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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 fulfilment of the requirements for an advanced degree at the 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 ^ ^ y c A s T t ^ * ^ / The University of British Columbia Vancouver, Canada Date He* Q - ; /990. DE-6 (2/88) 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). Addi-tionally, 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 immedi-ately 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 Pro-gramme 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 pro-gramme facets and individual characteristics of children is recommended. iii TABLE OF CONTENTS Abstract ii Table of Contents iv List of Tables '. ix List of Figures .- ; 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 218 Table of contents for Appendix B : 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 .- .. 64 Composition of Hospital Behaviour Questionnaire Item Factors (Pattern Matrix): Varimax Rotation of Principal Components Analysis (N=200) TABLE 1 75 Frequency Distributions for Categorical Independent Variables TABLE 3 76 Summary of Statistics and Tests of Normality for the Continuous Moderating Variables TABLE 4 ; J 76 Internal Consistency Coefficients for Child and Parent trait Anxiety and Health Locus of Control TABLE 5 77 Summary Statistics, Reliabilities and Normality Tests for Continuous Outcome Variables TABLE 6 78 Inter-Rater Reliabilites for Observation Scales TABLE 7 78 Marital Status of Parents TABLE 8 78 Measures of association for Agegroup and Gender with Marital Status TABLE 9 79 Gender of Child by Marital Status of Parents TABLE 10 79 Frequency of Number in Household TABLE 11 79 Summary of Analysis of Variance for Number in Household with Age Group, Gender, and Programme TABLE 12 80 Ethnic Background of Mothers and Fathers TABLE 13 81 Ethnic Background of Families TABLE 14 81 Activity Level Within Identified Ethnic Communities TABLE 15 81 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). ix TABLE 16 '. 82 Average Number in Household for each Ethnic Group of Fathers TABLE 17 ., 82 Number of Languages Spoken by Children TABLE 18 : ...83 Breakdown of the Sample and Programme Cells by the Blocking Factors TABLE 19 84 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. TABLE 20 84 Measures of Association for Agegroup (Age), Gender, and Surgical Category (SURCAT). TABLE 21 : .' 85 Measures of Association for AgeGroup (Age) and Gender with Position of Child in Family Structure TABLE 22 ., 85 Summary of Analysis of Variance for Socio-Economic Status (SES) and Age, Gender, and Position in Family Structure TABLE 23 85 Frequencies of Position in Sibling Structure (Position) and Age TABLE 24 86 Summary of Analyses of Variance for Children's Personality Characteristics (Verbal Ability, Health L O C , Tr. Anxiety) and Blocking Variables (Agegroup, Gender, Surcat) TABLE 25 86 Mean Health Locus of Control Scores for Each Age Group TABLE 26 86 Correlation Among Children's Personality Characteristics TABLE 27 86 Summary of Relationships Among Chronic Conditions, Previous Experience, Age, and Gender TABLE 28 87 Summary of Analysis of Variance for Blocking and Child History Variables TABLE 29 87 Obtained and Expected Frequencies for Previous Experience by Gender TABLE 30 89 Means for Group x Gender on the Children's State Anxiety Scale TABLE 31 90 Means for Control Groups on the Non-Verbal Observation Scale TABLE 32 92 Mean Scores for Programme x Gender on HBQ Factor 2 and HBQ Total Score x TABLE 33 Mean Scores for Programme on HBQ Factor 1: Contentiousness, HBQ Factor 2: Dependent Anxiety, and Verbal Observation Scale. 93 TABLE 34 : 95 Mean Scores for Tour x Gender on HBQ Factor 2: Dependent Anxiety and Children's State Anxiety TABLE 35 97 Mean Scores for Tour on Observation Rating, Verbal and Non-Verbal Scales. TABLE 36 ; : 99 Mean Scores on Programme x Tour x Agegroup on the Verbal Observation Scale TABLE 37 100 Mean Scores on Programme x Tour x Gender on HBQ Factor 2: Dependent Anxiety TABLE 38 101 Mean Scores on Programme x Tour on Observation Rating, Verbal and Non-Verbal Scales TABLE 39 105 Mean Score on Approach x Gender on HBQ Factor 4: Appetite Disturbance TABLE 40 107 Mean Scores for Verbal and Rating Scales of the Observation Scales and HBQ Factor 2 (Dependent Anxiety) for Instructional Approach TABLE 41 108 Mean Scores for Factors 2,3, and 4 on Mode of Presentation TABLE 42... 110 Approach x Mode x Agegroup on Observation Rating Scale TABLE 43 I l l Mean Scores for Approach x Mode on Observation Rating Scale and Observation Verbal Scale TABLE 44 112 Mean Scores for Approach x Mode on State Anxiety TABLE 45 113 Mean Scores for Approach x Tour onObservation Verbal Scale, and Children's State Anxiety Inventory. TABLE 46 117 Mean Scores for Age Groups on HBQ Sleep Disturbance and Appetite Disturbance and Children's State Anxiety TABLE 47 120 Summary Statistics of Regression Lines of Z Scores of Residuals on SES by Approach by Mode TABLE 48 122 Summary Statistics of Regression Line of Z Scores of Residuals on Programme x SES xi TABLE 49 ..... 125 Summary Statistics for Regression Line of Z Scores of Residuals on Trait Anxiety x Approach x Tour on HBQ Factor 2: Dependent Anxiety TABLE 50 , 127 Summary Statistics for Regression Line of Z Scores of Residuals on Trait Anxiety x Approach x Tour TABLE 51 ; 130 Summary Statistics for Regression Line of Z Scores of Residuals on Trait Anxiety x Mode xTour TABLE 52 133 Summary Statistics for Regression Line of Z Scores of Residuals on Health Locus of Control x Approach x Tour TABLE 53 '. '. 135 Summary Statistics for Regression Line of Z Scores of Residuals on Health Locus of Control x Mode x Tour TABLE 54 137 Summary Statistics for Regression Line of Z Scores of Residuals on Health Locus of Control x Approach x Mode TABLE 55 139 Summary Statistics for Regression Line of Z Scores of Residuals on Health Locus of Control by Programme by Tour TABLE 56 141 Summary Statistics for Regression Line of Z Scores of Residuals on Health Locus of Control by Tour TABLE 57 143 Summary Statistics for Regression Line of Z Scores of Residuals on Verbal Ability by Mode TABLE 58 144 Summary Statistics for Regression Line of Z Scores of Residuals on Tour by Verbal Ability TABLE 59 146 Cell Frequencies for Previous Experience x Programme x Tour TABLE 60 147 Mean Z Score Residuals for HBQ Factor 1: Contentiousness on Previous Experience by Approach TABLE 61 147 Mean Z Score Residuals for HBQ Factor 4: Appetite Disturbance on Previous Experience by Approach TABLE 62 148 Mean Z Score Residuals Observation Verbal Scale on Chronic Conditions (CQ by Approach TABLE 63 148 Mean Z Score Residuals for Observation Non-Verbal Scale on Chronic Conditions (CC) by Approach by Tour xii LIST OF FIGURES FIGURE PAGE FIGURE 1 47 Location of Study Area FIGURE 2 .... 50 Experimental and Control Variables FIGURE 3 ., 53 Dependent Variables: The Instruments Used and the Occasions of their Use. FIGURE 4 ; '. 51 Instruments and the Variables Measured. FIGURE 5 89 Mean State Anxiety Scores on 2 Occasions for Control Groups x Gender FIGURE 6 92 Significant Terms in the MANOVA Analyses Performed for Questions 2 and 3 and the Affected Scales (Variables) FIGURE 7 93 Mean HBQ: Factor 2 Scores on 2 Occasions for Programme x Gender FIGURE 8 94 Mean HBQ: Factor 1 Scores on 2 Occasions for Programme FIGURE 9 94 Mean HBQ: Factor 2 Scores on 2 Occasions for Programme FIGURE 10 95 Mean Verbal Observation Scores on 2 Occasions for Programme FIGURE 11 96 Mean HBQ: Factor 2 Scores on 2 Occasions for Tour x Gender FIGURE 12 96 Mean Children's State Anxiety Scores on 3 Occasions for Tour x Gender FIGURE 13 97 Mean Observation Rating Scale Scores on 2 Occasions for Tour FIGURE 14 98 Mean Verbal Observation Scores on 2 Occasions for Tour FIGURE 15 98 Mean Non-Verbal Observation Scores on 2 Occasions for Tour FIGURE 16 99 Mean Verbal Observation Scale Scores on 2 Occasions for Programme x Tour x Agegroup xiii FIGURE 17 ! 100 Mean HBQ: Factor 2 Scores on 2 Occasions for Programme x Tour x Gender FIGURE 18 , 101 Mean Observation Raring Scale Scores on 2 Occasions for Programme x Tour FIGURE 19 102 Mean Verbal Observation Scale Scores on 2 Occasions for Programme x Tour FIGURE 20 102 Mean Non-Verbal Observation Scale Scores on 2 Occasions for Programme x Tour FIGURE 21 105 Significant Terms in the MANOVA Analyses Performed for Questions 4,5, and 6 FIGURE 22 ; '. 106 Mean HBQ: Factor 4 Scores on 2 Occasions for Approach x Gender FIGURE 23 107 Mean Observation Rating Scale Scores on 2 Occasions for Approach FIGURE 24 107 Mean Verbal Observation Scale Scores on 2 Occasions for Approach FIGURE 25 108 Mean HBQ: Factor 2 Scores on 2 Occasions for Approach FIGURE 26 109 Mean HBQ: Factor 2 Scores on 2 Occasions for Mode FIGURE 27 109 Mean HBQ: Factor 3 Scores on 2 Occasions for Mode FIGURE 28 109 Mean HBQ: Factor 4 Scores on 2 Occasions for Mode FIGURE 29 110 Mean Observation Rating Scale Scores on 2 Occasions for Approach x Mode x Age Group FIGURE 30 I l l Mean Observation Rating Scale Scores on 2 Occasions for Approach x Mode FIGURE 31 112 Mean Verbal Observation Scale Scores on 2 Occasions for Approach x Mode FIGURE 32 113 Mean Children's State Anxiety Scores on 3 Occasions for Approach x Mode FIGURE 33 114 Mean Verbal Observation Scale Scores on 2 Occasions for Approach x Tour FIGURE 34 114 Mean Children's State Anxiety Scores on 3 Occasions for Approach x Tour xiv FIGURE 35 :. 117 Mean Children's State Anxiety Scores on 3 Occasions for Age Group FIGURE 36 119 Summary of Dependent Variables showing Significant Effects of Multiple Regression Analysis of Cluster 2: Family Characteristics FIGURE 37 120 Mean Z Score Residuals for HBQ Factor on SES xApproach x Mode FIGURE 38 , ". 121 Mean Z Score Residuals for Observation Non-Verbal on SES x Approach x Mode FIGURE 39 121 Mean Z Score Residuals for State Anxiety at Follow-Up on SES x Approach x Mode FIGURE 40 '. '. 123 Mean Z Score Residuals for HBQ Factor 2 on SES x Programme FIGURE 41 '. 123 Mean Z Score Residuals for Non-Verbal Observation Scale on SES x Programme FIGURE 42 ..• 124 Mean Z Score Residuals for Children's State Anxiety Inventory on SES x Programme FIGURE 43 125 Summary of Significant F Values for Effects of Multiple Regression Analyses of Cluster 3: Personality Characteristics FIGURE 44 .' 126 Mean Z Score Residuals for HBQ Factor 2 on Trait Anxiety x Approach x Tour FIGURE 45 127 Mean Z Score Residuals for Observation Rating Scale on Trait Anxiety x Approach x Tour FIGURE 46 128 Mean Z Score Residuals for Verbal Observation Scale on Trait Anxiety x Approach x Tour FIGURE 47 128 Mean Z Score Residuals for Non-Verbal Observation Scale on Trait Anxiety x Approach x Tour FIGURE 48 129 Mean Z Score Residuals for State Anxiety Inventory at 6 Week Follow-up on Trait Anxiety x Approach x Tour FIGURE 49 131 Mean Z Score Residuals for HBQ Factor 2 on Trait Anxiety x Mode x Tour FIGURE 50 131 Mean Z Score Residuals for HBQ Factor 3 on Trait Anxiety x Mode x Tour FIGURE 51 132 Mean Z Score Residuals for Verbal Observation Scale on Trait Anxiety x Mode x Tour xv FIGURE 52 Mean Z Score Residuals for Observation Non-Verbal Scale on Trait Anxiety x Mode x Tour 132 FIGURE 53 134 Mean Z Score Residuals for HBQ Factor 3 on Health Locus of Control x Approach x Tour FIGURE 54 134 Mean Z Score Residuals for Children's State Anxiety at 6 Week Follow-up on Health Locus of Control x Approach x Tour FIGURE 55 '. 136 Mean Z Score Residuals for HBQ Factor 4 on Health Locus of Control x Mode x Tour FIGURE 56 136 Mean Z Score Residuals for Children's State Anxiety at 6 Week Follow-up on Health Locus of Control x Mode x Tour FIGURE 57 138 Mean Z Score Residuals for HBQ Factor 2 on Health Locus of Control x Approach x Mode FIGURE 58 138 Mean Z Score Residuals for Observation Non-Verbal Scale on Health Locus of Control x Programme x Tour FIGURE 59 140 Mean Z Score Residuals for Observation Verbal Scale on Health Locus of Control x Programme x Tour FIGURE 60 140 Mean Z Score Residuals for Children's State Anxiety at Pre-Surgery on Health Locus of Control x Programme x Tour FIGURE 61 141 Mean Z Score Residuals for Observation Non-Verbal Scale on Health Locus of Control x Tour FIGURE 62 142 Mean Z Score Residuals for Children's State Anxiety at 6 Week Follow-up on Health Locus of Control x Tour FIGURE 63 143 Mean Z Score Residuals for HBQ Factor 4 on Verbal Ability x Mode FIGURE 64 144 Mean Z Score Residuals for Observation Non-Verbal Scale on Verbal Ability x Mode FIGURE 65 144 Mean Z Score Residuals for HBQ Factor 4 on Verbal Ability x Tour FIGURE 66 145 Mean Z Score Residuals for Observation Non-Verbal Scale on Verbal Ability x Tour FIGURE 67 146 Summary of Significant F Values for Effects of Multiple Regression Analyses of Cluster 4: Personal History xvi FIGURE 68 1 150 Summary of the Relationship of Higher Socio-Economic Status and Approach and Mode FIGURE 69 150 Summary of the Relationship of Higher Socio-Economic Status and Programme FIGURE 70 151 Relationship between more Internal Health Locus of Control and Approach and Tour FIGURE 71 152 Relationship between more Internal Health Locus of Control and Mode and Tour FIGURE 72 153 Summary of the Relationship of Internal Health Locus of Control and Mode and Approach FIGURE 73 •. J 153 Summary of the Relationship of Internal Health Locus of Control and Programme and Tour FIGURE 74 154 Summary of the Relationship of Internal Health Locus of Control and Tour FIGURE 75 155 Relationship of Higher Trait Anxiety scores and Approach and Tour FIGURE 76 155 Summary of Effects of Trait Anxiety on Mode and Tour FIGURE 77 169 Number of Significant Effects for each Dependent Variable used in the ANOVAs (Questions 2,3,4,5, & 6) 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 the final stages 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 hospitali-zation 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 psycho-social 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 perti-nent 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 hos-pitalization 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 proce-dures. 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 pro-ceeding 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 adenoton-sillectomies (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 inclu-sion 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) eco-nomic, 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 ad-mission." (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 implementa-tion 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-experi-mental 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 con-ventional 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 comfort-able 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 tremen-dous 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 sur-geons. 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 post-operative 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-medica-tion 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 anaesthe-sia 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 difficul-ties. ( 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 hospitaliza-tion 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 hospitaliza-tion. 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 admis-sion 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 their fifth year. 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 behavi-oural problems. He found a significant relationship between mother's assessment of post-hospitalization behavi-our 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 pre-existing 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 inter-views 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 admis-sions, 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 hospitalized fifteen years 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 the first five years 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 hospitali-zation 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 the first, 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 success-fully 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 demon-strated 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 ton-sillectomy 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 the first few 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 2 years. Their length of 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 predic-tors of upset before the admissions. The children and their mothers were interviewed one week before admis-sion, 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 behavi-ourally 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 non-hospitalized 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 dis-charge. 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 hospitaliza-tion 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' first names, 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 dis-turbed 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 V2to 6 V2 years, hospitalized for illness or medical diagnostic procedures. 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. Dav-enport and Werry (1970) examined the post-hospital behaviour of 145 children (100 hospitalized for tonsillecto-mies 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 Vancou-ver 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 ad-mission 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 hospitaliza-tion 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 ad-justment 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 hospitali-zation 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 deter-mine 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 be-havioural 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 hospitaliza-tion. 