR  •  PROGVNO TOUR  •  NO PROG ./TOUR  O  NO PROG/NO TOUR  On the Non-Verbal behaviour observation scale (Figure 20), only scores of children in the No Programme/Tour group increased from pre-admission to pre-surgery while scores of those in the other groups dropped.  FIGURE 19 Mean Verbal Observation Scale Scores on 2 Occasions for Programme x Tour  PRE TIME  102  Summary of Questions 2 and 3 The results of analyses undertaken to investigate Research Questions 2 and 3 on the effects of Programmes and Tours will be summarized below. Interactions with Agegroup: Only one interaction with agegroup was observed: Agegroup x Programme x Tour, on one variable: Observation Verbal Scale. All children were observed to decrease their verbal behaviours associated with anxiety prior to surgery with the most dramatic drop occurring in young children in the No Programme/Tour condition. Therefore in this study, agegroup appears to have only a very limited influence on the effectiveness of Programmes and Tours.  Interactions with Gender Gender appears to have had a more substantial relationship with the variables Programme and Tour. In the interaction of gender with Programme and Tour on HBQ Factor 2: Dependent Anxiety, males tended to increase their scores following surgery and females tended to decrease their scores with two notable exceptions: this trend was reversed for those in the Programme/No Tour Condition. The effects of gender on Programme alone were seen on the same variable: HBQ Factor 2: Dependent Anxiety, with girls who did not receive a Programme obtaining lower dependent anxiety scores at the six week follow-up. Gender was observed to interact with Tour on two variables: HBQ Factor 2: Dependent Anxiety and State Anxiety Scores at the pre-surgery measure. Girls who had Tours had decreased dependent anxiety scores at the 6 week follow-up. Their self-reported State Anxiety was decreased at pre-surgery and continued to decline while all others had increased scores at the pre-surgery measure.  Tour x Programme Interactions: As well as the significant multivariate analyses, all three variables were seen to be affected by this interaction. On the Observation Rating and Verbal Scales, the smallest effects were seen in the No Programme/No Tour groups. However, on the Verbal Scale, the most dramatic decrease in scores was observed in the No Programme/Tour condition. On the Non-Verbal Observation Scale, all groups had decreasing scores except the No Programme/Tour group which showed an increase in the number of Verbal behaviours associated with anxiety.  103  Effects of Tour: Children in the Tour condition had greater decreases in Observation Verbal and Observation Rating Scale Scores, but smaller decreases in Observation Non-Verbal Scale scores than children in the No Tour condition.  Effects of Programme: Children in the. Programme condition showed higher HBQ Factor 1: Contentiousness and HBQ Factor 2: Dependent Anxiety scores at post-test measure than those in the No Programme Condition. They also demonstrated more verbal behaviours associated with anxiety at the pre-surgery measure than at the pre-test measure.  Questions 4.5. and 6: Facets of Preparation Programmes Questions considered the main effects of the facets of preparation programmes: Instructional Approach and Mode of Presentation. Question 6 considered the interaction between the facets as well as the interactions of Tour, agegroup and gender.  Tables 6-8 in Appendix B contain the summary tables for each of the analyses, including F ratios and P values less than .06. These tables are structured in the same way as those in Appendix B, Tables 3-5 (see p.93 for description). The usual method of discussing the results of analysis of variance is to consider the interactions first, then report main effects. However, because of the structure of the questions in this study, main effects and the interactions with the blocking variables will be considered first, then the interactions in descending order. Figure 21 is provided to describe the order for presenting the interactions and to summarize the significant effects.  Approach x Gender: This interaction was observed to be significant on only once scale; HBQ Factor 4: Appetite Disturbance (p=.01) (See Appendix B Table 6). Table 39 displays the mean scores for each group and Figure 22 shows the relationship graphically. Boys were described by their parents as demonstrating fewer behaviours related to appetite disturbance after discharge than before surgery if they were in the Rehearsal-  104  Instruction group. The same was true of girls in the Modeling group. The opposite, or more appetite disturbance behaviours following discharge than before surgery, was reported by parents of boys in the Modeling group and girls in the Rehearsal-Instruction Group.  FIGURE 21 Significant Terms in the MANOVA Analyses Performed for Questions 4,5, and 6 Interactions Instructional Approach Approach x Gender Approach  Scales with Significant F Ratios  P  HBQ Factor 4: Appetite Disturbance Multivariate of Observation Scales Rating Scale Verbal Scale HBQ Factor 2: Dependent Anxiety  .01 .01 .02 .01 .04  Multivariate of HBQ Factor Scores HBQ Factor 2: Dependent Anxiety HBQ Factor 3: Sleep Disturbance HBQ Factor 4: Appetite Disturbance  .01 .01 .01 .01  Mode of Presentation Mode  Instructional Approach bv Mode of Presentation Approach x Mode x Agegroup Rating Scale Approach x Mode Multivariate of Observation Scales Rating Scale Verbal Scale State Anxiety at Surgery  .05 .01 .01 .01 .04  Instructional Approach bv Mode of Presentation bv Tour Approach x Tour State Anxiety at Surgery Observation Verbal Scale  .01 .01  T A B L E 39 Mean Score on Approach x Gender on HBQ Factor 4: Appetite Disturbance Group  N  Pre  Post  22 8  46.23 51.03  46.80 45.51  22 10  57.58 45.64  52.36 47.93  Modeling /Males /Females Rehearsal-Instruction /Males /Females  105  FIGURE 22 Mean HBQ: Factor 4 Scores on 2 Occasions for Approach x Gender  Main Effect for Instructional Approach. Instructional approach (type) was found to effect the multivariate analysis of the Observation Scales (p=.01) (See Appendix B, Table 7). The effect was observed on both the Rating Scale (p=.02) and the Verbal Scale (p=.01). Instructional approach was also seen to effect HBQ Factor 2, Dependent Anxiety (p=.04) (See Appendix B, Table 6). Table 40 records the mean scores for children receiving each type of instruction on these three scales. Figures 23,24, and 25 depict the change in scores over time graphically. On both the Rating (Figure 23) and the Verbal Scales (Figure 24), children in the Rehearsal-Instruction programme were observedtodisplay more anxiety-related behaviours at the pre-preparation interview than those in the Modeling programme. However, approximately one hour before surgery, anxiety related behaviours in both groups had decreased, with children in the Rehearsal-Instruction group displaying even fewer behaviours than the modeling group. On the factor of the HBQ labelled Dependent Anxiety (Figure 25), the Rehearsal-Instruction group were considered by their parents to display more dependent related behaviours following discharge than those in the Modeling group.  106  T A B L E 40 Mean Scores for Verbal and Rating Scales of the Observation Scales and HBQ Factor 2 (Dependent Anxiety) for Instructional Approach Approach  Rating Scale Surg Pre  Verbal Scale Surg Pre  30  8.57  6.87  6.46  5.72  49.28  49.94  32  10.05  6.64  8.44  5.59  48.30  52.96  N Modeling RehearsalInstruction  HBQ Factor 2 Pre Post  FIGURE 24 Mean Verbal Observation Scale Scores on 2 Occasions for Approach  z a  S  I  SURG  PRE TIME  107  |  MODELING  •  REHEARSALINSTRUCTION  FIGURE 25 Mean HBQ: Factor 2 Scores on 2 Occasions for Approach 53  48 PRE  B  MODELING  •  REHEARSALINSTRUCTION  POST TIME  Main Effect of Mode of Presentation. Mode of Presentation was found to have a main effect on the Multivariate analysis of the Hospital Behaviour Questionnaire (p=.01) (Appendix B, Table 6) with effects observed on Factor 2: Dependent Anxiety (p=.01), Factor 3: Sleep Disturbance (p=.01), and Factor 4: Appetite Disturbance (p=.01). Table 41 displays the means for each of these scales on this factor and Figures 26,27, and 28 show the graphic representation. All of the scales affected by Mode of Presentation are parent report behaviour scales. Figure 26 demonstrates how children who received an audio-visual programme increased the number of dependent anxiety related behaviours while little change was shown in those behaviours in children having a print programme. In sleep disturbance behaviours (Figure 27), again children who received a print programme showed little change; however those having an audio-visual programme decreased their sleep disturbance related behaviours. Children receiving print programmes increased their appetite disturbance behaviours; while those receiving an audiovisual programme decreased the number of such behaviours (Figure 28).  TABLE 41 Mean Scores for Factors 2, 3, and 4 on Mode of Presentation  Mode A/V Print  N 30 32  HBQ Factor 2 Pre Post 46.70 54.69 49.77 50.74  HBQ Factor 3 Pre Post 59.16 47.87  108  51.39 47.16  HBQ Factor 4 Pre Post 52.27 46.81 47.97 49.49  FIGURE 26 Mean HBQ: Factor 2 Scores on 2 Occasions for Mode 51 50  x o  u  49  V) Ed  s  48 47 46  PRE  POST TIME  FIGURE 27 Mean HBQ: Factor 3 Scores on 2 Occasions for Mode  109  •  AUDIOVISUAL  •  PRINT  Approach x Mode x Agegroup: This interaction was observed on' the univariate analysis of the Observation Rating Scale (p=.05) (See Appendix B, Table 7). Table 42 lists the mean scores for each group on this scale and Figure 29 displays the relationships among the scores of the group graphically.  On the Rating Scale for Observed Behaviour associated with anxiety (Figure 29), no change was observed from pre-admission to pre-surgery in older children receiving the Modeling/Print programme or the Rehearsal-Instruction-Audio/Visual programme. The most dramatic drop in scores occured in both older and younger children receiving the Rehearsal-Instruction/Print programme. The only increase in scores occurred in the younger children receiving the Rehearsal-Instruction/Print programme.  TABLE 42 Approach x Mode x Agegroup on Observation Rating Scale Observation Rating Scale N Pre Surg  Groups  RI/AV/Young /Old RI/Print/Young /Old Mod/AV/Young /Old Mod/Print/Young /Old  14 2 11 5 10 4 13 4  8.57 6.50 1.36 13.40 8.67 8.50 8.92 7.00  6.07 6.50 7.82 5.80 5.89 7.00 7.54 7.00  FIGURE 29 Mean Observation Rating Scale Scores on 2 Occasions for Approach x Mode x Age Group 14 R.-I./A.-V. g young • old R.-I./PRINT 0 young  3  at O U M 25  O  oW MOD./A.-V. young  A old MOD./PRINT young old  S SURG  PRE TIME  110  Approach x Mode; This interaction was observed on the multivariate analysis of the Observation Scale (p=.01), affecting the Rating Scale (p=.01) and the Verbal Scale (p=.01) and the Children's State Anxiety Scale (p=.04)(See Appendix B, Tables 7 and 8). Table 43 gives the means for each observation scale where a significant effect was seen and Figures 30 and 31 depict the relationships among the groups graphically. Lower scores on the Observation Rating Scale (Figure 30) and the Observation Verbal Scale (Figure 31) were observed at pre-surgery than pre-preparation. The smallest drop was reported by parents of the Modeling/Print group children. On the Verbal Scale, a dramatic drop in verbal behaviour associated with anxiety prior to surgery was observed in the Reheareal-mstruction/Print group. This may be due to the very high pre-admission score achieved by this group.  TABLE 43 Mean Scores for Approach x Mode on Observation Rating Scale and Observation Verbal Scale  Group  N  Modeling/AV /Print Rehearsal-Instruction/AV /Print  14 16 16 16  Rating Scale Pre Surg 8.65 8.49 8.31 11.79  111  6.28 7.45 6.12 7.15  Verbal Scale Pre Surg 6.90 6.01 6.69 10.18  5.54 5.90 5.06 6.13  FIGURE 31 Mean Verbal Observation Scale Scores on 2 Occasions for Approach x Mode 11 10  9  o o  8 . 7  .  6 5  •  MODELING/ A-V  •  MODELING/ PRINT  £  R-I/A-V  O R-I/PRINT  4 I POST  PRE  TIME  Table 44 displays the group means on the child's State Anxiety Scale and Figure 32 depicts the scores graphically. The significant change was seen at the rating taken prior to surgery (see Appendix B, Table 8). At that time the Rehearsal-Instruction/Print group reported an increase in anxiety over their pre-admission rating, whereas the other groups' scores changed minimally.  TABLE 44 Mean Scores for Approach x Mode on State Anxiety Group R-I/A-V R-I/Print Mod/A-V Mod/Print  N  Pre  Surg  Post  14 15 13 14  31.14 33.07 33.38 33.43  31.71 35.33 33.62 34.93  29.28 30.00 28.07 31.50  112  FIGURE 32 Mean Children's State Anxiety Scores on 3 Occasions for Approach x Mode  361 3534-  i  R-I/A-V R-I/PRINT  •  33n o  u to z  • •  O  MODELING/A-V MODELING/PRINT  323130-  292827.  PRE  SURG  POST  TIME  Approach x Toun Univariate analyses of the Verbal Observation Scale (p=.01) (Appendix B, Table 17), and the Children's State Anxiety Scale (p=.03) (Appendix B, Table 8) showed significant differences on Approach x Tour. Table 45 gives the mean scores for each group on the three scales. Figures 33 and 34 present the graphic representation. Children were observed to demonstrate fewer verbal behavioursrelatedto anxiety prior to surgery (Figure 33) than before admission in all groups, but a more dramatic drop was observed in the RehearsalInstruction/No Tour group.  TABLE 45 Mean Scores for Approach x Tour on Observation Verbal Scale, and Children's State Anxiety Inventory.  Group  N  R-I/Tour /NoTour Modeling/Tour /No Tour  15 17 14 16  Verbal Scale Pre Surg 7.20 9.67 7.46 5.46  Children's State Anxiety N Pre Surg Post  5.63 5.56 6.31 5.12  13 16 12 15  113  31.96 32.15 33.42 33.36  33.79 33.21 33.75 34.55  30.61 28.76 27.17 31.88  All children reported higher levels of anxiety just before surgery than prior to admission and lower levels at the 6 week follow-up (Figure 34). However, the rise in scores at pre- surgery was minimal (0.33 points) and the drop following discharge was largest for the Modeling/Tour group. The group whose score rose most at pre-surgery and dropped least following discharge was the Rehearsal-Instruction/Tour group.  114  Summary of Questions 4. 5 and 6 The results of the analyses done to address Research Questions 4,5, and 6 will be summarized below. Interactions of Agegroup with Approach and Mode. Agegroup was observed to interact together with Approach and Mode on the Observation Rating Scale. Scores decreased from pre-test to pre-surgery observations for both old and young children in the Rehearsal-Instruction/Print conditions. Little change in scores was observed for older children in the Modeling/Print or RehearsaWnstraction/Audio-Visual conditions.  Interactions of Gender with Approach and Mode. Gender was not observed to interact with Mode in any way. Gender did interact with Approach alone on the HBQ Factor 4: Appetite Disturbance, with girls in the Rehearsal-Instruction and boys in the Modeling conditions having the greatest decrease in scores over time.  Interactions of Tour with Approach and Mode. Tour was not observed to interact with either Approach or Mode. Tour interacted with Approach alone on two scales. On the Observation Verbal Scale, all scores decreased over time, with those in the Rehearsal-Instruction/No Tour condition showing the greatest decline. State Anxiety scores changed most negatively for the Rehearsal-Instruction/Tour group and changed most positively for those in the Modeling/Tour condition.  Interactions of Approach and Mode. These variables significantly interacted to affect three scales. On the Observation Rating Scale, all scores were lower at the pre-surgery observation than at the pre-test measure, with those in the Rehearsal-Instruction/Print condition showing the greatest change and the Modeling conditions showing the least change. On the Observation Verbal Scale, a similiar pattern occurred, with the Modeling/Print condition scores showing minimal declines and the Rehearsal-Instruction/Print condition having the most marked change in scores. On the Children's State Anxiety Scale, children in the Rehearsal-Instruction/Print group rated themselves as having higheranxiety at the time of surgery than prior to their admissions. Other children reported little change.  115  Main Effects of Approach were observed on three scales. The Observation Rating and Verbal Scales scores dropped for those in both conditions, but more so for those in the Rehearsal-Instruction condition. However, HBQ Dependent Anxiety scores increased for those children in the Rehearsal-Instruction group more than for those in the Modeling group.  Main Effect of Mode was observed on three scales. Scores on both the HBQ Sleep Disturbance Scale and HBQ Appetite Disturbance Scale declined for those in the Audio-Visual group, whereas scores either remained similiar or rose for those children in the Modeling condition. On the Dependent Anxiety factor, scores rose following discharge for both groups, but more dramatically for the Audio-Visual group.  Main Effects of Agegroup and Gender The blocking variable, agegroup was seen to have an effect, regardless of Programme condition on several of the variables. No significant main effects were observed for gender on any of the dependent variables.  Age was seen to have an effect on the pre-test scores of two of the HBQ factors; Factor 3: Sleep Disturbance (p=.01) and Factor 4: Appetite Disturbance (p=.01) (see Appendix B, Table 6). Table 46 shows that younger children were more likely to obtain higher sleep disturbance scores and older children to obtain higher appetite disturbance scores, prior to the hospital experience and to maintain that difference at the post-test measurement. Age was also shown to affect scores on the Children's State Anxiety Inventory (p=.01) (see Appendix B, Table 8). Older childrenreportedhigher anxiety scores at the pre-surgery measurement than did the younger children. However, all children reported lower anxiety scores at the 6 week follow-up than during the hospital stay or prior to admission. (See Table 46 and Figure 35).  116  TABLE 46 Mean Scores for Age Groups on HBQ Sleep Disturbance and Appetite Disturbance and Children's State Anxiety  Age Group  N  Pre  Occasions Surg  Post  Sleep Disturbance <9 >9  68 22  52.61 44.03  51.16 43.71  Appetite Disturbance <9 >9  68 22  49.83 57.27  48.71 54.87  Child State Anxiety <9 >9  61 21  32.09 33.89  32.48 37.12  29.39 28.15  FIGURE 35 Mean Children's State Anxiety Scores on 3 Occasions for Age Group  1  PRE  I HOSP OCCASION  117  •  <9  o  >9  [_ POST  Exploratory Analyses of Individual Characteristics The purpose of Question 7 was to consider whether selected individual characteristics of the children or their families interacted with preparation (Programme or No Programme, Approach, Mode, and Tour) to affect children's responses to hospitalization. Cluster 1. The biodemographic characteristics, age and gender were included in the ANOVAs and MANOVAs for research questions 2 through 6. The results of these analyses have been reported in.the preceding sections and will not be repeated here. Clusters 2.3. and 4. Appendix C, Tables 1 - 27, summarizes the results of the Multiple Regression Analyses of each cluster on each dependent variable. Thefirstrow gives the cumulative R for those interactions 2  which were included in the model but not relevant to these questions. Column 1 names the interaction, column 2 gives the R , or the amount of variance accounted for to that point in the model, Column 3 gives the R Change, 2  2  or the amount of variance accounted for by that particular interaction. Columns 4 and 5 give the F value for the change in variance and the significance level of the F value. Please refer to chapter 3, pages 69-72 for a full description of the model used in these analyses. Figures 36,43, and 67 summarize the interactions for each cluster. Each row in thefiguresrepresents one of the interactions of interest. Variables which were significant at the .05 level or less are listed to the right of the interaction. An asterisk (*)is placed to the left of each interaction where significant effects were observed on two or more dependent variables. These were the interactions considered in the second stage regression analyses. Figures 36,43, and 67 are placed at the beginning of each section discussing the results of the corresonding cluster (i.e., Figure 36 summarizes Cluster 2 and is included with the results of Cluster 2). Cluster 2: Characteristics of the Family This cluster contained two variables: Socio-economic status (SES), a continuous variable, and position of the child in the sibling structure, a categorical variable. Position in the sibling structure was not found to enter sufficiently into the regression analysis to be considered for interpretation. SES was found to signficantly interact with Mode x Approach on three scales and with Programme on three scales. See Appendix C, Tables 1 9, and Figure 36 (below) for the summary.  118  FIGURE 36 Summary of Dependent Variables showing Significant Effects of Multiple Regression Analysis of Cluster 2: Family Characteristics Interactions *SES x Programme Position x Programme SES x Tour Position x Tour SES x Mode Position x Mode SES x Approach Position x Approach SES x Programme x Tour Position x Programme x Tour *SES x Mode x Approach Position x Mode x Approach SES x Mode x Tour Position x Mode x Tour SES x Approach x Tour Position x Approach x Tour SES x Mode x Approach x Tour Position x Mode x Approach x Tour  Dependent Variables HBQ:F2, Obs. Non-Verb., State Anxiety Pre-Surg. Obs. Verb..  HBQ:F4 Obs. Non-Verb. Obs. Rat. HBQ: F l , Obs. Non-Verb., State Anx. at 6 weeks  * Interactions chosen for the second stage of the Regression Analysis.  SES x Mode x Approach. This interaction was found to significantly affect HBQ Factor 1: Contentiousness (p=.00), Observation Non-Verbal Scale (p=.02), and State Anxiety at the 6 week follow-up (p=.05). See Appendix C, Tables 1-9 and Figure 36 above. Table 47 and Figures 37,38, and 39 summarize the results of these analyses. On the Contentiousness factor (Figure 37), children from families with a higher socio-economic status were rated by their parents as displaying more contentious behaviours if they were in the Rehearsal-Instruction/ Print or the Modeling/Audio-Visual groups than children from lower socio-economic status families in the same group. The reverse was found for children in the other three Instructional Approach groups, particularly those in the Modeling/Print group. On the Observation Non-Verbal Scale (Figure 38), a similar association between socio-economic status and scores on the HBQ Contentiousness factor was observed for children in the Modeling/Audio-Visual, Modeling/Print, and Reheaisal-Instruction/Print groups. The association between higher socio-economic status and lower scores was stronger in the Observation Non-Verbal scale than in the Contentiousness scale, and for the Rehearsal-Instruction/Audio-Visual group, lower socio-economic status was associated with lower scores.  119  Table 47 Summary Statistics of Regression Lines of T Scores of Residuals on SES x Approach x Mode Group  N  R2  Y Intercept  Slope  Min.X  Max.X  HBO Factor 1: Contentiousness 12  .18  36.12  .27  27  70  /Print  15  .16  64.52  —.33  28  72  /A-V  14  .07  55.58  —.15  24  72  /Print  15  .34  29.13  .46  29  72  25  .03  54.14  —.08  18  72  Modeling /A-V Rehearsal-Instruction No Programme  Observation Non-Verbal Scale Modeling Rehearsal-Instruction  /A-V  11  .22  37.33  .25  27  70  /Print  16  .38  73.12  —.43  28  72  /A-V  14  .07  39.89  .15  24  70  /Print  15  .23  32.57  .35  29  72  25  .26  67.04  —.33  18  72  No Programme  State Anxietv at 6 Week Follow-Uo Modeling Rehearsal-Instruction No Programme  /A-V  12  .03  39.66  .10  27  70  /Print  15  .07  63.06  —.20  28  72  /A-V  13  .17  60.94  —.21  24  72  /Print  15  .03  55.13  —.10  29  72  24  .03  56.06  —.11  18  72  FIGURE 37 Z Score Residuals for HBQ Factor 1 on SES x Approach x Mode  •  MODELING/A-V  • MODELING/PRINT • R-I/A-V O R-I/PRINT A NO PROGRAMME  SOCIO-ECONOMIC STATUS  120  FIGURE 38 T Score Residuals for Observation Non-Verbal Scale on SES x Approach x Mode  • MODELING/A-V • MODELING/PRINT • R-I/A-V O R-1/PRINT A NO PROGRAMME 15  20  25  30  35  40  45  50  55  60  65  70  75  SOCIO-ECONOMIC STATUS  On the State Anxiety Inventory at 6 weeks following surgery (Figure 39), higher socio-economic status of the families was associated with lower scores for children in all groups except Modeling/Audio-Visual, where higher socio-economic status was associated with higher scores.  121  SES x Programme: This interaction was found to significantly affect HBQ Factor 2: Dependent Anxiety (p=.0O), Non-Verbal Observation Scale (p=.00), and Children's State Anxiety Inventory at pre-surgery measure (p=.04). Table 48 and the accompanying graphs (Figures 40-42) summarize the results of these analyses. On HBQ Factor 2: Dependent Anxiety (Figure 40), for children in the Programme condition, the higher the socio-economic status (SES) the lower the score. SES did not appear to have as great an affect on the scores of those in the No Programme condition; however the higher the SES score, the higher the dependent anxiety score. In contrast, on the Non-Verbal Observation Scale (Figure 41), for children in the Programme condition, the higher the SES, the higher the score. The higher the SES, the lower the score in the No-Programme condition. The pattern on the Children's State Anxiety Inventory at pre-surgery (Figure 42) is similar to that seen on the Non-Verbal Observation scale (Figure 41), where scores of children from higher SES families in the Programme condition were higher than those of children from lower SES families, but those scores of children from higher SES families in the No Programme condition were smaller than those of children from lower SES families in the same condition.  