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 pre-vious 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 (Teich-man 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 characteris-tics 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. How-ever, 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 hospitali-zation 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 man-aged 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 not find a significant relationship between post-hospital 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 hospitaliza-tion 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 hospi-talization 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 identi-fied 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 informa-tion 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 their first study, 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 prepara-tion 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 pro-gramme 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 a filmed model. 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 a filmed mastery 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 behavi-oural 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 used filmed modeling 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 pro-gramme 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 pre-hospitalization personality. They also did not include parents in their treatment programmes, a variable consid-ered 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 (Associa-tion for the Care of Children in Hospital, B.C. Affiliate, 1980; Canadian Institute for Child Health 1979; Th-ompson & 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 meas-ures: 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 preadmis-sion 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 Behavi-our 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 to first voiding. 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 pro-grammes. 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 hospital-ized 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 "in-formation" 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 instruc-tion 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 summa-rize: 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 (Mel-amed & Siegel, 1975,1980), researchers have attempted to examine the effectiveness of other types of prepara-tion 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 hospitaliza-tion, 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 physio-logical 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 prepara-tion 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' pres-ence. However, these authors (Crocker, 1980; Melamed & Siegel, 1980) agree that parental presence is impor-tant 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 & Shiget-omi, 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 latter finding as 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 al , 1984) parents rated their child's usual reaction to medical procedures and their child's coping disposition. No signifi-cant 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 self-reported 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 infor-mational 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 ques-tioned. 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 descrip-tion 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 consid-ered. 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 hos-pitalization 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 be-haviours 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 self-esteem 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 behavi-oural 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). Al-though 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 hospi-talization, 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.J7erguson, 1979; Melamed et al., 1976). For measuring post-hospitaliza-tion reactions, most studies have relied upon 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 recog-nized (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 af-fect 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 De-partment 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 prepara-tion 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 pro-grammes: 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 prepara-tion 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, myrongoto-mies 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 the fifteen participating 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 reac-tions 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 de-scribed. 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 Cauca-sian 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 Visin-tainer (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 oppor-tunities 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 hospital tours given 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 pro-gramme 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 Yes A No B No Experimental Conditions Modeling/Audio-Visual Yes Modeling/Audio-Visual No Modeling/Print Yes Modeling/Print No Rehearsal-Instrucuon/Audio-Visual Yes Rehearsal-Instrucuon/Audio-Visual No Rehearsal-Instruction/Print Yes Rehearsal-Instruction/Print 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 Mod-eling, 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 photo-graphs 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 prepara-tion (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 back-grounds 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 hospitaliza-tion. 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 Children's State Anxiety prior to surgery and Inventory (Spielberger et al., 1973) following discharge 2. Observed anxiety prior to Observation Rating Scale surgery B. Child's Post Hospitalization Behavioural Adjustment 3. Parent-reported behaviour Hospital Behaviour Questionnaire (adapted 1,4 rating scales from Vernon, et al., 1966) *Occasions: 1 Visit 1 5-10 days prior to surgery 2 Visit 2 1-3 days prior to surgery 3 Visit 3 1 hour prior to surgery 4 Visit 4 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 Chil-dren's Hospital. The new hospital was opened in the Spring of 1982. 53 2,3,4 2,3 Staffing Interviewers. Three graduate students in Clinical and Educational Psychology were hired to act as inter-viewers. An orientation to the study and the hospital was provided. They were then trained in the use of all inter-views 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 proce-dural 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 pre-selected. 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 was reviewed and 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 acceptabil-ity of questions. Final revisions to 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 pre-sented 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 re-quirements 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 immedi-ately 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 Ques-tionnaire. 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. Behavi-oural 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 six-week follow-up data. Data Processing As instruments were returned to the Project Office by the interviewers, they were checked for identifica-tion 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 conversa-tional 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 conditions reported by 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 house-hold. 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 Variables Type of 1. Background Interview a. Age moderator b. Gender . moderator c. Surgical Category descriptive d. Previous hospitalizations moderator e. Chronic handicaps and conditions moderator f. Ethnic background descriptive g. Marital status of parents descriptive h. Position in sibling structure moderator i. Number in household descriptive j . Socio-economic status moderator B. Adapted Instruments 2. Observation Rating Scale 3. Hospital Behaviour Questionnaire (four factor-analytically derived scales) k. Observed anxiety 1.. Parent-reported behaviour dependent dependent 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 m. Language ability level 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 moderator moderator moderator dependent 61 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 Mel-amed 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-rater reliability for the Verbal, Non-Verbal and Rating Scales was established prior to commence-ment 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 main-tained 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 Question-naire 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 Program-mes 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 Conten-tiousness, Dependent Anxiety, Sleep Disturbance, and Appetite Disturbance; had principal loadings on (corre-lations 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 vo-cabulary was used as a measure of language ability level. Standard scores, calculated following the instruc-tions 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 were reported as .82 for immediate retest and .78 for retest after one year or more. Correlations with the earlier version of the PPVT are reported as 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 Factors1 (Pattern Matrix): Varimax Rotation of Principal Components Analysis (N=200)* Descriptors: Factor Loadings 2 II. Factors/Items3 I II III IV CONTENTIOUSNESS 25. Disobedient 69 07 31 20 15. Doesn't talk 66 09 -02 01 26. Breaks things 56 02 13 03 14. Temper tantrums 52 -07 32 15 18. Attention seeking 47 26 23 -02 10. Needs help doing things 44 43 -09 24 16. Upset with mention of doctors 27 21 17 -04 6. Disinterested in goings on ' 22 18 -21 19 DEPENDENT ANXIETY 5. Afraid to leave house 18 76 -05 09 12. Avoids new things 15 65 12 -02 9. Upset when left alone -19 60 19 28 13. • Can't decide 24 50 10 03 17. Follows parent around 31 43 07 36 3. Lies about doing nothing 32 42 -26 -15 8. Bites nails 08 20 -17 -05 SLEEP DISTURBANCE 19. Afraid of dark 01 35 65 -01 1. Fuss at bedtime 24 -01 64 06 20. Bad dreams 11 01 61 04 22. Can't get to sleep 18 -01 49 -07 23. Shy with strangers 01 33 43 -05 7. Wets bed 08 -06 20 -12 APPETITE DISTURBANCE 24. Poor appetite 01 06 10 75 27. Sucks thumb 22 -03 -10 52 2. Fusses over eating 06 -01 40 50 11. Disinterested in play 39 19 06 -41 4. Needs pacifier -05 24 -07 38 21. Irregular bowels 24 00 -21 32 Factor variance: 2.76 2.69 2.42 1.93 1 Loadings rounded to 2 significant figures; decimals omitted. 2 Items ranked within factor clusters by magnitude of principal loading. 3 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 "begin-ning 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 were reported as: (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 been reported in the manual. Evidence of construct validity of the state scale is reported where scores on each item were higher during stressful situations than in non-stressful situ-ations. Concurrent validity of the Trait Anxiety Scale has been indicated by reports of 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 dis-cussed 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 categori-cal variables, Chi-squared and Kendall's Tau statistics were calculated; for continuous variables, Pearson correla-tions 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. MANOV As 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 inter-action 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 exam-ined 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 consid-ered. 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 character-istics, 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 signifi-cant one, and higher order interactions. For example, if the following equation had been tested for significance in the first model: 70 Y= Yj+ U.+XA +X0 +P + T + PT + X A P + X A T + X Q P + X Q T + X A P T + X 0 P T + £ , where Y is the dependent variable (eg. State Anxiety), Yl is the pre-test of the dependent variable X A is the effect of the "age" individual difference variable, X Q is the effect of the "gender" individual difference variable, P is the effect of the "Programme" experimental variable, T is the effect of the "Tour" experimental variable, PT is the interaction effect of Programme and Tour, and X A P through X G P T are the interactions between individual difference variables and experimen-tal factors, and the [XATJ interaction had proven significant, the "reduced" model constructed for the second stage analysis would be: _ Y=Y,+ n+xA + x 0 + p+e . This equation was then applied to the full sample: its residuals included the variance associated with the [XAT] term found to be significant in the initial analysis, as well as the variance associated with the main effect of 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 por-trayals 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 the first-stage analysis, the plot resulting from the second-stage 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 scores 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 prepa-ration 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. • Tour • No Tour 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 Charac-teristics, 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 dis-cussion). 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 Original N % Age Groups Under 9 Over 9 Total Gender Male 74 67.3 Female 26 32.7 Total 110 100 80 72.7 20. 212 110 100 Previous Hospital Experience Some 87 79.1 None 21 19.1 Missing Data 2 1A Total 110 100 Chronic Conditions Some 61 55.5 None 49 44.5 Total 110 100 Position in Sibling Structure Youngest or Only 50 45.5 Other 6J2 54£ Total 110 100 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 con-dition. 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 esti-mates 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 ex-pected. 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 Stressful Events 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 TABLE 4 Internal Consistency Coefficients for Child Trait Anxiety and Health Locus of Control VARIABLE N Number of Items Hoyt's R Child's Trait Anxiety 88 20 0.84 Health Locus of Control 80 20 0.77 76 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 (K-S). 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 Items X S.D. Min Max K-S P Hoyt'sR Hospital Behaviour Questionnaire Contentiousness-Pre 109 8 49.87 10.02 32.87 87.77 1.58 0.01 * Post 110 8 51.14 9.98 35.44 90.35 0.88 0.42 Dependent Anxiety-Pre 109 7 49.91 10.09 17.43 66.84 1.03 0.24 * Post 110 7 51.45 9.94 24.65 74.12 1.34 0.05 * Sleep Disturbance-Pre 109 6 50.55 10.35 23.55 93.22 1.24 0.10 * Post 110 6 49.20 10.01 27.50 88.20 1.29 0.07 * Appetite Disturbance-Pre 109 6 50.28 11.04 32.61 84.15 1.53 0.02 * Post 110 6 49.34 10.02 27.48 79.42 1.13 0.16 * Child's State Anxietv-Pre 90 20 33.04 5.23 21 49 1.70 0.01 0.85 During 101 20 34.13 6.24 21 59 1.99 0.00 0.91 Post 107 20 29.73 4.60 20 43 1.53 0.02 0.87 Observation Rating Scale Pre 91 5 9.67 3.07 5 15 1.42 0.04 0.78 During 109 5 7.39 2.50 5 18 2.59 0.00 0.75 Observation Verbal Scale Pre 91 27 7.90 3.03 1 15 1.00 0.01 0.76 During 109 27 5.38 1.96 2 11 1.34 0.06 0.54 Observation Nonverbal Scale Pre 91 48 8.62 3.16 0 16 1.15 0.14 0.69 During 109 48 6.89 3.16 0 16 1.15 0.14 0.69 •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 2 Rating Scale 35 G.78 Verbal Scale 35 0.65 Non-Verbal Scale 35 0.82 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 Percent Married to each other 90 81.8 Separated 9 8.2 Divorced 3 2.7 Other & ZI Total 110 100 TABLE 8 Measures of association for Agegroup and Gender with Marital Status Variables N Chi-square P Kendall's Tau P Pearson R P Age 110 2.86 0.58 0.02 0.38 0.00 0.50 Gender 110 6.12 0.19 0.14 0.03 0.22 0.01 78 TABLE 9 Gender of Child by Marital Status of Parents Gender Marital Status Male Female Married 64 (60.5)* 26 (29.5) Separated 6( 6.1) 3 ( 2.9) Divorced 1 ( 2.0) 2( 1.0) Other 3( 5.4) 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. TABLE 10 Frequency of Number in Household Number in Household Frequency Percent 2 2 1.8 3 16 14.5 4 47 42.7 5 24 21.8 6 6 5.5 7 1 .9 8 2 1.8 Missing Data 12 10.9 Total 110 100 TABLE 11 Summary of Analysis of Variance for Number in Household with Age Group, Gender, and Programme Variables N Sum of Squares DF Mean Square F P Age Group 98 1.5138 6 .2523 1.38 .23 Gender 98 1.1884 6 .1981 .89 .51 Programme 91 10.7261 9 1.1918 1.05 .41 79 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%) and fifty-three fathers (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 TABLE 12 Ethnic Background of Mothers and Fathers Mothers Fathers Ethnic Background Frequency Percent Frequency Percent Canadian 58 52.8 53 48.3 Greek 2 1.8 3 2.7 Italian 0 0 2 1.8 Other Western European 16 14.5 14 12.7 Eastern European 7 6.4 5 4.5 East Indian 5 4.5 5 4.5 Chinese 9 8.2 9 8.2 Japanese 1 .9 1 .9 Other Asian 2 1.8 2 1.8 Canadian Indian 3 2.7 1 .9 Others 6 5.5 9 8.2 Not applicable*0?arent not present) 1 •9 _£ 5,5 Total 110 100 110 100 *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' Fathers' Background Background Can Greek Ital W.Eur E.Eur E.Ind Chin Jap Asian Can Ind Other N/A Can 48* 0 1 2 1 0 0 0 0 0 2 4 (43.6) (0) (.9) (1.8) (.9) (0) (0) (0) (0) (0) (1.8) (3.6) Greek 0 2 0 0 0 0 0 0 0 0 0 0 (0) (1.8) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) WJBur 4 0 1 10 0 0 0 0 0 0 0 1 (3.6) (0) (-9) (9.1) (0) (0) (0) (0) (0) (0) (0) (.9) E.Eur 1 1 0 1 4 0 0 0 0 0 0 0 . (.9) (.9) (0) (.9) (3.6) (0) (0) (0) (0) (0) (0) (0) E.Indian 0 0 0 0 0 5 0 0 0 0 0 0 (0) (0) (0) (0) (0) (4.5) (0) (0) (0) (0) (0) (0) Chinese 0 0 0 0 0 • 0 9 0 0 0 0 0 (0) (0) (0) (0) (0) (0) (8.2) (0) (0) (0) (0) (0) Japanese 0 0 0 0 0 0 0 1 0 0 0 0 (0) (0) (0) (0) (0) (0) (0) (.9) (0) (0) (0) (0) Asian 0 0 0 0 0 0 0 0 2 0 0 0 (0) (0) (0) (0) (0) (0) (0) (0) (1.8) (0) (0) (0) Can Ind 0 0 0 1 0 0 0 0 0 1 0 1 (0) (0) (0) (.9) (0) (0) (0) (0) (0) (.9) (0) (0) Other • 0 0 0 0 0 0 0 0 0 0 6 0 (0) (0) (0) (0) (0)) (0) (0) (0) (0) (0) (.5) (0) N/A 0 0 0 0 0 0 0 0 0 0 1 0 (0) (0) (0) (0) (0) (0) (0)) (0) (0) (0) (.9) (0) •Frequency (Percent of Total) TABLE 14 Activity Level Within Identified Ethnic Communities Mother's Father's Response Frequency Percent Frequency Percent Very active 5 9.6 6 12.2 Somewhat active 19 36.5 19 38.8 Not at all active 28 53.9 24 49.0 Total 52 100 49 100 TABLE 15 Summary of Analyses of Variance for Parent's Ethnic Background with Socio-economic Status (SES) and Number in House (House) Sum of Mean Variables N Squares DF Square F P Mother's Ethnic & SES 98 1860.8059 9 206.7562 In ~A1 Father's Ethnic & SES 98 3444.7378 11 313.1580 1.57 .12 Mother's Ethnic & House 91 17.5647 9 1.95 1.85 .07 Father's Ethnic & House 91 21.8962 11 1.9906 1.94 .04 81 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. TABLE 16 Average Number in Household for each Ethnic Group of Fathers Ethnic Group N Mean Number Canadian 50 4.3 Greek 3 4.3 Italian 2 4.0 West European 6 . 