TABLE 48 Summary Statistics of Regression Line of T Scores of Residuals on Programme x SES Groups  N  R  2  YIntercept  Slope  MinX  MaxX  Programme No Programme  HBO Factor 2: Dependent Anxietv 56 .22 67.32 -.30 25 .02 45.57 .08  24.00 18.00  72.00 72.00  Programme No Programme  Observation Non-Verbal Scale 56 .03 43.14 .10 25 .30 66.83 -.36  24.00 18.00  72.00 72.00  Children's State Anxietv Inventory (Dre-surgerv measure) 51 .02 45.02 .09 24.00 Programme 24 .07 58.43 -.20 18.00 No Programme  72.00 72.00  122  FIGURE 40  7/1  15  '  i  '  20  i  25  '  i  30  •  I  35  '  i  40  '  i  •  45  I  50  '  i  1  —r >—i—•  55  -  60  65  i  •  70  i—•i  75  80  SOCIO-ECONOMIC STATUS  FIGURE 41 Mean T Score Residuals for Non-Verbal Observation Scale on SES x Programme 64-,  20  30 40 50 SOCIO-ECONOMIC STATUS  123  60  70  80  FIGURE 42 Mean T Score Residuals for Children's State Anxiety Inventory on SES x Programme  SOCIO-ECONOMIC STATUS  Cluster 3: Children's Personality Characteristics This cluster contained three variables: Trait Anxiety, Health Locus of Control, and Verbal Ability. Trait anxiety was found to interact with Approach and Tour on five scales and Mode and Tour on four scales. Health Locus of Control was found to interact on two scales with each of the following: Approach and Tour, Mode and Tour, Mode and Approach, Programme and Tour, and Tour alone. Verbal Ability was found to interact with Mode on two scales and with Tour on two scales. See Appendix C, Tables 10-18 and Figure 43 (below).  Trait Anxiety x Approach x Tour: This interaction was found to significantly affect 5 scales: HBQ Factor 2: Dependent Anxiety (p=.01), Observation Rating Scale (p=.01), Observation Verbal Scale (p=.01), Observation Non-Verbal Scale (p=.01) and the Children's State Anxiety Inventory at 6 week follow-up (p=.03). See Appendix C, Tables 10-18 and Figure 43 (below). Tables 49 and 50 and Figures 44- 48 summarize the results of these analyses. On HBQ Factor 2: Dependent Anxiety (Table 49, Figure 44), dependent anxiety scores decreased as trait anxiety scores increased, except for those in the Rehearsal-Instruction/Tour condition where the scores increased simultaneously.  124  FIGURE 43 Summary of Significant F Values for Effects of Multiple Regression Analyses of Personality Characteristics Ouster Interactions  Dependent Variables  Verbal Ability x Programme Health Locus of Control x Programme Trait Anxiety x Programme •Verbal Ability x Tour •Health Locus of Control x Tour Trait Anxiety x Tour •Verbal Ability x Mode Health Locus of Control x Mode Trait Anxiety x Mode Verbal Ability x Approach Health Locus of Control x Approach Trait Anxiety x Approach Verbal Ability x Programme x Tour •Health Locus of Control x Programme x Tour Trait Anxiety x Programme x Tour Verbal Ability x Mode x Approach Health Locus of Control x Mode x Approach Trait Anxiety x Mode x Approach Verbal Ability x Mode x Tour •Health Locus of Control x Mode x Tour •Trait Anxiety x Mode x Tour Verbal Ability x Approach x Tour •Health Locus of Control x Approach x Tour •Trait Anxiety x Approach x Tour  State Anx. Pre-Surg. HBQ:F1, Obs. Non-Verb. Obs. Non-Verb., State Anx. 6 wks. HBQ:F4, Obs. Non-Verb. HBQ:F3  State Anx. Pre-Surg. Obs. Verb., State Anx. Pre-Surg. State Anx. 6 wks. HBQ:F2, Obs. Non-Verb. HBQ:F1 State Anx. 6 wks. HBQ:F4, State Anx. 6 wks. HBQ:F2, HBQ:F3, Obs. Verb., Obs. Non-Verb. HBQ:F3 HBQ:F3, State Anx. 6 wks. HBQ:F2, Obs. Rating, Obs. Verb., Obs. Non-Verb., State Anx. 6 wks.  • Interactions chosen for the second stage of the Regression Analysis.  TABLE 49 Summary Statistics for Regression Line of T Scores of Residuals on Trait Anxiety x Approach x Tour on HBQ Factor 2: Dependent Anxiety  Group Modeling/Tour /No Tour Rehearsal-Instraction/Tour /No Tour No Programme/Tour /No Tour  N  R  13 16 10 16 10 15  .01 .04 .21 .01 .02 .17  2  125  YIntercept 54.39 56.22 29.13 56.08 58.34 66.20  Slope  MinX  -.18 -.20 .69 -.11 -.21 -.43  25.0 22.0 24.0 23.0 21.0 23.0  MaxX 41.0 48.0 42.0 48.0 51.0 55.0  FIGURE 44 Mean T Score Residuals for HBQ Factor 2 on Trait Anxiety x Approach x Tour MOD. /TOUR  60 -,  MOD. /NOTOUR R-I /TOUR R-I /NOTOUR NOPROG /TOUR NOPROG /NOTOUR 20  30 50 40 CHILDREN'S TRAIT ANXIETY  60  The Observation Rating Scale (Table 50, Figure 45) did not appear to be affected by trait anxiety scores in children in the Modeling/Tour and Rehearsal-Instruction/No Tour conditions. Scores increased as trait anxiety increased in children in other groups except for the No Programme/Tour condition where scores decreased as trait anxiety scores increased. The Verbal Observation Scale (Table 50, Figure 46) appeared to be only slightly affected by Children's Trait Anxiety in children in the Rehearsal-Instruction/No Tour, Modeling/No Tour or No Programme conditions. Observations of verbal behavioursrelatedto anxiety increased as trait anxiety scores increased in children in the Rehearsal-Instruction/Tour condition and as trait anxiety scores decreased in children in the Modeling/Tour condition. On the Non-Verbal Observation Scale (Table 50, Figure 47), scores decreased as trait anxiety increased in children in the Modeling/Tour condition, whereas scores increased with trait anxiety score increases in all other children. On the Children's State Anxiety Inventory at six week follow-up (Table 50, Figure 48), trait anxiety scores had little effect on children in the Modeling/No Tour and the Rehearsal-Instruction/No Tour conditions. Scores varied most dramatically in the No Programme/Tour and No Programme/No Tour conditions where higher levels of trait anxiety were associated with higher levels of state anxiety at the 6 week follow-up.  126  T A B L E 50 Summary Statistics for Regression Line of T Scores of Residuals on Trait Anxiety X Approach x Tour Group  N  R  2  YIntercept  Slope  MinX  Observation Rating Scale .00 53.21 13 -.06 25.0 .06 15 4121 .18 22.0 33.44 10 .36 .45 24.0 16 .00 48.56 -.01 23.0 .10 10 64.87 21.0 -.48 .13 15 29.07 23.0 .50 Observation Verbal Scale Modeling/Tour .02 13 64.85 -.37 25.0 /No Tour .00 15 47.70 .02 22.0 Rehearsal-InstructionA'our .20 10 17.66 24.0 1.03 /No Tour 16 .01 46.77 .10 23.0 No Programme/Tour 10 .00 48.98 .02 21.0 /No Tour .02 15 58.23 -.17 23.0 Observation Non-Verbal Scale Modeling/Tour 13 .06 60.96 25.0 -.39 /No Tour 15 .01 45.60 .12 22.0 Rehearsal-Instrucrion/Tour 10 .01 45.68 24.0 .15 /No Tom16 .00 23.0 48.25 -.05 No Program me/Tour .05 43.41 10 .28 21.0 /No Tour 27.44 15 .23 23.0 .47 Children's State Anxietv Inventory at 6 Week Follow-uo Modeling/Tour .02 12 50.06 -.21 25.0 /No Tour .00 16 52.95 22.0 .06 Rehearsal-Instruction/Tour 54.92 10 24.0 .01 -.13 /No Tom.00 50.01 16 -.01 23.0 No Programme/Tour .17 10 33.93 21.0 .40 /No Tour .06 15 40.09 23.0 .30  Modeling/Tour /No Tour Rehearsal-Instrucuori/Tour /No TomNo Programme/Tour /No Tour  127  MaxX  41.0 48.0 42.0 48.0 51.0 55.0 41.0 48.0 42.0 48.0 51.0 55.0 41.0 48.0 42.0 48.0 51.0 55.0 41.0 48.0 42.0 48.0 51.0 55.0  FIGURE 46 Mean T Score Residuals for Verbal Observation Scale on Trait Anxiety x Approach x Tour  MOD. /TOUR  62 -. CZ3  a  60 58 -  MOD. /NOTOUR  56 -  R-I  54 -  /TOUR  52 -  R-I /NOTOUR  O 50 H Z <  48 -  NOPROG /TOUR  46 44 •  42 -  20  25  r~  35 40 45 30 CHILDREN'S TRAIT ANXIETY  50  NO PROG /NOTOUR  55  FIGURE 47 Mean T Score Residuals for Non-Verbal Observation Scale on Trait Anxiety x Approach x Tour  g. a  60-,  •  MOD. /TOUR  56_|  o  MOD. /NOTOUR  *  R-I /TOUR  ^  R-I /NOTOUR  •  NO PROG /TOUR  •  NO PROG /NOTOUR  54.  -  w  5 2  <* §  5048-  8 46  M  44-  £ «. W  2  " 38-  4 0  ^r 20  -r 25  -  —r30  35  40  45  CHILDREN'S TRAIT ANXIETY  128  50  55  FIGURE 48 Mean T Score Residuals for State Anxiety Inventory at 6 Week Follow-up on Trait Anxiety x Approach x Tour 9  60-, CO  58-  <  56-  Q  54-  P  hH  CO  W  a a* o u CO  H  o  MOD. /TOUR MOD. /NOTOUR  • *d  52-  ^  504846-  •  NO PROG /TOUR  •  NO PROG /NOTOUR  44-  se 42-  i T~  20  l  25  I  30  —T  -  35  T" 40  ~~T~  45  -r~ 50  55  /TOUR R-I /NOTOUR  -I  60  CHILDREN'S TRAIT ANXIETY  Trait Anxietv x Mode x Tour This interaction was found to significantly affect four scales: HBQ Factor 2: Dependent Anxiety (p=.01), HBQ Factor 3: Sleep Disturbance OP=-01), Observation Verbal Scale 0p=.01), and Observation Non-Verbal Scale (p=.05). See Appendix C, Tables 10-18 and Figure 43 (above). Tables 51- 55 and Figures 49- 52 summarize the results of these analyses. On HBQ Factor 2: Dependent Anxiety (Figure 49), the trait anxiety score made little difference to the dependent anxiety score of children in the Print/No Tour condition (slope=.01). For those in the Print/Tour and Audio-Visual/Tour conditions dependent anxiety scores increased while trait anxiety scores increased, while the opposite was found for those in other conditions. On HBQ Factor 3: Sleep Disturbance (Figure 50), the trait anxiety score made little difference to the sleep disturbance score of those children in the No Programme/No Tour condition (slope = -.02). For those in the Print/Tour and Audio-Visual/No Tour conditions, sleep disturbance scores decreased as trait anxiety scores increased, while the opposite occurred for those in other conditions.  129  T A B L E 51 Summary Statistics for Regression Line of T Scores of Residuals on Trait Anxiety x Mode x Tour Group  Print/Tour /No Tour Audio-Visual/Tour /No TomNo Programme/Tour /No Tour Print/Tour /No Tour Audio-Visual/Tour /No TomNo Program me/Tour /No Tour Print/Tour /No TomAudio- Visual/Tour /No Tour No Programme/Tour /No Tour  N  R  YIntercept  2  HBO Factor 2: Dependent Anxietv 11 .37 9.85 15 .00 50.95 12 .01 42.69 17 .17 66.83 10 .02 58.13 15 .17 65.90 HBO Factor 3: Sleep Disturbance 11 .00 52.68 15 .09 41.61 12 .08 26.85 17 58.32 .01 10 .27 24.13 15 .00 51.79 Verbal Observation Scale 11 -2.10 .33 14 .12 59.90 12 .00 57.86 17 .19 29.89 10 49.74 .00 15 .02 58.24  Slope  MinX  1.14 .01 .22 -.46 -.21 -.42  30 23 24 22 21 23  42 48 38 48 51 55  -.13 .32 .67 -.16 .67 -.02  30 23 24 22 21 23  42 48 38 48 51 55  1.44 -.37 -.13 .55 -.02 -.16  30 23 24 22 21 23  42 48 38 48 51 55  -.13  24  38 48  Max  Observation Non-Verbal Scale Print/Tour  12  .00  /No Tour  17  .01  47.23  .09  22  Audio-Visual/Tour  11  .42  100.27  --1.40  30  42  /No Tom-  14  .00  46.00  .08  23  48  No Programme/Tour  10  .03  47.55  .21  21  51  /No Tour  15  .23  24.63  .59  23  55  130  54.51  FIGURE 49 Mean T Score Residuals for HBQ Factor 2 on Trait Anxiety x Mode x Tour  co  <  60 58 -  Q  56 -  c«  54 _  •  PRINT /TOUR  o  PRINT /NOTOUR  4>  52 -  « O O  CO  A-V /TOUR A-V /NOTOUR  50 48  • NO PROG  46 -  /TOUR  44 -  •  42 20  25  -r40 45 CHILDREN'S TRAIT ANXIETY 30  T" 35  —T-  50  55  NOPROG /NOTOUR  60  FIGURE 50 Mean T Score Residuals for HBQ Factor 3 on Trait Anxiety x Mode x Tour  CO  < Q  i—< c« W «  «  o H  2  •  PRINT /TOUR  60 58 56 54 52 50 48 46 44 42 40 38 36  o  PRINT /NO TOUR  •  A-V /TOUR A-V /NO TOUR  • NO PROG /TOUR  • 20  V 25  30  35  —V 40  45  50  T" 55  NOPROG /NO TOUR  I 60  CHILDREN'S TRAIT ANXIETY  On the Verbal Observation Scale (Figure 51), trait anxiety score made little difference to the verbal expression of anxiety prior to surgery for those children in the No Programme/Tour condition (slope = -.02). For those in the Print/Tour and Audio-Visual/No Tour conditions, verbal expressions of anxiety increased as trait anxiety scores increased, while the opposite was observed for those in other conditions. The Audio-Visual/Tour and No Programme/No Tour effects were much smaller (slope = -.13 and -.16) than the Print/No Tour effect (slope = -.37).  131  FIGURE 51 Mean T Score Residuals for Verbal Observation Scale on Trait Anxiety x Mode x Tour  •  PRINT  60-, < 58Q 56i—i co 54W 06-52Ed « 50O U 48CO H 46442 42CO  i  /TOUR  o PRINT •  /NOTOUR A-V /TOUR A-V /NOTOUR  • NOPROG /TOUR  • V  20  —r 25  T  I  I I 30 40 35 TRAIT ANXIETY 45 CHILDREN'S  i— —r~ 1  50  55  NOPROG /NOTOUR  I 60  On the Observation Non-Verbal Scale (Figure 52), children with higher trait anxiety demonstrated more non-verbal anxiety-related behaviours prior to surgery than those with lower trait anxiety if they did not receive a Programme. Children with higher trait anxiety exhibited fewer such behaviours than those with lower trait anxiety if they were in the Print/Tour and, even more dramatically, in the Audio-Visual/Tour groups.  132  Health Locus of Control x Approach x Tour: This interaction was found to significantly affect HBQ Factor 3: Sleep Disturbance (p=.01),) and Children's State Anxiety Inventory at 6 week follow-up (p=.03). Table 52 and Figures 53 and 54 summarize the results of these analyses. On HBQ Factor 3: Sleep Disturbance (Figure 53), the children's health locus of control score made little difference to those in the No Tour conditions (slopes -.19 and .07). However for those in the RehearsalInstruction/Tour and the No Programme/No Tour Conditions, the higher the health locus of control score, the lower the sleep disturbance score; and for those in the Modeling/Tour group the higher the locus of control score the higher the Sleep Disturbance score. On the Children's State Anxiety Inventory at 6 week follow-up (Figure 54), for children in the Programme/No Tour conditions, health locus of control had little effect (slopes -.04, -.02). For all three Tour conditions, the higher the health locus of control score, the higher the stated anxiety at 6 weeks after discharge. For those in the No Programme/No Tour condition, the higher the health locus of control score the lower the state anxiety score at this measure.  TABLE 52 Summary Statistics for Regression Line of T Scores of Residuals on Health Locus of Control x Approach x Tour Groups  N  R  2  YIntercept  Slope  MinX  HBO Factor 3: Sleep Disturbance Modeling/Tour 13 .35 -13.17 26.0 2.06 56.12 23.0 /No Tour 16 .01 -.19 Rehearsal-Instruction/Tour 10 .01 56.82 -.27 25.0 50.26 26.0 /No Tour 16 .00 .07 -.92 24.0 No Programme/Tour 10 .16 77.65 62.72 25.0 /No Tour 15 .06 -.39 Children's State Anxietv Inventory at 6 Week Follow-uD Modeling/Tour 12 16.02 .84 26.0 .09 56.47 -.04 23.0 /No Tour 16 .00 25.0 Rehearsal-Instruction/Tour 10 .61 14.37 1.16 -.02 /No Tour 16 49.59 26.0 .00 .54 No Programme/Tour 10 31.50 24.0 .15 25.0 /No Tour 15 42.59 .27 .01  133  MaxX  36.0 38.0 38.0 36.0 38.0 38.0 36.0 38.0 38.0 36.0 38.0 38.0  FIGURE 53 Mean T Score Residuals for HBQ Factor 3 on Health Locus of Control x Approach x Tour  •  62 -j 60 58 56 54 52 -' 50 48 46 44 42 40 38 -  <  !=>  i—i tn Q  H 06 W 06 O U Z 2  MOD. /TOUR  o MOD.  /NOTOUR  •  •  R-I /TOUR R-I /NOTOUR NO PROG /TOUR  • NOPROG  /NOTOUR  -V  25  -V  30  35  HEALTH LOCUS OF CONTROL  I  40  FIGURE 54 Mean T Score Residuals for Children's State Anxiety at 6 Week Follow-Up on Health Locus of Control x Approach x Tour  60 -j 58 56 -  #  o MOD.. /NOTOUR  3 : 54  § 55  5 2  „ R-I /TOUR  :  50 g 48: O  44  MOD. /TOUR  * R-I /NOTOUR  J  "H> 42 Z 40 d 38: ^ 36: -r  -  25  —r  30  35  HEALTH LOCUS OF CONTROL  134  40  •  NOPROG /TOUR  •  NO PROG /NOTOUR  Health Locus of Control x Mode x Tour. This interaction was found to significantly affect 2 scales: HBQ Factor 4: Appetite Disturbance(p=.0O) and State Anxiety at 6 week follow-up(p=.03). See Appendix C, Tables 13 and 18 and Figure 43 (above). Table 53 and Figures 55 and 56 present a summary of the second stage analyses. On the Appetite Disturbance Factor (Figure 55), for children in the Print/No Tour or No Programme/No Tour groups, external locus of control was associated with less appetite disturbance after surgery, while internal locus of control was associated with more disturbance. The opposite was found for children in the Audio-Visual/ No Tour and Print/Tour groups. On the State Anxiety scale 6 weeks after surgery (Figure 56), no, or very little, association was observed between locus of control and anxiety scores for children in the Print/No Tour, No Programme/Tour and No Programme/No Tour groups. For children in the Print/Tour and Audio-Visual/Tour groups, more external locus of control was associated with lower state anxiety scores. The opposite was found for the Audio-Visual/No Tour group. TABLE 53 Summary Statistics of Regression Lines of T Scores of Residuals on Health Locus of Control x Mode x Tour Group  N  R2  Y Intercept  Slope  Min.X  Max.X  HBO Factor 4: Appetite Disturbance Print /Tour /No Tour Audio-Visual /Tour /No Tour No Programme /Tour /No Tour  12  .23  76.14  —.92  26  38  17  .07  31.94  .72  23  36  11  .01  37.76  .26  25  36  15  .12  72.82  —.82  23  38  10  .08  76.22  —.76  24  38  15  .19  16.28  1.04  25  38  State Anxietv at 6 Week FO11OW-UD Print /Tour /No Tour Audio-Visual /Tour /No Tour No Programme /Tour /No Tour  12  .07  36.40  .44  26  38  17  .00  53.15  .00  23  36  11  .04  25.41  .61  25  36  15  .09  67.57  —.59  23  38  10  .00  49.01  .00  24  38  15  .00  53.30  —.08  25  38  135  FIGURE 55 Mean T Score Residuals for HBQ Factor 4 on Health Locus of Control x Mode X Tour  FIGURE 56 Mean T Score Residuals for State Anxiety at 6 Week Follow-Up on Health Locus of Control x Mode x Tour  •  PRINT/TOUR  •  PRINT/NO TOUR  •  A-V/TOUR  O A-V/NOTOUR •  NO PROGRAMME/TOUR  A. NO PROGRAMME/NO TOUR 22  23  24  25  26  27  28  29  30  31  32  33  34  H E A L T H LOCUS OF CONTROL  136  35  36  37  38  39  Health Locus of Control x Mode x Approach. This interaction was observed to significantly affect 2 scales: HBQ Factor 2:Dependent Anxiety(p=.05) and the Observation Non-Verbal Scale(p=.00). See Appendix C, Tables 11 and 16 and Figure 43 (above). Table 54 and Figures 57 and 58 present the findings of these second stage analyses. On the HBQ Factor 2: Dependent Anxiety (Figure 57), the two Modeling programmes reacted differently from the others. Children with more internal locus of control (higher scores) had less dependent anxiety after surgery than other children. For those with more external locus of control (lower scores), the Modeling/ Print programme was associated with lower dependent anxiety scores after discharge. On the Observation Non-Verbal Scale (Figure 58), the Modeling/Audio-Visual and Rehearsal-Instruction/Print programmes affected children in a similar way and differently from the other programmes. Children with more internal locus of control (higher scores) were observed to demonstrate little non-verbal anxiety prior to surgery, the opposite was observed in children with more external locus of control.  Table 54 Summary Statistics of Regression Lines of T Scores of Residuals on Health Locus of Control x Approach x Mode Group  N  R2  Y Intercept  Slope  Min.X  Max.X  HBO Factor 2: Dependent Anxietv Modeling /A-V  14  .19  78.00  —.98  23  38  /Print  15  .14  23.08  .82  23  36  /A-V  12  .00  50.64  .10  25  36  /Print  14  .00  53.30  —.07  26  38  25  .00  52.04  —.06  24  38  Rehearsal-Instruction No Programme  Observation Non-Verbal Scale Modeling /A-V  13  .22  75.92  —.85  23  38  /Print  15  .09  27.72  .71  23  36  /A-V  12  .03  35.74  .43  25  36  /Print  14  .20  94.94  —1.40  26  38  25  .05  33.03  .55  24  38  Rehearsal-Instruction No Programme  137  FIGURE 57 T Score Residuals for HBQ Factor 2 'on Health Locus of Control x Approach x Mode  FIGURE 58 T Score Residuals for Observation Non-Verbal Scale on Health Locus of Control x Approach x Mode  138  Health Locus of Control x Programme x Tour. This interaction was found to significantly affect Observation Verbal Scale(p=.02) and State Anxiety at the pre-surgery measurement (p=.03). See Appendix C, Tables 15 and 17 and Figure 43 (above). Table 55 and Figures 59 and 60 present the findings of the second stage analyses. On the Observation Verbal Scale (Figure 59), children with more internal locus of control (higher scores) did not differ in their verbalizations of anxiety prior to surgery, regardless of their programme condition. Children with more external locus of control (lower scores) verbally expressed the least amount of anxiety in the Tour only group and the most in the Programme/Tour group. On the State Anxiety scale at pre-surgery (Figure 60), children with more internal locus of control (higher scores) gave themselves lowerratingsof anxiety if they were in the No Programme groups, with the most extreme interaction observed in the No Programme/No Tour group.  TABLE 55 Summary Statistics of Regression Lines of T Scores of Residuals on Health Locus of Control x Programme x Tour Group  N  R  2  Y Intercept  Slope  Min.X  Max.X  Observation Verbal Scale Programme/Tour  23  .01  43.35  .29  25  38  /No Tom-  32  .13  25.85  .76  23  38  No Program me/Tour  10  .43  1.21  1.47  24  38  /NoTour  15  .07  27.96  .70  25  38  State Anxietv at Pre-Surgerv Programme/Tour  23  .08  68.44  —.55  25  38  /No Tom-  32  .01  57.24  —.21  23  38  No Program me/Tour  10  .06  33.23  .54  24  38  /No Tour  15  .08  18.69  .94  25  38  139  FIGURE 59 T Score Residuals for Observation Verbal Scale on Health Locus of Control x Programme x Tour  FIGURE 60 T Score Residuals for State Anxiety at Pre-Surgery on Health Locus of Control x Programme x Tour  140  Health Locus of Control x Tour. This interaction significantly affected the Observation Non-Verbal Scale(p=.02) and the State Anxiety Scale at the 6 week follow-up(p=.02). See Appendix C, Tables 16 and 18 and Figure 43 (above). Table 56 and Figures 61 and 62 summarize the results of the second stage analyses. On the Observation Non-Verbal Scale (Figure 61), Tour had a positive effect (lower scores) for children with internal locus of control (higher scores) and a negative effect on those with ex ternal locus of control. The opposite was found for those in the No Tour condition. On the State Anxiety Inventory at 6 weeks following surgery, (Figure 58), there was little difference between the scores of children in the Tour or No Tour groups if they had internal locus of control. However, for those with external locus of control, Tours were associated with lower self-reported anxiety.  Table 56 Summary Statistics of Regression Lines of T Scores of Residuals on Tour x Health Locus of Control Group  N  R  2  Y Intercept Slope  Min.X  Max.X  Observation Non-Verbal Scale Tom-  33  .06  72.38  —.67  24  38  No Tour  47  .06  31.29  .55  23  38  Tour  33  .03  37.13  .34  24  38  NoTour  47  .01  60.33  —.28  23  38  State Anxietv at Follow Up  FIGURE 61 T Score Residuals for Observation Non-Verbal Scale on Health Locus of Control x Tour  co <  55  i—<  53  u.  51  Oi O  49  Q  in W  w  u  <» H se < w  • TOUR • NOTOUR  57  47 • 45 • 43 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 HEALTH LOCUS OF CONTROL  141  FIGURE 62 T Score Residuals for State Anxiety at Follw-Up on Health Locus of Control x Tour 58 to  < Q  56  to W  54  w  06  52  u  50  et  • TOUR  •  NOTOUR  ©  CO  H Z  48  w  46 .  •<  44 22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  HEALTH LOCUS OF CONTROL  Verbal Ability x Mode. This interaction was found to significanUy affect HBQ Factor 4: Appetite Disturbance(p=.03) and Observation Non-Verbal Scale(p=.05). See Appendix C, Tables 13 and 16 and Figure 43 (above). Table 57 and Figures 63 and 64 summarize the results of the second stage analyses. On the Appetite Disturbance factor (Figure 63), very small differences were observed, with AudioVisual programmes and No Programme having a stronger relationship between higher verbal ability and greater appetite disturbance after discharge. On the Observation Non-Verbal Scale (Figure 64), a similar, but stronger, pattern of relationships was observed; again with Audio-Visual programmes and No Programme affecting children in a similar way, with higher verbal ability scores associated with higher levels of non-verbal anxiety prior to surgery. Verbal Ability x Tour. This interaction was found to significantly affect HBQ Factor 1: Contentiousness(p=.05) and Observation Non-Verbal Scale (p=.02). See Appendix C, Tables 10 and 16 and Figure 43 (above). Table 58 and Figures 65 and 66 summarize the results of the second stage analyses. On the Contentiousness factor (Figure 65), those children with higher verbal ability who had a Tour had lower scores after discharge, those who had no Tour had higher scores. The opposite effect was observed in children with lower verbal ability.  142  Table 57 Summary Statistics of Regression Lines of T Scores of Residuals on Verbal Ability x Mode Group  N  R  2  Y Intercept  Slope  Min.X  Max.X  HBO Factor 4: Appetite Disturbance Audio-Visual  26  .01  43.78  .05  40  132  Print  29  .00  49.97  .03  41  127  No Programme  25  .00  45.28  .05  54  137  Observation Non-Verbal Scale Audio-Visual  25  Print  29  No Programme  25  .10  38.99  .13  40  132  .00  48.33  .02  41  127  .08  34.15  .16  54  137  FIGURE 63 T Score Residuals for HBQ Factor 4 on Verbal Ability x Mode  143  FIGURE 64  y  i  30  •  i  40  —  50  i  — r — • — i  60  70  i  •  80  •  i  90  •  i  100  —  110  i  •  i  120  —  i  •  130  i  140  VERBAL ABILITY  Table 58 Summary Statistics of Regression Lines of T Scores of Residuals on Tour x Verbal Ability Group  N  R  2  Y Intercept  Slope  Min.X  Max.X  HBO Factor 4 Arjoetite Disturbance Tour  41  .04  59.27  —.09  40  136  No Tour  50  .03  39.89  .09  54  137  Observation Non-Verbal Scale Tour  41  .00  49.12  .03  40  136  No Tour  50  .11  32.58  .17  54  137  144  On the Observation Non-Verbal Scale (Figure 66), little difference-was observed between children with higher and lower verbal ability if they had a Tour. For those who did not have a Tour, higher verbal ability was also associated with greater verbal expressions of anxiety prior to surgery.  FIGURE 66 T Score Residuals for Observation Non-Verbal Scale on Verbal Ability x Tour  40  /-r-  •  TOUR  •  NOTOUR  /  30  40  50  60  70  80  90  100  110  120  130  140  VERBAL ABILITY  Cluster 4: Child's Personal History: This cluster contained three variables: presence or absence of Chronic conditions, previous hospitalization experience, and stressful life events in the past six months. Of these, previous experience was found to interact with Programme and Tour (two scales) and with Approach (two scales). Chronic conditions was found to interact with Approach and Tour (two scales). Stressful life events in the past six months was not found to enter into any interaction sufficiently to be included in this stage of the analysis (see Appendix C, Tables 19- 27 and Figure 67, below). Previous Experience bv Programme bv Toun This interaction was found to affect HBQ Factor 4: Appetite Disturbance (p=.02) and Children's State Anxiety Inventory (p=.01). As can be seen in Table 59, a cell of n=l occurs in each case and, therefore, these interactions were not interpreted. Previous Experience x Approach. This interaction was found to significantly affect HBQ Factor 1: Contentiousness (p=.02) and HBQ Facor 4: Appetite Disturbance (p=.01). See Appendix C, Tables 19 and 22 and Figure 67 (below). Tables 60 and 61 present the summary of the second stage analyses for the two dependent variables. In examining the Tables, it can be seen that the extreme scores fall in cells with only 2 cases. Therefore, these results will not be interpreted.  145  . FIGURE 67 Summary of Significant F Values for Effects of Multiple Regression Analyses of Cluster 4: Personal History Interactions  Dependent Variables  Stress x Programme Chronic Condition x Programme Previous Experience x Programme Stress x Tour Chronic Condition x Tour Previous Experience x Tour Stress x Mode Chronic Condition x Mode Previous Experience x Mode Stress x Approach . Chronic Condition x Approach •Previous Experience x Approach Stress x Programme x Tour Chronic Condition x Programme x Tour •Previous Experience x Programme x Tour Stress x Mode x Approach Chronic Condition x Mode x Approach Previous Experience x Mode x Approach Stress x Mode x Tour Chronic Condition x Mode x Tour Previous Experience x Mode x Tour Stress x Approach x Tour •Chronic Condition x Approach x Tour Previous Experience x Approach x Tour  Obs. Rating Obs. Non-Verb. State Anx. Pre-Surg. Obs. Non-Verb.  HBQ:F1 HBQ:F1,HBQ:F4 Obs. Rating HBQ:F4, State Anx. Pre-Surg. Obs. Non-Verb. Obs. Verb.  State Anx. 6 wks.  Obs. Verb., Obs. Non-Verb.  • Interactions chosen for the second stage of the Regression Analysis.  T A B L E 59 Cell Frequencies for Previous Experience x Programme x Tour Group  N  Programme/Tour/Some Prev Exp /No Prev. Exp. /No Tour/Some Prev Exp /No Prev Exp No Programme/Tour/Some Prev Exp /No Prev Exp /No Tour/Some Prev Exp /No Prev Exp  146  22 3 31 3 11 1 9 6  Table 60 Mean T Score Residuals for HBQ Factor 1: Contentiousness on Previous Experience x Approach Group Modeling /Prev. Experience /No Experience Rehearsal-Instruction/Prev. Experience/No Experience No Programme  /Prev. Experience /No Experience  N  X  S.D.  Min.  Max.  26  49.21  9.85  31.97  69.70  3  52.45  4.75  47.04  55.97  28  50.20  11.01  31.01  72.32  2  58.70  14.13  45.32  73.47  20  50.21  5.58  42.21  63.75  7  49.57  8.47  35.27  61.35  Table 61 Mean T Score Residuals for HBQ Factor 4: Appetite Disturbance on Previous Experience x Approach Group Modeling /Prev. Experience /No Experience Rehearsal-Instruction/Prev. Experience /No Experience No Programme /Prev. Experience /No Experience  N  X  S.D.  Min.  Max.  26  49.42  9.02  34.10  68.32  3  48.89  9.65  42.11  59.94  28  49.66  9.72  22.55  75.86  2  42.82  5.77  39.46  49.48  20  50.86  9.75  34.87  71.94  7  46.13  4.20  40.53  53.08  Chronic Conditions x Approach x Tour. This interaction was found to significantly affect the Observation Verbal Scale (p=.05) and the Observation Non-Verbal Scale (p=.00). See Appendix C, Tables 24 and 25 and Figure 67 (above). Tables 62 and 63 summarize the results of the second stage analyses. On the Obervation Verbal Scale (Table 62), children with chronic conditions demonstrated fewest verbalizations of anxiety if they were in the Modeling/No Tour group or No Programme/Tour group. Highest scores were observed in the Modeling/Tour and No Programme/No Tour groups. On the Observation Non-Verbal Scale (Table 63), children with chronic conditions had lowest scores in the Rehearsal-Instruction/Tour group. The Rehearsal-Instruction/Tour group was associated with the highest scores in children without chronic conditions.  147  Table 62 Mean T Score Residuals for Observation Verbal Scale on Chronic Conditions (CC) x Approach x Tour Group Modeling  /Tour  Modeling  N  X  /CC  7  53.51  10.50  45.06  75.82  /NoCC  6  52.09  13.93  34.08  69.25  7  45.29  6.90  36.74  55.50  /NoCC  9  50.73  10.14  30.18  . 62.16  /CC  7  49.12  8.23  36.24  58.49  /NoCC  7  48.59  12.87  36.43  67.78  6  50.00  8.96  38.63  60.64  11  48.76  6.01  35.84  60.75  /CC  8  46.29  11.32  34.68  69.80  /NoCC  4  51.77  2.50  48.63  53.94  9  53.24  9.09  38.52  64.16  6  47.03  10.72  38.73  65.97  /NoTour /CC • /Tour  Rehearsal-Instruction Rehearsal-Instruction  /No Tour /CC /NoCC /Tour  No Programme  /No Tour /CC  No Programme  /NoCC  S.D.  Min.  Max.  Table 63 Mean T Score Residuals for Observation Non-Verbal Scale on Chronic Conditions (CC) x Approach x Tour Group Modeling Modeling  /Tour  N  X  /CC  7  52.91  11.44  38.32  69.75  /NoCC  6  47.33  5.59  39.73  55.40  7  51.01  11.18  36.44  64.94  /NoCC  9  53.29  6.54  41.36  62.57  /CC  7  45.98  10.49  29.91  63.48  /NoCC  7  57.21  6.04  52.08  69.26  6  49.70  7.77  39.18  59.89  29.34  58.68  /No Tour /CC  Rehearsal-Instruction  /Tour  Rehearsal-Instruction  /No Tour /CC /NoCC  No Programme No Programme  /Tour  S.D.  Min.  Max.  11  46.57  9.73  /CC  8  53.03  9.76  37.71  69.85  /NoCC  4  52.29  11.75  39.41  67.18  9  46.63  11.10  24.87  62.14  6  51.24  10.80  35.36  69.06  /No Tour /CC /NoCC  148  Summary of Question 7 In analysing the effects of individual characteristics of the children on the effectiveness of the programmes, a two-step regression analysis process was used. Appendix C, Tables 1 - 27 summarize the results of the first step and Figures 36,43, and 67 provide a more condensed summary which denotes the interactions selected for the second stage of the analyses. The second stage regression analyses results are summarized individually for each cluster below. Cluster 2: Characteristics of the Family. The two variables included in this cluster were socio-economic status and position of the child in the sibling structure. Only the former was found to affect sufficient variables to be included in step two of the regression analysis. Socio-economic status interacted with Mode x Approach and Programme. Figure 68 summarizes the relationship among higher socio-economic status (SES), Approach and Mode for each dependent variable. The slope of the regression line is included so that the magnitude of the relationship can be considered. The relationship of lower SES to the experimental variables can be considered by reversing the relationship (Higher scores on the Figure, indicate lower scores for lower SES level children in the same, but converse relationship.) Children from higher SES families in the Modeling/Print group had lower scores on observed non-verbal anxiety-related behaviours before surgery and were rated as less contentious and rated themselves as less anxious 6 weeks after discharge than were the children from lower SES families in the same group. Children from lower SES families in the Modeling/Audio-Visual and Rehearsal-Instruction/Print groups had lower scores on observed anxiety prior to surgery and were rated as less contentious following discharge than were the higher SES children in the same groups.  Figure 69 summarizes the relationship between socio-economic status and Programme and the dependent variables. For children in each group, higher socio-economic status was associated with the dependent variables as described. The slope of the regression line is included so that the magnitude of the relationship may be considered.  149  FIGURE 68 Summary of the Relationship of Higher Socio-Economic Status and Approach and Mode Group Modeling/Audio-Visual  Higher Scores Slope  Lower Scores Slope  Contentiousness 0.27  Min. Effect Slope State Anx. @ 6 wks. 0.10  Obs. Non-Verbal 0.25 Modelmg/Print  Contentiousness -0.33 Obs. Non-Verbal -0.43 State Anx. @ 6 wks. -0.20  Rehearsal-Instr7Audio-Vis.  Obs. Non-Verbal 0.15  Contentiousness -0.15 State Anx. @ 6 wks. -0.21  Rehearsal-Instr./Print  Contentiousness 0.46  State Anx. @ 6 wks.-0.10  Obs. Non-Verbal 0.35 No Programme  Obs. Non-Verbal -0.33  Contentiousness -0.08  State Anx. @ 6 wks. -0.11  FIGURE 69 Summary of the Relationship of Higher Socio-Economic Status and Programme Group Programme  Higher Scores Slope  Lower Scores Slope Dependent Anx. -.30  Min. Effect Slope State Anx. @ Surg. .09 Obs Non-Verb. .10  No Programme  Obs Non-Verb. -.36  Dependent Anx. .08  State Anx. @ Surg. -.20  For children who received Programmes, the higher their socio-economic status, the higher their scores were likely to be on pre-surgery, self reported anxiety and non-verbal observed anxiety related behaviour. The opposite was found for children who did not receive Programmes: the lower their socio-economic status, the higher their scores. On the dependent anxiety scale a different effect was observed. For children who had programmes, the higher socio-economic scale levels were related to lower scores.  150  Cluster 3: Children's Personality Characteristics. The three variables included in this cluster were Trait Anxiety, Health Locus of Control, and Verbal Ability. Health Locus of Control interacted with Instructional Approach by Tour, Mode by Tour, Mode by Approach, Programme by Tour, and Tour alone. Trait Anxiety was found to interact with Instructional Approach by Tour and Mode of Presentation by Tour. Verbal Ability interacted with Mode and with Tour. Health Locus of Control and Approach and Tour interacted with two scales. Figure 70. summarizes the relationships between more internally controlled children and the experimental variables. As in Figures 68 and 69, the slope of each line is included in the figure so that the magnitude of the relationships can be compared. Children who received higher scores for Health Locus of Control (more internally controlled) and who received a Modeling/Tour programme, also received higher scores on sleep disturbance ratings after discharge and reported themselves as more anxious following surgery than more externally controlled children in the same Programme. A similar pattern was observed for children in the Rehearsal-Instruction/Tour and No Programme/ Tour conditions on self-expressed state anxiety at the six week follow-up visit. For children in the No Programme/No Tour conditions, as external health locus of control increased, self-expressed state anxiety at the six week follow-up decreased.  FIGURE 70 Relationship between more Internal Health Locus of Control and Approach and Tour Group Modeling/Tour  Higher Scores - Slope  Lower Scores - Slope  Minimal Effect - Slope  Sleep Dist 2.06 State Anx.@ 6Wks. .84  Modeling/No Tour R-I/Tour R-I/No Tour  State Anx.@ 6 Wks.  No Programme/Tour No Programme/No Tour  State Anx.@ 6 Wks. State Anx.@ 6 Wks.  Sleep Dist Sleep Dist  1.16  .54 .27  Sleep Dist Sleep Dist  151  -.19 -.27  -.92 -.39  State Anx.@ 6 Wks.  -.04  Sleep Dist State Anx.@ 6 Wks.  .07 .02  Health Locus of Control interacted with Mode and Tour on four scales. Figure 71 summarizes the relationships among more internally controlled children and the experimental variables on each of the dependent variables. Children with more internal locus of control in the Print/Tour group were more likely to have higher state anxiety but lower appetite disturbance following discharge than those with more external locus of control. Children with more internal control in the Print/No Tour and No Programme/No Tour groups were more likely to have greater appetite disturbance but similar state anxiety to those with more external locus of control. Children with more internal control in the Audio-Visual/Tour group were more likely to have higher appetite disturbance and state anxiety scores after discharge than those with more external control. The opposite was observed in the Audio-Visual/No Tour group. Children with more internal control in the No Programme/Tour group were more likely to have lower appetite disturbance but similar state anxiety following discharge to the more externally controlled children.  FIGURE 71 Summary of the Relationship of Internal Health Locus of Control and Mode and Tour Group  Higher Scores Slope  Print/Tour  State Anx. @ 6 wks. 0.44  Print/No Tour  Appetite DisL 0.72  Audio-Visual/Tour  Appetite DisL 0.26  Lower Scores Slope  Min. Effect Slope  Appetite DisL -0.92 State Anx. @ 6 wks. 0.00  State Anx. @ 6 wks. 0.61 Appetite DisL -0.82  Audio-Visual/No Tour  State Anx. @ 6 wks. -0.59 No Programme/Tour No Programme/No Tour  Appetite DisL -0.82  State Anx. @ 6 wks. 0.00 State Anx. @ 6 wks. 0.00  Appetite DisL 1.04  Health Locus of Control by Mode by Approach is summarized in Figure 72, with the relationship between more internally controlled children (higher scores) and the experimental variables described. Children with more internal control in the Modeling/Audio-Visual group were more likely to have less observed anxiety prior to surgery and less dependent anxiety after discharge than those with more external control. The opposite was found for those in the Modeling/Print group.  152  FIGURE 72 Summary of the Relationship of Internal Health Locus of Control and Mode and Approach Group  Higher Scores Slope  Modeling/A-V  Lower Scores Slope  Min. Effect Slope  Dependent Anxiety -0.98 Obs. Non-Verb. -0.85  Modeling/Print Rehearsal-InstryA-V  Dependent Anxiety 0.82 Obs. Non-Verb. 0.71  Dependent Anxiety 0.10  Obs. Non-Verb. 0.43  Dependent Anxiety -0.07  Rehearsal-InstryPrint  Obs. Non-Verb. -1.40  No Programme  Obs. Non-Verb. 0.55 •  Dependent Anxiety -0.06  Children with more internal control in the Rehearsal-Instruction/Audio-Visual or No Programme groups were more likely to have higher observed non-verbal anxiety scores than those with more external control. The opposite was observed in children in the Rehearsal-Instruction/Print group. Health Locus of Control by Programme by Tour is summarized in Figure 73, with the relationships between more internally controlled children (higher scores) and the experimental variables described.  FIGURE 73 Summary of the Relationship of Internal Health Locus of Control and Programme and Tour Group  Higher Scores Slope  Lower Scores Slope  Programme/Tour  Obs. Verb. 0.29  State Anx. @ Pre-Surg. -0.55  Programme/No Tour  Obs. Verb. 0.76  State Anx. @ Pre-Surg. -0.21  No Programme/Tour  Min. Effect Slope  Obs. Verb. 1.47 State Anx. @ Pre-Surg. 0.54  No Programme/No Tour  Obs. Verb. 0.70 State Anx. @ Pre-Surg. 0.94  Children with more internal locus of control all had higher verbal anxiety scores than those with more external control. However, for the No Programme/Tour group this relationship was more extreme. Children with more internal locus of control in the Programme groups claimed to have lower anxiety at surgery than did those in the No Programme groups.  153  Health Locus of Control and Tour is summarized in Figure 74. Again, the relationship between more internal health locus of control and Tour is described. Opposite effects were observed for these two groups. Children with more internal control and a Tour had lower observed anxiety at pre-surgery and higher state anxiety after discharge than those with more external control. The opposite was observed in children in the No Tour group.  FIGURE 74 Summary of the Relationship of Internal Health Locus of Control and Tour Group  Higher Scores Slope  Lower Scores Slope  Tow-  State Anx. @ 6 wks 0.34  Obs. Non-Verb. -0.67  No Tour  Obs. Non-Verb. 0.55  State Anx. @ 6 wks -0.28  Min. Effect Slope  Trait anxiety interacted with Approach and Tour on nine scales. Figure 74 summarizes the relationship between higher levels of trait anxiety and the experimental variables. For more highly anxious children, the Rehearsal-Instruction/Tour and the No Programme/No Tour programmes were associated with increased scores on more measures associated with anxiety, whereas the Rehearsal-Instruction/No Tour and Modeling/Tour programmes were associated with lower scores on more measures. The opposite was found for more low-anxious children. The interaction of Trait Anxiety with Mode and Tour on four scales is summarized in Figure 75. Higher levels of trait anxiety were associated with higher scores on the dependent anxiety and sleep disturbance scales for children in the Audio-Visual/Tour group but a much lower score on the non-verbal anxiety observation scale. The opposite effect was observed for children in the Audio-Visual/No Tour group, with higher scores on the observations of verbal anxietyrelatedbehaviour prior to surgery and lower scores on dependent anxiety. Lower scores on dependent anxiety and observed verbal anxiety related behaviour were observed in children in the Print/Tour group who had lower levels of trait anxiety. Children with lower levels of trait anxiety in the Print/No Tour group were likely to have higher scores on the observed verbal anxiety related behaviour and lower scores on the sleep disturbance scale. Litde relationship was observed between Trait Anxiety and dependent anxiety scores or non-verbal anxiety for this group.  154  FIGURE 75 Relationship of Higher Trait Anxiety scores and Approach and Tour Group  Higher Scores Slope  Mod/Tour  R-I/Tour  Obs. Rating Obs. Non-Verbal Dep. Anxiety  R-I/No Tom-  Obs, Rating .45 Obs. Verbal 1.03 Obs. Non-Verbal .15 Obs. Verbal .10  Mod/No Tour  No Prog/Tour No ProgVNo Tour  Obs. Non-Verbal State Anx.@ 6 Wks. Obs. Rating Obs. Non-Verbal State Anx.@ 6 Wks.  ,18 .12 .69  Lower Scores Slope  Dep. Anxiety Obs. Verbal Obs. Non-Verbal State Anx.@ 6 Wks. Dep. Anxiety  -.18 -.37 -.37  State Anx.@ 6 Wks.  -.13  Dep. Anxiety  -.11  Dep. Anxiety Obs. Rating Dep. Anxiety Obs. Verbal  -.21 -.48 -.43 -.17  .27 .40 .50 .47 .30  Minimal Effect Slope Obs. Rating  -.06  Obs. Verbal State Anx.@ 6 Wks.  .02 .06  Obs. Rating Obs. Non-Verbal State Anx.@ 6 Wks. Obs. Verbal  -.01 -.05 -.01 .02  -21 -.20  FIGURE 76 Summary of Effects of Trait Anxiety on Mode and Tour Group A-V/Tour A-V/NoTour Print/Tour Print/No Tour No Prog./Tour NoProg./NoTour  Higher Scores - Slope Dep. Anxiety Sleep Dist. Obs. Verbal  .22 .67 .55  Dep. Anxiety 1.14 Obs. Verbal 1.44 Sleep Dist. .32 Sleep Dist. Obs. Non-Verb. Obs. Non-Verb.  .67 .21 .59  Lower Scores - Slope  Obs. Non-Verb. -1.40 Dep. Anxiety  -.46  Obs. Verbal  -.37  Dep. Anxiety  -.21  Dep. Anxiety  -.42  155  Minimal Effect - Slope Obs. Verbal  -.13  Sleep Dist. -.16 Obs. Non-Verb. .08 Sleep Dist. -.13 Obs. Non-Verb. -.13 Dep. Anxiety .01 Obs. Non-Verb. .09 Obs. Verbal -.02 Sleep Dist. Obs. Verbal  -.02 -.16  The interaction of verbal ability and Mode was observed on two dependent variables. Only small differences were observed on the Appetite Disturbance factor, with children having higher verbal ability in the AudioVisual or No Programme groups having greater appetite disturbance and more non-verbal observed anxiety than those children with lower verbal ability. The interaction of verbal ability and Tour was also observed on the same two scales. Children with higher verbal ability who received Tours were more likely to have less appetite disturbance after discharge and observed anxiety prior to surgery than those children with lower verbal ability. The opposite was observed in children in the No Tour group.  Cluster 4: Personal History. This cluster contained three variables: presence or absence of chronic conditions, previous hospitalization experience, and stressful life events in the past six months.The final variable did not interact with sufficient dependent variables to be included in step two of the analysis. Chronic conditions interacted with Approach x Tour and previous experience interacted with Programme x Tour, and Approach alone. Previous experience interacted with Programme and Tour on four scales. However, cell frequencies of n=l occurred and no interpretation was made. Previous experience interacted with Approach on two scales. However, again, insufficient cell sizes made interpretation inadvisable. Chronic conditions interacted with Approach and Tour on two scales. Children with chronic conditions had lower verbal anxiety scores prior to surgery if they were in the Modeling/No Tour or No Programme/Tour groups but lower non-verbal anxiety scores if they were in the Rehearsal-Instruction/Tour or No Programme/No Tour groups. Children without chronic conditions had lower verbal anxiety if they were in the No Programme/ No Tour group and lower non-verbal anxiety if they were in the Rehearsal-Instruction/No Tour group.  156  CHAPTER V DISCUSSION  This research study was designed as an experimental comparison of approaches and modes of preadmission preparation and of interactions of preparation with selected individual difference characteristics of the children. However, it was also intended to have some practical (clinical) significance for professionals involved in paediatric day care surgery. The research questions were designed so that the study would provide data to assist clinicians in developing the most appropriate forms of preadmission preparation, and indeed, in evaluating the need for preparation of children undergoing day care surgery. By bringing together and comparing the effects of different programmes, already documented as achieving positive effects on inpatient surgical patients, it was hoped that some directions for the development and evaluation of clinical programmes might become clear. In achieving some clinical significance, it was also an objective of this study to obtain valid results generalizable to the population from which the sample was drawn. Like many research studies, more questions were raised than were answered. However, directions for clinicians' and researchers' investigations may be more clear as a result of this study. Because the description of the results in Chapter IV is long, a summary of the results is presented in this chapter, as well as discussion of the findings. When interpreting these results, two issues should be kept in mind: 1)One particular preparation programme may increase one manifestation of anxiety while reducing another. The relative weight of importance of these indications of anxiety must be considered and interpretations must be drawn cautiously at this time; and 2)That a particular programme appears to be most beneficial for one group of children in the study does not mean that other programmes were harmful to that group or that the programme was harmful to other children. It may be that there was litUe change in other's reaction or a similar but far less extreme change may have been observed.  Description of the Sample Of the 110 children included in this study, over 75% came from two parent families of three to five members. Over half the families considered themselves to be Canadian, without any separate ethnic identity. Other parents identified Western European, Chinese, and East Indian as the cultural background of their families,  157  but almost half of this group did not consider themselves to be active members of their identified ethnic community. Almost 70% of the children spoke only English at home. In comparing the study sample to a sample of the hospital day care surgery population, the trend towards more younger children and more boys admitted for day-care surgery was similar in the two groups. However, the general population had more children operated on by Orthopaedic surgeons and fewer by Genitourinary, Plastic, or Dental surgeons than the study sample. The descriptive statistics reported for the study's patients describe the diversity of the sample. Reviewers of other preadmission preparation studies have been critical that studies of inpatient surgery have used very narrow samples, containing only children with no previous hospital experience or undergoing only one or two types of surgical procedures (e.g, Elkins & Roberts,1983). The characteristics of the children and families participating in this study appear to reflect the diversity of the population found at B.C.'s Children's Hospital and assures a generalizability offindingsbroader in scope than typical of samples used in previous studies of inpatient preadmission preparation.  Question 1: Attention Effects The purpose of this question was to determine whether there was any effect from simply participating in the study, which included several hours of contact with hospital-associated persons within the week prior to day care surgery. The two groups compared were (a) a group receiving attention in the form of data collection carried out by an interviewer and a no-preparation control contact, which included an opportunity to ask questions, carried out by an experimenter, and fb) a group who did not know about the research project until after they came to the hospital. Of the eight dependent variables used in this analysis, only two showed any effect. Just before surgery, children who received no attention appeared more anxious than those who had attention. But the girls who had received attention had higher ratings of state anxiety, while the boys who received attention had lower ratings of state anxiety than either gender in the no-attention group. At the same time, immediately prior to their surgery, there was a positive effect of attention in reducing observed non-verbal anxiety related behaviours but a negative effect of high state anxiety in girls. These results must be interpreted with caution because the observers were not  158  blind to the control condition of the children and those in the attention condition had filled in the state anxiety scale in the proceeding two weeks. Wolfer and Visintainer (1979) found that primary care nursing and supportive attention during inpatient hospitalization for surgery was no more effective than routine nursing care. They concluded that attention was not enough; a primary element of the effectiveness of the preadmission preparation programme was the information received by the children and their parents. In this study, two of the eight dependent variables were affected by attention alone. Simply being visited by an interested and sympathetic professional prior to and during the hospitalization made some difference. However, compared to the effects seen in considering the facets of programmes, this difference may be consideredrelativelysmall.  