3.8 East European 4 3.2 East Indian 5 4.6 Chinese 7 4.7 Japanese 1 4.0 Other Asian 2 6.0 Canadian Indian 1 6.0 Other 10 3.8 TABLE 17 Number of Languages Spoken by Children Number Frequency Percent 1 75 68.2 2 30 27.3 3 3 2.7 4 1 .9 5 0 0 6 1 .9 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 de-scribed in Chapter 3. These were: age group, gender, and surgical category. The first two 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 discrepan-cies 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 discrep-ancy 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. TABLE 18 Breakdown of the Sample and Programme Cells by the Blocking Factors Programme/ Groups Age Group <9 >9 M Gender F Gen/Gu. Surgical Category ENT Ortho Pi/Dent Total Sample 80 30 74 36 46 41 8 15 Rehearsal-Instruction /Print 11 5 10 6 6 6 2 2 /Audio-visual 14 2 9 7 6 7 1 2 Modeling /Print 13 4 13 4 9 6 0 2 /Audio-visual 10 4 13 1 7 6 0 1 Control A 21 7 18 10 11 11 2 4 Control B 11 8 11 8 7 5 3 4 83 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 Population Variables N % . N % Sureical Category General 16 14.5 44 10.9 ENT 41 37.3 133 33.1 Orthopedic 8 7.3 143 35.6 Genitourinary 30 27.3 71 17.7 Plastic and Dental 15 13.6 11 2.7 Age Groups <9 80 72.7 255 63.4 >9 30 27.3 147 36.6 Gender Male 74 67.3 227 56.5 Female 26 32.7 m 43.5 Total 110 100 402 100 TABLE 20 Measures of Association for Agegroup (Age), Gender, and Surgical Category (SURCAT). Variables N Chi-square P Kendal's Tau P Pearson's R P Age & Gender 110 0.10 0.76 0.05 0.30 0.05 0.30 Age & SURCAT 110 6.85 0.23 0.12 0.09 0.13 0.08 Gender & SURCAT 110 4.44 0.49 0.08 0.21 0.21 0.17 Cluster 2: Family Characteristics Socio-economic status (SES) of the families (as computed using the method outlined in the Instrumen-tation 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. TABLE 21 Measures of Association for AgeGroup (Age) and Gender with Position of Child in Family Structure (Position) Variables N Chi-square P Kendall's Tau P Pearson's R P Age & Position Gender & Position 110 110 3.16 0.08 . 0.00 1.00 0.19 0.02 0.19 0.01 0.44 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 F Squares P SES by Agegroup SES by Gender SES by Position 98 98 98 5.8862 8.2439 39.6894 33 .1784 .8348 33 .2498 1.2346 1 39.6894 .1855 .71 .23 .67 TABLE 23 Frequencies of Position in Sibling Structure (Position) and Age Position N Age Group <9 >9 Youngest or Only Other 38 53 41(36.4)* 9( 3.6) 39(43.6) 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) Variables N Sum of Squares DF Mean Square F P Verbal Ability Age Group Gender Surcat 91 91 91 214.63 270.00 2368.30 | 214.63 4.04 473.66 .58 .01 1.31 .45 .91 .27 Health LOC Age Group Gender Surcat 80 80 80 390.30 19.91 78.47 ; 390.30 19.91 26.16 39.18 1.35 1.83 .00 .25 .15 Trait Anxiety Age Group Gender Surcat 88 88 88 101.88 1.04 7.19 3 101.88 1.04 2.04 1.91 .02 .04 .17 .89 .99 TABLE 25 Mean Health Locus of Control Scores for Each Age Group Age Groups N Mean SD Under 9 Over 9 58 22 29.44 34.39 3.38 2.46 TABLE 26 Correlation Among Children's Personality Characteristics Variables N R P Verb ABx LOC Verb AB x Tr. Anx LOC x Tr. Anx 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 N Chi-square P Kendall's Tau P Pearson' sR P CC and Prev. Exp. 109 1.60 0.45 -0.03 0.40 -0.01 0.48 CC and Age 110 0.14 1.71 -0.05 0.27 -0.06 0.28 CC and Gender 110 0.05 0.83 -0.04 0.33 -0.04 0.34 Prev. Exp. and Age 109 0.59 0.74 -0.06 0.28 -0.06 0.26 Prev. Exp. and Gender 109 7.12 0.03 0.22 0.01 0.20 0.02 86 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 relation-ships were observed. Table 29 shows that more boys and less girls than expected had previous experience with hospitalization. TABLE 28 Summary of Analysis of Variance for Blocking and Child History Variables Sum of Mean Variables N Squares DF Squares F P Gender by L. Events 109 804.86 1 804.86 .08 .72 Prev. Exp. by L. Events 108 9645.16 1 4822.58 .45 .64 C.C. by L. Events 109 2091.33 1 2091.33 .20 .66 TABLE 29 Obtained and Expected (*) Cell Frequencies for Previous Experience by Gender Previous Experience Gender Male Female Some 63 (58.3) 24 (28.7) None 10 (14.8) 12 (7.2) 87 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 vari-ables 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 pre-surgery 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 those receiving no 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 7 29.95 27.80 Female 8 46.21 30.36 Group B Male 9 35.50 30.83 Female 8 34.23 28.23 89 Main Effect of Attention (Group'): Again; this effect was observed on only one variable, the Non-Verbal 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 Group N Means A (Attention) 16 6.00 B (No Attention) 19 9.00 Summary: 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 prepara-tion 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 post-surgery (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 Scales (Dependent Variables) P 1) Programme x Gender HBQ Factor 2: Dependent Anxiety .01 Programme HBQ Factor 1: Contentiousness .04 HBQ Factor 2: Dependent Anxiety .04 Verbal Observation Scale .04 2) Tour x Gender HBQ Factor 2: Dependent Anxiety .03 Child State Anxiety - Post Occas. .05 3) Programme x Tour x Agegroup Verbal Observation Scale .02 Programme x Tour x Gender ' HBQ Factor 2: Dependent Anxiety .04 Programme x Tour Observation Rating Scales Multivariate .00 Rating Scale .00 Verbal Scale .00 Non-Verbal Scale .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 over time graphically. 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; they reported fewer behaviours. TABLE 32 Mean Scores for Programme x Gender on HBQ Factor 2 and HBQ Total Score HBQ Factor 2 Group N Pre Post Programme/Males 44 48.85 50.29 /Females 18 49.35 54.37 No Programme/Males 18 52.44 54.77 /Females 10 51.57 47.88 92 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. HBQ Factor 1 HBQ Factor 2 Verbal Scale Group N Pre Post Pre Post Pre Surg Programme 62 46.82 49.75 49.10 52.33 7.48 5.64 No Programme 28 51.75 50.81 52.00 51.32 8.61 5.48 93 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 non-treated group. FIGURE 8 Mean HBQ: Factor 1 Scores on 2 Occasions for Programme 52 51 a 5 0 ee 8 49 Vi 1 48 47 46 • PROGRAMME • NO PROGRAMME PRE I POST TIME 94 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. TABLE 34 Mean Scores for Tour x Gender on HBQ Factor 2: Dependent Anxiety and Children's State Anxiety HBQ Factor 2 Child's State Anxiety Group N Pre Post N Pre Surg Post Tour/Male 31 48.63 51.65 31 33.44 35.00 28.72 /Female 9 52.93 50.70 9 29.96 28.39 26.00 No Tour/Male 31 52.65 53.40 31 31.58 32.08 29.56 /Female 19 47.98 51.55 19 33.02 34.92 30.31 95 FIGURE 11 Mean HBQ: Factor 2 Scores on 2 Occasions for Tour x Gender 54 —I 1 PRE POST TIME 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 POST 96 Main Effects of Tour: Tour was found to. have a main effect on the Multivariate analysis of the Obser-vation Rating Scale (p=.01) with effects observed on the Rating Scale (p=.01), Verbal Scale (p=.01) and Non-Verbal Scale (p=.01). Table 35 displays the mean scores and Figures 13,14, and 15 present the graphic repre-sentations. 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 Rating Scale Verbal Scale Non Verbal Scale N Pre Surg Pre Surg Pre Surg Tour 41 11.31 7.31 9.51 5.15 7.10 6.82 No Tour 49 8.56 7.01 7.10 5.37 9.45 6.07 o tn z < 12 11 10 9 -7 • FIGURE 13 Mean Observation Rating Scale Scores on 2 Occasions for Tour • TOUR • NOTOUR PRE I SURG TIME 97 FIGURE 14 Mean Verbal Observation Scores on 2 Occasions for Tour 10 R «s o o (A 55 9 L • TOUR • NO TOUR I PRE I SURG TIME FIGURE 15 Mean Non-Verbal Observation Scores on 2 Occasions for Tour 10 CO w a o u CO 5S < w • TOUR • NO TOUR * PRE I SURG TIME 98 Programme x Tour x Agegroup: This interaction was found to significantly affect the Verbal Observa-tion 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 N Pre Surg Programme/Tour/Y ounger 22 6.59 5.82 /Older 7 9.14 6.29 Programme/No Tour/Younger 25 7.60 5.00 /Older 8 8.12 6.62 No Programme/Tour/Younger 8 12.12 4.12 /Older 4 10.75 6.50 No Programme/No Tour/Younger 13 6.08 5.31 /Older 3 7.33 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 PROGRAMME/TOUR ^ younger / \ older NO PROG/NO TOUR ^younge r f o l d e r < I I PRE SURG TIME 99 Programme x Tour x Gender: This interaction was observed to significantly affect HBQ Factor 2: De-pendent 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), parents recorded higher 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 Group N Pre Post Programme/Tour/Male 21 47.61 51.21 /Female 7 53.68 52.88 Programme/No Tour/Male 23 50.09 49.36 /Female 11 45.02 55.87 No Programme/Tour/Male 10 49.65 52.09 /Female 2 52.18 48.53 No Programme/No Tour/Male 8 55.22 57.43 /Female 8 50.95 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 male A female NO PROGRAMME/ NO TOUR ^ male ^ female PRE POST TIME 100 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 graphi-cally. 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 Pro-gramme/Tour or Programme/No Tour conditions made the most dramatic drop from pre-admission to pre-surgery, 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 Rating Verbal Non-Verbal Group N Pre Surg Pre Surg Pre Surg Programme/Tour 29 9.65 7.18 7.55 6.29 9.07 6.59 /No Tour 33 10.35 6.26 8.21 5.50 8.60 5.73 No Programme/Tour 12 11.70 7.70 11.40 4.95 5.80 7.95 /No Tour 16 7.50 6.88 6.21 5.00 10.33 6.17 FIGURE 18 Mean Observation Rating Scale Scores on 2 Occasions for Programme x Tour 12 it 2 io « o u Vi z • PROG/TOUR • PROGVNO TOUR • NO PROG ./TOUR O NO PROG/NO TOUR 1 PRE SURG TIME 101 On the Non-Verbal behaviour observation scale (Figure 20), only scores of children in the No Pro-gramme/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 Program-mes and Tours will be summarized below. Interactions with Agegroup: Only one interaction with agegroup was observed: Agegroup x Pro-gramme 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 Ob-servation 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: Conten-tiousness 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 be-haviours 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 Scales with Significant F Ratios P Instructional Approach Approach x Gender HBQ Factor 4: Appetite Disturbance .01 Approach Multivariate of Observation Scales .01 Rating Scale .02 Verbal Scale .01 HBQ Factor 2: Dependent Anxiety .04 Mode of Presentation Mode Multivariate of HBQ Factor Scores .01 HBQ Factor 2: Dependent Anxiety .01 HBQ Factor 3: Sleep Disturbance .01 HBQ Factor 4: Appetite Disturbance .01 Instructional Approach bv Mode of Presentation Approach x Mode x Agegroup Rating Scale .05 Approach x Mode Multivariate of Observation Scales .01 Rating Scale .01 Verbal Scale .01 State Anxiety at Surgery .04 Instructional Approach bv Mode of Presentation bv Tour Approach x Tour State Anxiety at Surgery .01 Observation Verbal Scale .01 TABLE 39 Mean Score on Approach x Gender on HBQ Factor 4: Appetite Disturbance Group N Pre Post Modeling /Males 22 46.23 46.80 /Females 8 51.03 45.51 Rehearsal-Instruction /Males 22 57.58 52.36 /Females 10 45.64 47.93 105 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 multivari-ate 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 observed to display 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 TABLE 40 Mean Scores for Verbal and Rating Scales of the Observation Scales and HBQ Factor 2 (Dependent Anxiety) for Instructional Approach Approach Rating Scale Verbal Scale HBQ Factor 2 N Pre Surg Pre Surg Pre Post Modeling 30 8.57 6.87 6.46 5.72 49.28 49.94 Rehearsal-Instruction 32 10.05 6.64 8.44 5.59 48.30 52.96 FIGURE 24 Mean Verbal Observation Scale Scores on 2 Occasions for Approach z a S | MODELING • REHEARSAL-INSTRUCTION PRE I SURG TIME 107 FIGURE 25 Mean HBQ: Factor 2 Scores on 2 Occasions for Approach 53 48 B MODELING • REHEARSAL-INSTRUCTION PRE 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 demon-strates 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 audio-visual programme decreased the number of such behaviours (Figure 28). TABLE 41 Mean Scores for Factors 2, 3, and 4 on Mode of Presentation Mode N HBQ Factor 2 Pre Post HBQ Factor 3 HBQ Factor 4 Pre Post Pre Post A/V Print 30 32 46.70 54.69 49.77 50.74 59.16 51.39 47.87 47.16 52.27 46.81 47.97 49.49 108 FIGURE 26 Mean HBQ: Factor 2 Scores on 2 Occasions for Mode x o u V) Ed s 51 50 49 48 47 46 • AUDIO-VISUAL • PRINT PRE POST TIME FIGURE 27 Mean HBQ: Factor 3 Scores on 2 Occasions for Mode 109 Approach x Mode x Agegroup: This interaction was observed on' the univariate analysis of the Obser-vation 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 Groups Observation Rating Scale N Pre Surg RI/AV/Young 14 8.57 6.07 /Old 2 6.50 6.50 RI/Print/Young 11 1.36 7.82 /Old 5 13.40 5.80 Mod/AV/Young 10 8.67 5.89 /Old 4 8.50 7.00 Mod/Print/Y oung 13 8.92 7.54 /Old 4 7.00 7.00 3 at O U M 25 Mean 14 FIGURE 29 Observation Rating Scale Scores on 2 Occasions for Approach x Mode x Age Group R.-I./A.-V. g young • old R.-I./PRINT 0 young O oW MOD./A.-V. young A old MOD./PRINT S young old PRE SURG 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 Model-ing/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-admis-sion score achieved by this group. TABLE 43 Mean Scores for Approach x Mode on Observation Rating Scale and Observation Verbal Scale Rating Scale Verbal Scale Group N Pre Surg Pre Surg Modeling/AV 14 8.65 6.28 6.90 5.54 /Print 16 8.49 7.45 6.01 5.90 Rehearsal-Instruction/AV 16 8.31 6.12 6.69 5.06 /Print 16 11.79 7.15 10.18 6.13 111 o o Mean FIGURE 31 Verbal Observation Scale Scores on 2 Occasions for Approach x Mode 11 10 9 8 . 7 . 6 5 4 PRE I POST • MODELING/ A-V • MODELING/ PRINT £ R-I/A-V O R-I/PRINT 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 N Pre Surg Post R-I/A-V 14 31.14 31.71 29.28 R-I/Print 15 33.07 35.33 30.00 Mod/A-V 13 33.38 33.62 28.07 Mod/Print 14 33.43 34.93 31.50 112 361 35-34-n 33-o u to 32-z i 31-30-29-28-27. FIGURE 32 Mean Children's State Anxiety Scores on 3 Occasions for Approach x Mode PRE SURG TIME • R-I /A-V • R-I/PRINT • M O D E L I N G / A - V O MODELING/PRINT POST 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 behaviours related to anxiety prior to surgery (Figure 33) than before admission in all groups, but a more dramatic drop was observed in the Rehearsal-Instruction/No Tour group. TABLE 45 Mean Scores for Approach x Tour on Observation Verbal Scale, and Children's State Anxiety Inventory. Verbal Scale Children's State Anxiety Group N Pre Surg N Pre Surg Post R-I/Tour 15 7.20 5.63 13 31.96 33.79 30.61 /NoTour 17 9.67 5.56 16 32.15 33.21 28.76 Modeling/Tour 14 7.46 6.31 12 33.42 33.75 27.17 /No Tour 16 5.46 5.12 15 33.36 34.55 31.88 113 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 observa-tions 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 Distur-bance (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 children reported higher 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 • <9 o >9 1 PRE I HOSP OCCASION [_ POST 117 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 MA-NOV As 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. The first row gives the cumulative R 2 for those interactions which were included in the model but not relevant to these questions. Column 1 names the interaction, column 2 gives the R2, or the amount of variance accounted for to that point in the model, Column 3 gives the R 2 Change, 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 the figures represents 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 cor-resonding 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 Dependent Variables *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 HBQ:F2, Obs. Non-Verb., State Anxiety Pre-Surg. Obs. Verb.. HBQ:F4 Obs. Non-Verb. Obs. Rat. Position x Programme x Tour *SES x Mode x Approach HBQ: F l , Obs. Non-Verb., State Anx. at 6 weeks 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 * 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: Contentious-ness (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, Model-ing/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 Modeling /A-V 12 .18 36.12 .27 27 70 /Print 15 .16 64.52 —.33 28 72 Rehearsal-Instruction /A-V 14 .07 55.58 —.15 24 72 /Print 15 .34 29.13 .46 29 72 No Programme 25 .03 54.14 —.08 18 72 Observation Non-Verbal Scale Modeling /A-V 11 .22 37.33 .25 27 70 /Print 16 .38 73.12 —.43 28 72 Rehearsal-Instruction /A-V 14 .07 39.89 .15 24 70 /Print 15 .23 32.57 .35 29 72 No Programme 25 .26 67.04 —.33 18 72 State Anxietv at 6 Week Follow-Uo Modeling /A-V 12 .03 39.66 .10 27 70 /Print 15 .07 63.06 —.20 28 72 Rehearsal-Instruction /A-V 13 .17 60.94 —.21 24 72 /Print 15 .03 55.13 —.10 29 72 No Programme 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 condi-tion. 