Question 2: Effects of Programme The purpose of this question was to determine whether the preparation programmes could reduce negativereactionsto day care surgery. This question was addressed by comparing the reactions of children receiving programmes to those of childrenreceivingno programmes. In previousresearchof children undergoing inpatient surgery which included no-preparation control groups, preparation did appear to be effective in reducing behavioural upset and increasing co-operation during the hospitalization (e.g., Wolfer and Visintainer, 1975) and inreducingbehavioural disturbance following discharge (e.g,. Melamed and Siegel, 1975). However, not all studies have achieved significant results (e.g., Crocker, 1980). In the one study of preadmission preparation for day care surgery, preparation was not observed to make a difference (Abrams, 1982). In the present study, Programme (with or without a tour) was not beneficial. Children who received programmes displayed greater contentiousness and dependent anxiety after discharge than they did before surgery. Those children not receiving programmes diplayed fewer of these behaviours. Although both groups displayed fewer verbal anxiety-related behaviours after discharge than they did before their surgery, the change was greater in the No Programme group. It should be noted that half of the children receiving Programmes and half receiving No Programmes also received a tour.  159  When interaction with Tour was considered, the benefit of either a tour or a programme was observed in the decrease in verbal andratedobserved anxiety-related behaviour from prior to preparation to after preparation. The No Program me/Tour group displayed more non-verbal anxiety- related behaviour but fewer verbal anxiety-related behaviours prior to surgery. Melamed and Ridley-Johnson (1988) suggested that preparation may be contra-indicated for some children. For this sample, programmes (regardless of their composition) may have contributed to post-discharge behavioural disturbances and the verbal expression of anxiety just before surgery. The supposition, "anything is better than nothing," did not appear to be true for this sample. However, preparation in the form of programmes or tours appeared to be better than no preparation at all in reducing in-hospital anxiety-related behaviours. When the facets of the programme and the individual characteristics of the children were considered, a more complex picture was presented. This will be discussed in the following sections.  Question 3: Effects of Tour The purpose of this question was to determine whether atourof the surgical day care suite and operating room anterooms could reduce the negative reactions of children to day care surgery. A group receiving tours was compared with a group which did not receive tours. Half of the children in each group also received a programme. The research literature has not provided clear evidence of the effectiveness oftoursin reducing the negative reactions of children to inpatient surgery. In the most recent study, comparing tours to other forms of preparation (Peterson et al., 1984), children in the tour group were found to be more anxious and less cooperative during their hospitalization than those children in the other preparation groups. The authors expressed concern that tours continue to enjoy wide clinical acceptance (Peterson and Ridley-Johnson, 1980) when other forms of preparation appear to be more effective. The most recent study to compare tours to a no-treatment control (Azarnoff et al., 1975) did find some limited support for the use of tours with their inpatient sample. It may be that clinicians feel comfortable with this long-used form of preparation which is expensive in staff-time but costs little in the way of materials (videos, printed materials, play equipment, etc.) or pre-planning.  160  In this study, with a day care surgery population, a Tour did appear to be more effective than No Tour in reducing verbal and general anxiety prior to surgery, but not effective in reducing non-verbal anxiety-related behaviour. When the interactions with the Programme were examined (see discussion of Question 2), either a Tour or a Programme, or both were effective in reducing observed anxiety prior to surgery, with the Tour only group displaying more non-verbal, but less verbal anxiety-related behaviour than the other groups.  Very mixed findings were observed. The most reasonable conclusion to be drawn is that tours increase some negative reactions, such as non-verbal expressions of anxiety, while reducing others such as verbal expressions of anxiety. This pattern, of reducing some measures of negative reactions while increasing others, will be found throughout the discussion of the other facets of programmes and will be considered in more detail in a later section. However, it appears that for this day care surgery sample, tours were effective in reducing some of the negative observed reactions during hospitalization. It may be concluded that tours are better than no preparation at all and may be better than some other forms of preparation. The interaction of tour with the specific facets of preparation and with the individual characteristics of the children will be discussed in following sections.  Question 4: Effects of Approach The purpose of this question was to determine whether Rehearsal-Instruction or Modeling was more effective in reducing the negativereactionsof children to day care surgery. Both approaches have been shown to be effective in reducing negative effects in inpatient surgery (e.g., Melamed and Siegel, 1975; Wolfer and Visintainer, 1975,1979) but studies which have compared similar programme approaches (e.g., Peterson and Shigetomi, 1981; Peterson et al., 1984) have created programmes also presented in differing modes and lengths. In this study, approach was observed to affect three dependent variables. Children in the RehearsalInstruction group were observed to have significantly lower verbal and overall anxiety before surgery than before preparation. This drop was not observed in children in the Modeling group. However, children in the RehearsalInstruction group displayed increased dependent anxiety following discharge, whereas dependent anxiety scores  161  remained almost constant from pre-preparation to post-discharge in the Modeling group. Therefore, RehearsalInstruction was seen to be more effective in reducing negative effects at the time of surgery but increased dependent anxiety behaviours following discharge.  Question 5: Effects of Mode The purpose of this question was to determine whether an Audio-Visual or a Print Mode of Presentation was more effective in reducing negative reactions of children to day care surgery. Both modes of presentation have been shown to be effective (e.g., Melamed and Siegel, 1975; Wolfer and Visintainer, 1979) but no study has made a direct comparison between the two. No significant differences were found between print, a discussion, and a puppet play (Lende, 1971) or between a live demonstration and an audio-visual presentation (Twardoz et al., 1980) or a tour and an audio-visual presentation (Harper, 1981) for inpatient samples. In this study, differential effects of Mode were observed on three variables. Children in the AudioVisual group were more likely to display increased dependent anxiety, but decreased sleep disturbance and appetite disturbance. Children in the Print group showed no change in their scores on dependent anxiety or sleep disturbance and were more likely to show an increase in their appetite disturbance. It appears that the AudioVisual programme is more effective than the Print programme in decreasing negative reactions to day care surgery. However, it is the effects of the interactions of Approach and Mode which has the most clinical interest, since the two do not exist in isolation. This interaction is described in Question 6.  Question 6: Effects of Interactions The purpose of this question was to determine whether the interactions of Approach, Mode, and Tour might result in a particular preparation programme which might best reduce the negative reactions of children to day care surgery. As mentioned in the discussion of Questions 4 and 5, research studies have compared the effectiveness of different Approaches to preparation. However, no studies were found which examined the interactions of Approach and Mode for an inpatient or day care sample.  162  Approach x Mode. It may be concluded, from the discussions of Approach alone and Mode alone, that the Rehearsal-Instruction/Audio-Visual programme might be the most effective in reducing negative reactions (except for increasing dependent anxiety following discharge — see pp. 160-161). Least deterioration in selfreported state anxiety from pre-preparation to just prior to surgery was observed in children in the RehearsalInstruction/Audio-Visual group. Children in the Rehearsal-Instruction/Print group showed greatest improvement in verbal and overall ratings of anxiety-related behaviour at surgery. This group, however, also had notably higher scores at pre-preparation measurement than the other three groups. Approach x Tour. Children who had a Rehearsal-Instruction/No Tour programme were observed to demonstrate fewer verbal anxiety-related behaviours but self-reported anxiety scores were higher prior to surgery than in the other children. They also demonstrated less sleep disturbance following discharge. Children who had a Rehearsal-Instniction/rour programme obtained higher self-reported anxiety scores before surgery, continued to report higher scores after discharge, and had more difficulties with sleep disturbance after discharge than the other children. Children in the Modeling/Tour programme, like those in the Rehearsal-Instruction/No Tour group, had fewer sleep disturbances after discharge than other children. They also had the smallest rise prior to, and the greatest drop after surgery in self-reported state anxiety. Mode x Tour. No effects were observed for this interaction. Approach x Mode x Tour. No effects were observed for this interaction. It might then be concluded that the Rehearsal-Instruction/Audio-Visual programme with no Tour might be the best programme to choose. Alternately, a Modeling programme with a Tour might also create some positive effects and few negative effects. In designing a clinical programme, it appears that the Instructional Approach may be more important to consider than the Mode of Presentation. This conclusion also lends justification to the design of studies of Approaches to preparation (such as Peterson et al., 1984) which have not considered Mode of Presentation. It is also noteworthy that Tour interacted with Instructional Approach, ie. a tour was not necessarily a positive influence depending upon the nature of the programme preceding it This confirms the observations made when looking at the main effects of Tour and Programme.  163  Question 7: Effects of Individual Characteristics The purpose of this question was to consider whether individual characteristics of the children and their families would make a difference to the effectiveness of the preparation programmes. A number of characteristics have been identified as affecting children's reactions to inpatient hospitalization (c.f. Vemon and Foley, 1965). However, the cumulative research in this area is not consistent and researchers of preadmission preparation have called for investigation of the interaction between child characteristics and preparation (e.g., Elkins and Roberts, 1983; Melamed et al., 1982). Studies were examined which found a relationship between preparation programme variables and age (Ferguson, 1979; Melamed et al., 1976), race (Melamed, 1976), previous hospitalization experience (Siegel, 1976), and coping styles (Peterson et al., 1984). In this study, three characteristics were used as blocking variables in assigning children to treatment cells. They were age, gender, and surgical category. There were not enough children in some of the surgical categories to provide sufficient data to determine whether type of surgical procedure interacted with response to preadmission preparation variables and therefore, this characteristic could not be included as a moderating variable. This study examined the influence of ten moderating variables on the programme variables. Two of these variables, which also acted as the blocking variables described above, were age and gender. Of the ten, four moderating variables were not found to interact sufficiently with the experimental variables or contained cell sizes too small to be worthy of interpretation. Of the remaining six, some interactions clearly indicated that a particular type of treatment was most beneficial for a child with a particular characteristic. For other characteristics, the data provided no uniform picture but, rather, a variety of unique effects, particular to individual measurements of anxiety. Age. A main effect for age was observed on three scales; younger children exhibited more sleep disturbances and older children's self-reported anxiety scores were higher prior to surgery. Older children also displayed greater appetite disturbance following discharge. Treated as a categorical variable in the MANOVAs, age interacted with Programme x Tour on only one variable and with Approach x Mode on one variable. Therefore, the interaction of agegroup with preparation programme variables was found to be insufficient for interpretation.  164  Earlier studies have noted that age interacts with timing of preparation (Ferguson, 1979; Melamed and Siegel, 1980). Since all children in this study were prepared three to five days prior to admission, timing was not a variable in this study and no further evidence was provided to support the conclusion that age of the children makes a difference to the type of preparation programme they should receive. Gender was not observed to have a main effect on any dependent variables. In the analysis of variance model, gender interacted with Programme alone, Approach alone and Programme x Tour, each on one dependent variable. Gender interacted with Tour on two dependent variables. Girls appeared to benefit especially from Tours, although boys also showed positive effects of Tours on one scale. Most studies of inpatient preadmission preparation have not found gender to interact with the experimental variables (e.g., Peterson and Shigetomi, 1981). However, Melamed et al. (1976) did discover a relationship between gender and timing of preparation, with boys, prepared one week in advance, observed to be more anxious than girls at admission. In this study of day care preadmission preparation, with all children prepared three to five days in advance of admission, Tours were particularly effective in minimizing negative reactions in girls. Boys' anxiety levels were more stable and less affected by preparation. Socio-Economic Status (SES). This characteristic, which was based upon the occupation of the child's parents, was found to interact significantly with Programme on three scales and Approach x Mode on three scales. Children from higher SES families benefitted most from the Modeling/Print programme, whereas those from lower SES families benefitted more from Modeling/Audio-Visual or Rehearsal-Instruction/Print programmes. In general, it appears that children from lower SES families have greater negative reactions to day-care surgery and preparation minimizes those effects. Although SES has not been included in inpatient preadmission preparation studies, studies of the effects of inpatient hospitalization on children have considered this characteristic to be significantly related to negative effects (Quinton and Rutter, 1976; Shannon et al., 1984). In this study, while preparation made small difference to the anxiety measure scores of children from higher SES families (i.e. they reacted less negatively to the experience regardless of whether they were prepared or not), preparation was particularly effective in reducing negative effects of day-care surgery in lower SES children. Additionally, children from high and low SES families responded more favourably to different preparation programmes.  165  Position in the Sibling Structure. Being the youngest or only child in the family has been considered by some researchers to contribute to negative reactions to hospitalization (Dearden, 1970). Other researchers have been unable to find evidence to support this position (e.g., Vernon et al., 1966). In the present study, no evidence was found to indicate that being a youngest or only child affected the response to preadmission preparation for day-care surgery. Trait Anxiety. The usual anxiety level of the children interacted with Instructional Approach and Tour on five scales and with Mode and Tour on four scales. On the Approach x Tour interaction, highly anxious children appeared to do best with a Modeling/Tour programme (decreasing observed verbal and non-verbal pre-surgery anxiety, and dependent anxiety, and selfreported anxiety after discharge). For less anxious children, the Rehearsal-Instruction/Tour programme might be considered most effective in curbing negative reactions. In the Mode of Presentation and Tour interaction, findings were different from scale to scale, with no clear pattern emerging for highly anxious children. For example, in the Audio-Visual/No Tour programme, highly anxious children were more likely to have higher observed verbal anxiety prior to surgery, while less anxious children were more likely to demonstrate greater dependent anxiety after discharge. However, the Print/ Tour programme appeared to be most effective for low trait anxiety children. It is interesting to note that the form the preadmission preparation took affected the highly anxious and less anxious children differently and that not all highly anxious children expressed higher state or situational anxiety. For example, more verbal expressions of anxiety were observed in highly anxious children who received an Audio-Visual/No Tour programme and in less anxious children who received a Print/No Tour programme. Children's personalities have long been noted as a factor influencing their reactions to inpatient hospitalization (e.g., Prugh et al., 1953; Vernon et al., 1966). However, preadmission preparation research has just recently begun to consider which aspects of personality might influence the effectiveness of preparation (e.g., Peterson et al., 1984). From the results of this study it is evident that trait anxiety does influence the effectiveness of preadmission preparation for day care surgery. Health Locus of Control. Another aspect of children's personalities is their locus of control. Children with more external locus of control believe that outside influences, either other people or luck, control their lives.  166  Children with more internal locus of control believe that they have some control over what happens to themselves. This characteristic was identified by Bolig (1981) as affecting children's reactions to hospitalization. In this study, Health Locus of Control interacted with Approach x Tour on two scales, Mode x Tour on four scales, Mode x Approach on two scales, Programme on two scales and Tour on two scales. Again, a very mixed pattern of results was presented, with individual scales reacting differently. However from considering all the interactions simultaneously, it may be argued that externally controlled children have more negative reactions to day-care surgery than internally controlled children when they are not prepared with or without a Tour. More internally controlled children benefitted most from a Modeling/Tour programme. More externally controlled children benefitted most from the Modeling/Audio-Visual/No Tour programme. Verbal Ability. This characteristic was observed by Dearden (1970), Pill (1979), and Pillowsky et al. (1982) to influence reactions to hospitalization in inpatients. In this study, verbal ability interacted with Mode and Tour, each on two scales. However the actual differences were so small, that they might not be considered clinically relevant to consider when planning preadmission preparation for day care surgery. Chronic Conditions. This characteristic interacted with Approach x Tour on two scales. Children with chronic conditions reacted best with the Rehearsal-Instruction/Tour programme. Those without chronic conditions reacted best with the Rehearsal-Instruction/No Tour programme. Previous Hospitalization Experience. It has been suggested that children who have previous experience with hospitalization demonstrate fewer negative reactions (Sides, 1977). Siegel (1977) observed that children with previous inpatient experience benefit less from preadmission preparation. Faust and Melamed (1984) reported that children with previous experince had increased arousal following preparation. In this study of reactions to day care surgery, previous hospitalization interacted with Approach on two scales. However, because of the few children in some groups, interpretations were not made. Life Stress. This variable, which measured stressful events in the children's lives in the six months preceding surgery, was not found to interact sufficiently to be considered a significant characteristic in influencing the effectiveness of preparation programmes. Shannon et al. (1984) perceived life stress to be a strong contributing factor to reactions of children to hospitalization . No evidence was found to support the conclusion that life stress should be considered in planning a child's preparation for day care surgery.  167  Summary. Of the ten individual characteristics chosen to be examined for interaction effects with preadmission preparation, three did not influence sufficient dependent variables to be considered significant; these were: age, position in the sibling structure and life stress. Two variables, previous experience and verbal ability, did not warrent interpretation. In the remaining five (gender, SES, trait anxiety , health locus of control and chronic conditions), trends could be observed that suggested that a particular form of preparation might be more suitable than another or that preparation was particularly helpful to a specific group of children in reducing the negative reactions to day care surgery.  Measures of Reactions to Dav Care Surgery In the two most recent analytical reviews of the literature on preparation for inpatient hospitalization and surgery, the need for multi-modal measurement of anxiety and other negative reactions to hospitalization was clearly expressed (Elkins and Roberts, 1983; Melamed et al., 1982). The tradition in research of preadmission preparation has been to do just that Most researchers have combined physiological and self-report measures (eg. Faust & Melamed, 1984: Melamed & Siegel, 1975) or physiological and ratings (eg. Wolfer & Visintainer, 1975,1979) of in-hospital adjustment with parent-report of behavioural adjustment following discharge. Studies often include eight or more dependent variables. For example, Zastowny et al. (1986) used a behavior checklist, a self-report scale, six observation measures, a nurse's rating, and seven physiological measures. Other researchers have focused on in-hospital adjustment but havecontinued to use multi-dimensional measures. Peterson and Shigetomi (1981) included three physiological variables and nine observation variables in their study. Peterson et al. (1984) used seven observation outcomes, seven behavioural checklist variables, a child self-report and two physiological measures. In keeping with this tradition, this study contained three different measures, creating eight scales, were used. The HBQ was a parent report of negative behaviour. The State Anxiety scale measured self-reported anxiety and had two occasions of post treatment measurement The Observation Rating Scale measured observed behavioural indicators of anxiety on three scales. These scales were not equally effective in detecting changes in reactions to day care surgery. As an example of this, Figure 77 shows the number of times a significant effect was observed on each of the dependent variables in the MANOV As of Programme and Tour and Approach,  168  FIGURE 77 Number of Significant Effects for each Dependent Variable used in the ANOVAs (Questions 2,3,4,5, & 6) Dependent Variables  Number of Effects  HBQ  Factor 1: Contentiousness .. Factor 2: Dependent Anxiety Factor 3: Factor 4: .; Observation Rating Scale Verbal Scale Non-Verbal Scale State Anxiety: Pre-Surgery Post-Surgery  ,  1 7 2 2 6 7 2 3 1  Mode and Tour (Questions 2-6). Of a possible thirty-one main effects and interactions, nineteen were significant on any of the dependent variables. For each dependent variable, the range of significant effects was from zero to seven. It was also noted that, in examining the effects of interactions, both positive and negative effects were observed in some treatment combinations. For example, children in the Rehearsal-Instruction/Print group showed the greatest decline in rated and verbal expressions of observed anxiety prior to surgery. However, the children's ratings of their own anxiety were higher than those in other groups at exacdy the same time. The purpose of this study was to use a multi-modal approach to examining the effects of different facets of preadmission preparation for day care surgery, as suggested by the literature (see above). The study was not designed to evaluate the effectiveness of the measures used. However, this study does indicate that not all measures of anxiety are equally sensitive to the reactions of children to the day care surgery experience and that the choice of instruments certainly affects the outcome of the study. Not all of the instruments were equally reliable. The relationship among these anxiety measures is not clear. The factors of the behavioural adjustment questionnaire were not equally sensitive and showed main effect differences for age. Simultaneous observed and self-reported anxiety (as in the example above) often contradicted each other. Douglas (1975) warned that in-hospital and long-term adjustment were not related and Prugh et al. (1953) suggested that even short-term post-hospitalization adjustment (such as is measured in this study) is not always related to in-hospital adjustment Not only were these conclusions supported by the results of this study, but simultaneous measures also did not appear to be related.  169  Clinicians and theoreticians should become involved in the decisions as to which reactions should be reduced and which could be ignored or should be reinterpreted. For example, it may be decided that in-hospital behavioural expressions, particularly verbal expressions of anxiety, are healthy releases of stress and should be perceived as positive rather than negative. A theoretical framework should be developed which would conceptualize the stress reactions of children and provide the groundwork from which to evaluate programmes. Further investigation should be undertaken to determine therelationshipsamong the different negative reactions to hospitalizations. Relationships among the parent behavioural rating scales (e.g., among the four factors of the HBQ) should be examined. Therelationshipbetween simultaneously administered measures, such as self-report and observed anxiety should be examined. Additionally therelationshipbetween inhospital adjustment and post-hospital adjustment, as suggested by Douglas (1975) and Prugh et al.(1953), should be examined with the wide variety of anxiety-related instruments now available. It would be most beneficial, if research into the effects of hospitalization is to continue, to further explore the validity and reliability of instruments used to measure "reactions to hospitalization and day care surgery."  Clinical Implications Theresultsof this study indicate that even though different programmes may be best for any given child, there is evidence to suggest that one programme (possibly the Rehearsal-Instruction/Audio-Visual/ No Tour) may be successfully used to reduce many (but not all) of the potential negative reactions to hospitalization. There is also evidence to suggest that individual characteristics of the children are important to be aware of and consider when planning preparation. Results of this study suggest that some individual characteristics are important, others are not; and that there is still a great deal of informationrequiredbefore the relationship of preparation to individual characteristics is truly understood. Since this study did not ascertain the inter-relationships among the individual characteristics of the children, theresultsof this study cannot be used to attempt to design the "perfect" programme for any given child. Several different programmes may be indicated for a child given his/her individual characteristics (e.g., a highly anxious child with a chronic condition). The purpose of this study was to begin an exploration of the impact of individual characteristics on the effectiveness of preadmission preparation. Further research is needed to develop "profiles" of children and explore their relationship to preparation.  170  The examination of the individual characteristics of the children in this study related only to the interaction of these variables with preadmission preparation treatments in affecting reactions to day-care surgery. No attempt was made to determine which children were most negatively affected by the day care surgery experience; only which programmes (or any) might be most effective in reducing negative reactions. It is an important concept to consider that some children at some times are best not given further preparation. Individual differences in personality and coping styles suggest different needs for information and support, which may be contrary to the belief system of the clinicians involved. Some children appear to require and benefit-more from preparation than others (e.g., children from lower SES families, those with more external health locus of control) and to react more strongly to the method of preparation used. Efforts should be made toreachthese particular children and to provide them with the most suitable programmes. The notion that not all negative or anxiety reactions to day care surgery can be controlled at once and that some reactions appear to increase with the same preparation method used successfully to decrease other negativereactionsis of interest Clinicians need to become involved in the discussion andresearchof which behaviours, or negative reactions, should be reduced and which might bereinterpretedas healthy ventilation of the stress of undergoing day care surgery. Most importantly, clinicians need to be sensitive to the individual settings in which they work and the children and families they serve. Although theoretical facets of preparation programmes are supported in the research literature, each unique programme within its unique setting should be carefully evaluated.  First Do No Harm is the title of an Association for the Care of Children's Health film on psychosocial aspects of paediatric hospitalization and it is an important motto to consider when planning preadmission preparation. The fact that preadmission preparation is provided is not enough. The theoretical approach, timing, and the professional support must all be evaluated. The potential for increasing sequelae of the day care surgery experience exists. It is the responsibility of the clinicians to make sure that their programme not only decreases negative reactions to day care surgery, but does not exacerbate other reactions.  171  Limitations of the Study The limitaions of the study desribed below are typical of those found in clinical research literature. These limitations should be kept in mind while examining thefindingsof the study. The validity of conducting clinical research, i.e., the process of examining a problem within the context of its natural setting, generates the limitations or threats to reliability of such a study and are difficult to escape. Context. This study was conducted at B.C.'s Children's Hospital between August 15,1983, and June 1, 1984. Children in the study were between 5 and 12 years of age inclusive, lived within the Greater Vancouver area and were admitted to the Day Care Surgery Unit of the hospital. Children in six different surgical specialties were included in the sample. Conclusions cannot be generalized to children other than those represented by the sample and to hospital conditions other than those existing at the time of the study. Programmes. The preparation packages used in the study were developed with reference to descriptions of programmes with similar instructional approaches and modes of presentation found in the research literature. However, findings are limited to the particular embodiments of these approaches and modes of preparation as used in this study. This limitation applies to informational content, length of programme and timing of preparation. Sampling. Subjects and their families were volunteers. They were required to make a trip to the hospital three days prior to their surgery. Their willingness to participate in the study differentiates them from other families who would or could not participate. Sampling procedures changed during the course of the data collection. For thefirstfew months, surgeon referral was relied upon. Subsequently, referrals were made through the Admissions department of the hospital. Although this created a discrepancy, it is assumed that the subjects involved were randomly distributed throughout the treatment groups. Nevertheless, caution should be used in generalizing the results of the study beyond the description of the sample given here. Cell Size. It was anticipated that there would be ten children assigned to each treatment condition. Unfortunately, fewer children entered the study than expected, resulting in seven or eight in each treatment cell. Although the data collection period was extended as long as practicable, the power of the statistical analyses was diminished and some interaction effects of interest could not be examined because there were too few children per cell.  172  Study Design. In combining the eight dependent variables with the number of research questions included in this study, the possibiltiy occurs of obtaining significant effects by chance. The research questions considering the effects of approach, mode, and tour were analyzed using a multivariate analysis of variance, with the purpose of decreasing the likelihood of significant effects occuring by chance. Question 7, which examined the possible effects of ten individual difference characteristics, was exploratory in nature. The consideration of such characteristics in the research literature is scant. In these analyses the potential for Type I error increased with the numbers of individual regression analyses. Safeguards in this study included: grouping the characteristics into clusters, thereby reducing the number of first-stage analyses; and selecting only those interactions where there were at least two significant dependent variables for the second stage. The logic of this second safgeguard was that random results might more likely occur independently of other findings. A more stringent criterion, of three or more dependent variables, would have greatlyreducedthe number of interpretable results and increased the likelihood of a Type II error. Since the objective of this question was to explore an area not previously considered and to identify likely characteristics for further in-depthresearch,this was not a viable option. However, despite the design described above, the possibility that unusual findings may be theresultof random significance rather than a true difference among the groups is acknowledged.  Summary It appears that the preadmission preparation programmes are helpful in reducing potential negative reactions to day care surgery. Simple attention to the children and their families, without providing preparation, did not result in sufficient increased adaptation to be considered clinically valuable. The tour of the hospital did appear to be beneficial, particularly to girls, in adjusting to the hospitalization experience. However, when examined in combination with other programmes, the efficacy of the tour was not substantiated. Preparation packages with tour components did not always appear to be as effective as those without tours. When the Instructional Approaches and Modes of Presentation were considered separately, positive effects of preparation were observed. The Instructional Approach appeared to make more difference to children'sreactionsto day care surgery than did the Mode of Presentation when the interactions of the two were considered. Recent research of inpatient preparation has focused on comparisons of Instructional Approaches  173  (e.g., Peterson et al., 1984). These have generally been confounded with Mode of Presentation (modeling associated with audio-visual and instruction in coping techniques with a personal presentation). The results of the present study imply that the conclusions of these studies are justified. Peterson and Shigetomi (1981) found that insruction in coping techniques was more effective than modeling in reducing negative effects of hospitalization as measured in their study. From the results of this study, when all the children were considered, it may also be concluded that the Rehearsal-Instruction/Audio-Visual programme resulted in the greatest reduction and fewest increases in negative reactions to hospitalization. Some of the individual characteristics of the children interacted with preparation to affect their reactions to hospitalization for day care surgery. Age, position in the family, verbal ability, and life stress were not found to interact sufficiently with preparation to warrant interpretation. Gender and previous hospitalization did appear significantly to affect the effectiveness of the preparation programmes, but interpretation of three-way interactions could not be made because of small cell sizes. Preparation programmes were found to be particularly effective for children from lower Socio-Economic Status families in reducing negative reactions to the hospitalization. Girls benefitted more fromtoursthan boys. For highly anxious children, the Modeling/Tour or Rehearsal-Instruction/No Tour programmes appeared to be most effective. For children with lower trait anxiety, the Modeling/No Tour or Rehearsal-Instruction/Tour programme appeared to be most effective. For children with external locus of control, a programme with No Tour reduced more negative reactions to day care surgery than did the other programmes. For those with chronic conditions, a Rehearsal-Instruction Tour only preparation appeared to be the best choice. The purposes of this study were twofold: l)to examine the interactions of participation, preparation, approach, mode and tour; and 2) to explore the possibility that individual characteristics might interact with preparation variables. The findings are sumarized immediately above. A clinician might wish to extract from the findings one best overal method of preparing children for day care surgery or a formula for mapping children with various profiles into different programmes of different types. However, it was not the intent of this study to create a diagnostic profile from which to determine a specific programme for use with any particular child. The examination of the individual difference variables was exploratory, and simply concludes that some of these differences are important to consider in further research , of  174  both the characteristics and their interrelationships. Most importantly, this study is only one embodiment of a preparation programme and any clinical extrapolation of findings should be used as a point of departure from which to base an evaluation of a particular programme in its individual context. Recommendations for future research are generated from what was learned in the study. The findings of this, partially exploratory, study indicated interesting relationships (or lack of relationships) and directions of further exploration and for examination in detail.'  Recommendations for Further Research 1. Effects of Day Care Surgery: The psychological reactions to day care surgery have not been studied. An earlier study (Abrams, 1982) did not find that preadmission preparation made a significant difference to the adjustment of children to day care surgery. This study did find some forms of preparation to be beneficial. But other forms of preparation and, for particular children preparation in general did not appear to be of benefit in reducing negative reactions to the experience. Further research to investigate the psychosocial impact of day care surgery is warranted. This could be combined with a study of the individual characteristics of the children in an attempt to determine the characteristics of children who are most negatively affected. In that way, further preparation might be geared to addressing the needs of those children. 2. Measurement of Reactions to Hospitalization: It has been observed that different measures of anxiety or reactions to day care surgery do not respond to preparation programmes in the same way. The relationships among the variables measuring reactions to day care surgery and hospitalization should be studied, both between variables purporting to measure the same type of anxiety, such as behavioural rating scales, and between different types, such as self-reported and observed data. Relationships between in-hospital adjustment and post-discharge adjustment should be further explored. The interrelationships may then be examined within one of the theoretical frameworks of anxiety and coping with stress, such as Janis' "the work of worrying"(1958). It may be that some forms of anxiety are actually positive coping techniques, rather than negative symptoms to be suppressed, and our view of stress reactions at various times prior to, during and following the hospitalization experience may change.  175  3.Individual Characteristics: The examination of the individual characteristics of the children in this study related only to the interaction of these variables with preadmission preparation treatments in affecting reactions to hospitalization. No attempt was made to determine which children were most negatively affected by the day care surgery experience; only which programmes (or any) might be effective in reducing negative reactions. Just as individual differences interacted with preparation, so may individual differences interact with each other and preparation. This inter-relationship of individual characteristics should be explored. In the present study ten characteristics were selected from those individual differences described in the literature as affecting- reaction to hospitalization. Other characteristics should be examined, particularly those associated with coping styles. Further research is required to confirm the results obtained in this study. 4.Programme Effects: The intention of the study was to compare the effectiveness of instructional approaches and modes of delivery of preadmission preparation programmes. Because the results described in this study are specific to the actual programmes as they were created for the study, further research with other programmes developed from the same models is required to support the evidence presented here that the Rehearsal-Instruction approach and Audio-Visual mode of presentation are the most generally beneficial programmes for reducing negative reactions to hospitalization. Since no other studies have found a significant effect of preadmission preparation for day care surgery, further research should be conducted to confirm the results obtained here. 4.The Hospital Tour: The hospital tour should be further evaluated. Recent research has found no support for including the tour in a preparation package (Peterson et al., 1984). Similarly, in this study, the tour did not appear to enhance the effectiveness of other preadmission preparation programmes. However, evaluated on its own, the Tour did appear to be better than no preparation at all, and indeed, better than some Programme/Tour combinations. Further research should examine the effectiveness of the hospital tour as a stand-alone programme, rather than as an addition to other services. An Example. The preceding general recommendations could be developed into several different lines of research. An example of one such line, or series of research projects, is developed below. Each research question builds on the data obtained in the preceeding studies.  176  1 .What are the psychosocial effects of day care surgery on children? Anthropological or case study style research could describe the reactions of children to day care surgery. Observing the children and their responses to the experience and observing and discussing changes in behavior with the parents following discharge would generate descriptive data. This type of research opens the perspective to include effects not previously identified in the literature on inpatient hospitalization. Positive effects might also be apparent. 2.Do children who have day care surgery differ in measurable psychosocial ways from children who have not had surgery? The descriptive data generated in Question 1 could be developed into instruments which might be used in examining the effects of day care surgery on children. These instruments would be validated by comparing hospitalized children with non-hospitalized children and by continuing to collect descriptive data to determine the sensitivity and reliability of the instruments. Comparisons with previously developed instruments could also be obtained. 3.What is the relationship of different manifestations of reactions to day care surgery? Once reliable and sensitive measures have been determined, the interrelationship of variables should be described. Sub-questions might include: a)What is the relationship between self-reported and observed anxiety? b)What is the relationship between in-hospital manifestations and post-hospital manifestations of stress or anxiety? c)What is the relationship between verbally expressed and observed anxiety? At this point a theoretical perpective should be included to explain the relationships observed. 4.Which children are most negatively affected by their day care surgery experience? A large number of characteristics could be individually and in-concert examined in a corelational study to determine whether a profile could be developed to describe the children most negatively affected by the day care experience.  177  5.What preparation programmes could be used in the particular setting of the study? An analysis of the conditions existing in the particular hospital, the population it serves, and the potential for changes to facilitate the use of a preparation programme should be.made. If this analysis is done first, then if a programme is found to be effective, it may actually be used. 6.Does preparation make a difference to the reactions of children to day care surgery? Which Instructional Approach is most effective? The effectiveness of the preparation programmes can be evaluated against the base-line data already collected (effects of day care surgery: Questions 2 and 3). 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S., & Meng, A. L. (1986). Coping skills training for children: Effects on distress before, during, and after hospitalization for surgery. Health Psychology, 5(3), 231 - 247.  185  APPENDIX A  186  APPENDIX A CONTENTS  ITEM  PAGE  Programme Manuals  Procedure for Treatments  ,  Procedure for Interviewers  188 194  Initial Telephone Contact  194  Procedure for First Home Visit  200  Second Telephone Contact  216  Visit #2  217  187  Procedure for Treatments  Interviewer Invite  Say:  will  them into  bring  the family  the office.  to the Project  Establish  Office  and introduce  them.  rapport.  I'd like to thank you,(child's name) and (parent's name), for participating in our study. We really appreciate your, taking the time to answer our questions. Pause for response.  There are two purposes to our project. One i s to find out how children and their parents feel about coming to the hospital, how they feel while they are here, .' and how they feel looking back on the experience once they are back home again and feeling fine. The other purpose is to find out the kind of information that people have been able to obtain about the hospital and the surgery.  (Child's name), have you  ever been to the hospital before? Find out the child's  experiences  Acknowledge the information Proceed with To  connected with the  he/she is likely  hospital.  to have had.  interview.  parent:  1. Did Dr. (doctor's name) describe the operation to you? Do'you feel satisfied that you understand what he is going to do?;  (Probe:  Check lc '2b, 2c. s  2. Did he/she give you any information about the hospital, about what would happen (tomorrow), how the day would proceed? Check 2d, 2e.  3. Did he/she describe the anaesthetic? Check 2e.  4. Did he/she talk about how (child's name) would feel when he/she woke up? Check 2f.  5.  Did he/she talk to you about talking to (child's name) about coming to the hospital Check 2h,g.  '  188  6. What about your paediatrician or family doctor,..did he/she t e l l you anything about the hospital or the operation? Check 2-1,3.  7. Has anyone else told you anything about the hospital? Check 1 and 2.  :• .  •  8. Have you had any other experiences with the hospital? Refer to information  received  from  child.  Check le,f,. etc., and Zd,e.  To child:  (confirm  responses with parent)  9. (Child's name), were you with your (parent) when Dr. (surgeon's name) told her about what is going to be happening (tomorrow)? ,  Response.  What did he/she say?  What is he/she going to do? What will happen?  How will you feel afterwards? Check 4,5c. To parent:  10.  Have you talked about i t at home very much?  ^  Check 4a,d. To child:  11.  *"  (Child's name), some children have read books about going to the hospital, like Curious'George or Sesame Street.  Have you read any of these?  Check 5b.  12. ' Have any of your friends/brothers/sisters been in the hospital? If yes: Did they t e l l you anything about what happened? Check 5 d,e.  Say:  Okay. Now I think (interviewer's name) has a few questions for you and your mom/dad, so I ' l l just go outside to give you a bit more room. Leave.  Check Interview  (green  sheet).  and score Programme Log Rating Scale  189  -  Discussion  When parent  has finished  questionnaire,  chat with them. If they are NOT in Control  say: We have developed a book/video tape that  tells  what i t ' s l i k e to come into the hospital or what happened to two c h i l d r e n who came into the h o s p i t a l f o r surgery. I'd  l i k e to show'it to you and ( c h i l d ' s name) and see what you think o f i t .  