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 Pro-gramme 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) Programme No Programme 51 .02 45.02 .09 24 .07 58.43 -.20 24.00 18.00 72.00 72.00 122 FIGURE 40 7 / 1 ' i ' i ' i • I ' i ' i • I ' i 1 —r - >—i—• i • i — • i 15 20 25 30 35 40 45 50 55 60 65 70 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 60 70 80 SOCIO-ECONOMIC STATUS 123 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 N R 2 YIntercept Slope MinX MaxX Modeling/Tour 13 .01 54.39 -.18 25.0 41.0 /No Tour 16 .04 56.22 -.20 22.0 48.0 Rehearsal-Instraction/Tour 10 .21 29.13 .69 24.0 42.0 /No Tour 16 .01 56.08 -.11 23.0 48.0 No Programme/Tour 10 .02 58.34 -.21 21.0 51.0 /No Tour 15 .17 66.20 -.43 23.0 55.0 125 FIGURE 44 Mean T Score Residuals for HBQ Factor 2 on Trait Anxiety x Approach x Tour 60 -, MOD. /TOUR MOD. /NOTOUR R-I /TOUR R-I /NOTOUR NOPROG /TOUR NOPROG /NOTOUR 20 30 40 50 60 CHILDREN'S TRAIT ANXIETY 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 condi-tions. Observations of verbal behaviours related to 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 TABLE 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 MaxX Observation Rating Scale Modeling/Tour 13 .00 53.21 -.06 25.0 41.0 /No Tour 15 .06 4121 .18 22.0 48.0 Rehearsal-Instrucuori/Tour 10 .36 33.44 .45 24.0 42.0 /No Tom- 16 .00 48.56 -.01 23.0 48.0 No Programme/Tour 10 .10 64.87 -.48 21.0 51.0 /No Tour 15 .13 29.07 .50 23.0 55.0 Observation Verbal Scale Modeling/Tour 13 .02 64.85 -.37 25.0 41.0 /No Tour 15 .00 47.70 .02 22.0 48.0 Rehearsal-InstructionA'our 10 .20 17.66 1.03 24.0 42.0 /No Tour 16 .01 46.77 .10 23.0 48.0 No Programme/Tour 10 .00 48.98 .02 21.0 51.0 /No Tour 15 .02 58.23 -.17 23.0 55.0 Observation Non-Verbal Scale Modeling/Tour 13 .06 60.96 -.39 25.0 41.0 /No Tour 15 .01 45.60 .12 22.0 48.0 Rehearsal-Instrucrion/Tour 10 .01 45.68 .15 24.0 42.0 /No Tom- 16 .00 48.25 -.05 23.0 48.0 No Program me/Tour 10 .05 43.41 .28 21.0 51.0 /No Tour 15 .23 27.44 .47 23.0 55.0 Children's State Anxietv Inventory at 6 Week Follow-uo Modeling/Tour 12 .02 50.06 -.21 25.0 41.0 /No Tour 16 .00 52.95 .06 22.0 48.0 Rehearsal-Instruction/Tour 10 .01 54.92 -.13 24.0 42.0 /No Tom- 16 .00 50.01 -.01 23.0 48.0 No Programme/Tour 10 .17 33.93 .40 21.0 51.0 /No Tour 15 .06 40.09 .30 23.0 55.0 127 FIGURE 46 Mean T Score Residuals for Verbal Observation Scale on Trait Anxiety x Approach x Tour CZ3 a O H Z < 62 -. 60 -58 -56 -54 -52 -50 -48 -46 -44 -42 -20 25 r~ 30 35 40 45 50 55 • MOD. /TOUR MOD. /NOTOUR R-I /TOUR R-I /NOTOUR NOPROG /TOUR NO PROG /NOTOUR CHILDREN'S TRAIT ANXIETY FIGURE 47 Mean T Score Residuals for Non-Verbal Observation Scale on Trait Anxiety x Approach x Tour 60-, g. 56_| a 54. w 5 2 -<* 50-§ 48-8 46-M 44-£ «. W 4 0 " 2 38-^ r 20 - r-25 —r-30 35 40 45 CHILDREN'S TRAIT ANXIETY 50 55 • MOD. /TOUR o MOD. /NOTOUR * R-I /TOUR ^ R-I /NOTOUR • NO PROG /TOUR • NO PROG /NOTOUR 128 CO < P Q hH CO W a a* o u CO H se 60-, 58-56-54-52-50-48-46-44-42-i FIGURE 48 Mean T Score Residuals for State Anxiety Inventory at 6 Week Follow-up on Trait Anxiety x Approach x Tour 9 MOD. /TOUR o MOD. /NOTOUR • *d /TOUR ^ R-I /NOTOUR • NO PROG /TOUR • NO PROG /NOTOUR T~ 20 l 25 I 30 —T -35 T" 40 ~~T~ 45 - r ~ 50 55 - 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 TABLE 51 Summary Statistics for Regression Line of T Scores of Residuals on Trait Anxiety x Mode x Tour Group N R 2 YIntercept Slope MinX Max HBO Factor 2: Dependent Anxietv Print/Tour 11 .37 9.85 1.14 30 42 /No Tour 15 .00 50.95 .01 23 48 Audio-Visual/Tour 12 .01 42.69 .22 24 38 /No Tom- 17 .17 66.83 -.46 22 48 No Programme/Tour 10 .02 58.13 -.21 21 51 /No Tour 15 .17 65.90 -.42 23 55 HBO Factor 3: Sleep Disturbance Print/Tour 11 .00 52.68 -.13 30 42 /No Tour 15 .09 41.61 .32 23 48 Audio-Visual/Tour 12 .08 26.85 .67 24 38 /No Tom- 17 .01 58.32 -.16 22 48 No Program me/Tour 10 .27 24.13 .67 21 51 /No Tour 15 .00 51.79 -.02 23 55 Verbal Observation Scale Print/Tour 11 .33 -2.10 1.44 30 42 /No Tom- 14 .12 59.90 -.37 23 48 Audio- Visual/Tour 12 .00 57.86 -.13 24 38 /No Tour 17 .19 29.89 .55 22 48 No Programme/Tour 10 .00 49.74 -.02 21 51 /No Tour 15 .02 58.24 -.16 23 55 Observation Non-Verbal Scale Print/Tour 12 .00 54.51 -.13 24 38 /No Tour 17 .01 47.23 .09 22 48 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 FIGURE 49 Mean T Score Residuals for HBQ Factor 2 on Trait Anxiety x Mode x Tour 60 58 -56 -co < Q c« 54 _ « O O 48 CO CO < Q i—< c« W « « o H 2 52 -50 -46 -44 -42 -20 25 30 T" 35 —T-40 - r -45 50 55 • PRINT /TOUR o PRINT /NOTOUR 4> A-V /TOUR A-V /NOTOUR • NO PROG /TOUR • NOPROG /NOTOUR 60 CHILDREN'S TRAIT ANXIETY FIGURE 50 Mean T Score Residuals for HBQ Factor 3 on Trait Anxiety x Mode x Tour 60 58 56 54 52 50 48 46 44 42 40 38 36 20 • PRINT /TOUR o PRINT /NO TOUR • A-V /TOUR A-V /NO TOUR • NO PROG /TOUR • NOPROG /NO TOUR V 25 30 35 —V 40 45 50 T" 55 I 60 CHILDREN'S TRAIT ANXIETY On the Verbal Observation Scale (Figure 51), trait anxiety score made little difference to the verbal ex-pression 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 CO < Q i—i co W 06-Ed « O U CO H 2 60-, 58-56-54-52-50-48-46-44-42-i V 20 —r 25 T 30 I 35 I 40 I 45 i— 1—r~ 50 55 • PRINT /TOUR o PRINT /NOTOUR • A-V /TOUR A-V /NOTOUR • NOPROG /TOUR • NOPROG /NOTOUR I 60 CHILDREN'S TRAIT ANXIETY 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 Rehearsal-Instruction/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 Pro-gramme/No Tour conditions, health locus of control had little effect (slopes -.04, -.02). For all three Tour condi-tions, 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 MaxX HBO Factor 3: Sleep Disturbance Modeling/Tour 13 .35 -13.17 2.06 26.0 36.0 /No Tour 16 .01 56.12 -.19 23.0 38.0 Rehearsal-Instruction/Tour 10 .01 56.82 -.27 25.0 38.0 /No Tour 16 .00 50.26 .07 26.0 36.0 No Programme/Tour 10 .16 77.65 -.92 24.0 38.0 /No Tour 15 .06 62.72 -.39 25.0 38.0 Children's State Anxietv Inventory at 6 Week Follow-uD Modeling/Tour 12 .09 16.02 .84 26.0 36.0 /No Tour 16 .00 56.47 -.04 23.0 38.0 Rehearsal-Instruction/Tour 10 .61 14.37 1.16 25.0 38.0 /No Tour 16 .00 49.59 -.02 26.0 36.0 No Programme/Tour 10 .15 31.50 .54 24.0 38.0 /No Tour 15 .01 42.59 .27 25.0 38.0 133 FIGURE 53 Mean T Score Residuals for HBQ Factor 3 on Health Locus of Control x Approach x Tour < !=> Q i—i tn H 06 W 06 O U Z 2 62 -j 60 -58 -56 -54 -52 -' 50 -48 -46 -44 -42 -40 -38 -• MOD. /TOUR o MOD. /NOTOUR • R-I /TOUR R-I /NOTOUR • NO PROG /TOUR • NOPROG /NOTOUR -V 25 30 -V 35 I 40 HEALTH LOCUS OF CONTROL 60 -j 58 -56 -3 5 4: § 5 2 : 55 50 -g 48: O 44 J "> 42 -H Z 40 -d 38: ^ 36: 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 - r -25 30 —r 35 # MOD. /TOUR o MOD.. /NOTOUR „ R-I /TOUR * R-I /NOTOUR • NOPROG /TOUR • NO PROG /NOTOUR 40 HEALTH LOCUS OF CONTROL 134 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 ob-served 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 12 .23 76.14 —.92 26 38 /No Tour 17 .07 31.94 .72 23 36 Audio-Visual /Tour 11 .01 37.76 .26 25 36 /No Tour 15 .12 72.82 —.82 23 38 No Programme /Tour 10 .08 76.22 —.76 24 38 /No Tour 15 .19 16.28 1.04 25 38 State Anxietv at 6 Week FO11OW-UD Print /Tour 12 .07 36.40 .44 26 38 /No Tour 17 .00 53.15 .00 23 36 Audio-Visual /Tour 11 .04 25.41 .61 25 36 /No Tour 15 .09 67.57 —.59 23 38 No Programme /Tour 10 .00 49.01 .00 24 38 /No Tour 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 35 36 37 38 39 HEALTH LOCUS OF CONTROL 136 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 differ-ently 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-Instruc-tion/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 Rehearsal-Instruction /A-V 12 .00 50.64 .10 25 36 /Print 14 .00 53.30 —.07 26 38 No Programme 25 .00 52.04 —.06 24 38 Observation Non-Verbal Scale Modeling /A-V 13 .22 75.92 —.85 23 38 /Print 15 .09 27.72 .71 23 36 Rehearsal-Instruction /A-V 12 .03 35.74 .43 25 36 /Print 14 .20 94.94 —1.40 26 38 No Programme 25 .05 33.03 .55 24 38 137 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 Obser-vation 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 lower ratings of 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 State Anxietv at Follow Up Tour 33 .03 37.13 .34 24 38 NoTour 47 .01 60.33 —.28 23 38 FIGURE 61 T Score Residuals for Observation Non-Verbal Scale on Health Locus of Control x Tour co < Q i—< i n W u. w Oi O u <» H se < w 57 55 53 51 49 47 • 45 • 43 • TOUR • NOTOUR 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 to W et w 06 © u CO H Z •< w 56 54 52 50 48 46 . 44 • TOUR • NOTOUR 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 Audio-Visual 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 .10 38.99 .13 40 132 Print 29 .00 48.33 .02 41 127 No Programme 25 .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 • i — i — r — • — i • i • i • i — i • i — i • i 30 40 50 60 70 80 90 100 110 120 130 140 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 • TOUR • NOTOUR 40 //-r-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 hospitaliza-tion 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: Ap-petite 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: Con-tentiousness (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. There-fore, 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 Obs. Rating Chronic Condition x Programme Obs. Non-Verb. Previous Experience x Programme State Anx. Pre-Surg. Stress x Tour Obs. Non-Verb. Chronic Condition x Tour Previous Experience x Tour Stress x Mode Chronic Condition x Mode Previous Experience x Mode Stress x Approach . HBQ:F1 Chronic Condition x Approach •Previous Experience x Approach HBQ:F1,HBQ:F4 Stress x Programme x Tour Chronic Condition x Programme x Tour Obs. Rating •Previous Experience x Programme x Tour HBQ:F4, State Anx. Pre-Surg. Stress x Mode x Approach Obs. Non-Verb. Chronic Condition x Mode x Approach Obs. Verb. Previous Experience x Mode x Approach Stress x Mode x Tour Chronic Condition x Mode x Tour State Anx. 6 wks. Previous Experience x Mode x Tour Stress x Approach x Tour •Chronic Condition x Approach x Tour Obs. Verb., Obs. Non-Verb. Previous Experience x Approach x Tour • Interactions chosen for the second stage of the Regression Analysis. TABLE 59 Cell Frequencies for Previous Experience x Programme x Tour Group N Programme/Tour/Some Prev Exp 22 /No Prev. Exp. 3 /No Tour/Some Prev Exp 31 /No Prev Exp 3 No Programme/Tour/Some Prev Exp 11 /No Prev Exp 1 /No Tour/Some Prev Exp 9 /No Prev Exp 6 146 Table 60 Mean T Score Residuals for HBQ Factor 1: Contentiousness on Previous Experience x Approach Group N X S.D. Min. Max. Modeling /Prev. Experience 26 49.21 9.85 31.97 69.70 /No Experience 3 52.45 4.75 47.04 55.97 Rehearsal-Instruction/Prev. Experience- 28 50.20 11.01 31.01 72.32 /No Experience 2 58.70 14.13 45.32 73.47 No Programme /Prev. Experience 20 50.21 5.58 42.21 63.75 /No Experience 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 N X S.D. Min. Max. Modeling /Prev. Experience 26 49.42 9.02 34.10 68.32 /No Experience 3 48.89 9.65 42.11 59.94 Rehearsal-Instruction/Prev. Experience 28 49.66 9.72 22.55 75.86 /No Experience 2 42.82 5.77 39.46 49.48 No Programme /Prev. Experience 20 50.86 9.75 34.87 71.94 /No Experience 7 46.13 4.20 40.53 53.08 Chronic Conditions x Approach x Tour. This interaction was found to significantly affect the Observa-tion 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 ver-balizations 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 N X S.D. Min. Max. Modeling /Tour /CC 7 53.51 10.50 45.06 75.82 /NoCC 6 52.09 13.93 34.08 69.25 Modeling /NoTour /CC • 7 45.29 6.90 36.74 55.50 /NoCC 9 50.73 10.14 30.18 . 62.16 Rehearsal-Instruction /Tour /CC 7 49.12 8.23 36.24 58.49 /NoCC 7 48.59 12.87 36.43 67.78 Rehearsal-Instruction /No Tour /CC 6 50.00 8.96 38.63 60.64 /NoCC 11 48.76 6.01 35.84 60.75 No Programme /Tour /CC 8 46.29 11.32 34.68 69.80 /NoCC 4 51.77 2.50 48.63 53.94 No Programme /No Tour /CC 9 53.24 9.09 38.52 64.16 /NoCC 6 47.03 10.72 38.73 65.97 Table 63 Mean T Score Residuals for Observation Non-Verbal Scale on Chronic Conditions (CC) x Approach x Tour Group N X S.D. Min. Max. Modeling /Tour /CC 7 52.91 11.44 38.32 69.75 /NoCC 6 47.33 5.59 39.73 55.40 Modeling /No Tour /CC 7 51.01 11.18 36.44 64.94 /NoCC 9 53.29 6.54 41.36 62.57 Rehearsal-Instruction /Tour /CC 7 45.98 10.49 29.91 63.48 /NoCC 7 57.21 6.04 52.08 69.26 Rehearsal-Instruction /No Tour /CC 6 49.70 7.77 39.18 59.89 /NoCC 11 46.57 9.73 29.34 58.68 No Programme /Tour /CC 8 53.03 9.76 37.71 69.85 /NoCC 4 52.29 11.75 39.41 67.18 No Programme /No Tour /CC 9 46.63 11.10 24.87 62.14 /NoCC 6 51.24 10.80 35.36 69.06 148 Summary of Question 7 In analysing the effects of individual characteristics of the children on the effectiveness of the program-mes, 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-ver-bal 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 depend-ent 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 Higher Scores Slope Lower Scores Slope Group Modeling/Audio-Visual Modelmg/Print Rehearsal-Instr./Print No Programme Contentiousness 0.27 Obs. Non-Verbal 0.25 Contentiousness 0.46 Obs. Non-Verbal 0.35 Contentiousness -0.33 Obs. Non-Verbal -0.43 State Anx. @ 6 wks. -0.20 Contentiousness -0.15 State Anx. @ 6 wks. -0.21 Obs. Non-Verbal -0.33 State Anx. @ 6 wks. -0.11 Min. Effect Slope State Anx. @ 6 wks. 0.10 State Anx. @ 6 wks.-0.10 Contentiousness -0.08 Rehearsal-Instr7Audio-Vis. Obs. Non-Verbal 0.15 FIGURE 69 Summary of the Relationship of Higher Socio-Economic Status and Programme Group Higher Scores Slope Lower Scores Slope Min. Effect Slope Programme Dependent Anx. -.30 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 Pro-gramme/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 Higher Scores - Slope Lower Scores - Slope Minimal Effect - Slope Modeling/Tour Sleep Dist 2.06 State Anx.@ 6Wks. .84 Modeling/No Tour Sleep Dist -.19 State Anx.@ 6 Wks. -.04 R-I/Tour State Anx.@ 6 Wks. 1.16 Sleep Dist -.27 R-I/No Tour Sleep Dist .07 State Anx.@ 6 Wks. .02 No Programme/Tour State Anx.@ 6 Wks. .54 Sleep Dist -.92 No Programme/No Tour State Anx.@ 6 Wks. .27 Sleep Dist -.39 151 Health Locus of Control interacted with Mode and Tour on four scales. Figure 71 summarizes the rela-tionships 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 Lower Scores Slope Min. Effect Slope Print/Tour State Anx. @ 6 wks. 0.44 Appetite DisL -0.92 Print/No Tour Appetite DisL 0.72 State Anx. @ 6 wks. 0.00 Audio-Visual/Tour Appetite DisL 0.26 State Anx. @ 6 wks. 0.61 Audio-Visual/No Tour Appetite DisL -0.82 State Anx. @ 6 wks. -0.59 No Programme/Tour Appetite DisL -0.82 State Anx. @ 6 wks. 0.00 No Programme/No Tour Appetite DisL 1.04 State Anx. @ 6 wks. 0.00 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 Lower Scores Slope Min. Effect Slope Modeling/A-V Dependent Anxiety -0.98 Obs. Non-Verb. -0.85 Modeling/Print Dependent Anxiety 0.82 Obs. Non-Verb. 0.71 Dependent Anxiety 0.10 Rehearsal-InstryA-V 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 Min. Effect 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 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 Min. Effect 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 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 pro-grammes were associated with increased scores on more measures associated with anxiety, whereas the Re-hearsal-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 ob-servations of verbal anxiety related behaviour 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 Lower Scores Slope Minimal Effect Slope Mod/Tour Dep. Anxiety Obs. Verbal Obs. Non-Verbal State Anx.@ 6 Wks. -.18 -.37 -.37 -21 Obs. Rating -.06 Mod/No Tour Obs. Rating ,18 Dep. Anxiety -.20 Obs. Verbal .02 Obs. Non-Verbal .12 State Anx.@ 6 Wks. .06 R-I/Tour Dep. Anxiety Obs, Rating Obs. Verbal Obs. Non-Verbal .69 .45 1.03 .15 State Anx.@ 6 Wks. -.13 R-I/No Tom- Obs. Verbal .10 Dep. Anxiety -.11 Obs. Rating Obs. Non-Verbal State Anx.@ 6 Wks. -.01 -.05 -.01 No Prog/Tour Obs. Non-Verbal .27 Dep. Anxiety -.21 Obs. Verbal .02 State Anx.@ 6 Wks. .40 Obs. Rating -.48 No ProgVNo Tour Obs. Rating .50 Dep. Anxiety -.43 Obs. Non-Verbal .47 Obs. Verbal -.17 State Anx.@ 6 Wks. .30 FIGURE 76 Summary of Effects of Trait Anxiety on Mode and Tour Group Higher Scores - Slope Lower Scores - Slope Minimal Effect - Slope A-V/Tour Dep. Anxiety .22 Obs. Non-Verb. -1.40 Obs. Verbal -.13 Sleep Dist. .67 A-V/NoTour Obs. Verbal .55 Dep. Anxiety -.46 Sleep Dist. -.16 Obs. Non-Verb. .08 Print/Tour Dep. Anxiety 1.14 Sleep Dist. -.13 Obs. Verbal 1.44 Obs. Non-Verb. -.13 Print/No Tour Sleep Dist. .32 Obs. Verbal -.37 Dep. Anxiety .01 Obs. Non-Verb. .09 No Prog./Tour Sleep Dist. .67 Dep. Anxiety -.21 Obs. Verbal -.02 Obs. Non-Verb. .21 NoProg./NoTour Obs. Non-Verb. .59 Dep. Anxiety -.42 Sleep Dist. -.02 Obs. Verbal -.16 155 The interaction of verbal ability and Mode was observed on two dependent variables. Only small differ-ences were observed on the Appetite Disturbance factor, with children having higher verbal ability in the Audio-Visual 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 con-ditions, 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 preadmis-sion 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 compar-ing 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 interpreta-tions 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 chil-dren. 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 commu-nity. 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 Genito-urinary, Plastic, or Dental surgeons than the study sample. The descriptive statistics reported for the study's patients describe the diversity of the sample. Review-ers 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 of findings broader 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 inpa-tient 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 considered relatively small. Question 2: Effects of Programme The purpose of this question was to determine whether the preparation programmes could reduce negative reactions to day care surgery. This question was addressed by comparing the reactions of children receiving programmes to those of children receiving no programmes. In previous research of 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 in reducing behavioural 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 ob-served 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 and rated observed anxiety-related behaviour from prior to preparation to after prepara-tion. 