Response from parent. Because of the way the study i s set up, (interviewer's name) doesn't know that I'll  be showing t h i s to you.. I ' l l ask ( c h i l d ' s name) to keep i t a secret from  her f o r tomorrow when she comes.  Response from parent. Child and interviewer Invite  will  parent and child  Rehedrsal/Instruction  come put and interviewer  back into the  excuse herself  and leave.  office.  Conditions:  I have here a book/TV programme which t e l l s what i t ' s l i k e to come to  Say:  Children's Hospital to have an operation.  Modelling  will  Would you. l i k e to see i t ?  Conditions:  Say:  I have a book/TV programme here which t e l l s  the story o f what happened  to two c h i l d r e n , Eileen and Drew/Andrew, when they came to Children's Hospital to have an operation.  Would you l i k e to see i t ?  If NO, ask why they don't want to see it. If parent Say:  Encourage and reassure them.  is adamant about not seeing the book/TV programme, do not press.  W e l l , thank you f o r your time.  I hope everything goes well f o r you on  (date of surgery).  Record response  and inform interviewer.  STOP INTERVIEW.  If YES, say: Good.  Let's a l l look at i t together.  Turn on TV or read book with parent and child,  stopping where necessary to  answer questions. Monitor  child's  stop treatment  ' and parent's response.  and reassure.  them to discuss his/her  If child  is appearing  Discuss problem with child  concern.  190  highly  and parent.  anxious, Encourage  group,  For example, say: (Child's name), you don't seem to want to'watch this any more.  Is that right  Pause for response. Is there something in the TV show that you'd rather not see? Try to find out what is bothering  the child.  . Say: What happened to Andrew happens to lots of kids.  But you see, Andrew  is fine now.' He had his operation and now he's at home. When you. see the end, you will see that  he went home and is just f i n e .  LISTEN TO THE CHILD. Try to find Then diffuse Say:  out what is his/her  specific  concern.  the concern.  Now, shall we finish watching the TV?  There are only a few minutes  left. .  If the parent appears highly treatment the  if possible.  anxious,  note when this occurred  ...Engage the child  and finish  in another activity.  the  Then  confront  parent.  'For example, say: I noticed that you seemed uncomfortable when we watched the part of the .programme on the anaesthesia.  Are you particularly concerned about  (child's name)'s anaesthesia? Encourage  both the child  encourage  them to seek information  the anaesthetist, Include  Rehearsal/Instruction  to ventilate  from appropriate  hospital  their  fears, and  personnel, e.g.,  surgeon, the ward nurse, etc.  the parent in the child's  the parent's  Say:  their  and parent to talk,  concerns.  "~  Try not to include  the child in  concerns. Condition  - ai the end of the programme  And I have here for you a Hospital K i t , just  a s  y°u saw on the TV. in the book.  Open the kit.  Look at each item and discuss  or toy. Print  Condition Say:  - at the end of the programme  You may keep the book, (child's name).  191  practicing  with parent,  sibling,  Tour  Condition:  Say:  Now I'd like to take you all/6oth on a short tour of some of the parts of .  the hospital you will see while you are here. Okay? Inpatients: 1.  •  On the way to the third  floor,  note the  following:  Lobby, Admitting Admitting  T- discuss: signing papers, asking questions, someone will bring you up to the ward.  getting  armband,  Define ward.  *  2.  Playroom.  3.  Parents'  Note:  4.  Nurses' Station.  S:  Child's  Lounge.  Important  place.  Point out:  Point out the toys and books.  microwave oven, telephones,  Room. Remind that nurse will  Discuss:  show you all the  bathroom, locker, table, call bed-chair for parent next morning, will  parent be  Transport  O.K. Ante-room.  Elevator.  8.  Return  Describe  Note:  to Lobby.  things.  button and  light,  TV to  share,  there?  This is where you say "See you later", can come along and see where they will  7.  children.  Define.  Point out:  6.  shower, no  but for now take you.  parent  stretcher.  O.R. clothes,  sterile  area.  Questions?  Day Care: .  *"  1.  On the way to Lobby,.note the following:  2.  Information  3.  Day Care Waiting Area.  4.  Day Care Unit.  Desk. Discuss: Point out: Discuss:  5.  O.R. Ante-room.  6.  Return  to Lobby.  Note:  checking  Note:  Leave time for  in, signing  parking.  papers.  wait only for a few  minutes.  corner for weighing and measuring, getting armband, beds, curtains, wd~shroom outside in waiting area. going in same bed to O.R. parents here.  O.R. clothes,  Point out:  sterile  Saying  area.  parents to wait in cafeteria, for child.  Questions?  192  "See you later"  back to Day Care  to  All  Conditions  Say: Do you have any questions you'd like to ask me about the hospital or (child's name)'s surgery? Answer questions Do not discuss the  about the general hospitalization technicalities  of the specific  and surgical  surgery.  Direct  experience. the parent to  surgeon.  Be honest and be accurate. say so.  If there is no definite  e.g., "How long will  Answer:  he be in  answer to the question,  recovery?"  Until the nurses and the anaesthetist feel that he/she waking up and doing okay.  It's usually about an hour,  but i t could be longer. Say:  (Child's name), do you have any questions?  Answer the child's  questions.  Take your time with the family.  When you are satisfied  that their  are answered, say:  I'd really like to thank you for participating  in our study.  (Interviewer's name) will see you on (date of surgery). Let me show you back to the elevator/Lobby.  193  questions  1. INITIAL TELEPHONE CONTACT Hi.  Is Mrs.  Hi, Mrs.  there? .  This is  (your name)  from the Preadmission Preparation Study  at Children's Hospital. Dr. _ . (or nurse/receptionist) told me that (child's name) will be going to the hospital for surgery soon and he/she suggested you might be interested in participating in our study. If parent  seems unclear  as to what you are talking  about, say:  Do you recall receiving a letter - in the mail - at Dr. 's office telling you about the Preadmission Preparation Study at Children's Hospital? If parent  does not recall  or did not receive  letter,  say:  (Name of receptionist/nurse) at Dr. 's office told me that she had mentioned the study to you. The letter is from the Department of Paediatrics at UBC and the •Children's Hospital, explaining our Preadmission Preparation Study. We are attempting to determine how to make hospitalization and surgery as easy for children as possible. In order to do this, we are studying methods of preparing children for their hospital stay. Do you recall the letter? If parent  s t i l l does not recall,  say:  May I read the letter to you? If YES, read letter  as  follows:  Dr. has informed us that your child is going into the Children's Hospital for surgery. We would very much appreciate the participation of you and your child in our study. . In a will time This  few days, a research assistant (Pat Palulis, Qonna Schmirler or Gail Matiaszow) contact you by telephone and, i f you agree to participate, will arrange a one to two weeks before your child's surgery to visit you in'your home. visit will take approximately 45 minutes to one hour.  If your child will be admitted to the hospital as an inpatient, you will be asked to come to the hospital approximately one hour earlier than the admission time. If your child is having day care surgery or is admitted the day of surgery, you . will be asked to bri ng your child to the Children's Hospital a few days before the surgery so that further questionnaires can be completed. Also at this time, I will meet with you to discuss preparing your child for his hospitalization and surgery. ' (continued over)  194  Also, you will be contacted one month, three months and six. months following your child's hospitalization. At each of the times mentioned above, the research assistant will v i s i t your home. You will be asked to complete questionnaires regarding your child's feelings, behaviour and your own feelings. Your child will be asked questions concerning his feelings. Information such as the length of anaesthesia and type of medication will be taken .from your child's medical chart. All information will be kept confidential. You will have the right to withdraw from the study at any time and withdrawal will not affect further medical care or treatment of your child. The hospital and Dr. have approved this study and are interested in the findings. We would appreciate your participation in the study. The letter is signed by Jeanine Harper, the Project Coordinator and assistant to Dr. Geoffrey Robinson, a paediatrician in the Department of Paediatrics at the Children's Hospital.  If they say NO to reading the letter,  say:  May I.ask why? If they continue  to express no interest,  say:  Well, thank you for your time.  If parent  seems familiar  STOP INTERVIEW.  with the study or recalls  receiving  the letter,  say:  May I t e l l you a l i t t l e more about our study? If parent  asks'how long this  will  take or express some concern regarding  time, say:  It will take about 10 minutes. If they are s t i l l concerned regarding  time, say:  Could I call you back at a more convenient time? If parents May  says NO, say:  I ask why?  Record  response.  Well, thank you for your time. If parent  •  Arrange time.  STOP INTERVIEW.  says IES, say:  The purpose of this study is to find out how parents and''children feel about having surgery and going into the hospital. (continued over)  195  Our goal is to develop methods of  preparing children for their hospital stay so that the whole experience will go as easily as possible for them. In this study, we are including children who are • having elective surgery and (child's name) i s just the right age. We were hoping you and (child's name), would like to participate in our study. What that means is that I would interview you and (child's name) before his/her surgery, then stay in contact with you during the hospitalization and after i t i s over. Does this seem clear st) far? Pause for  reaction.  The general procedure for the study is outlined in the letter you received. Maybe I could review this with you just to c l a r i f y . i t . I will see you both at your home and in the hospital. and  I would like to v i s i t you  (child's name) in your home before (child's name) goes for surgery.  This v i s i t takes about 45 minutes to an hour. There are some questions for both you and  (child's name) . The purpose of this v i s i t is to get to know you and get  some background information. If INPATIENT, say:  Then the project coordinator and I would like to meet you at the hospital just before  (child's name) is admitted so that we can discuss the ways children and  parents get ready for surgery and hospitalization.  *•  If DAI CARE or ADMIT-DAI-OF-SURGERX, say:  Then the project coordinator and I would like to meet you at the hospital a day or two before the surgery so that we can discuss the ways children and parents get ready for surgery and hospitalization, and  (child's name) will have a chance  to look at the hospital. To ALL:  .  Then I will see you at the hospital on the morning of (child's name)'s surgery for a very short time. The final home visits are after (child's name) is back home and recovered. The purpose of these visits is to get, your and reactions to the hospitalization.  196  (child's name)'  4.  We will use all.this information to decide how best to prepare children for hospitalization at the Children's Hospital. How does this sound to you? Do you think it might be something you'd be interested in participating in? If parent  says  IES,*say:  That's great.  Can we set a time for me to visit you and (child's name)  It should be before  at home?  (T week before surgery) .  Make appointment. Get  directions.  Say:  Do you have any other questions about the study?  Answer questions.  Then say: .  If you think of any (other) questions between now and (date of appointment), I will be glad to answer them for you at that time. Or, you can call our office. -The phone number is on the letter you received and I ' l l give it to you again, if you like.  It is 433-4449.  Confirm date and time. Say:  Thank you very much.  I'll look forward to meeting you and (child's name) . * STOP INTERVIEW/.  If parent  says NO, say:  May I ask why?  Record response.  Well, thank you for your time. *  STOP INTERVIEW.  English Competency Criteria If you are really  not sure that they understand what you are asking, say:  Do you understand what I mean? If you feel  they are not comprehending, say:  I don't think this would work out. Thank you for your time, but (child's name) cannot be part of our study. Before you hang up, make sure they understand at the  that you will  not see them  hospital.  If they offer See instructions  to get a translator,  accept the offer  for parents who cannot read  197  and proceed.  English.  QUESTIONS AND COMMENTS  Too much time is involved.  . '  There is a certain time commitment involved, but we have organized the project so that it will be as convenient as possible for people to participate. I will arrange the home interviews at your convenience. The first one is about an hour in length, but most of the others aremuch shorter. Inpatients:  You would have to come to the hospital only about an hour ahead of your regular admission time. Day Care and A.dmit-Day-o f-Surgery:  We can arrange your visit to the hospital for any time'that is convenient for you within the three days before the surgery. And it is a good opportunity for (child's name) to see the hospital. If it is necessary,  we can offer  transportation  to and from the  hospital.  I work all day.  I can arrange the interview for an evening or on a weekend i f that would be more convenient for you. If there is a question The respondent other  about who should  should  answer  be the primary  questions.  caretaker,  whether mother, father  or •  adult.  Who would know (child's name) the best and be able to answer our questions? With shared responsibility, If parent  is afraid  we need one adult  that questioning  may increase  to respond child's  consistently.  anxiety.  We certainly do not want to increase (child's name)'s fears or the fears of any children. We are concerned about children.like (child's name), who may be anxious about the hospital. There are many children who feel exactly the same way. (continued on next page) /  198  6. When I v i s i t you before the hospitalization, I will have a few questions for you about the up-coming surgery.  But I won't be asking  (child's name)  anything  specifically related to the event. The purpose of this v i s i t is to get to know what he/she is normally like,.so we can compare that to how he/she behaves in the hospital and afterwards.  We do ask a few questions about health in  general, for example, "What can children do to have healthy teeth?", just to get an idea of his/her concept of healthiness.  We don't feel that this should make  (child's name) more anxious. When we meet at the hospital, again . we don't ask specific questions about the hospitalization.  For example, we have a questionnaire about how he or  she is feeling at the moment, but i t doesn't mention the hospital. You are welcome to look over a l l the questionnaires before v/e give them to (child's name) . The questions that the project coordinator asks are also very general. They are designed to find out what he/she knows already about the hospital and . . his/her surgery.  5.  Asks for more details  The questions are actually directed to you, the parent.  of  questionnaires.  Well, there is an interview in which I ask you some questions, about your family's background, how many members in your family, questions like that, and a l i t t l e bit about  (child's name) 's health history.  you to f i l l out questionnaires describing and important events in his/her l i f e .  And I ' l l be asking  (child's name)'s normal behaviour  And there is a brief questionnaire  asking you to describe your own feelings.  We will be asking (child's name)  to describe his/her feelings, his/her concept of health, and his/her vocabulary. ' After the hospitalization, T w i l l ask similar questions and also questions on your reaction to the hospital experience. You are welcome to look over a l l the questionnaires before I give them to (child's name).  199  PROCEDURE FOR FIRST HOME VISIT  Introduce yourself to parent and child. Preparation Study. Get seated.  Establish  Include your name and- the  Preadmission  rapport.  Before we get started, I'd just like to tell you a little more about the Preadmission Preparation Study and also explain more about what we are going to do today. I contacted your family because (child's name) is going in for surgery soon. I am talking to lots of parents and children who are having surgery to find out more about them, especially what they think about hospitals, surgery and • how it affects everyone. To  Parent:  I'm gtjing to be asking you some questions about yourself and your family ibackground, and about your perceptions of To  (child's name) .  Child:  I'm going to talk with your (Mom, parent, caregiver) for a little bit and then while he/she answers some questions on his/her own, I'd like to talk with you for a little while. Continue:  Any questions before we get started? If you have any questions as we go along, please feel free to ask them. Before we get into the interview, I need to have you sign a consent form. It says that you have given your permission for you and (child's name) to participate in the study. I want to tell you that all the information you give me will be kept completely confidential and anonyiflous, so that your name will not be directly attached to any of the questionnaires. Give consent form and have parent sign.  Then sign it  If there are others present who may distract  yourself.  or interfere,  say:  For the purpose of the study, it's important that we have the opinion of only one person.  200  BACKGROUND INTERVIEW  Code Visit  Number 1 on cover  Record Subject  sheet.  Code on pages 1, 2 and 3.  Say: First of a l l , I'd like to get some background information. I'd like to start out by asking you some questions about you and your family. 1.  Record date (e.g., June IS, 1983).  .  1.  1_ S_ / 0_ §_ /  5 3_  2.  2_ 6_ / 0_ 2_ / 7; 0_  2. Say: (Child's name), do you know when your birthday is? Confirm response with parent 3.  Sex.  (e.g., Feb. 26, 1970).  Can be confirmed with referral  4. say tb child:  source,  [2] Male [ 2 ] Female  And where do you come in the family?  oldest or older has both older and younger siblings youngest or younger only child .5 J twin Count only natural or adopted siblings (i.e, those coded in #5 e and f) e.g., Jane*, 5 Sue, 7 e.g., Jane*, 7 'Sue, 3 (natural sibling) Tom, 2 (common-law sibling) Joe, 17 (common-law sibling)  5.  Say to respondent:  You are  children^  Code: 3  Code: 1  (child's name) 's  (relationship)?  [ i ] Mother: mother, step-mother, long-term foster mother (over 2 years) [ 2 ] Father: father, step-father, long-term foster father (over 2 years) [3] Other relative: natural or common-law relationship, grandparent, aunt/uncle [4] Foster parent: short-term or new (less than 2 years) placement [ 5 ] Other: live-in partner of parent e.g., "I'm not her natural mother but we live together as a family." e.g., "We're taking care of Johnny for a l i t t l e while." e.g., "Susan and her mom moved in with my son and I last year."  201  1 4 3  9. 6a. Say: Who lives in the house with you? Code number in each category. Do not include child. a) b) c) d) e) f) g) h) i) j)  Include  respondent.  Natural or adopted mother Step or common-law motherNatural or adopted father Step or common-law father Older siblings (natural or adopted) lounger siblings (natural or adopted) Other related children: step or common-law siblings, cousins, etc. Non-related children (foster, 'communal) Other adults, respondent's boyfriend or girlfriend, relatives, etc. Twin e.g.  Subject  = Jane*, age 7  Jane 's mom Fred, common-law father Fred's sons, Jim, age 9, and Peter, age 3 Tom, Jane's brother, age S Jane's grandmother  6b.  Marital [i] [2] [3] [4j  Code: 1 0 Q . j g  '  status.: married, common-law separated divorced other (widowed, single)  7. Say to parent:  Are you currently employed?  Response: no Response: yes.  Say:  Is that full time?  Response: full-time Response: part-time e.g., "I work full-time at a clinic."  Code: 1  Code: 2 3 building  boats and part-time Code: 2  8. Say: What do you do? Record response, probing for tasks, position in hierarchy, etc. Occupations are to be coded according of the "Blishen Scale.  responsibilities,. ' to the categories  202  j 2 0 1 0  9. Say: And your husband/wife, is he/she employed? Continue as if 7. If no spouse, but other adults  living  in home, say:  Does anyone else contribute to your family's income? This does not include  boarders, paying food and/or  If there is no other adult contributing  10.  ,  lodging.  to income, code 9.  Continue as #S. e.g., Jane's* grandfather lives in home, and works as a boatbuilder. Code his occupation. e.g., Jane's mom, hairdresser Jane 's dad, carpenter Jane's grandmother, owns hair salon - code Jane 's mom and dad only  full-time  11. -.Say: Now I'd like to ask you some questions about your family's background. First, what is the cultural background of your family? What country does'your family come from? Note:  For mother, code only natural, For father, code only natural,  adopted or step-mother. adopted or step-father.  Probe: How many generations back did your family come to Canada? Do you consider yourself ? If respondent is not sure, may have to move to #12. If answer to if 12 is No, code 01. e.g., Mom - parents born in England - has no accent, does not consider  herself  British Code: 01  e.g., Dad - white South African - immigrated 10 years ago * Code: ill] Other: South  Code: 11 African  If answer id] Canadian or American, omit ff!2 and/or ff!3. Code ill'] Other - New Zealand - Turkey - Columbia Code il2] Canadian Indian  203  11.  12 and 13.  If $11 is coded [ f l i ] , code 4. Responses to these questions must depend on respondent's If they are confused, say:.  perceptions.  Do you belong to any clubs; associations, or groups which have mainly . members? Do you observe any of the traditions in your home, such as food, ceremonies, special holidays, etc.? 13b.  If no common-law father,  code 9_.  14.  Say: How many languages does  (child's name) speak?  Code the number of languages.  15.  Say: What is the language (child's name) spoke/learned first? Note:  If the child learned 2 languages together, e.g., English and Portuguese, code English as the first language and Portuguese as the second language.  Record first,  second and third  languages.  See code sheet. 1st  language:  [l]  English French Asian (Chinese, Japanese, Korean, Vietnamese, Philipino) Western European (German, Scandinavian, Italian, Portuguese) [ 5 ] Eastern European (Serbo-Croatian, Greek, Hungarian, Slavic) \6~\ Middle East (Turk, Hebrew, Arabic) \7~\ East Indian (Punjabi, Hindi) 3} Other (keep a l i s t ) - Spanish,  204  16. Say: Now I'd like to ask some more "specific questions about (child's name)'s health history. Does (child's name) have any chronic diseases, disabilities . or other conditions? Note: Condition should be handicapping treatment/supervision. If parent is unsure, examples might asthma allergies speech problem  mental handicap learning disability hearing impairment  Record all diseases, parent reports.  disabilities  and/or require  medical  include: -  diabetes arthritis  and conditions  that the  If respondent is unsure, ask:  Does (child's name) find the condition handicapping? Does i t affect his/her normal activities? Code first two mentioned by parent. See code sheet attached. * •  Chronic  Diseases  and  Disabilities:  .00. No, None '.10'.Allergy - reaction unspecified ~ll\ Exzema .12'. Hay fever '13'. 'M'. Asthma palsy '.20'.Cerebral *• 21 Spina bifida '.22'.Epilepsy '23' < Tuberous sclerosis \30\ Pneumonia '31 Bronchitis ' 32. Tonsilitis diseases - ears plugged, infections, hearing loss '33' Respiratory diseases - nose plugged '.34. Respiratory palate '40' Cleft 'AS. Club foot, amputated foot - kidney, bladder, ureters 'SO' Urinary tract infection SS\ Heart problems '60' Obesity '65'. Eye problems '70' Behaviour problems - general .71. Hyperactivity '72. Depression .75. Learning disabilities .90'. Others - high blood pressure, cysts, skin problems, bum scars '81 Orthopaedic problems '  205  13.  17. Say: Has (child's name) been in the hospital before? Code:  Note:  If  [li Yes No  [2]  This includes day care as.well Emergency. • "  as overnight  This does not include doctor's lab tests or x-rays.  office  visits  stays and trips to at hospital,  outpatient  in doubt, record.  18. Say: How many times has he/she been in the hospital? Code the number of times. Note:  If parent does not know or is unsure, ask: if they can find out or. get permission to ask their doctor.  Say:  Would your doctor have all the dates?  19. 20 and 21.  Say: •  'All right, now I need to ask you a little bit about each hospitalization. a) How long ago was the most recent? • Code actual month and year, if If season given, code as: [02 J [04~\ [07] [20]  b)  ^  Why was he/she in the hospital? Code:  [i] [2] [3]  Medical (see attached list) Surgical (see attached list) Emergency (see attached list)  c) ' How long was his/her stay? Code number of days.  d)  given. Winter Spring Summer Fall  (number of days)  If their  stay was under 24 hours,  Where did you go? Record:  Code:  - name of hospital - type of hospital - location of hospital [2] [2] [3] [4] [5]  *.  B.C. 's Children's Hospital Acute care hospital Chronic care hospital Other paediatric hospital Old Children's Hospital  2Q6  :  code as 1 day.  14. 19, 20, 21. Medical  [l]  : First  blank.  Second blank:  ii]  Clinical investigation - chest test, test for hole . .'in heart, observation, EEG, brain scan , •Musculoskeletal - physiotherapy, knee aspiration [2] Respiratory - bronchial cyst, bronchial pneumonia, croup, ear infection, flu Central nervous system - convulsions, reaction to medication, took adult medicine Castro-intestinal - diarrhea, dehydration [5] Genito-urinary - kidney infection, urinary infection [7] Miscellaneous - high fever, abscess drained, prematurity, herpes infection  [<1  Surgical  [2 3  First blank. Second blank: \_i] [2] [3] [4] [S]  [t>] [7] [s] [s]  Emergency  [ 3 ] ; First  ENT - tubes, tonsils, adenoids, removal of laryngeal palilloma General - circumcision, hernia Genito-urinary - undescended testes, hypospadius, kidney operation, systoscopy Plastic - nose revision, cleft palate surgery, burn scars, tongue-tied Orthopaedic - foot amputation, broken arm/leg, cast manipulation and change, hip casting, orthopaedic leg surgery Dental surgery Eye surgery Neurosurgery - shunt revision, closure on spine for spina bifida Cardiology  blank.  Second blank: [l] [2] [3]  [4] [5] [6] [73 [5]  Fractures, sprains, contusions - sprained ankle, broken arm, thumb in door Head injury - fall on head, concussion,.head cut, hairline skull facture Other injuries (not specified) - hit by car, fell down stairs, face cut, fell off swing, stitches, rock in eye Foreign bodies - swallowing objects, FB up nose, broken needle in leg Gastro-intestinal - stomach cramps, bowel obstruction Allergic reactions Acute infection - hip infection Poisoning  207  15  20.  What about the time before that?  When was it?"  Proceed the same as #19, a,b,c,d  21.  And what about the time before that? Proceed the same as #19, a,b,c,d  22.  Note:  If there are more than 3 hospitalizations (excluding current hospitalization), record the 3 most recent and mark #22 as [2] Ies, to receive an additional questionnaire.  We are very interested in the effects of hospitalization on children* so I'd like to ask you about (child's name)'s earlier hospitalizations in more detail(at a later dateTI . Use discretion whether to administer If parent has poor recall, say:  now or  later.  Would i t be possible to get this information from your doctor? 23.  Has (child's name) been separated from your family for any 'extended .period of time, for any other reason, besides being in the hospital? Note:  Code  Extended refers to 3 weeks or more, or whatever the defines as extended.  parent  Children  siblings.  [7.]  [2]  Separation  should be separated  from both parents, and  Ies (If Ies, see Separation No  Questionnaire)  «•  Questionnaire:  If Yes to #23,  ask:  - age of child at separation -•length of separation (weeks) - record reason : If more than 1 separation for each, separation. 24.  has occurred, .  ask these  questions  Now I'd like to ask you a few questions about (child's name)'s hospital stay. Who will be taking (child's name) to the hospital? Code: [ l ] Mother: natural, [2] Father: natural, [3] Both [4] Other [5] Don 't know .  step, common-law, long-term step, common-law, long-term  fosterfoster  16.  25. Will anyone be staying with (child's name)? If No, Code O]  No one.  If Ies, say: Who will that be? Code:  [l] [2] [3] [4] [5] [S]  Mother: natural, step, common-law, long-term Father: natural, step, common-law, long-term Both • Other Mother, father and others Don't know  foster foster  26. How much time will you spend with (child's name) at the hospital? Note:' If more than 1 person is staying (non-overlapping) hours.  with child,  code their  combined  e.g., Johnny's mother stays with him 3 hours in morning. Johnny's father stays with him 3 hours in evening. Code [2] 4-7 hours 'e.g., Johnny's mother and father 3 hours Code 1-3 hours  both stay with him for  e.g., At least 1 person is with Johnny at all times, day and night. ' .If Day Care, Code [5].  27. Who will be looking a.'ter (child's name) when he/she comes home from the hospital? If parent seems confused, say:  Who will look after or take care of (child's name) while he/she is getting better? Note:  [4] Other (relative or friend), not paid [5] Baby sitter/housekeeper - paid position  209  15.  PARENT'S BOOKLET  Good. That's the f i r s t part of the interview finished. To  Child:  Now,  (child's name), I've got some questions just for you and some for your  mom/dad. To Parent:  .  (Parent's name), here are some questions I'd like you to answer in writing. Hand booklet  to parent and review it with him/her.'  Each set of questions is a different colour. The f i r s t one i s called The Life Events Scale, and here you have to answer for your c h i l d , so you are asked i f any of these things have happened to (child's name) in the past year. The next three sections ask you some pretty detailed and specific questions about (child's name)'s behaviour and personality.  You may.notice some overlap  •-".in the questions and also some of the questions may not apply to your c h i l d , because he/she is too young or too old. These questions are meant to be given to a wide age range of children, that's why there are so many different kinds of behaviour included. It looks like quite a few questions, but i t usually doesn't take too long. The last one, the Self-Evaluation Questionnaire, asks you some questions about yourself, your perception of yourself. To  Child:  Now, (child's name), I'll just show your mom/dad.the questions that we'll be doing while she/he i s busy with her/his questions. To Parent:  The f i r s t set of questions is just to get an idea of his/her vocabulary l e v e l . The second and third parts ask what he/she thinks about him/her self and his/her feelings.  The last part is to get an idea of his/her understanding  of the concept of health. Allow parent  to examine the booklet.  I ' l l let you go on your own, then.  If you have any questions as you go along,  please ask.  Don't write your name on any of the pages and be sure to answer  every item.  Don't forget that the green pages are to be answered from (child's name)  point of view. For example, when i t says parent (point to Item 12), that means you.  210  If parents Life  ask:  Events Scale,  Item $30,31:  - Does the mother perceive  visible it as a  - Is it a problem to the child  Behaviour  Checklist  A, Item 856:  deformity deformity?  in any way?  physical  problems without -known medical cause  e.g., headaches - because of sinus condition headaches - because of tension  are not counted,  or anxiety  211  are counted.  17 FOR PARENTS WHO MAY HAVE DIFFICULTY READING .THE QUESTIONNAIRES"  Note response to read  to Consent Form.  This may give you an indication  as to their  ability  English.  PARENT'S BOOKLET:  Say: That is the f i r s t part of the interview finished. Say to the  child:  Now, (child's name), I have some questions just for you and some for your mom/dad. We will do your mom/dad's f i r s t , okay? So maybe you could find something to play with for a l i t t l e while and I will call you when i t ' s your turn. Okay? .:  Pause for reaction  and for child  to leave if he  chooses.  Say to the parent:  (Parent's name), here i s the Parent's Booklet. questions to you and you tell me your answer.  -  I will just read the If there is^anything  you are unsure of or don't understand, just ask me, okay? Monitor  the parent's reaction.  elaborate If.another  on the question.  If he/she seems confused,  pause and  Use your discretion.  adult or older child  offers  to interpret,  ^ say:  That would be great, but i t ' s really important that we have only (parent's name)'s answer to the questions.  So you will have to try  to t e l l me only his/her opinion, okay? If there is a great deal of discussion or you are suspicious  of the nature of the translation,  Read each questionnaire When finished,  call  between the two  adults, repeat  the warning  to the parent.  back the child  and proceed with the Child's  212  Booklet.  CHILD'S BOOKLET  Okay, (child's name), let's find a quiet spot where we won't disturb your mom/dad. Find a place.  If no other room easily  and ask that other children Establish  available,  place child  with back to parent  leave the area.  rapport.  Today we are going to look at some pictures- together, and then after that I'm going to interview you, just like on TV. I want to get your opinions about yourself and what you think about some things. Okay? •In the game . . .  (Follow standardized  encouragement, praise  instructions  for Peabody.  throughout, make it a positive  Okay.  That was really good.  Follow  standardized  experience  Give child  lots of  for him/her.  Now I'd like to do my interview with you, all right?  directions.  on top of questionnaires.  "What I Am Like" and "Bow I Usually Feel": For younger children, response  substitute  child's  name for "I" in items and repeat  choices for each item to guard against  children  falling  into a  response set. For  "Children's  Health Interview", say:  Now I'd like to get your opinion on health, or Now I'd like to ask you to tell me what you think about health (depending  on the age of  child).  So I'm going to ask you some questions. just tell me what you think. Probe for further E.g.,  "Anything  responses else?",  give me another Probe for clarification. E.g.,  There are no right or wrong answers,  in each item.  "Is there anything  else people can do?",  or "Can you  reason?" If you do not understand  "What do you mean?", or "Tell me a little  213  their  response,  more about  question  that."  further.  19.  Children's  Health  Questionnaire:  This is the last set of questions. Just t e l l me whether you think these sentences are true or not true. Well, (child's name), that's i t . you.  You really di'd a good job.  I had fun interviewing  Let's go see how your mom/dad is doing.  Return to parent.'  Check over booklet for missed items. . Say:  I'm just going to check through this to see.that you didn't miss anything. f/hen checked, say:  That looks good. Thank you very much. Do you have any questions? Answer  questions.  Before I go, I want to talk to you about the next part of the study. INPATIENT:  (Child's name) is going to the hospital on (date).  The hospital will phone you  the day before,, but they can't usually confirm that''there will be a bed available until the (date of admission). They will ask you to call the hospital at 10:00 a.m. Explain  further  if necessary.  However, we will assume that there will be a bed and everything will go smoothly. Could ydu plan to be at the hospital at (time) ? Don't go to the Admission Desk. I will meet you in the lobby and take you to our office. is admitted,  It's important that we have a chance to talk before (child's name) I will have a few questions for you, similar to the last question-  naire you did today, and I'll be able to see how_(child's name) is reacting to the hospital.  I ' l l just be watching you and (child's name) talking together  for a few minutes. The project coordinator will also have a few questions for you.  Then, (child's name) will be admitted at (one hour l a t e r ) .  on the evening before or in the morning, just to confirm the time.  I ' l l call you Okay?  DAI CARE or ADMIT-DAI-OF-SURGERI:  (Child's name) is going into the hospital on (date). to the hospital a day or two. before that. you to our office.  wVwould like you to come  I ' l l meet you in the lobby and take  I'll have a few questions for you similar to  214  20  those on the last questionnaire you did today, and I'll be able to see how (child's name) is reacting to the hospital. I'll just be watching you and (child's name) talking together for a few minutes. When would be a convenient time for you to come? Arrange  date and time, no more than 3 days before surgery.  E.g., if surgery on 26, come on 23, 24 or 25. Offer  ALL:  transportation  ONLY IF NECESSARY.  Confirm  that they know directions  Present  business card and say:  to hospital  and location  of lobby.  Now i f you have any questions before I-see you again, or i f something comes up or any changes occur in the date of surgery, here's the phone number of our office so you can get in touch with me. I may not be there, but you can leave a message and I will get right back to you. Confirm  next meeting  time or phone call.  STOP INTERVIEW/  215  21.  SECOND TELEPHONE CONTACT  Call  on the evening or morning before scheduled visit  at the  hospital.  Hi, (parent's name), this is (your name) from the Preadmission Preparation Study. I am just calling to confirm that we are meeting tomorrow at the hospital at (time). Pause for  reaction.  Let me just remind you about what we will be doing at the hospital. I will introduce you to the project coordinator. I will have a short questionnaire for you and for (child's name). And while you are talking to the project coordinator, I will be doing what we call a 'behaviour observation'. •This means that I will be watching (child's name) for a few minutes to get an idea of his/her reaction to the hospital. If you can pretend that I'm not watching and just act normally, that would be great. If parent says "Won't (child's  name) know that you are watching?", say:  I'll .tell him/her that I have some work on my own to do for a few minutes. Pause for reaction  and questions.  Don't forget to wait for me in the lobby.  I will meet you there.  "~  INPATIENTS:  Don't go to the Admission Desk until after I have seen you, okay? DAICABE: If transportation  has been promised, confirm  arrangements.  All:- Will anyone else be coming with you and (child's name) to the hospital tomorrow? Record  response.  That's great.  So we will see you tomorrow at (time) in the lobby at the  Children's Hospital.  NOTE: Call Project  Coordinator  if any change in time has been made for VISIT #2.  216  22.  VISIT # 2  Meet family Project  in lobby.  Coordinator  Introduce  family  Establish  Establish  rapport.  will meet family  to Project  Escort  family  and-Interviewer  Coordinator,  to Project  Office. *;  at office.  who will invite  the family  • inside.  rapport.  P.C. says: (Child's name), we've got some games here that you and your mom/brothers/ sisters can play. Would you like to choose one to have a look at? When the child's  attention  and/or mother, complete When observations  has been directed  to game or interaction  with  coordinator  observations.  are complete, and a natural  break occurs,  say: •  Okay, (parent's name), I have a questionnaire for you to f i l l in. It's very similar to one you did the last time. But in this one, you are asked to describe how you feel right now. Okay? Give booklet  to parent.  And, (child's name), I want to ask you a few questions, too.  To child:  Proceed with Child's Project  Pause for reaction.  Coordinator  removed from-office Interviewer  will  Booklet.'  engage siblings  in games or conversation.  They will be  if necessary.  says:  (Project Coordinator's name) has a few questions for you now. I have to leave, but I will see you (day ancftime) in your room/the day ca unit. Pause for  reaction.  Good-bye.  217  APPENDIX B  218  APPENDIX B: CONTENTS  PAGE TABLE B.l  :  220  Results of MANOVAs : Continuous Variables for Attention Contrast (Group) and Agegroup and Gender T A B L E B.2  220  Results of MANOVAs (interactions with occasions): Children's State Anxiety Inventory for Attention Contrast (Group), Agegroup and Gender T A B L E B.3  :  221  Results of MANOVAs (interactions with occasions): Hospital Behaviour Questionnaire for Programme and Tour with Agegroup (Agegrp) and Gender T A B L E B.4  222  Results of MANOVAs (interactions with occasions): Observation Scales for Programme and Tour with Agegroup and Gender TABLE B.5  223  Results of MANOVAs (interactions with occasions): Children's State Anxiety Inventory for Programme and Tour with Agegroup and Gender TABLE B.6  224  Results of MANOVAs (interactions with occasions): Hospital Behaviour Questionnaire for Approach, Mode, Tour, Agegroup and Gender TABLE B.7  226  Results of MANOVAs (interactions with occasions): Observation Scales on Approach.Tour, Agegroup and Gender TABLE B.8  228  Results of MANOVAs (interactions with occasions): Children's State Anxiety Inventory on Approach, Tour, Agegroup and Gender  219  TABLE B.l Results of MANOVAs (interactions with occasions): Continuous Variables for AttentionContrast (Group), Agegroup and Gender  Hospital Behaviour Questionnaire Contentiousness V2F1 F P  Source of Variance Main Effects Group Surcat Agegroup Gender Explained  0.562 0355 0.195 0.097 2.167 0.562  Dependent Anxiety V2F2 F P 1.060 0.491 0.701 0.259 1.875 1.060  Sleep Disturbance V2F3 F P  Appetite Disturbance V2F4 F P  1.034 1.023 0.050 0.445 0.816 0.349 3.934 0.057 4,166 0.011 0.410 1.034 1.023  0.051 .  Observation Scale  Verbal F P 0.707 1.446 0.854 0.906 0.154 0.707  Non-Verb. F P 1.228 4.993 0.035 0.223 0.465 0.260 1.228  Rating F 0.494 1.766 0.186 0.066 1.108 0.494  T A B L E B.2  Results of MANOVAs (interactions with occasions): Children's State Anxiety Inventory for Attention Contrast (Group ) and Agegroup, Gender Pre Surgery Source of Variance Time Group Agegroup Gender Group x Agegroup Group x Gender Agegroup x Gender Group x Agegroup x Gender  F 1230.103 .542 2.549 3.974 1.914 9.146 6.513 1.198  6 Week Post P  F  P  .000  23.29465 1.52663 12.28868 6.40927 2.92437 4.33803 8.63675 .48237  .000  .058 .006 .017  220  .002 .018 .048 .007  P  TABLE B.3 Results of MANOVAs (interactions with occasions): Hospital Behaviour Questionnaire for Programme and Tour with Agegroup and Gender Multivariate Source of Variance  Pre  P  AgeGroup x Programme x Tour *** Time Agegroup .4.77 .002 Programme 3.57 .01 Tour .28 Agegroup x Programme 3.65 .009 Agegroup x Tour .79 Programme x Tour .62 Agegroup x Programme x Tour 1.06 Gender x Programme x Tour *** Time Gender 1.98 .44 Programme Tom.16 Gender x Programme 1.51 Gender x Tour .25 Programme x Tour 1.19 Gender x Programme x Tour .59  Source of Variance  AgeGroup x Programme x Tour Time Agegroup Programme Tour Agegroup x Programme Agegroup x Tour Programme x Tour Agegroup x Programme x Tour Gender x Programme x Tour Time Gender Programme Tour Gender x Programme Gender x Tour Programme x Tour Gender x Programme x Tour  Occas  P  F l Contentiousness Pre  P  ***  Occas  .85 .28 .91 .96 .81 .48 .55  1.68 3.80 .82 2.35 1.32 " .00  .15 .38 2.72 2.03 .05 .07 .10  .84  2.75  .28  1.23 .97 2.42 1.51 2.93 1.31 .50  *** .35 .90 .06 .70 .18 .58  .30 .22 4.30 1.99 .71 .10 .07  1.24  .88  .00  P  ***  10.88 2.31 .13 2.36 .01 2.30 .44  ***  2.92 .01 .05 2.64 .00 3.39 1.59  221  .001  .00 .01 1.11 .55 .01  1.05 .32 1.39 .77 2.12 1.19 1.47  .98  1.73  10  *** .041  F3 Sleep Disturbance Pre P Occas P  ***  F2 Dependent Anxiety Pre P Occas  1.85 .42 4.37 .040 .88 6.59 .012 4.65 .034 1.04  .10 .14 .03 1.48 .94 .43 .42  Pre  .52 .18 .65 1.37 .16 .50 .00 1.00  *** 7.69 9.35 .20 11.33 1.84 .14 1.03  2.46 1.86 1.86 .71 .96 .13 .17 .00  ***  5.09 .60 .55 1.28 .07 .40 .04  P  4.48  .037  F4 Appetite Disturbance P Occas P  .007 .003 .001  2.66 .34 .45 1.41 11.31 .60 .60 1.11  3.17 .60 1.01 1.88 3.20 .03 .26 .20  TABLE B.4 Results of MANOVAs (interactions with occasions): Observation Scales for Programme and Tour with Agegroup and Gender  Source of Variance  Pre  Multivariate P Occas P  Rating Pre  P  Agegroup x Programme x Tour Time Agegroup Programme Tour Agegroup x Programme Agegroup x Tour Programme x Tour AgeGroup x Prog x Tour  *** 5.73 .99 3.44 2.90 1.34 3.48 .31  21.81 .000 2.16 2.92 7.6 .000 1.05 .68 11.05 .000 2.40  1.54 2.48 6.93 .010 1.02 1.90 4.64 .034 .81  Gender x Programme x Tour Time Gender Programme Tour Gender x Programme Gender x Tour Programme x Tour Gender x Prog x Tour  *** .16 1.37 3.44 .67 .68 3.58 .42  27.13 1.27 1.86 8.24 .40 1.00 11.75 1.88  .39 3.76 9.44 .003 .60 .33 6.00 .016 .18  .017  .000 .000 .000  Verbal Source of Variance  Pre  Time Agegroup Programme Tour Agegroup x Programme Agegroup x Tour Programme x Tour AgeGroup x Prog x Tour  ***  Gender x Programme x Tour Time Gender Programme Tour Gender x Programme Gender x Tour Programme x Tour Gender x Prog x Tour  5.19 .72 6.77 .38 .00 5.42 .26  Occas P  .025 .011 .022  ***  .00 .66 5.44 .05 .43 5.42 .32  .022 .022  Pre  ***  .000  .001 .018  .03 .40 3.65 7.78 1.43 6.33 .014 .16  57.12 3.14 5.17 10.62 .02 .07 19.38 .06  .000  ***  222  .026 .002 .000  P  30.48 .000 1.09 .89 .002 10.48 2.68 1.30 13.74 .000 .04  42.87 .01 .13 8.34 .06 1.93 14.98 2.46  .000 .005 .000  Non-Verbal P Occas  50.14 .50 4.51 9.63 1.78 .13 11.59 5.78  .037 .003  Occas  .or .45 1.56 1.01 1.08 5.78 .018 .60  7.10 5.59 2.46 7.10 .02 .33 12.44 .55  .009 .020  14.16 .67 .36 10.24 1.00 .00 9.98 3.79  .000  .009 .001  .002 .002  TABLE B.5 Results of MANOVAs (interactions with occasions):Children's State Anxiety Inventory for Programme and Tour with Agegroup and Gender  Source of Variance  Pre  P  Child State Anxiety Occas P Hosp  P  Post  P  Agegroup x Programme x Tour Time Agegroup Programme Tour Agegroup Agegroup x Tour Programme x Tour Agegroup x Prog x Tour  *** 2.05 0.02 0.73 0.93 0.01 0.00 0.29  29.62 7.34 0.90 1.22 1.77 2.56 0.03 0.24  .000 .001  31.97 4.11 1.25 1.41 1.03 0.36 0.05 0.46  .000 .046  44.80 .000 13.87 .000 1.09 0.43 3.32 3.75 .056 0.00 0.00  Gender x Programme x Tour Time Gender Programme Tour Gender x Programme Gender x Tour Programme x Tour Gender x Prog x Tour  *** 1.24 .080 2.04 0.80 6.55 .013 0.32 3.76 .056  11.99 0.25 1.29 1.03 2.59 2.05 0.33 1.33  .000  19.38 0.00 1.38 1.69 3.35 0.22 0.36 0.08  .000  12.41 .001 0.47 0.45 0.03 0.51 4.12 .046 0.11 2.63  223  TABLE B.6 Results of MANOVAs (interactions with occasions):Hospital Behaviour Questionnaire for Approach, Mode, Tour, Agegroup and Gender  Source of Variance  Approach x Mode x Tour Time Approach Mode Tour Approach x Mode Approach x Tour Mode x Tour Mode x Tour  Pre  Multivariate P Occas  *** 1.05 1.10 1.01 2.44 .11 .77 3.40  Approach x Mode x Gender . *** Time Approach .46 Mode 1.06 Gender .49 Approach x Mode 1.03 Approach x Gender .92 Mode x Gender .89 Approach x Mode x Gender .27 Approach x Mode x Aeeeroup *** Time Approach 1.01 Mode .37 Agegroup 2.96 Approach x Mode 1.09 Approach x Agegroup .48 .94 Mode x Agegroup Approach x Mode x Agegroup 1.29  .015  P  2.78 1.17 2.23 1.42 1.19 .30 .44 .16  ..036  2.68 .41 2.93 .96 1.11 1.98 .80  .042  F l Contentiousness P Pre Occas P  ***  F2 Dependent Anxiety Pre P Occas  5.52 .76 .03 .85 1.14 .01 .04 .25  .022 * * * .17 .47 .00 3.26 .18 1.06 .39  6.98 3.95 1.97 .15 .33 .01 .66 .30  3.18 .16 .04 .01 .12 .66 .38  ***  .46 3.40 .53 .32 .97 2.77  .01 .80 .48 .65 .21 .01  8.92 1.34 3.38 3.40 .33 .33 1.09  1.55  .59  .50  .47  1.59  .92 .44 .70 .86 .79  ***  2.17 .38 .03 .50 .80  ***  .06 1.24 9.65 2.13  .49 .22 1.70 .53  1.92 1.19 .15 2.71 .13  .29 .58  .00 .00  .04 .03  .82 .42  .74 1.14  .55  1.56  .00  3.27  .17  .03 1.78 2.34 3.03 .26 1.61 8.35  .006  ***  .003  ...continued  224  TABLE B.6 (continued)  Source of Variance  Approach x Mode x Tour Time Approach Mode Tour Approach x Mode Approach x Tour Mode x Tour Approach x Mode x Tour Approach x Mode x Gender Time Approach Mode Gender Approach x Mode Approach x Gender Mode x Gender Approach x Mode x Gender Approach x Mode x Aeeeroup Time Approach Mode Agegroup Approach x Mode Approach x Agegroup Mode x Agegroup Appro x Mode x Agegrp  F3 Sleep Disturbance Pre P Occas P  ***  F4 Appetite Disturbance Pre P Occas P  ***  .00 1.55 2.85 2.70 . .15 15  2.87 1.61 .04 1.07 2.02 .12 .06  4.11 .06 .01 .26 .00 .22  1.64 1.02 6.80 4.37 1.43 1.22 .45  .46 '  .11  1.69  .00  ***  3.00 .30 .01 1.45 2.09 .31 .32  ***  .03 .07 .00 2.64 .07 1.40  1.38 .07 1.17 .07 2.80 .12  2.22 .14 6.98 .07 .20 6.60 .13  .08  .88  .15  .64  1.57 1.30 .13 .06 1.73  ***  .97 .02 2.32 1.11  2.81 .11 .11 .00  .31 .28 2.84 .08 .08  1.25 3.30  .02 .05  .00 .14  .02 .36  .00  .10  .35  1.81  ***  225  TABLE B.7 Results of MANOVAs (interactions with occasions): Observation Scales on Approach, Mode, Tour, Agegroup and Gender Multivariate Source of Variance  Pre  Approach x Mode x Tour Time Approach Mode Tour Approach x Mode Approach x Tour Mode x Tour Approach x Mode x Tour  2.95 5.76 1.00 4.67 5.46 3.90 3.11  Approach x Mode x Gender Time Approach Mode Gender Approach x Mode Approach x Gender Mode x Gender Approach x Mode x Gender  2.91 5.88 .46 1.43 .15 4.32 .62  Approach x Mode x Aseeroup Time Approach Mode Agegroup Approach x Mode Approach x Agegroup Mode x Agegroup Approach x Mode x Agegrp  *** 2.23 3.37 3.82 4.70 .15 1.45 2.72  P.  *** .041 . .002 .006 .002 .014 .034  *** .002  .009  .015 .006  .  