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 a tour of the surgical day care suite and operat-ing 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 pro-gramme. The research literature has not provided clear evidence of the effectiveness of tours in 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 co-operative 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 expres-sions 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 negative reactions of 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 pro-gramme 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 Rehearsal-Instruction 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 Rehearsal-Instruction 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, Rehearsal-Instruction 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 Audio-Visual 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 Audio-Visual 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 self-reported state anxiety from pre-preparation to just prior to surgery was observed in children in the Rehearsal-Instruction/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 distur-bance 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 Ap-proaches 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 characteris-tics 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 prepara-tion 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 hospitali-zation 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 character-istics, the data provided no uniform picture but, rather, a variety of unique effects, particular to individual meas-urements of anxiety. Age. A main effect for age was observed on three scales; younger children exhibited more sleep distur-bances 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 prepara-tion 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 Pro-gramme 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 experi-mental variables (e.g., Peterson and Shigetomi, 1981). However, Melamed et al. (1976) did discover a relation-ship 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 program-mes. 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 self-reported 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 hospi-talization (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 effective-ness 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 them-selves. 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 condi-tions 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 pre-ceding 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 contribut-ing 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 preadmis-sion 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. Stud-ies often include eight or more dependent variables. For example, Zastowny et al. (1986) used a behavior check-list, 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 .. , 1 Factor 2: Dependent Anxiety 7 Factor 3: 2 Factor 4: .; 2 Observation Rating Scale 6 Verbal Scale 7 Non-Verbal Scale 2 State Anxiety: Pre-Surgery 3 Post-Surgery 1 Mode and Tour (Questions 2-6). Of a possible thirty-one main effects and interactions, nineteen were signifi-cant 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 adjust-ment 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 conceptu-alize the stress reactions of children and provide the groundwork from which to evaluate programmes. Further investigation should be undertaken to determine the relationships among 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. The relationship between simultaneously administered measures, such as self-report and observed anxiety should be examined. Additionally the relationship between 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 instru-ments used to measure "reactions to hospitalization and day care surgery." Clinical Implications The results of 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 hospitali-zation. 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 information required before the relationship of preparation to individual characteristics is truly understood. Since this study did not ascertain the inter-relation-ships among the individual characteristics of the children, the results of 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 pread-mission 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. Indi-vidual 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 to reach these 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 negative reactions is of interest Clinicians need to become involved in the discussion and research of which behaviours, or negative reactions, should be reduced and which might be reinterpreted as 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 prepa-ration. 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 the findings of 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 special-ties 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 prepara-tion. 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 the first few 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. Un-fortunately, 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 in-cluded in this study, the possibiltiy occurs of obtaining significant effects by chance. The research questions con-sidering 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 greatly reduced the 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-depth research, this was not a viable option. However, despite the design described above, the possibility that unusual findings may be the result of 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 reac-tions 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 chil-dren's reactions to 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 hospitali-zation 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 reac-tions 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-Eco-nomic Status families in reducing negative reactions to the hospitalization. Girls benefitted more from tours than 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 spe-cific programme for use with any particular child. The examination of the individual difference variables was ex-ploratory, 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 relation-ships 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 inter-relationships 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 differ-ences 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 differ-ences 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 sur-gery. 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 Instruc-tional 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 , 188 Procedure for Interviewers 194 Initial Telephone Contact 194 Procedure for First Home Visit 200 Second Telephone Contact 216 Visit #2 217 187 Procedure for Treatments Interviewer will bring the family to the Project Office and introduce them. Invite them into the office. Establish rapport. Say: 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 is 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 connected with the hospital. Acknowledge the information he/she is likely to have had. Proceed with interview. To parent: 1. Did Dr. (doctor's name) describe the operation to you? (Probe: Do'you feel satisfied that you understand what he is going to do?; Check lcs '2b, 2c. 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 tell 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 tell 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'll just go outside to give you a bit more room. Leave. Check Interview and score Programme Log Rating Scale - Discussion (green sheet). 189 When parent has finished questionnaire, chat with them. If they are NOT in Control group, say: We have developed a book/video tape that t e l l s what i t ' s like to come into the hospital or what happened to two children who came into the hospital for surgery. I ' d l i k e to show'it to you and (child's name) and see what you think of i t . Response from parent. Because of the way the study is set up, (interviewer's name) doesn't know that I ' l l be showing this to you.. I ' l l ask (child's name) to keep i t a secret from her for tomorrow when she comes. Response from parent. Child and interviewer will come put and interviewer will excuse herself and leave. Invite parent and child back into the office. Rehedrsal/Instruction Conditions: Say: I have here a book/TV programme which t e l l s what i t ' s l i k e to come to Children's Hospital to have an operation. Would you. l i k e to see i t ? Modelling Conditions: Say: I have a book/TV programme here which t e l l s the story of what happened to two children, Eileen and Drew/Andrew, when they came to Children's Hospital to have an operation. Would you li k e to see i t ? If NO, ask why they don't want to see it. Encourage and reassure them. If parent is adamant about not seeing the book/TV programme, do not press. Say: Well, thank you for your time. I hope everything goes well for 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 and parent's response. If child is appearing highly anxious, stop treatment and reassure. Discuss problem with child and parent. Encourage them to discuss his/her concern. 190 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 fine. LISTEN TO THE CHILD. Try to find out what is his/her specific concern. Then diffuse the concern. Say: Now, shall we finish watching the TV? There are only a few minutes le f t . . If the parent appears highly anxious, note when this occurred and finish the treatment if possible. ...Engage the child in another activity. Then confront the 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 and parent to talk, to ventilate their fears, and encourage them to seek information from appropriate hospital personnel, e.g., the anaesthetist, their surgeon, the ward nurse, etc. "~ Include the parent in the child's concerns. Try not to include the child in the parent's concerns. Rehearsal/Instruction Condition - ai the end of the programme Say: And I have here for you a Hospital Kit, just a s y°u saw on the TV. in the book. Open the kit. Look at each item and discuss practicing with parent, sibling, or toy. Print Condition - at the end of the programme Say: You may keep the book, (child's name). 191 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, getting armband, someone will bring you up to the ward. Define ward. 2. Playroom. Note: Important place. Point out the toys and books. 3. Parents' Lounge. Point out: microwave oven, telephones, shower, no children. 4. Nurses' Station. Define. * S: Child's Room. Remind that nurse will show you all the things. Point out: bathroom, locker, table, call button and light, TV to share, bed-chair for parent Discuss: next morning, will parent be there? This is where you say "See you later", but for now parent can come along and see where they will take you. 6. Transport Elevator. Describe stretcher. 7. O.K. Ante-room. Note: O.R. clothes, sterile area. 8. Return to Lobby. Questions? Day Care: . *" 1. On the way to Lobby,.note the following: Leave time for parking. 2. Information Desk. Discuss: checking in, signing papers. 3. Day Care Waiting Area. Note: wait only for a few minutes. 4. Day Care Unit. Point out: corner for weighing and measuring, getting armband, beds, curtains, wd~shroom outside in waiting area. Discuss: going in same bed to O.R. Saying "See you later" to parents here. 5. O.R. Ante-room. Note: O.R. clothes, sterile area. 6. Return to Lobby. Point out: parents to wait in cafeteria, back to Day Care for child. Questions? 192 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 about the general hospitalization and surgical experience. Do not discuss technicalities of the specific surgery. Direct the parent to the surgeon. Be honest and be accurate. If there is no definite answer to the question, say so. e.g., "How long will he be in recovery?" Answer: 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 questions 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 1. INITIAL TELEPHONE CONTACT Hi. Is Mrs. there? Hi, Mrs. . 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 few days, a research assistant (Pat Palulis, Qonna Schmirler or Gail Matiaszow) will contact you by telephone and, i f you agree to participate, will arrange a time one to two weeks before your child's surgery to visit you in'your home. This 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 visit 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. STOP INTERVIEW. If parent seems familiar with the study or recalls receiving the letter, say: May I tell 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? - Arrange time. If parents says NO, say: May I ask why? Record response. Well, thank you for your time. STOP INTERVIEW. If parent 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. Our goal is to develop methods of (continued over) 195 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) is 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 is 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 clarify . i t . I will see you both at your home and in the hospital. I would like to visit you and (child's name) in your home before (child's name) goes for surgery. This visit takes about 45 minutes to an hour. There are some questions for both you and (child's name) . The purpose of this visit 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 (child's name)' reactions to the hospitalization. 196 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) at home? It should be before (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'll give it to you again, i f 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 that you will not see them at the hospital. If they offer to get a translator, accept the offer and proceed. See instructions for parents who cannot read English. 197 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 are-much 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 if that would be more convenient for you. If there is a question about who should answer questions. The respondent should be the primary caretaker, whether mother, father or • other adult. Who would know (child's name) the best and be able to answer our questions? With shared responsibility, we need one adult to respond consistently. If parent is afraid that questioning may increase child's 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 visit 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 visit 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 all 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. The questions are actually directed to you, the parent. 5 . Asks for more details 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. And I ' l l be asking you to f i l l out questionnaires describing (child's name)'s normal behaviour and important events in his/her l i f e . 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, Twill ask similar questions and also questions on your reaction to the hospital experience. You are welcome to look over all the questionnaires before I give them to (child's name). 199 PROCEDURE FOR FIRST HOME VISIT Introduce yourself to parent and child. Include your name and- the Preadmission Preparation Study. Get seated. Establish 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 (child's name) . To 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 yourself. If there are others present who may distract 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 sheet. Record Subject 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. Say: (Child's name), do you know when your birthday is? Confirm response with parent (e.g., Feb. 26, 1970). 2. 2_ 6_ / 0_ 2_ / 7; 0_ 3. Sex. Can be confirmed with referral source, [2] Male [2] Female 4. say tb child: 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 children^ coded in #5 e and f) e.g., Jane*, 5 Sue, 7 Code: 3 e.g., Jane*, 7 'Sue, 3 (natural sibling) Tom, 2 (common-law sibling) Joe, 17 (common-law sibling) Code: 1 5 . Say to respondent: You are (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." 1 e.g., "We're taking care of Johnny for a l i t t l e while." 4 e.g., "Susan and her mom moved in with my son and I last year." 3 201 9. 6a. Say: Who lives in the house with you? Code number in each category. Include respondent. Do not include child. a) Natural or adopted mother b) Step or common-law mother-c) Natural or adopted father d) Step or common-law father e) Older siblings (natural or adopted) f) lounger siblings (natural or adopted) g) Other related children: step or common-law siblings, cousins, etc. h) Non-related children (foster, 'communal) i) Other adults, respondent's boyfriend or girlfriend, relatives, etc. j) Twin e.g. Subject = Jane*, age 7 Code: 1 0 Jane 's mom Q Fred, common-law father . j Fred's sons, Jim, age 9, and Peter, age 3 g Tom, Jane's brother, age S ' j Jane's grandmother 2 0 1 0 6b. Marital status.: [ i ] married, common-law [2 ] separated [ 3 ] divorced [4j other (widowed, single) 7. Say to parent: Are you currently employed? Response: no Code: 1 Response: yes. Say: Is that full time? Response: full-time Code: 2 Response: part-time 3 e.g., "I work full-time building boats and part-time at a clinic." Code: 2 8. Say: What do you do? Record response, probing for tasks, responsibilities,. position in hierarchy, etc. ' Occupations are to be coded according to the categories of the "Blishen Scale. 202 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 lodging. If there is no other adult contributing to income, code 9. 10. Continue as #S. e.g., Jane's* grandfather lives in home, and works full-time 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 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, adopted or step-mother. For father, code only natural, 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: 11 Code: ill] Other: South 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 perceptions. If they are confused, say:. 