Rating  Occas  P  24.71 4.80 1.24 1.10 6.30 2.29 2.03 .52  .000 .005  13.15 2.64 1.53 1.55 4.91 .21 2.12 .85  .000 .059  14.75 3.75 2.17 .86 6.41 .54 1.74 1.68  .000 .020  .001  .004  .001  Pre  P  *** 3.40 16.58 1.72 6.70 4.25 6.89 5.63  .000 .012 .044 .011 .021  *** 4.99 15.37 1.32 1.09 .43 4.10 .07  *** 2.19 8.97 .71 7.71 .00 .22 1.85  .030 .000  .048  .004 .008  Occas  P  50.80 .000 5.66 .021 .62 .97 6.93 .11 .09 1.72 1.41  27.07 .000 5.66 .021 1.46 .04 4.17 .046 .62 2.39 .95  34.07 5.82 3.02 .11 12.17 1.62 3.80 4.06  .000 .019  .001 .056 .049  ...continued  226  TABLE B.7 (continued) Verbal Source of Variance  Pre  Non-Verbal  P  Occas  P  31.19 10.68 .84 1.86 8.23 6.85 3.34 .35  .000 .002  22.91 3.88 .05 2.69 8.28 .02 .31 1.19  .000 .054  7.11 7.17 1.01 .00 9.62 .05 .01 2.49  .000 .010  Pre  P  Occas  P  Approach x Mode x Tour Time Approach Mode Tour Approach x Mode Approach x Tour Mode x Tour Approach x Mode x Tour  *** 6.83 8.06 .31 12.86 15.51 7.58 .19  .012 .006 .001 .000 .008  •  .006 .011  ***  30.54 .000 .63 1.82 .63 3.76 .058 .00 1.26 .00  2.62 .03 1.62 1.26 3.16 2.55 .17  Approach x Mode x Gender Time Approach Mode Gender Approach x Mode Approach x Gender Mode x Gender Approach x Mode x Gender  *** 5.59 8.03 .19 4.06 .09 3.50 .15  .022 .006  .006  *** 2.16 1.33 .21 .88 .05 7.92 1.86  .007  11.60 .001 .06 1.42 1.93 3.02 .06 .69 .47  Approach x Mode x Agegroup Time Approach Mode Agegroup Approach x Mode Approach x Agegroup Mode x Agegroup Approach x Mode x Agegrp  *** 6.62 3.17 5.00 9.62 .15 .87 2.08  .013 .029 .003  227  .003  *** 1.18 1.59 2.20 5.27 .12 2.68 6.68  .026  .012  13.37 .001 .43 1.76 2.63 1.08 .05 .19 .70  TABLE B.8 Results of MANOVAs (interactions with occasions): Children's State Anxiety Inventory on Approach, Mode, Tour, Agegroup and Gender Source of Variance  Pre  Approach x Mode x Tour Time Approach Mode Tour Approach x Mode Approach x Tour Mode x Tour Approach x Mode x Tour  0.38 2.90 0.30 0.15 1.68 2.38 0:32  Multi  P  Surg  P  Post  P  21.48 0.71 0.77 0.70 2.21 3.79 1.78 1.41  .000  25.38 1.45 0.88 1.23 3.13 7.57 0.13 0.32  .000  25.05 0.00 0.47 0.36 2.04 0.70 3.62 2.78  .000  Approach x Mode x Gender Time Approach Mode Gender Approach x Mode Approach x Gender Mode x Gender Approach x Mode x Gender  8.76 0.14 0.92 0.82 0.50 0.17 0.29 0.86  .001  9.28 0.27 0.10 1.62 1.02 0.34 0.30 0.04  .004  12.20 0.00 1.56 0.00 0.03 0.07 0.40 1.75  .001  0.02 2.42 3.00 0.01 0.02 0.14 0.11  Approach x Mode x Aeeeroup Time Approach Mode Agegroup Approach x Mode Approach x Age Mode x Agegroup Approach x Mode x Agegroup  *** 2.43 4.48 0.15 0.04 3.18 0.48 0.80  17.54 1.26 2.03 1.35 2.18 2.33 1.57 1.24  .000  17.30 1.96 1.09 0.40 4.41 2.20 1.15 1.60  .000  ***  ***  P  228  .030  .008  .041  25.40 1.10 2.86 2.66 0.36 3.45 1.43 0.53  •  .000  APPENDIX C  229  APPENDIX C: CONTENTS  TABLES  PAGE  TABLE C.l : ., 233 Summary of Regression Analyses of Family .Characteristics Cluster Interactions on HBQ Factor 1: Contentiousness TABLE C.2 233 Summary of Regression Analyses of Family Characteristics Cluster Interactions on HBQ Factor 2: Dependent Anxiety TABLE C.3 -. .....234 Summary of Regression Analyses of Family Characteristics Cluster Interactions on HBQ Factor 3: Sleep Disturbance TABLE C.4 234 Summary of Regression Analyses of Family Characteristics Cluster Interactions on HBQ Factor 4: Appetite Disturbance TABLE C.5 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Rating Scale  235  TABLE C.6 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Verbal Scale  236  TABLE C.7 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Non-Verbal Scale  236  TABLE C.8 237 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Children's State Anxiety Inventory at Presurgery Measurement TABLE C.9  237  Summary of Regression Analyses of Family Characteristics Cluster Interactions on Children's State Anxiety Inventory at 6 Week Follow-up Measurement 230  TABLE C I O  238  Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 1: Contentiousness T A B L E C. 11  239  Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 2: Dependent Anxiety T A B L E C.12  ;  240  Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 3: Sleep Disturbance TABLE C.13  241  Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 4: Appetite Disturbance TABLE C.14 : : Summary of Regression Analyses of Personality Cluster Interactions on Observation Rating Scale  242  TABLE C.15  243  Summary of Regression Analyses of Personality Cluster Interactions on Observation Verbal Scale  TABLE C. 16  244  Summary of Regression Analyses of Personality Cluster Interactions on Observation Non-Verbal Scale T A B L E C. 17  245  Summary of Regression Analyses of Personality Cluster Interactions on Children's State Anxiety Inventory at Presurgery Measurement T A B L E C.18  246  Summary of Regression Analyses of Personality Cluster Interactions on Children's State Anxiety Inventory at 6 Week Follow-up Measurement TABLE C. 19  247  Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on HBQ Factor 1: Contentiousness TABLE C.20  248  Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on HBQ Factor 2: Dependent Anxiety TABLE C.21  249  Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on HBQ Factor 3: Sleep Disturbance  231  T A B L E C.22  250  Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on HBQ Factor 4: Appetite Disturbance T A B L E C.23  251  Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on Observation Rating Scale T A B L E C.24  252  Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on Observation Verbal Scale T A B L E C.25  ,  253  Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on Observation Non-Verbal Scale T A B L E C.26  254  Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on Children's State Anxiety Inventory at Presurgery Measurement T A B L E C.27  255  Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on Children's State Anxiety Inventory at 6 Week Follow-up Measurement Note: Each of the following 72 tables reports the regression analyses of a single dependent variable. The Model used for this analysis is described on p. 68-71. The description of reading the tables is found on p. 137  232  T A B L E C.l Summary of Regression Analyses of Family Characteristics Cluster Interactions on HBQ Factor 1: Contentiousness Interactions  cum.R  (Cumulative Effects) SES x Prog Position x Prog SES x Tour Position x Tour SES x Mode Position x Mode SES x Appr Position x Appr SES x Prog x Tour Position x Prog x Tour SES x Mode x Appr Position x Mode x Appr SES x Mode x Tour Position x Mode x Tour SES x Appr x Tour Position x Appr x Tour SES x Mode x Appr x Tour Position x Mode x Appr x Tour  (.6608) .6666 .6672 .6676 .6709 .6725 .6743 .6805 .6942 .6942' .6978 .7501 .7519 .7597 .7597 .7747 .7747 .7752 .7759  R Change  2  2  *** .0058 .0006 .0004 .0034 .0016 .0018 .0062 .0137 .0000 .0036 .0523 .0018 .0077 .0000 .0150 .0000 .0005 .0007  F Change  ***  Sig  ***  1.140 .114 .072 .637 .295 .327 1.141 2.602 .004 .672 11.51 .384 1.708 .008 3.400 .000 .115 .152  .190 .737 .789 .428 .589 .570 .290 .112 .947 .416 .001 .538 .197 .931 .071 .995 .736 .698  F Change  Sig  TABLE C.2 Summary of Regression Analyses of Family Characteristics Cluster Interactions on HBQ Factor 2: Dependent Anxiety Interactions  cum.R  (Cumulative Effects) SES x Prog Position x Prog SES x Tour Position x Tour SES x Mode Position x Mode SES x Appr Position x Appr SES x Prog x Tour Position x Prog x Tour SES x Mode x Appr Position x Mode x Appr SES x Mode x Tour Position x Mode x Tour SES x Appr x Tour Position x Appr x Tour SES x Mode x Appr x Tour Position x Mode x Appr x Tour  (.5907) .6485 .6490 .6513 .6549 .6557 .6564 .6636 .6637 .6704 .6709 .6709 .6730 .6734 .6738 .6827 .6877 .6877 .6956  R Change  2  2  *** .0578 .0006 .0022 .0036 .0008 .0008 .0072 .0001 .0067 .0005 .0000 .0021 .0004 .0004 .0089 .0050 .0000 .0079  233  *** 10.686 .102 .405 .650 .136 .132 1.257 .017 1.163 .078 .004 .353 .064 .057 1.428 .803 .002 1.249  *** .002 .751 .527 .423 .714 .717 .267 .897 .285 .782 .948 .555 .801 .813 .238 .375 .967 .269  TABLE C.3 Summary of Regression Analyses of Family Characteristics Cluster Interactions on HBQ Factor 3: Sleep Disturbance Interactions  cum.R  (Cumulative Effects) SES x Prog Position x Prog SES x TomPosition x Tour SES x Mode Position x Mode SES x Appr Position x Appr SES x Prog x Tour Position x Prog x Tour SES x Mode x Appr Position x Mode x Appr SES x Mode x Tour Position x Mode x Tour SES x Appr x Tour Position x Appr x Tour SES x Mode x Appr x Tour Position x Mode x Appr x Tour  (.5953) .5975 .5989 .6097 .6285 .6369 .6429 .6604 .6610 .6664 ' .6670 .6857 .6918 .6955 .6956 .6983 .6984 .7037 .7039  R Change  2  2  *** .0022 .0014 .0108 .0188 .0084 .0060 .0175 .0006 .0055 .0006 .0187 .0061 .0037 .0001 .0027 .0001 .0053 .0002  F Change  Sig  ***  ***  .347 .215 1.749 3.136 1.408 1.014 3.033 .100 .933 .095 3.279 1.064 .644 .019 .460 .012 .877 .026  .558 .644 .191 .082 .240 .318 .087 .752 .338 .759 .076 .307 .426 .891 .500 .913 .354 .873  F Change  Sig  TABLE C.4 Summary of Regression Analyses of Family Characteristics Cluster Interactions on HBQ Factor 4: Appetite Disturbance Interactions  cum.R  (Cumulative Effects) SES x Prog Position x Prog SES x Tour Position x Tour SES x Mode Position x Mode SES x Appr Position x Appr SES x Prog x Tour Position x Prog x Tour SES x Mode x Appr Position x Mode x Appr SES x Mode x Tour Position x Mode x Tour SES x Appr x Tour Position x Appr x Tour SES x Mode x Appr x Tour Position x Mode x Appr x Tour  (.4552) .4552 .4552 .4633 .4731 .5082 .5114 .5157 .5164 .5169 .5613 .5642 .5682 .5717 .5723 .5723 .5806 .5812 .5812  R Change  2  2  *** .0000 .0000 .0081 .0098 .0352 .0032 .0043 .0007 .0004 .0445 .0029 .0040 .0035 .0006 .0000 .0083 .0006 .0000  234  ***  ***  .000 .000 .953 1.148 4.364 .389 .524 .087 .049 5.680 .363 .501 .435 .070 .001 .987 .006 .004  .984 .983 .333 .288 .041 .535 .472 .769 .826 .021 .549 .482 .512 .792 .975 .325 .798 .949  TABLE C.5 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Rating Scale Interactions  cum.R  (Cumulative Effects) SES x Prog Position x Prog SES x TomPosition x Tour SES x Mode Position x Mode SES x Appr Position x Appr SES x Prog x Tour Position x Prog x Tour SES x Mode x Appr Position x Mode x Appr SES x Mode x Tour Position x Mode x Tour SES x Appr x Tour Position x Appr x Tour SES x Mode x Appr x Tour Position x Mode x Appr x Tour  (.2157) .2266 .2272 .2272 .2305 .2361 .2365 .2463 .2482 .3299 ' .3580 .3595 .3654 .3661 .3690 .3699 .3730 .3731 .3739  R Change  2  2  ***  .0109 .0006 .0000 .0032 .0057 .0003 .0098 .0019 .0817 .0282 .0015 .0059 .0007 .0030 .0009 .0031 .0000 .0008  235  F Change  Sig  ***  *%*  .917 .050 .002 .261 .454 .027 .768 .146 6.947 2.456 .126 .500 .057 .245 .072 .248 .003 .064  .342 .823 .967 .611 .503 .870 .384 .704 .011 .123 .724 .483 .812 .623 .790 .620 .954 .801  TABLE C.6 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Verbal Scale Interactions  cum.R  (Cumulative Effects) SES x Prog Position x Prog SES x Tour Position x Tour SES x Mode Position X Mode SES x Appr Position x Appr SES x Prog x Tour Position x Prog x Tour SES x Mode x Appr Position x Mode x Appr SES x Mode x Tour Position x Mode x Tour SES x Appr x Tour Position x Appr x Tour SES x Mode x Appr x Tour Position x Mode x Appr x Tour  (.1723) .1756 2589 ,2608 .2609 .2856 .3268 .3294 .3295 .3369' .3370 .3793 .3796 .3799 .4026 .4194 .4198 .4230 .4232  R Change  2  2  *** .0033 .0832 .0020 .0001 .0248 .0411 .0026 .0001 .0075 .0001 .0423 .0003 .0004 .0227 .0168 .0004 .0031 .0003  F Change  Sig  ***  ***  .262 7.188 .167 .006 2.114 3.666 .230 .007 .642 .005 3.745 .028 .031 1.974 1.478 .034 .265 .021  .610 .009 .685 .940 .151 .060 .634 .933 .426 .942 .058 .869 .861 .166 .230 .854 .609 .885  TABLE C.7 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Non-Verbal Scale Interactions  cum.R  (Cumulative Effects) SES x Prog Position x Prog SES xTour Position x Tour SES x Mode Position x Mode SES x Appr Position x Appr SES x Prog x Tour Position x Prog x Tour SES x Mode x Appr Position x Mode x Appr SES x Mode x Tour Position x Mode x Tour SES x Appr x Tour Position x Appr x Tour SES x Mode x Appr x Tour Position x Mode x Appr x Tour  (.1925) .3017 .3061 .3162 .3163 .3348 .3379 .4080 .4096 .4240 .4490 .5009 .5197 .5218 .5218 .5293 .5457 .5629 .5637  R Change  2  2  *** .1092 .0045 .0101 .0001 .0185 .0032 .0701 .0016 .0144 .0250 .0518 .0189 .0020 .0000 .0075 .0164 .0173 .0007  236  F Change  *** 10.161 .412 .929 .006 1.695 .286 6.987 .155 1.425 2.545 5.713 2.120 .224 .000 .815 1.804 1.938 .082  Sig  *** .002 .523 .339 .940 .198 .595 .011 .696 .238 .116 .020 .151 .638 .997 .371 .185 .170 .775  T A B L E C.8 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Children's State Anxiety Inventory at Presurgery Measurement Interactions  cum.R  (Cumulative Effects) SES x Prog Position x Prog SES x Tour Position x Tour SES x Mode Position x Mode SES x Appr Position x Appr SES x Prog x Tour Position x Prog x Tour SES x Mode x Appr Position x Mode x Appr SES x Mode x Tour Position x Mode x Tour SES x Appr x Tour Position x Appr x Tour SES x Mode x Appr x Tour Position x Mode x Appr x Tour  (.5591) .5895 :5921 -5970 .6067 .6069 .6102 .6105 .6109 .6123' .6127 .6169 .6393 .6510 .6512 .6513 .6565 .6635 .6648  R Change  2  2  *** .0304 .0026 .0049 .0097 .0002 .0033 .0002 .0004 .0014 .0004 .0043 .0224 .0117 .0001 .0001 .0052 .0070 .0013  F Change  Sig  ***  ***  4.374 .366 .693 1.383 .035 .460 .033 .051 .188 .050' .544 2.982 1.576 .016 .013 .667 .900 .164  .041 .548 .409 .245 .853 .500 .858 .822 .666 .824 .464 .091 .216 .900 .909 .419 .348 .688  TABLE C.9 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Children's State Anxiety Inventory at 6 Week Follow-Up Measurement Interactions  cum.R  (Cumulative Effects) SES x Prog Position x Prog SES x Tour Position x Tour SES x Mode Position x Mode SES x Appr Position x Appr SES x Prog x Tour Position x Prog x Tour SES x Mode x Appr Position x Mode x Appr SES x Mode x Tour Position x Mode x Tour SES x Appr x Tour Position x Appr x Tour SES x Mode x Appr x Tour Position x Mode x Appr x Tour  (.4526) .4526 .4652 .4802 .4988 .4995 .5009 .5025 .5063 .5246 .5278 .5602 .5620 .5633 .5808 .5813 .5850 .5850 .5912  R Change  2  2  *** .0000 .0126 .0149 .0186 .0007 .0014 .0016 .0038 .0183 .0032 .0325 .0017 .0014 .0174 .0005 .0037 .0000 .0063  237  F Change  Sig  ***  ***  .004 1.483 1.783 2.265 .081 .164 .190 .439 2.152 .374 3.988 .207 .164 2.121 .060 .438 .000 .720  .948 .228 .187 .137 .776 .687 .665 .510 .148 .544 .051 .651 .687 .151 .807 .511 .994 .400  TABLE CIO Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 1: Contentiousness Interactions  cum.R  (Cumulative Effects) Verb Ab x Prog HLocxProg Tr Anx x Prog Verb Abx Tour HLoc x Tour Tr Anx x Tour Verb Ab x Mode HLoc x Mode Tr Anx x Mode Verb Ab x Appr HLoc x Appr Tr Anx x Appr Verb Ab x Prog x Tour HLoc x Prog x Tour Tr Anx x Prog x Tour . Verb Ab x Mode x Appr H Loc x Mode x Appr Tr Anx x Mode x Appr Verb Ab x Mode x Tour HLoc x Mode x Tour Tr Anx x Mode x Tour Verb Ab x Appr x Tour HLoc x Appr x Tour Tr Anx X Appr x Tour Verb Ab x Mode x Appr x Tour HLoc x Mode x Appr x Tour Tr Anx x Mode x Appr x Tour  (.6806) .6807 .6813 .6894 .7090 .7119 .7144 .7148 .7149 .7169' .7170 .7174 .7198 .7199 .7292 .7305 .7321 .7351 .7626 .7626 .7626 .7631 .7636 .7640 .7775  .0001 .0006 .0081 .0196 .0029 .0025 .0004 .0001 .0021 .0001 .0004 .0024 .0001 .0093 .0014 .0016 .0030 .0275 .0000 .0000 .0005 .0004 .0004 .0135  *** *** ***  *** *** ***  R Change  2  2  ***  238  F Change  Sig  ***  ***  .023 .119 1.590 4.044 .589 .507 .078 .019 .407 .***  .880 .732 .212 .049 .446 .479 .781 .891 .526 .896 .795 .509 .894 .197 .620 .599 .467 .026 .998 .971 .771 .779 .794 .127 *** *** ***  .017 .069 .441 .018 1.712 .281 .537 5.333 .000 .001 .086 .079 .069 2.430 *** *** ***  TABLE C . l l Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 2: Dependent Anxiety Interactions  cum.R  (Cumulative Effects) Verb Ab x Prog HLoc x Prog Tr Anx x Prog Verb Ab x Tour HLoc x Tour Tr Anx x Tour Verb Ab x Mode HLoc x Mode Tr Anx x Mode Verb Ab x Appr HLoc xAppr Tr Anx x Appr Verb Ab x Prog x Tour HLoc x Prog x Tour Tr Anx x Prog X Tour Verb Abx Mode x Appr HLoc x Mode x Appr Tr Anx x Mode x Appr Verb Abx Mode x Tour HLoc x Mode x Tour Tr Anx x Mode x Tour Verb Ab x Appr x Tour HLoc x Appr x Tour Tr Anx x Appr x Tour Verb Ab x Mode x Appr x Tour HLoc x Mode x Appr x Tour Tr Anx x Mode x Appr x Tour  (.5924) .6084 .6094 .6150 .6158 .6161 .6211 .6347 .6426 .6485 ' .6514 .6514 .6522 .6523 .6553 .6692 .6822 .7084 .7094 .7094 .7123 .7567 .7567 .7575 .8338  R Change  2  2  *** .0160 .0010 .0056 .0008 .0003 .0051 .0136 .0079 .0059 .0029 .0000 .0008 .0001 .0031 .0138 .0130 .0262 .0010 .0010 .0028 .0445 .0000 .0008 .0763 *** *** ***  *** *** ***  239  F Change  *** 2.574 .164 .885 .125 .042 .775 2.118 1.238 .926 .450 .003 .115 .009 .443 2.050 1.968 4.220 .162 .001 .435 7.862 .001 .135 18.355 *** *** ***  Sig *** .114 .687 .351 .725 .839 .382 .151 .271 .340 .505 .957 .735 .925 .509 .159 .167 .046 .689 .980 .513 .008 .978 .716 .000 *** *** ***  TABLE C.12 Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 3: Sleep Disturbance Interactions  cum.R  (Cumulative Effects) Verb Ab x Prog HLoc x Prog Tr Anx x Prog Verb Ab x Tour HLoc x Tour Tr Anx x Tour Verb Ab x Mode HLoc x Mode Tr Anx x Mode Verb Ab x Appr HLoc x Appr Tr Anx x Appr Verb Ab x Prog x Tour HLoc x Prog x Tour Tr Anx x Prog x Tour Verb Ab-x Mode x Appr HLoc x Mode x Appr Tr Anx x Mode x Appr Verb Ab x Mode x Tour HLoc x Mode x Tour Tr Anx x Mode x Tour Verb Ab x Appr x Tour HLoc x Appr x Tour Tr Anx x Appr x Tour Verb Ab x Mode x Appr x Tour HLoc x Mode x Appr x Tour Tr Anx x Mode x Appr x Tour  (.5624) .5758 .5853 ,5853 .5968 .5968 .6017 .6144 .6426 .6461' .6574 .6632 .6830 .6832 .6977 .6994 .7079 .7221 .7274 .7394 .7407 .8204 .8702 . .9182 .9240 *** *** ***  R Change  2  2  ***  •  240  .0134 .0095 .0000 .0115 .0000 .0049 .0127 .0282 .0035 • .0113 .0058 .0198 .0002 .0145 .0016 .0086 .0142 .0052 .0120 .0014 .0797 .0498 .0479 .0059 *** *** ***  F Change *** 1.989 1.416 .006 1.713 .000 .707 1.883 4.415 .545 1.784 .905 3.255 .035 2.401 .265 1.407 2.400 .886 2.076 .229 19.072 16.127 24.009 3.092 *** *** ***  Sig *** .163 .239 .936 .196 .995 .404 .175 .040 .464 .187 .346 .077 .852 .128 .609 .241 .128 .352 .157 .634 .000 .000 .000 .086 *** *** ***  TABLE C.13 Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 4: Appetite Disturbance Interactions  cum.R  (Cumulative Effects) Verb Ab x Prog HLoc x Prog Tr Anx x Prog Verb Ab x Tour HLoc X Tour Tr Anx x Tour Verb Ab x Mode HLoc X Mode Tr Anx x Mode Verb Ab x Appr HLoc x Appr Tr Anx x Appr Verb Ab x Prog x Tour HLoc x Prog x Tour Tr Anx x Prog x Tour Verb Ab x-Mode x Appr HLoc x Mode x Appr Tr Anx x Mode x Appr Verb Ab x Mode x Tour HLoc x Mode x Tour Tr Anx x Mode x Tour Verb Ab x Appr x Tour HLoc x Appr x Tour Tr Anx x Appr x Tour Verb Ab x Mode x Appr x Tour HLoc x Mode x Appr x Tour Tr Anx x Mode x Appr x Tour  (.4627) .4667 .4742 .5014 .5199 .5208 .5242 .5641 .5653 .5811 ' .5818 .5855 .5869 .6075 .6105 .6132 .6268 .6479 .6484 .6479 .7194 .7322 .7349 .7515 .7713 *** *** ***  R Change  2  2  *** .0040 .0076 .0272 .0185 .0008 .0034 .0399 .0013 .0157 .0007 .0037 .0014 .0206 .0030 .0027 .0136 .0211 .0005 .0012 .0697 .0129 .0027 .0165 .0198 *** *** ***  241  F Change *** .472 .894 3.323 2.316 .102 .420 5.214 .163 2.066 .097 .467 .182 2.674 .386 .339 1.750 2.822 .060 .156 10.935 2.068 .425 2.729 3.469 ***  ***  ***  Sig *** .494 .348 .073 .133 .751 .519 .026 .688 .156 .757 .497 .671 .108 .537 .563 .192 .100 .808 .695 .002 .158 .518 .106 .070 *** *** ***  TABLE C.14 Summary of Regression Analyses of Personality Cluster Interactions on Observation Rating Scale Interactions  cum.R  (Cumulative Effects) Ver Ab x Prog HLoc x Prog Tr Anx x Prog Verb Ab x Tour HLoc x Tour Tr Anx x Tour Verb Ab x Mode HLoc x Mode Tr Anx x Mode Verb Ab x Appr HLoc x Appr Tr Anx x Appr Verb Ab x Prog x Tour HLoc x Prog x Tour Tr Anx x Prog x Tour Verb Ab x Mode x Appr HLoc x Mode x Appr Tr Anx x Mode x Appr Verb Ab x Mode x Tour HLoc x Mode x Tour Tr Anx x Mode x Tour Verb Ab x Appr x Tour HLoc x Appr x Tour Tr Anx x Appr x Tour Verb Ab x Mode x Appr x Tour HLoc x Mode x Appr x Tour Tr Anx x Mode x Appr x Tour  (.1850) .1955 .2116 .2121 .2218 .2224 .2531 .2571 .2763 .2814 .2842 ' .2894 .2987 .2996 .3033 .3241 .3269 .3555 .3606 .3758 .3758 .3819 .3868 .3966 .5799  . . R Change  2  2  ***  .0105 .0161 .0005 .0097 .0006 .0308 .0039 .0193 .0050 .0029 .0051 .0093 .0010 .0037 .0207 .0029 .0286 .0051 .0152 .0000 . .0061 .0049 .0097 .1833  *** *** ***  *** *** ***  242  F Change ***  .805 1.248 .036 .736 .041 2.350 .298 1.463 .378 .212 .375 .677 .068 .261 1.472 .200 2.039 .359 1.070 .001 .413 .331 .645 17.019 *** *** ***  Sig ***  .373 .268 .850 .394 .840 .131 .588 .232 .541 .647 .543 .414 .795 .612 .231 .657 .160 .552 .306 .976 .524 .568 .427 .000 *** *** ***  TABLE G.15 Summary of Regression Analyses of Personality Cluster Interactions on Observation Verbal Scale Interactions  cum.R  (Cumulative Effects) Verb Ab x Prog HLoc x Prog Tr Anx x Prog Verb Ab x Tour HLoc x Tour Tr Anx x Tour Verb Ab x Mode HLoc x Mode Tr Anx x Mode Verb Ab x Appr HLoc x Appr Tr Anx x Appr Verb Ab x Prog x Tour HLoc x Prog x Tour Tr Anx x Prog x Tour Verb Ab x Mode x Appr HLoc x Mode x Appr Tr Anx x Mode x Appr Verb Ab x Mode x Tour HLoc x Mode x Tour Tr Anx x Mode x Tour Verb Ab x Appr x Tour HLoc x Appr x Tour Tr Anx x Appr x Tour Verb Ab x Mode x Appr x Tour HLoc x Mode x Appr x Tour Tr Anx x Mode x Appr x Tour  (.1972) .2103 .2280 .2323 .2348 .2354 .2484 .2588 .2671 .2700 .2729 ' .2778 .3217 .3229 .3990 .4037 .4080 .4215 .4217 .4527 .4562 .5602 .5604 .5610 .6610 *** *** ***  2  • R Change 2  *** .0131 .0177 .0042 .0025 .0006 .0130 .0104 .0083 .0029 .0029 .0048 .0439 .0012 .0761 .0047 .0043 .0135 .0001 .0310 .0035 .1041 .0002 .0006 .1000 *** *** ***  243  F Change  Sig  ***  ***  1.027 1.402 .332 .193 .045 .988 .787 .625 .212 .213 .349 3.303 .088 6.200 .382 .344 1.071 .010 2.496 .273 9.941 .061 .057 11.513 *** *** ***  .315 .241 .567 .662 .834 .324 .379 .433 .647 .646 .557 .075 .768 .016 .540 .561 .306 .919 .121 .604 .003 .900 .812 .002 *** *** ***  TABLE G.16 Summary of Regression Analyses of Personality Cluster Interactions on Observation Non-Verbal Scale Interactions  cum.R  (Cumulative Effects) Verb Ab x Prog HLoc x Prog Tr Anx x Prog Verb Ab x Tour HLoc x Tour Tr Anx x Tour Verb Ab x Mode HLoc x Mode Tr Anx x Mode Verb Ab x Appr HLoc x Appr Tr Anx x Appr Verb Ab x Prog x Tour HLoc x Prog x Tour Tr Anx x Prog x Tour Verb Ab x Mode x Appr HLoc x Mode x Appr Tr Anx x Mode x Appr Verb Ab x Mode x Tour HLoc x Mode x Tour Tr Anx x Mode x Tour Verb Ab x Appr x Tour HLoc x Appr x Tour Tr Anx x Appr x Tour Verb Ab x Mode x Appr x Tour HLoc x Mode x Appr x Tour Tr Anx x Mode x Appr x Tour  (.1940) .1948 .2168 .2444 .3131 .3720 .3802 .4230 .4236 .4249 .4267 ' .4342 .4538 .4581 .4639 .4641 .4734 .6203 .6214 .6430 .6457 .6766 .6766 .6801 .8106  . R Change  2  2  *** .0008 .0220 .0276 .0688 .0589 .0081 .0428 .0006 .0013 .0018 .0075 .0196 .0043 .0059 .0001 .0094 .1469 .0011 .0216 .0027 .0309 .0000 .0035 .1305  *** *** ***  ***  *** ***  244  F Change *** .063 1.711 2.192 5.906 5.441 .747 4.157 .054 .125 .167 .690 1.829 .394 .537 .012 .836 17.795 .131 2.659 .329 4.013 .000 .440 26.867 *** *** ***  Sig *** .803 .196 .144 .018 .023 .391 .046 .818 .725 .684 .410 .182 .533 .467 .912 .365 .000 .719 .110 .569 .052 .983 .511 .000 *** *** ***  TABLE C.17 Summary of Regression Analyses of Personality Cluster Interactions on Children's State Anxiety Inventory at Pre-Surgery Measurement Interactions  cum.R  (Cumulative Effects) Verb Ab x Prog HLoc x Prog Tr Anx x Prog Verb Ab x Tour HLoc x Tour Tr Anx x TomVerb Ab x Mode HLoc x Mode Tr Anx x Mode Verb Ab x Appr HLoc x Appr Tr Anx x Appr Verb Ab x Prog x Tour HLoc x Prog x Tour Tr Anx x Prog x Tour Verb Ab-x Mode x Appr HLoc x Mode x Appr Tr Anx x Mode x Appr Verb Ab x Mode x Tour HLoc x Mode x Tour Tr Anx x Mode x Tour Verb Ab x Appr x Tour HLoc x Appr x Tour Tr Anx x Appr x Tour Verb Ab x Mode x Appr x Tour HLoc x Mode x Appr x Tour Tr Anx x Mode x Appr x Tour  (.6077) .6105 :6424 .6521 .6611 .6613 .6613 .6613 .6628 .6628' .6659 .6662 .6707 .7028 .7313 .7381 .7388 .7477 .7494 .7619 .7672 .7788 .7799 . .7844 .7853  R Change  2  2  *** .0028 .0319 .0097 .0090 .0002 .0000 .0000 .0015 .0000 .0031 .0002 .0045 .0321 .0285 .0069 .0006 .0089 .0017 .0126 .0007 .0161 .0012 .0045 .0009 *** *** ***  *** *** ***  245  F Change  Sig  ***  ***  .443 5.345 1.646 1.544 .033 .000 .001 .237 .003 .487 .034 .687 5.297 5.082 1.233 .109 1.589 .297 2.272 .127 2.988 .210 .810 .151 *** *** ***  .508 .024 .205 .219 .856 .994 .971 .628 .959 .488 .854 .411 .026 .029 .272 .742 .214 .588 .139 .723 .091 .649 .373 .700 *** *** ***  TABLE C.18 Summary of Regression Analyses of Personality Cluster Interactions on Children's State Anxiety Inventory at 6 Week Follow-up Measurement Interactions  cum.R  (Cumulative Effects) Verb Ab x Prog HLoc x Prog Tr Anx x Prog Verb Abx Tour HLoc x Tour Tr Anx x Tour Verb Ab x Mode HLoc x Mode Tr Anx x Mode Verb Ab x Appr HLoc x Appr Tr Anx x Appr Verb Ab x Prog x Tour HLoc X Prog x Tour Tr Anx x Prog x Tour Verb Ab x Mode x Appr HLoc x Mode x Appr Tr Anx x Mode x Appr Verb Ab x Mode x Tour HLoc x Mode x Tour Tr Anx x Mode x Tour Verb Ab x Appr x Tour HLoc x Appr x Tour Tr Anx x Appr x Tour Verb Ab x Mode x Appr x Tour HLoc x Mode x Appr x Tour Tr Anx x Mode x Appr x Tour  (.5685) .5762 .5763 .5927 .5931 .6290 .6307 .6307 .6318 .6323 ' .6439 .6439 .6440 .6461 .6462 .6546 .6933 .6938 .7080 .7462 .7736 .7882 .7987 .8202 .8405 *** ***  R Change  2  2  *** .0077 .0001 .0164 .0004 .0359 .0016 .0000 .0011 .0004 .0117 .0000 .0001 .0021 .0001 .0084 .0387 .005 .0141 .0382 .0275 .0146 .0105 .0216 .0203 *** *** ***  ***  246  F Change  Sig  ***  ***  1.132 .008 2.413 .064 5.617 .255 .003 .168 .064 1.737 .000 .008 .301 .015 1.164 5.926 .081 2.178 6.623 5.214 2.885 2.135 4.796 4.964 *** *** ***  .291 .930 .126 .800 .021 .616 .954 .683 .802 .193 .991 .929 .586 .904 .286 .019 .777 .147 .014 .027 .097 .152 .034 .032 *** *** ***  TABLE C.19 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions for HBQ Factor 1: Contentiousness Interactions  cum.R  (Cumulative Effects) Stress x Prog Chronic Cond x Prog Prev Exp x Prog Stress x Tour Chronic Cond x Tour Prev Exp x Tour Stress x Mode Chronic Cond x Mode Prev Exp x Mode Stress x Appr Chronic Cond x Appr Prev Exp x Appr Stress x Prog x Tour Chronic Cond x Prog x Tour Prev Exp x Prog x Tour Stress x Mode x Appr Chronic Cond x Mode x Appr Prev Exp x Mode x Appr Stress x Mode x Tour Chronic Cond x Mode x Tour Prev Exp x Mode x Tour Stress x Appr x Tour Chronic Cond x Appr x Tour Prev Exp x Appr x Tour Stress x Mode x Appr x Tour Chr Cond x Mode x Appr x Tour Prev Exp x Mode x Appr x Tour  (.6630) .6651 .6652 .6693 .6703 .6813 .6817 .6823 .6945 .6971" .7174 .7178 .7441 .7453 .745