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 and/or require medical treatment/supervision. If parent is unsure, examples might include: asthma mental handicap diabetes allergies learning disability - arthritis speech problem hearing impairment Record all diseases, disabilities and conditions that the parent reports. If respondent is unsure, ask: Does (child's name) find the condition handicapping? Does it affect his/her normal activities? Code first two mentioned by parent. See code sheet attached. * • Chronic Diseases and Disabilities: No, None Allergy - reaction unspecified Exzema Hay fever Asthma Cerebral palsy Spina bifida *• Epilepsy < Tuberous sclerosis Pneumonia Bronchitis Tonsilitis ' Respiratory diseases - ears plugged, infections, hearing loss Respiratory diseases - nose plugged Cleft palate Club foot, amputated foot Urinary tract infection - kidney, bladder, ureters Heart problems Obesity Eye problems Behaviour problems - general Hyperactivity Depression Learning disabilities Others - high blood pressure, cysts, skin problems, bum scars Orthopaedic problems ' .00. '.10'. ~ll\ .12'. '13'. 'M'. '.20'. 21 '.22'. '23' \30\ '31 32. '33' '.34. '40' 'AS. 'SO' SS\ '60' '65'. '70' .71. '72. .75. .90'. '81 205 13. 17. Say: Has (child's name) been in the hospital before? Code: [li Yes [2] No Note: This includes day care as.well as overnight stays and trips to Emergency. • " This does not include doctor's office visits at hospital, outpatient lab tests or x-rays. If 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 given. If season given, code as: [02 J Winter [04~\ Spring [07] Summer ^ [20] Fall b) Why was he/she in the hospital? Code: [ i ] Medical (see attached list) [2] Surgical (see attached list) *. [3] Emergency (see attached list) c) ' How long was his/her stay? (number of days) Code number of days. If their stay was under 24 hours, code as 1 day. d) Where did you go? Record: - name of hospital - type of hospital - location of hospital Code: [2] B.C. 's Children's Hospital [2] Acute care hospital [3] Chronic care hospital [4] Other paediatric hospital [5] Old Children's Hospital 2Q6: 14. 19, 20, 21. Medical [ l ] : First blank. Second blank: ii] [2] [<1 [5] [7] Clinical investigation - chest test, test for hole . .'in heart, observation, EEG, brain scan , •Musculoskeletal - physiotherapy, knee aspiration Respiratory - bronchial cyst, bronchial pneumonia, croup, ear infection, flu Central nervous system - convulsions, reaction to medication, took adult medicine Castro-intestinal - diarrhea, dehydration Genito-urinary - kidney infection, urinary infection Miscellaneous - high fever, abscess drained, prematurity, herpes infection Surgical [2 3 First blank. Second blank: \_i] ENT - tubes, tonsils, adenoids, removal of laryngeal palilloma [2] General - circumcision, hernia [3] Genito-urinary - undescended testes, hypospadius, kidney operation, systoscopy [4] Plastic - nose revision, cleft palate surgery, burn scars, tongue-tied [S] Orthopaedic - foot amputation, broken arm/leg, cast manipulation and change, hip casting, orthopaedic leg surgery [t>] Dental surgery [7] Eye surgery [s] Neurosurgery - shunt revision, closure on spine for spina bifida [s] Cardiology Emergency [3 ] ; First blank. Second blank: [ l] Fractures, sprains, contusions - sprained ankle, broken arm, thumb in door [2] Head injury - fall on head, concussion,.head cut, hairline skull facture [3] Other injuries (not specified) - hit by car, fell down stairs, face cut, fell off swing, stitches, rock in eye [4] Foreign bodies - swallowing objects, FB up nose, broken needle in leg [5] Gastro-intestinal - stomach cramps, bowel obstruction [6] Allergic reactions [ 7 3 Acute infection - hip infection [5] 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 now or later. If parent has poor recall, say: 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: Extended refers to 3 weeks or more, or whatever the parent defines as extended. Children should be separated from both parents, and siblings. Code [7.] Ies (If Ies, see Separation Questionnaire) «• [2] No Separation Questionnaire: If Yes to #23, ask: - age of child at separation -•length of separation (weeks) - record reason : If more than 1 separation has occurred, ask these questions for each, separation. . 24. 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, step, common-law, long-term foster-[2] Father: natural, step, common-law, long-term foster [3] Both [4] Other [5] Don 't know . 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 ] Mother: natural, step, common-law, long-term foster [2] Father: natural, step, common-law, long-term foster [3] Both • [4] Other [5] Mother, father and others [S] Don't know 26. How much time will you spend with (child's name) at the hospital? Note:' If more than 1 person is staying with child, code their combined (non-overlapping) hours. 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 both stay with him for 3 hours Code 1-3 hours 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 PARENT'S BOOKLET 15. Good. That's the first 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 first one is called The Life Events Scale, and here you have to answer for your child, 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 child, 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 is busy with her/his questions. To Parent: The first set of questions is just to get an idea of his/her vocabulary level. 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'll 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. 2 1 0 If parents ask: Life Events Scale, Item $30,31: visible deformity - Does the mother perceive it as a deformity? - Is it a problem to the child in any way? Behaviour Checklist A, Item 856: physical problems without -known medical cause e.g., headaches - because of sinus condition are not counted, headaches - because of tension or anxiety are counted. 211 17 FOR PARENTS WHO MAY HAVE DIFFICULTY READING .THE QUESTIONNAIRES" Note response to Consent Form. This may give you an indication as to their ability to read English. PARENT'S BOOKLET: Say: That is the fir 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 it's your turn. Okay? .:- Pause for reaction and for child to leave if he chooses. Say to the parent: (Parent's name), here is the Parent's Booklet. I will just-read the questions to you and you tell me your answer. If there is^anything you are unsure of or don't understand, just ask me, okay? Monitor the parent's reaction. If he/she seems confused, pause and elaborate on the question. Use your discretion. ^ If.another adult or older child offers to interpret, say: That would be great, but it's really important that we have only (parent's name)'s answer to the questions. So you will have to try to tell me only his/her opinion, okay? If there is a great deal of discussion between the two adults, or you are suspicious of the nature of the translation, repeat the warning Read each questionnaire to the parent. When finished, call back the child and proceed with the Child's Booklet. 212 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 available, place child with back to parent and ask that other children leave the area. Establish 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 instructions for Peabody. Give child lots of encouragement, praise throughout, make it a positive experience for him/her. Okay. That was really good. Now I'd like to do my interview with you, all right? Follow standardized directions. on top of questionnaires. "What I Am Like" and "Bow I Usually Feel": For younger children, substitute child's name for "I" in items and repeat response 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. There are no right or wrong answers, just tell me what you think. Probe for further responses in each item. E.g., "Anything else?", "Is there anything else people can do?", or "Can you give me another reason?" Probe for clarification. If you do not understand their response, question further. E.g., "What do you mean?", or "Tell me a little more about that." 213 19. Children's Health Questionnaire: This is the last set of questions. Just tell me whether you think these sentences are true or not true. Well, (child's name), that's i t . You really di'd a good job. I had fun interviewing you. 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. It's important that we have a chance to talk before (child's name) is admitted, 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'll 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 later). I'll call you on the evening before or in the morning, just to confirm the time. Okay? DAI CARE or ADMIT-DAI-OF-SURGERI: (Child's name) is going into the hospital on (date). wVwould like you to come to the hospital a day or two. before that. I'll meet you in the lobby and take you to our office. 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 transportation ONLY IF NECESSARY. ALL: Confirm that they know directions to hospital and location of lobby. Present business card and say: Now i f you have any questions before I-see you again, or if 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 in lobby. Establish rapport. Escort family to Project Office. *; Project Coordinator will meet family and-Interviewer at office. • Introduce family to Project Coordinator, who will invite the family inside. Establish 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 has been directed to game or interaction with coordinator and/or mother, complete observations. When 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. Pause for reaction. To child: And, (child's name), I want to ask you a few questions, too. Proceed with Child's Booklet.' Project Coordinator will engage siblings in games or conversation. They will be removed from-office if necessary. Interviewer 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 TABLE B.2 220 Results of MANOVAs (interactions with occasions): Children's State Anxiety Inventory for Attention Contrast (Group), Agegroup and Gender TABLE B.3 : 221 Results of MANOVAs (interactions with occasions): Hospital Behaviour Questionnaire for Programme and Tour with Agegroup (Agegrp) and Gender TABLE 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 Observation Scale Conten- Dependent Sleep Appetite tiousness Anxiety Disturbance Disturbance Source of V2F1 V2F2 V2F3 V2F4 Verbal Non-Verb. Rating Variance F P F P F P F P F P F P F P Main Effects 0.562 1.060 1.034 1.023 0.707 1.228 0.494 Group 0355 0.491 0.050 0.445 1.446 4.993 0.035 1.766 Surcat 0.195 0.701 0.816 0.349 0.854 0.223 0.186 Agegroup 0.097 0.259 3.934 0.057 4,166 0.051 0.906 0.465 0.066 Gender 2.167 1.875 0.011 0.410 . 0.154 0.260 1.108 Explained 0.562 1.060 1.034 1.023 0.707 1.228 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 6 Week Post Source of Variance F P F P Time 1230.103 .000 23.29465 .000 Group .542 1.52663 Agegroup 2.549 12.28868 .002 Gender 3.974 .058 6.40927 .018 Group x Agegroup 1.914 2.92437 Group x Gender 9.146 .006 4.33803 .048 Agegroup x Gender 6.513 .017 8.63675 .007 Group x Agegroup x Gender 1.198 .48237 220 TABLE B.3 Results of MANOVAs (interactions with occasions): Hospital Behaviour Questionnaire for Programme and Tour with Agegroup and Gender Multivariate Fl Contentiousness F2 Dependent Anxiety Source of Variance Pre P Occas P Pre P Occas P Pre P Occas P AgeGroup x Programme x Tour Time *** .85 *** .15 *** 1.05 Agegroup .4.77 .002 .28 1.68 .38 10 .32 Programme 3.57 .01 .91 3.80 2.72 .00 1.39 Tour .28 .96 .82 2.03 .01 .77 Agegroup x Programme 3.65 .009 .81 2.35 .05 1.11 2.12 Agegroup x Tour .79 .48 1.32 .07 .55 1.19 Programme x Tour .62 .55 " .00 .10 .01 1.47 Agegroup x Programme x Tour 1.06 .84 2.75 .28 .98 1.73 Gender x Programme x Tour Time *** 1.23 *** .30 *** 1.85 Gender 1.98 .97 .35 .22 .10 .42 Programme .44 2.42 .90 4.30 .041 .14 4.37 .040 Tom- .16 1.51 .06 1.99 .03 .88 Gender x Programme 1.51 2.93 .70 .71 1.48 6.59 .012 Gender x Tour .25 1.31 .18 .10 .94 4.65 .034 Programme x Tour 1.19 .50 .58 .07 .43 1.04 Gender x Programme x Tour .59 1.24 .88 .00 .42 4.48 .037 F3 Sleep F4 Appetite Disturbance Disturbance Source of Variance Pre P Occas P Pre P Occas P AgeGroup x Programme x Tour Time *** .52 *** 2.66 Agegroup 10.88 .001 .18 7.69 .007 .34 Programme 2.31 .65 9.35 .003 .45 Tour .13 1.37 .20 1.41 Agegroup x Programme 2.36 .16 11.33 .001 11.31 Agegroup x Tour .01 .50 1.84 .60 Programme x Tour 2.30 .00 .14 .60 Agegroup x Programme x Tour .44 1.00 1.03 1.11 Gender x Programme x Tour Time *** 2.46 *** 3.17 Gender 2.92 1.86 5.09 .60 Programme .01 1.86 .60 1.01 Tour .05 .71 .55 1.88 Gender x Programme 2.64 .96 1.28 3.20 Gender x Tour .00 .13 .07 .03 Programme x Tour 3.39 .17 .40 .26 Gender x Programme x Tour 1.59 .00 .04 .20 221 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 Pre Rating P Occas P Agegroup x Programme x Tour Time *** Agegroup 5.73 Programme .99 Tour 3.44 Agegroup x Programme 2.90 Agegroup x Tour 1.34 Programme x Tour 3.48 AgeGroup x Prog x Tour .31 21.81 2.16 2.92 7.6 1.05 .68 11.05 2.40 .000 .000 .000 1.54 2.48 6.93 1.02 1.90 4.64 .81 .010 .034 30.48 .000 1.09 .89 10.48 2.68 1.30 13.74 .04 .002 .000 Gender x Programme x Tour Time *** Gender .16 Programme 1.37 Tour 3.44 Gender x Programme .67 Gender x Tour .68 Programme x Tour 3.58 Gender x Prog x Tour .42 .017 27.13 1.27 1.86 8.24 .40 1.00 11.75 1.88 .000 .000 .000 .39 3.76 9.44 .60 .33 6.00 .18 .003 .016 42.87 .01 .13 8.34 .06 1.93 14.98 2.46 .000 .005 .000 Source of Variance Pre Verbal Occas P Pre Non-Verbal P Occas Time *** 50.14 .000 *** 7.10 .009 Agegroup 5.19 .025 .50 .03 5.59 .020 Programme .72 4.51 .037 .40 2.46 Tour 6.77 .011 9.63 .003 3.65 7.10 .009 Agegroup x Programme .38 1.78 7.78 .02 Agegroup x Tour .00 .13 1.43 .33 Programme x Tour 5.42 .022 11.59 .001 6.33 .014 12.44 .001 AgeGroup x Prog x Tour .26 5.78 .018 .16 .55 Gender x Programme x Tour Time *** 57.12 .000 *** 14.16 .000 Gender .00 3.14 .or .67 Programme .66 5.17 .026 .45 .36 Tour 5.44 .022 10.62 .002 1.56 10.24 .002 Gender x Programme .05 .02 1.01 1.00 Gender x Tour .43 .07 1.08 .00 Programme x Tour 5.42 .022 19.38 .000 5.78 .018 9.98 .002 Gender x Prog x Tour .32 .06 .60 3.79 222 TABLE B.5 Results of MANOVAs (interactions with occasions):Children's State Anxiety Inventory for Programme and Tour with Agegroup and Gender Child State Anxiety Source of Variance Pre P Occas P Hosp P Post P Agegroup x Programme x Tour Time * * * Agegroup 2.05 Programme 0.02 Tour 0.73 Agegroup 0.93 Agegroup x Tour 0.01 Programme x Tour 0.00 Agegroup x Prog x Tour 0.29 29.62 .000 7.34 .001 0.90 1.22 1.77 2.56 0.03 0.24 31.97 .000 4.11 .046 1.25 1.41 1.03 0.36 0.05 0.46 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 1.24 Programme .080 Tour 2.04 Gender x Programme 0.80 Gender x Tour 6.55 .013 Programme x Tour 0.32 Gender x Prog x Tour 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 0.47 0.45 0.03 0.51 4.12 0.11 2.63 .001 .046 223 TABLE B.6 Results of MANOVAs (interactions with occasions):Hospital Behaviour Questionnaire for Approach, Mode, Tour, Agegroup and Gender Multivariate F l Contentiousness F2 Dependent Anxiety Source of Variance Pre P Occas P Pre P Occas P Pre P Occas Approach x Mode x Tour Time *** 2.78 ..036 *** 5.52 .022 * * * 6.98 Approach 1.05 1.17 .03 .76 .17 3.95 Mode 1.10 2.23 1.78 .03 .47 1.97 Tour 1.01 1.42 2.34 .85 .00 .15 Approach x Mode 2.44 1.19 3.03 1.14 3.26 .33 Approach x Tour .11 .30 .26 .01 .18 .01 Mode x Tour .77 .44 1.61 .04 1.06 .66 Mode x Tour 3.40 .015 .16 8.35 .006 .25 .39 .30 Approach x Mode x Gender . Time *** 2.68 .042 *** 3.18 *** 8.92 Approach .46 .41 .46 .16 .01 1.34 Mode 1.06 2.93 3.40 .04 .80 3.38 Gender .49 .96 .53 .01 .48 3.40 Approach x Mode 1.03 1.11 .32 .12 .65 .33 Approach x Gender .92 1.98 .97 .66 .21 .33 Mode x Gender .89 .80 2.77 .38 .01 1.09 Approach x Mode x Gender .27 1.55 .59 .50 .47 1.59 Approach x Mode x Aeeeroup Time *** .92 *** 2.17 *** 1.92 Approach 1.01 .44 .06 .38 .49 1.19 Mode .37 .70 1.24 .03 .22 .15 Agegroup 2.96 .86 9.65 .003 .50 1.70 2.71 Approach x Mode 1.09 .79 2.13 .80 .53 .13 Approach x Agegroup .48 .29 .00 .04 .82 .74 Mode x Agegroup .94 .58 .00 .03 .42 1.14 Approach x Mode x Agegroup 1.29 .55 1.56 .00 3.27 .17 ...continued 224 TABLE B.6 (continued) F3 Sleep Disturbance F4 Appetite Disturbance Source of Variance Pre P Occas P Pre P Occas P Approach x Mode x Tour Time *** 2.87 *** 1.64 Approach .00 1.61 4.11 1.02 Mode 1.55 .04 .06 6.80 Tour 2.85 1.07 .01 4.37 Approach x Mode 2.70 . 2.02 .26 1.43 Approach x Tour .15 .12 .00 1.22 Mode x Tour 15 .06 .22 .45 Approach x Mode x Tour .46 ' .11 1.69 .00 Approach x Mode x Gender Time *** 3.00 *** 2.22 Approach .03 .30 1.38 .14 Mode .07 .01 .07 6.98 Gender .00 1.45 1.17 .07 Approach x Mode 2.64 2.09 .07 .20 Approach x Gender .07 .31 2.80 6.60 Mode x Gender 1.40 .32 .12 .13 Approach x Mode x Gender .08 .88 .15 .64 Approach x Mode x Aeeeroup Time *** 1.57 *** .31 Approach .97 1.30 2.81 .28 Mode .02 .13 .11 2.84 Agegroup 2.32 .06 .11 .08 Approach x Mode 1.11 1.73 .00 .08 Approach x Agegroup 1.25 .02 .00 .02 Mode x Agegroup 3.30 .05 .14 .36 Appro x Mode x Agegrp .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 Rating Source of Variance Pre P. Occas P Pre P Occas P Approach x Mode x Tour Time *** 24.71 .000 *** 50.80 .000 Approach 2.95 .041 . 4.80 .005 3.40 5.66 .021 Mode 5.76 .002 1.24 16.58 .000 .62 Tour 1.00 1.10 1.72 .97 Approach x Mode 4.67 .006 6.30 .001 6.70 .012 6.93 .11 Approach x Tour 5.46 .002 . 2.29 4.25 .044 .09 Mode x Tour 3.90 .014 2.03 6.89 .011 1.72 Approach x Mode x Tour 3.11 .034 .52 5.63 .021 1.41 Approach x Mode x Gender Time *** 13.15 .000 *** 27.07 .000 Approach 2.91 2.64 .059 4.99 .030 5.66 .021 Mode 5.88 .002 1.53 15.37 .000 1.46 Gender .46 1.55 1.32 .04 Approach x Mode 1.43 4.91 .004 1.09 4.17 .046 Approach x Gender .15 .21 .43 .62 Mode x Gender 4.32 .009 2.12 4.10 .048 2.39 Approach x Mode x Gender .62 .85 .07 .95 Approach x Mode x Aseeroup Time *** 14.75 .000 *** 34.07 .000 Approach 2.23 3.75 .020 2.19 5.82 .019 Mode 3.37 2.17 8.97 .004 3.02 Agegroup 3.82 .015 .86 .71 .11 Approach x Mode 4.70 .006 6.41 .001 7.71 .008 12.17 .001 Approach x Agegroup .15 .54 .00 1.62 Mode x Agegroup 1.45 1.74 .22 3.80 .056 Approach x Mode x Agegrp 2.72 1.68 1.85 4.06 .049 ...continued 226 TABLE B.7 (continued) Verbal Non-Verbal Source of Variance Pre P Occas P Pre P Occas P Approach x Mode x Tour Time *** 31.19 .000 *** 30.54 .000 Approach 6.83 .012 10.68 .002 2.62 .63 Mode 8.06 .006 .84 .03 1.82 Tour .31 1.86 1.62 .63 Approach x Mode 12.86 .001 • 8.23 .006 1.26 3.76 .058 Approach x Tour 15.51 .000 6.85 .011 3.16 .00 Mode x Tour 7.58 .008 3.34 2.55 1.26 Approach x Mode x Tour .19 .35 .17 .00 Approach x Mode x Gender Time *** 22.91 .000 *** 11.60 .001 Approach 5.59 .022 3.88 .054 2.16 .06 Mode 8.03 .006 .05 1.33 1.42 Gender .19 2.69 .21 1.93 Approach x Mode 4.06 8.28 .006 .88 3.02 Approach x Gender .09 .02 .05 .06 Mode x Gender 3.50 .31 7.92 .007 .69 Approach x Mode x Gender .15 1.19 1.86 .47 Approach x Mode x Agegroup Time *** 7.11 .000 *** 13.37 .001 Approach 6.62 .013 7.17 .010 1.18 .43 Mode 3.17 1.01 1.59 1.76 Agegroup 5.00 .029 .00 2.20 2.63 Approach x Mode 9.62 .003 9.62 .003 5.27 .026 1.08 Approach x Agegroup .15 .05 .12 .05 Mode x Agegroup .87 .01 2.68 .19 Approach x Mode x Agegrp 2.08 2.49 6.68 .012 .70 227 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 P Multi P Surg P Post P Approach x Mode x Tour Time *** 21.48 .000 25.38 .000 25.05 .000 Approach 0.38 0.71 1.45 0.00 Mode 2.90 0.77 0.88 0.47 Tour 0.30 0.70 1.23 0.36 Approach x Mode 0.15 2.21 3.13 2.04 Approach x Tour 1.68 3.79 .030 7.57 .008 0.70 Mode x Tour 2.38 1.78 0.13 3.62 Approach x Mode x Tour 0:32 1.41 0.32 2.78 Approach x Mode x Gender Time *** 8.76 .001 9.28 .004 12.20 .001 Approach 0.02 0.14 0.27 0.00 Mode 2.42 0.92 0.10 1.56 Gender 3.00 0.82 1.62 0.00 • Approach x Mode 0.01 0.50 1.02 0.03 Approach x Gender 0.02 0.17 0.34 0.07 Mode x Gender 0.14 0.29 0.30 0.40 Approach x Mode x Gender 0.11 0.86 0.04 1.75 Approach x Mode x Aeeeroup Time *** 17.54 .000 17.30 .000 25.40 .000 Approach 2.43 1.26 1.96 1.10 Mode 4.48 2.03 1.09 2.86 Agegroup 0.15 1.35 0.40 2.66 Approach x Mode 0.04 2.18 4.41 .041 0.36 Approach x Age 3.18 2.33 2.20 3.45 Mode x Agegroup 0.48 1.57 1.15 1.43 Approach x Mode x Agegroup 0.80 1.24 1.60 0.53 228 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.5 235 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Rating Scale TABLE C.6 236 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Verbal Scale TABLE C.7 236 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Non-Verbal Scale 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 CIO 238 Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 1: Contentiousness TABLE C. 11 239 Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 2: Dependent Anxiety TABLE 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 : : 242 Summary of Regression Analyses of Personality Cluster Interactions on Observation Rating Scale 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 TABLE C. 17 245 Summary of Regression Analyses of Personality Cluster Interactions on Children's State Anxiety Inventory at Presurgery Measurement TABLE 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 TABLE C.22 250 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on HBQ Factor 4: Appetite Disturbance TABLE C.23 251 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on Observation Rating Scale TABLE C.24 252 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on Observation Verbal Scale TABLE C.25 , 253 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on Observation Non-Verbal Scale TABLE C.26 254 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions on Children's State Anxiety Inventory at Presurgery Measurement TABLE 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 TABLE C.l Summary of Regression Analyses of Family Characteristics Cluster Interactions on HBQ Factor 1: Contentiousness Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.6608) *** *** *** SES x Prog .6666 .0058 1.140 .190 Position x Prog .6672 .0006 .114 .737 SES x Tour .6676 .0004 .072 .789 Position x Tour .6709 .0034 .637 .428 SES x Mode .6725 .0016 .295 .589 Position x Mode .6743 .0018 .327 .570 SES x Appr .6805 .0062 1.141 .290 Position x Appr .6942 .0137 2.602 .112 SES x Prog x Tour .6942' .0000 .004 .947 Position x Prog x Tour .6978 .0036 .672 .416 SES x Mode x Appr .7501 .0523 11.51 .001 Position x Mode x Appr .7519 .0018 .384 .538 SES x Mode x Tour .7597 .0077 1.708 .197 Position x Mode x Tour .7597 .0000 .008 .931 SES x Appr x Tour .7747 .0150 3.400 .071 Position x Appr x Tour .7747 .0000 .000 .995 SES x Mode x Appr x Tour .7752 .0005 .115 .736 Position x Mode x Appr x Tour .7759 .0007 .152 .698 TABLE C.2 Summary of Regression Analyses of Family Characteristics Cluster Interactions on HBQ Factor 2: Dependent Anxiety Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.5907) *** *** *** SES x Prog .6485 .0578 10.686 .002 Position x Prog .6490 .0006 .102 .751 SES x Tour .6513 .0022 .405 .527 Position x Tour .6549 .0036 .650 .423 SES x Mode .6557 .0008 .136 .714 Position x Mode .6564 .0008 .132 .717 SES x Appr .6636 .0072 1.257 .267 Position x Appr .6637 .0001 .017 .897 SES x Prog x Tour .6704 .0067 1.163 .285 Position x Prog x Tour .6709 .0005 .078 .782 SES x Mode x Appr .6709 .0000 .004 .948 Position x Mode x Appr .6730 .0021 .353 .555 SES x Mode x Tour .6734 .0004 .064 .801 Position x Mode x Tour .6738 .0004 .057 .813 SES x Appr x Tour .6827 .0089 1.428 .238 Position x Appr x Tour .6877 .0050 .803 .375 SES x Mode x Appr x Tour .6877 .0000 .002 .967 Position x Mode x Appr x Tour .6956 .0079 1.249 .269 233 TABLE C.3 Summary of Regression Analyses of Family Characteristics Cluster Interactions on HBQ Factor 3: Sleep Disturbance Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.5953) *** *** *** SES x Prog .5975 .0022 .347 .558 Position x Prog .5989 .0014 .215 .644 SES x Tom- .6097 .0108 1.749 .191 Position x Tour .6285 .0188 3.136 .082 SES x Mode .6369 .0084 1.408 .240 Position x Mode .6429 .0060 1.014 .318 SES x Appr .6604 .0175 3.033 .087 Position x Appr .6610 .0006 .100 .752 SES x Prog x Tour .6664 ' .0055 .933 .338 Position x Prog x Tour .6670 .0006 .095 .759 SES x Mode x Appr .6857 .0187 3.279 .076 Position x Mode x Appr .6918 .0061 1.064 .307 SES x Mode x Tour .6955 .0037 .644 .426 Position x Mode x Tour .6956 .0001 .019 .891 SES x Appr x Tour .6983 .0027 .460 .500 Position x Appr x Tour .6984 .0001 .012 .913 SES x Mode x Appr x Tour .7037 .0053 .877 .354 Position x Mode x Appr x Tour .7039 .0002 .026 .873 TABLE C.4 Summary of Regression Analyses of Family Characteristics Cluster Interactions on HBQ Factor 4: Appetite Disturbance Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.4552) *** *** *** SES x Prog .4552 .0000 .000 .984 Position x Prog .4552 .0000 .000 .983 SES x Tour .4633 .0081 .953 .333 Position x Tour .4731 .0098 1.148 .288 SES x Mode .5082 .0352 4.364 .041 Position x Mode .5114 .0032 .389 .535 SES x Appr .5157 .0043 .524 .472 Position x Appr .5164 .0007 .087 .769 SES x Prog x Tour .5169 .0004 .049 .826 Position x Prog x Tour .5613 .0445 5.680 .021 SES x Mode x Appr .5642 .0029 .363 .549 Position x Mode x Appr .5682 .0040 .501 .482 SES x Mode x Tour .5717 .0035 .435 .512 Position x Mode x Tour .5723 .0006 .070 .792 SES x Appr x Tour .5723 .0000 .001 .975 Position x Appr x Tour .5806 .0083 .987 .325 SES x Mode x Appr x Tour .5812 .0006 .006 .798 Position x Mode x Appr x Tour .5812 .0000 .004 .949 234 TABLE C.5 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Rating Scale Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.2157) *** *** *%* SES x Prog .2266 .0109 .917 .342 Position x Prog .2272 .0006 .050 .823 SES x Tom- .2272 .0000 .002 .967 Position x Tour .2305 .0032 .261 .611 SES x Mode .2361 .0057 .454 .503 Position x Mode .2365 .0003 .027 .870 SES x Appr .2463 .0098 .768 .384 Position x Appr .2482 .0019 .146 .704 SES x Prog x Tour .3299 ' .0817 6.947 .011 Position x Prog x Tour .3580 .0282 2.456 .123 SES x Mode x Appr .3595 .0015 .126 .724 Position x Mode x Appr .3654 .0059 .500 .483 SES x Mode x Tour .3661 .0007 .057 .812 Position x Mode x Tour .3690 .0030 .245 .623 SES x Appr x Tour .3699 .0009 .072 .790 Position x Appr x Tour .3730 .0031 .248 .620 SES x Mode x Appr x Tour .3731 .0000 .003 .954 Position x Mode x Appr x Tour .3739 .0008 .064 .801 235 TABLE C.6 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Verbal Scale Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.1723) *** *** *** SES x Prog .1756 .0033 .262 .610 Position x Prog 2589 .0832 7.188 .009 SES x Tour ,2608 .0020 .167 .685 Position x Tour .2609 .0001 .006 .940 SES x Mode .2856 .0248 2.114 .151 Position X Mode .3268 .0411 3.666 .060 SES x Appr .3294 .0026 .230 .634 Position x Appr .3295 .0001 .007 .933 SES x Prog x Tour .3369' .0075 .642 .426 Position x Prog x Tour .3370 .0001 .005 .942 SES x Mode x Appr .3793 .0423 3.745 .058 Position x Mode x Appr .3796 .0003 .028 .869 SES x Mode x Tour .3799 .0004 .031 .861 Position x Mode x Tour .4026 .0227 1.974 .166 SES x Appr x Tour .4194 .0168 1.478 .230 Position x Appr x Tour .4198 .0004 .034 .854 SES x Mode x Appr x Tour .4230 .0031 .265 .609 Position x Mode x Appr x Tour .4232 .0003 .021 .885 TABLE C.7 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Observation Non-Verbal Scale Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.1925) *** *** *** SES x Prog .3017 .1092 10.161 .002 Position x Prog .3061 .0045 .412 .523 SES xTour .3162 .0101 .929 .339 Position x Tour .3163 .0001 .006 .940 SES x Mode .3348 .0185 1.695 .198 Position x Mode .3379 .0032 .286 .595 SES x Appr .4080 .0701 6.987 .011 Position x Appr .4096 .0016 .155 .696 SES x Prog x Tour .4240 .0144 1.425 .238 Position x Prog x Tour .4490 .0250 2.545 .116 SES x Mode x Appr .5009 .0518 5.713 .020 Position x Mode x Appr .5197 .0189 2.120 .151 SES x Mode x Tour .5218 .0020 .224 .638 Position x Mode x Tour .5218 .0000 .000 .997 SES x Appr x Tour .5293 .0075 .815 .371 Position x Appr x Tour .5457 .0164 1.804 .185 SES x Mode x Appr x Tour .5629 .0173 1.938 .170 Position x Mode x Appr x Tour .5637 .0007 .082 .775 236 TABLE C.8 Summary of Regression Analyses of Family Characteristics Cluster Interactions on Children's State Anxiety Inventory at Presurgery Measurement Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.5591) *** *** *** SES x Prog .5895 .0304 4.374 .041 Position x Prog :5921 .0026 .366 .548 SES x Tour -5970 .0049 .693 .409 Position x Tour .6067 .0097 1.383 .245 SES x Mode .6069 .0002 .035 .853 Position x Mode .6102 .0033 .460 .500 SES x Appr .6105 .0002 .033 .858 Position x Appr .6109 .0004 .051 .822 SES x Prog x Tour .6123' .0014 .188 .666 Position x Prog x Tour .6127 .0004 .050' .824 SES x Mode x Appr .6169 .0043 .544 .464 Position x Mode x Appr .6393 .0224 2.982 .091 SES x Mode x Tour .6510 .0117 1.576 .216 Position x Mode x Tour .6512 .0001 .016 .900 SES x Appr x Tour .6513 .0001 .013 .909 Position x Appr x Tour .6565 .0052 .667 .419 SES x Mode x Appr x Tour .6635 .0070 .900 .348 Position x Mode x Appr x Tour .6648 .0013 .164 .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.R2 R 2 Change F Change Sig (Cumulative Effects) (.4526) *** *** *** SES x Prog .4526 .0000 .004 .948 Position x Prog .4652 .0126 1.483 .228 SES x Tour .4802 .0149 1.783 .187 Position x Tour .4988 .0186 2.265 .137 SES x Mode .4995 .0007 .081 .776 Position x Mode .5009 .0014 .164 .687 SES x Appr .5025 .0016 .190 .665 Position x Appr .5063 .0038 .439 .510 SES x Prog x Tour .5246 .0183 2.152 .148 Position x Prog x Tour .5278 .0032 .374 .544 SES x Mode x Appr .5602 .0325 3.988 .051 Position x Mode x Appr .5620 .0017 .207 .651 SES x Mode x Tour .5633 .0014 .164 .687 Position x Mode x Tour .5808 .0174 2.121 .151 SES x Appr x Tour .5813 .0005 .060 .807 Position x Appr x Tour .5850 .0037 .438 .511 SES x Mode x Appr x Tour .5850 .0000 .000 .994 Position x Mode x Appr x Tour .5912 .0063 .720 .400 237 TABLE CIO Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 1: Contentiousness Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.6806) *** *** *** Verb Ab x Prog .6807 .0001 .023 .880 HLocxProg .6813 .0006 .119 .732 Tr Anx x Prog .6894 .0081 1.590 .212 Verb Abx Tour .7090 .0196 4.044 .049 HLoc x Tour .7119 .0029 .589 .446 Tr Anx x Tour .7144 .0025 .507 .479 Verb Ab x Mode .7148 .0004 .078 .781 HLoc x Mode .7149 .0001 .019 .891 Tr Anx x Mode .7169' .0021 .407 .526 Verb Ab x Appr .7170 .0001 .*** .896 HLoc x Appr .7174 .0004 .017 .795 Tr Anx x Appr .7198 .0024 .069 .509 Verb Ab x Prog x Tour .7199 .0001 .441 .894 HLoc x Prog x Tour .7292 .0093 .018 .197 Tr Anx x Prog x Tour . .7305 .0014 1.712 .620 Verb Ab x Mode x Appr .7321 .0016 .281 .599 H Loc x Mode x Appr .7351 .0030 .537 .467 Tr Anx x Mode x Appr .7626 .0275 5.333 .026 Verb Ab x Mode x Tour .7626 .0000 .000 .998 HLoc x Mode x Tour .7626 .0000 .001 .971 Tr Anx x Mode x Tour .7631 .0005 .086 .771 Verb Ab x Appr x Tour .7636 .0004 .079 .779 HLoc x Appr x Tour .7640 .0004 .069 .794 Tr Anx X Appr x Tour .7775 .0135 2.430 .127 Verb Ab x Mode x Appr x Tour *** *** *** *** HLoc x Mode x Appr x Tour *** *** *** *** Tr Anx x Mode x Appr x Tour *** *** *** *** 238 TABLE C. l l Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 2: Dependent Anxiety Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.5924) *** *** *** Verb Ab x Prog .6084 .0160 2.574 .114 HLoc x Prog .6094 .0010 .164 .687 Tr Anx x Prog .6150 .0056 .885 .351 Verb Ab x Tour .6158 .0008 .125 .725 HLoc x Tour .6161 .0003 .042 .839 Tr Anx x Tour .6211 .0051 .775 .382 Verb Ab x Mode .6347 .0136 2.118 .151 HLoc x Mode .6426 .0079 1.238 .271 Tr Anx x Mode .6485 ' .0059 .926 .340 Verb Ab x Appr .6514 .0029 .450 .505 HLoc xAppr .6514 .0000 .003 .957 Tr Anx x Appr .6522 .0008 .115 .735 Verb Ab x Prog x Tour .6523 .0001 .009 .925 HLoc x Prog x Tour .6553 .0031 .443 .509 Tr Anx x Prog X Tour .6692 .0138 2.050 .159 Verb Abx Mode x Appr .6822 .0130 1.968 .167 HLoc x Mode x Appr .7084 .0262 4.220 .046 Tr Anx x Mode x Appr .7094 .0010 .162 .689 Verb Abx Mode x Tour .7094 .0010 .001 .980 HLoc x Mode x Tour .7123 .0028 .435 .513 Tr Anx x Mode x Tour .7567 .0445 7.862 .008 Verb Ab x Appr x Tour .7567 .0000 .001 .978 HLoc x Appr x Tour .7575 .0008 .135 .716 Tr Anx x Appr x Tour .8338 .0763 18.355 .000 Verb Ab x Mode x Appr x Tour *** *** *** *** HLoc x Mode x Appr x Tour *** *** *** *** Tr Anx x Mode x Appr x Tour *** *** *** *** 239 TABLE C.12 Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 3: Sleep Disturbance Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.5624) *** *** *** Verb Ab x Prog .5758 .0134 1.989 .163 HLoc x Prog .5853 .0095 1.416 .239 Tr Anx x Prog ,5853 .0000 .006 .936 Verb Ab x Tour .5968 .0115 1.713 .196 HLoc x Tour .5968 .0000 .000 .995 Tr Anx x Tour .6017 .0049 .707 .404 Verb Ab x Mode .6144 .0127 1.883 .175 HLoc x Mode .6426 .0282 4.415 .040 Tr Anx x Mode .6461' .0035 .545 .464 Verb Ab x Appr .6574 • .0113 1.784 .187 HLoc x Appr .6632 • .0058 .905 .346 Tr Anx x Appr .6830 .0198 3.255 .077 Verb Ab x Prog x Tour .6832 .0002 .035 .852 HLoc x Prog x Tour .6977 .0145 2.401 .128 Tr Anx x Prog x Tour .6994 .0016 .265 .609 Verb Ab-x Mode x Appr .7079 .0086 1.407 .241 HLoc x Mode x Appr .7221 .0142 2.400 .128 Tr Anx x Mode x Appr .7274 .0052 .886 .352 Verb Ab x Mode x Tour .7394 .0120 2.076 .157 HLoc x Mode x Tour .7407 .0014 .229 .634 Tr Anx x Mode x Tour .8204 .0797 19.072 .000 Verb Ab x Appr x Tour .8702 . .0498 16.127 .000 HLoc x Appr x Tour .9182 .0479 24.009 .000 Tr Anx x Appr x Tour .9240 .0059 3.092 .086 Verb Ab x Mode x Appr x Tour *** *** *** *** HLoc x Mode x Appr x Tour *** *** *** *** Tr Anx x Mode x Appr x Tour *** *** *** *** 240 TABLE C.13 Summary of Regression Analyses of Personality Cluster Interactions on HBQ Factor 4: Appetite Disturbance Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.4627) *** *** *** Verb Ab x Prog .4667 .0040 .472 .494 HLoc x Prog .4742 .0076 .894 .348 Tr Anx x Prog .5014 .0272 3.323 .073 Verb Ab x Tour .5199 .0185 2.316 .133 HLoc X Tour .5208 .0008 .102 .751 Tr Anx x Tour .5242 .0034 .420 .519 Verb Ab x Mode .5641 .0399 5.214 .026 HLoc X Mode .5653 .0013 .163 .688 Tr Anx x Mode .5811 ' .0157 2.066 .156 Verb Ab x Appr .5818 .0007 .097 .757 HLoc x Appr .5855 .0037 .467 .497 Tr Anx x Appr .5869 .0014 .182 .671 Verb Ab x Prog x Tour .6075 .0206 2.674 .108 HLoc x Prog x Tour .6105 .0030 .386 .537 Tr Anx x Prog x Tour .6132 .0027 .339 .563 Verb Ab x-Mode x Appr .6268 .0136 1.750 .192 HLoc x Mode x Appr .6479 .0211 2.822 .100 Tr Anx x Mode x Appr .6484 .0005 .060 .808 Verb Ab x Mode x Tour .6479 .0012 .156 .695 HLoc x Mode x Tour .7194 .0697 10.935 .002 Tr Anx x Mode x Tour .7322 .0129 2.068 .158 Verb Ab x Appr x Tour .7349 .0027 .425 .518 HLoc x Appr x Tour .7515 .0165 2.729 .106 Tr Anx x Appr x Tour .7713 .0198 3.469 .070 Verb Ab x Mode x Appr x Tour *** *** *** *** HLoc x Mode x Appr x Tour *** *** *** *** Tr Anx x Mode x Appr x Tour *** *** *** *** 241 TABLE C.14 Summary of Regression Analyses of Personality Cluster Interactions on Observation Rating Scale Interactions cum.R2 . . R2 Change F Change Sig (Cumulative Effects) (.1850) *** *** *** Ver Ab x Prog .1955 .0105 .805 .373 HLoc x Prog .2116 .0161 1.248 .268 Tr Anx x Prog .2121 .0005 .036 .850 Verb Ab x Tour .2218 .0097 .736 .394 HLoc x Tour .2224 .0006 .041 .840 Tr Anx x Tour .2531 .0308 2.350 .131 Verb Ab x Mode .2571 .0039 .298 .588 HLoc x Mode .2763 .0193 1.463 .232 Tr Anx x Mode .2814 .0050 .378 .541 Verb Ab x Appr .2842 ' .0029 .212 .647 HLoc x Appr .2894 .0051 .375 .543 Tr Anx x Appr .2987 .0093 .677 .414 Verb Ab x Prog x Tour .2996 .0010 .068 .795 HLoc x Prog x Tour .3033 .0037 .261 .612 Tr Anx x Prog x Tour .3241 .0207 1.472 .231 Verb Ab x Mode x Appr .3269 .0029 .200 .657 HLoc x Mode x Appr .3555 .0286 2.039 .160 Tr Anx x Mode x Appr .3606 .0051 .359 .552 Verb Ab x Mode x Tour .3758 .0152 1.070 .306 HLoc x Mode x Tour .3758 .0000 .001 .976 Tr Anx x Mode x Tour .3819 . .0061 .413 .524 Verb Ab x Appr x Tour .3868 .0049 .331 .568 HLoc x Appr x Tour .3966 .0097 .645 .427 Tr Anx x Appr x Tour .5799 .1833 17.019 .000 Verb Ab x Mode x Appr x Tour *** *** *** *** HLoc x Mode x Appr x Tour *** *** *** *** Tr Anx x Mode x Appr x Tour *** *** *** *** 242 TABLE G.15 Summary of Regression Analyses of Personality Cluster Interactions on Observation Verbal Scale Interactions cum.R2 • R 2 Change F Change Sig (Cumulative Effects) (.1972) *** *** *** Verb Ab x Prog .2103 .0131 1.027 .315 HLoc x Prog .2280 .0177 1.402 .241 Tr Anx x Prog .2323 .0042 .332 .567 Verb Ab x Tour .2348 .0025 .193 .662 HLoc x Tour .2354 .0006 .045 .834 Tr Anx x Tour .2484 .0130 .988 .324 Verb Ab x Mode .2588 .0104 .787 .379 HLoc x Mode .2671 .0083 .625 .433 Tr Anx x Mode .2700 .0029 .212 .647 Verb Ab x Appr .2729 ' .0029 .213 .646 HLoc x Appr .2778 .0048 .349 .557 Tr Anx x Appr .3217 .0439 3.303 .075 Verb Ab x Prog x Tour .3229 .0012 .088 .768 HLoc x Prog x Tour .3990 .0761 6.200 .016 Tr Anx x Prog x Tour .4037 .0047 .382 .540 Verb Ab x Mode x Appr .4080 .0043 .344 .561 HLoc x Mode x Appr .4215 .0135 1.071 .306 Tr Anx x Mode x Appr .4217 .0001 .010 .919 Verb Ab x Mode x Tour .4527 .0310 2.496 .121 HLoc x Mode x Tour .4562 .0035 .273 .604 Tr Anx x Mode x Tour .5602 .1041 9.941 .003 Verb Ab x Appr x Tour .5604 .0002 .061 .900 HLoc x Appr x Tour .5610 .0006 .057 .812 Tr Anx x Appr x Tour .6610 .1000 11.513 .002 Verb Ab x Mode x Appr x Tour *** *** *** *** HLoc x Mode x Appr x Tour *** *** *** *** Tr Anx x Mode x Appr x Tour *** *** *** *** 243 TABLE G.16 Summary of Regression Analyses of Personality Cluster Interactions on Observation Non-Verbal Scale Interactions cum.R2 . R 2 Change F Change Sig (Cumulative Effects) (.1940) *** *** *** Verb Ab x Prog .1948 .0008 .063 .803 HLoc x Prog .2168 .0220 1.711 .196 Tr Anx x Prog .2444 .0276 2.192 .144 Verb Ab x Tour .3131 .0688 5.906 .018 HLoc x Tour .3720 .0589 5.441 .023 Tr Anx x Tour .3802 .0081 .747 .391 Verb Ab x Mode .4230 .0428 4.157 .046 HLoc x Mode .4236 .0006 .054 .818 Tr Anx x Mode .4249 .0013 .125 .725 Verb Ab x Appr .4267 ' .0018 .167 .684 HLoc x Appr .4342 .0075 .690 .410 Tr Anx x Appr .4538 .0196 1.829 .182 Verb Ab x Prog x Tour .4581 .0043 .394 .533 HLoc x Prog x Tour .4639 .0059 .537 .467 Tr Anx x Prog x Tour .4641 .0001 .012 .912 Verb Ab x Mode x Appr .4734 .0094 .836 .365 HLoc x Mode x Appr .6203 .1469 17.795 .000 Tr Anx x Mode x Appr .6214 .0011 .131 .719 Verb Ab x Mode x Tour .6430 .0216 2.659 .110 HLoc x Mode x Tour .6457 .0027 .329 .569 Tr Anx x Mode x Tour .6766 .0309 4.013 .052 Verb Ab x Appr x Tour .6766 .0000 .000 .983 HLoc x Appr x Tour .6801 .0035 .440 .511 Tr Anx x Appr x Tour .8106 .1305 26.867 .000 Verb Ab x Mode x Appr x Tour *** *** *** *** HLoc x Mode x Appr x Tour *** *** *** *** Tr Anx x Mode x Appr x Tour *** *** *** *** 244 TABLE C.17 Summary of Regression Analyses of Personality Cluster Interactions on Children's State Anxiety Inventory at Pre-Surgery Measurement Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.6077) *** *** *** Verb Ab x Prog .6105 .0028 .443 .508 HLoc x Prog :6424 .0319 5.345 .024 Tr Anx x Prog .6521 .0097 1.646 .205 Verb Ab x Tour .6611 .0090 1.544 .219 HLoc x Tour .6613 .0002 .033 .856 Tr Anx x Tom- .6613 .0000 .000 .994 Verb Ab x Mode .6613 .0000 .001 .971 HLoc x Mode .6628 .0015 .237 .628 Tr Anx x Mode .6628' .0000 .003 .959 Verb Ab x Appr .6659 .0031 .487 .488 HLoc x Appr .6662 .0002 .034 .854 Tr Anx x Appr .6707 .0045 .687 .411 Verb Ab x Prog x Tour .7028 .0321 5.297 .026 HLoc x Prog x Tour .7313 .0285 5.082 .029 Tr Anx x Prog x Tour .7381 .0069 1.233 .272 Verb Ab-x Mode x Appr .7388 .0006 .109 .742 HLoc x Mode x Appr .7477 .0089 1.589 .214 Tr Anx x Mode x Appr .7494 .0017 .297 .588 Verb Ab x Mode x Tour .7619 .0126 2.272 .139 HLoc x Mode x Tour .7672 .0007 .127 .723 Tr Anx x Mode x Tour .7788 .0161 2.988 .091 Verb Ab x Appr x Tour .7799 . .0012 .210 .649 HLoc x Appr x Tour .7844 .0045 .810 .373 Tr Anx x Appr x Tour .7853 .0009 .151 .700 Verb Ab x Mode x Appr x Tour *** *** *** *** HLoc x Mode x Appr x Tour *** *** *** *** Tr Anx x Mode x Appr x Tour *** *** *** *** 245 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.R2 R 2 Change F Change Sig (Cumulative Effects) (.5685) *** *** *** Verb Ab x Prog .5762 .0077 1.132 .291 HLoc x Prog .5763 .0001 .008 .930 Tr Anx x Prog .5927 .0164 2.413 .126 Verb Abx Tour .5931 .0004 .064 .800 HLoc x Tour .6290 .0359 5.617 .021 Tr Anx x Tour .6307 .0016 .255 .616 Verb Ab x Mode .6307 .0000 .003 .954 HLoc x Mode .6318 .0011 .168 .683 Tr Anx x Mode .6323 ' .0004 .064 .802 Verb Ab x Appr .6439 .0117 1.737 .193 HLoc x Appr .6439 .0000 .000 .991 Tr Anx x Appr .6440 .0001 .008 .929 Verb Ab x Prog x Tour .6461 .0021 .301 .586 HLoc X Prog x Tour .6462 .0001 .015 .904 Tr Anx x Prog x Tour .6546 .0084 1.164 .286 Verb Ab x Mode x Appr .6933 .0387 5.926 .019 HLoc x Mode x Appr .6938 .005 .081 .777 Tr Anx x Mode x Appr .7080 .0141 2.178 .147 Verb Ab x Mode x Tour .7462 .0382 6.623 .014 HLoc x Mode x Tour .7736 .0275 5.214 .027 Tr Anx x Mode x Tour .7882 .0146 2.885 .097 Verb Ab x Appr x Tour .7987 .0105 2.135 .152 HLoc x Appr x Tour .8202 .0216 4.796 .034 Tr Anx x Appr x Tour .8405 .0203 4.964 .032 Verb Ab x Mode x Appr x Tour *** *** *** *** HLoc x Mode x Appr x Tour *** *** *** *** Tr Anx x Mode x Appr x Tour *** *** *** *** 246 TABLE C.19 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions for HBQ Factor 1: Contentiousness Interactions cum.R2 R2 Change F Change Sig (Cumulative Effects) (.6630) *** *** *** Stress x Prog .6651 .0021 .435 .511 Chronic Cond x Prog .6652 .0000 .003 .956 Prev Exp x Prog .6693 .0041 .858 .358 Stress x Tour .6703 .0011 .220 .640 Chronic Cond x Tour .6813 .0110 2.311 .133 Prev Exp x Tour .6817 .0004 .085 .771 Stress x Mode .6823 .0006 .122 .728 Chronic Cond x Mode .6945 .0122 2.546 .115 Prev Exp x Mode .6971" .0027 .553 .460 Stress x Appr .7174 .0203 4.447 .039 Chronic Cond x Appr .7178 .0004 .081 .777 Prev Exp x Appr .7441 .0263 6.170 .016 Stress x Prog x Tour .7453 .0012 .284 .596 Chronic Cond x Prog x Tour .7458 .0004 .098 .756 Prev Exp x Prog x Tour .7461 .0004 .082 .776 Stress x Mode x Appr .7466 .0005 .107 .745 Chronic Cond x Mode x Appr .7535 .0071 1.590 .213 Prev Exp x Mode x Appr .7563 .0026 .575 .451 Stress x Mode x Tour .7568 .0005 .112 .739 Chronic Cond x Mode x Tour .7580 .0012 .253 .617 Prev Exp x Mode x Tour *** *** *** *** Stress x Appr x Tour .7626 .0016 .986 .325 Chronic Cond x Appr x Tour .7695 .0069 1.506 .225 Prev Exp x Appr x Tour .7700 .0004 .089 .767 Stress x Mode x Appr x Tour *** *** *** *** Chr Cond x Mode x Appr x Tour *** *** *** *** Prev Exp x Mode x Appr x Tour *** *** *** *** 247 TABLE C.20 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions for HBQ Factor 2: Dependent Anxiety Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.5676) *** *** *** Stress x Prog .5694 .0018 .299 .586 Chronic Cond x Prog .5707 .0013 .218 .642 Prev Exp x Prog ,5755 .0048 .785 .379 Stress x Tour .5869 .0113 1.867 .176 Chronic Cond x Tour .5929 .0058 .958 .331 Prev Exp x Tour .5956 .0029 .472 .495 Stress x Mode .5984 .0028 .451 .504 Chronic Cond x Mode .6037 .0053 .850 .360 Prev Exp x Mode .6057 .0021 .334 .565 Stress x Appr .6276 .0218 3.633 • .061 Chronic Cond x Appr .6277 .0001 .020 .887 Prev Exp x Appr .6283 .0006 .093 .761 Stress x Prog x Tour .6304 .0021 .334 .566 Chronic Cond x Prog x Tour .6412 .0109 1.760 .190 Prev Exp x Prog x Tour .6643 .0230 3.909 .053 Stress x-Mode x Appr .6652 .0009 .149 .701 Chronic Cond x Mode x Appr .6674 .0023 .373 .544 Prev Exp x Mode x Appr .6710 .0055 .581 .449 Stress x Mode x Tour .6713 .0004 .061 .806 Chronic Cond x Mode x Tour .6723 .0009 .149 .701 Prev Exp x Mode x Tour *** *** *** *** Stress x Appr x Tour .6832 .0109 1.759 .191 Chronic Cond x Appr x Tour .6832 .0000 .003 .955 Prev Exp x Appr x Tour *** *** *** *** Stress x Mode x Appr x Tour .6931 .0098 1.569 .216 Chr Cond x Mode x Appr x Tour *** *** *** *** Prev Exp x Mode x Appr x Tour *** *** *** *** 248 TABLE G.21 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions for HBQ Factor 3: Sleep Disturbance Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.5353) *** *** *** Stress x Prog .5356 .0003 .051 .821 Chronic Cond x Prog .5927 .0071 1.094 .299 Prev Exp x Prog .5549 .0122 1.885 .174 Stress x Tour .5551 .0002 .029 .866 Chronic Cond x Tour .5554 .0004 .053 .818 Prev Exp x Tour .5554 .0000 .000 .983 Stress x Mode .5592 .0037 .550 .461 Chronic Cond x Mode .5611 .0019 .281 .598 Prev Exp x Mode .5617 ' .0006 .088 .768 Stress x Appr .5705 .0088 1.271 .264 Chronic Cond x Appr .5752 .0047 .674 .415 Prev Exp x Appr .5897 .0146 2.128 .150 Stress x Prog x Tour .5906 .0009 .126 .724 Chronic Cond x Prog x Tour .6023 .0117 1.702 .197 Prev Exp x Prog x Tour .6042 .0019 .278 .600 Stress x Mode x Appr .6057 .0014 .204 .653 Chronic Cond x Mode x Appr .6122 .0065 .925 .340 Prev Exp x Mode x Appr .6176 .0054 .767 .385 Stress x Mode x Tour .6176 .0000 .001 .970 Chronic Cond x Mode x Tour .6267 .0090 1.259 .267 Prev Exp x Mode x Tour *** *** *** *** Stress x Appr x Tour .6422 .0156 2.217 .143 Chronic Cond x Appr x Tour .6490 .0067 .960 .332 Prev Exp x Appr x Tour *** *** *** *** Stress x Mode x Appr x Tour .6611 .0121 1.753 .192 Chr Cond x Mode x Appr x Tour *** *** *** *** Prev Exp x Mode x Appr x Tour *** *** *** *** 249 TABLE C.22 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions for HBQ Factor 4: Appetite Disturbance Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.4609) *** *** *** Stress x Prog .4719 .0110 1.480 .228 Chronic Cond x Prog .4731 .0012 .154 .696 Prev Exp x Prog .4802 .0071 .940 .336 Stress x Tour .4810 .0008 .103 .749 Chronic Cond x Tour .4822 .0013 .162 .688 Prev Exp x Tour .4825 .0003 .034 .854 Stress x Mode .4885 .0060 .761 .386 Chronic Cond x Mode .4929 .0044 .560 .457 Prev Exp x Mode .4929*' .0001 .007 .935 Stress x Appr .5149 .0219 2.804 .099 Chronic Cond x Appr .5166 .0017 .220 .641 Prev Exp x Appr .5634 .0468 6.431 .014 Stress x Prog x Tour .5658 .0023 .361 .576 Chronic Cond x Prog x Tour .5662 .0005 .066 .798 Prev Exp x Prog x Tour .6061 .0399 5.771 .020 Stress x Mode x Appr .6067 .0006 .088 .768 Chronic Cond x Mode x Appr .6087 .0019 .271 .605 Prev Exp x Mode x Appr .6297 .0210 3.064 .086 Stress x Mode x Tour .6342 .0045 .652 .423 Chronic Cond x Mode x Tour .6355 .0013 .182 .671 Prev Exp x Mode x Tour *** *** *** *** Stress x Appr x Tour .6421 .0066 .944 .336 Chronic Cond x Appr x Tour .6622 .0201 2.973 .091 Prev Exp x Appr x Tour *** *** *** *** Stress x Mode x Appr x Tour .6628 .0007 .095 .760 Chr Cond x Mode x Appr x Tour *** *** *** *** Prev Exp x Mode x Appr x Tour *** *** *** *** 250 TABLE C.23 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions for Observation Rating Scale Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.1954) *** *** *** Stress x Prog .2412 .0458 4.287 .042 Chronic Cond. x Prog .2435 .0023 .217 .642 Prev Exp x Prog .2452 .0016 .149 .700 Stress x Tour .2458 .0006 .055 .815 Chronic Cond x Tour .2861 .0403 3.785 .056 Prev Exp x Tour .2880 .0019 .172 .680 Stress x Mode .2915 .0035 .320 .573 Chronic Cond x Mode .2946 .0031 .282 .598 Prev Exp x Mode .3028 ' .0082 .743 .392 Stress x Appr .3032 .0004 .039 .844 Chronic Cond x Appr .3034 .0002 .019 .891 Prev Exp x Appr .3057 .0023 .195 .660 Stress x Prog x Tour .3071 .0014 .121 .729 Chronic Cond x Prog x Tour .3563 .0492 4.432 .040 Prev Exp x Prog x Tour .3590 .0027 .243 .624 Stress x Mode x Appr .3656 .0066 .580 .449 Chronic Cond x Mode x Appr .3656 .0000 .003 .959 Prev Exp x Mode x Appr .3656 .0000 .000 .991 Stress x Mode x Tour .3714 .0057 .485 .489 Chronic Cond x Mode x Tour .3938 .0224 1.924 .171 Prev Exp x Mode x Tour *** *** *** *** Stress x Appr x Tour .4072 .0134 1.151 .288 Chronic Cond x Appr x Tour .4202 .0130 1.123 .294 Prev Exp x Appr x Tour *** *** *** *** Stress x Mode x Appr x Tour .4204 .0002 .014 .908 Chr Cond x Mode x Appr x Tour *** *** *** *** Prev Exp x Mode x Appr x Tour *** *** *** *** 251 TABLE C.24 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions for Observation Verbal Scale Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.1880) *** *** *** Stress x Prog .1949 .0061 .542 .464 Chronic Cond x Prog .1949 .0001 .006 .941 Prev Exp x Prog .2016 .0067 .580 .449 Stress x Tour .2041 .0024 .206 .652 Chronic Cond x Tour .2044 .0003 .028 .868 Prev Exp x Tour .2078 .0034 .285 .595 Stress x Mode .2317 .0239 2.018 .160 Chronic Cond x Mode .2367 .0050 .419 .520 Prev Exp x Mode .2581' .0214 1.819 .182 Stress x Appr .2641 .0060 .505 .480 Chronic Cond x Appr .2644 .0003 .027 .871 Prev Exp x Appr .2648 .0004 .037 .849 Stress x Prog x Tour .2663 .0015 .117 .733 Chronic Cond x Prog x Tour .2800 .0137 . 1.101 .298 Prev Exp x Prog x Tour .2807 .0007 .056 .813 Stress x Mode x Appr .2822 .0015 .121 .730 Chronic Cond x Mode x Appr .3306 .0484 3.979 .051 Prev Exp x Mode x Appr .3368 .0061 .500 .483 Stress x Mode x Tour .3370 .0003 .020 .887 Chronic Cond x Mode x Tour .3546 .0176 1.417 .239 Prev Exp x Mode x Tour *** *** *** *** Stress x Appr x Tour .3547 .0001 .009 .924 Chronic Cond x Appr x Tour .4022 .0475 3.975 .052 Prev Exp x Appr x Tour *** *** *** *** Stress x Mode x Appr x Tour .4129 .0107 .892 .350 Chr Cond x Mode x Appr x Tour *** *** *** *** Prev Exp x Mode x Appr x Tour *** *** *** *** 252 TABLE C.25 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions for Observation Non-Verbal Scale Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.1793) *** *** *** Stress x Prog .2061 .0268 2.394 .126 Chronic Cond x Prog .2674 .0613 5.856 .018 Prev Exp x Prog .2835 .0161 1.552 .217 Stress x Tour .3222 .0387 3.882 .053 Chronic Cond x Tour .3375 .0153 1.550 .218 Prev Exp x Tour .3375 .0000 .004 .948 Stress x Mode .3443 .0067 .667 .417 Chronic Cond x Mode .3525 .0083 .816 .370 Prev Exp x Mode .3559' .0033 .326 .570 Stress x Appr .3625 .0066 .646 .424 Chronic Cond x Appr .3775 .0150 1.474 .229 Prev Exp x Appr .3936 .0161 1.589 .212 Stress x Prog x Tour .4062 .0126 1.256 .267 Chronic Cond x Prog x Tour .4175 .0112 1.120 .294 Prev Exp x Prog x Tour .4239 .0064 .634 .429 Stress x Mode x Appr .52259 .1020 12.045 .001 Chronic Cond x Mode x Appr .5266 .0007 .084 .773 Exp x Mode x Appr .5268 .0002 .021 .886 Stress x Mode x Tour .5298 .0030 .340 .562 Chronic Cond x Mode x Tour .5412 .0114 1.290 .261 Prev Exp x Mode x Tour *** *** *** *** Stress x Appr x Tour .5502 .0090 1.016 .318 Chronic Cond x Appr x Tour .6291 .0789 10.635 .002 Prev Exp x Appr x Tour *** *** *** *** Stress x Mode x Appr x Tour .6320 .0029 .387 .537 Chr Cond x Mode x Appr X Tour *** *** *** *** Prev Exp x Mode x Appr x Tour *** *** *** *** 253 TABLE C.26 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions for Children's Suite Anxiety Inventory at Pre-Surgery Measurement Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.5650) *** *** *** Stress x Prog .5738 .0088 1.347 .250 Chronic Cond x Prog ,5760 .0022 .332 .567 Prev Exp x Prog .6109 - .0349 5.655 .020 Stress x Tour .6109 .0000 .000 .983 Chronic Cond x Tour .6254 .0145 2.354 .130 Prev Exp x Tour .6352 .0098 1.610 .209 Stress x Mode .6354 .0003 .042 .838 Chronic Cond x Mode .6566 .0211 3.571 .064 Prev Exp x Mode .6567' .0001 .023 .880 Stress x Appr .6567 .0000 .001 .975 Chronic Cond x Appr .6568 .0000 .008 .931 Prev Exp x Appr .6608 .0041 .646 .425 Stress x Prog x Tour .6662 .0054 .863 .357 Chronic Cond x Prog x Tour .6683 .0020 .318 .575 Prev Exp x Prog x Tour .7342 .0659 12.644 .001 Stress x Mode x Appr .7346 .0005 .088 .768 Chronic Cond x Mode x Appr .7367 .0021 .384 .539 Prev Exp x Mode x Appr .7392 .0025 .455 .503 Stress x Mode x Tour .7414 .0023 .411 .525 Chronic Cond x Mode x Tour .7422 .0008 .137 .713 Prev Exp x Mode x Tour *** *** *** *** Stress x Appr x Tour .7504 .0092 1.483 .230 Chronic Cond x Appr x Tour .7532 .0028 .495 .485 Prev Exp x Mode x Tour *** *** *** *** Stress x Mode x Appr x Tour .7532 .0000 .000 .972 Chr Cond x Mode x Appr x Tour *** *** *** *** Prev Exp x Mode x Appr x Tour *** *** *** *** 254 TABLE C.27 Summary of Regression Analyses of Personal History Characteristics Cluster Interactions for Children's Suite Anxiety Inventory at 6 week Follow-up Measurement Interactions cum.R2 R 2 Change F Change Sig (Cumulative Effects) (.3963) *** *** *** Stress x Prog .3993 .0030 .349 .557 Chronic Cond x Prog .4031 .0037 .430 .514 Prev Exp x Prog .4061 .0030 .348 .557 Stress x Tour .4254 .0193 2.248 .138 Chronic Cond x Tour .4326 .0072 .842 .362 Prev Exp x Tour .4332 .0006 .066 .798 Stress x Mode .4455 .0123 1.419 .238 Chronic Cond x Mode .4479 .0024 .279 .599 Prev Exp x Mode .4563' .0034 .957 .332 Stress x Appr .4568 .0005 .052 .820 Chronic Cond x Appr .4735 .0167 1.906 .172 Prev Exp x Appr .4744 .0008 .095 .759 Stress x Prog x Tour .4862 .0118 1.331 .253 Chronic Cond x Prog x Tour .4882 .0021 .233 .631 Prev Exp x Prog x Tour .4943 .0060 .667 .418 Stress x Mode x Appr .4999 .0056 .620 .434 Chronic Cond x Mode x Appr .5001 .0002 .023 .879 Prev Exp x Mode x Appr .5201 .0199 2.201 .144 Stress x Mode x Tour .5206 .0005 .057 .812 Chronic Cond x Mode x Tour .5207 .0001 .010 .921 Prev Exp x Mode x Tour *** *** *** *** Stress x Appr x Tour .5251 .0045 .471 .496 Chronic Cond x Appr x Tour .5317 .0066 .690 .410 Prev Exp x Appr x Tour *** *** *** *** Stress x Mode x Appr x Tour .5323 .0005 .054 .818 Chr Cond x Mode x Appr x Tour *** *** *** *** Prev Exp x Mode x Appr x Tour *** *** *** *** 255 APPENDIX D 256 APPENDIX D CONTENTS ITEM PAGE Letter of permission for adapting tests 258 Letter of consent for study surgeons 259 Letters informing subjects 260 Letter of consent for subjects' parents 261 257 STUDY SURGEON'S CONSENT FORM TO PARTICIPATE IN THE.PREPARATION PROGRAMMES STUDY I understand that the purpose of this project is to determine whether or not preadmission preparation programmes are effective in reducing the negative effects of hospitalization on children and their parents and the comparative effects of different'types of programmes. I understand that some of my patients and their parents will participate in one of four preparation programmes on the day before surgery. Other patients will constitute a control group and will not receive any programmes. I understand that I will not be told to which programme or control group each patient is assigned. I understand that a l l information obtained, from my patient's parent or hospital record will be kept confidential and that I have the right to withdraw any patient from the study at any time without prejudice to further care or treatment. I agree to encourage my patients who f i t the sampling c r i t e r i a to participate in the study. Name Date Witness 259 U.B.C. Department of Paediatrics Preadmission Preparation Study • PARENT CONSENT•FORM • I hereby give consent for'myself and my child to participate in the Preadmission Preparation Study at B.C.'s Children's Hospital. I understand that our participation will require four one-hour interviews in my home, a one-hour interview at the hospital one or two days before my child's surgery and a brief observation period in the hospital on the day of surgery. Informa