Psychometric evaluation of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery and postoperative behvaior and recovery in children undergoing tonsil surgery

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Nilsson, Ulrica; Ericsson, Elisabeth; Eriksson, Mats; Idvall, Ewa; Bramhagen, Ann-Cathrine. (2019). Psychometric evaluation of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery and postoperative behvaior and recovery in children undergoing tonsil surgery. Journal of Perioperative Practice, vol. 29, issue 4, p. null


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The study comprised a prospective, comparative cross-sectional survey in 143 children 2

undergoing tonsil surgery. Parents answered the Post Hospitalization Behavior Questionnaire 3

for Ambulatory Surgery (PHBQ-AS), and children answered the questionnaire Postoperative 4

Recovery in Children (PRiC). The PHBQ-AS had positive correlation with the PRiC and with 5

general health. On day 10 after surgery, up to 1/3 of the children still reported physical 6

symptoms (PRiC). No gender or age differences concerning the items of behavior (PHBQ-7

AS) were found. The quality of postoperative recovery (PRiC) in girls was lower, with higher 8

levels of nausea, dizziness, coldness, and headache compared to the boys. Children <6 years 9

of age reported higher levels of dizziness, and lower sleep quality and lower general health. 10

Keywords: Behavior, Children, Pain, Postoperative recovery, Tonsil surgery 11





Postoperative recovery in children is an individual process with subjective experiences, 14

affecting daily life activities, physical and emotional comfort (Eriksson, Nilsson, Bramhagen, 15

Idvall, & Ericsson, 2017), and behavioral changes (Karling, Stenlund, & Hägglöf, 2007; 16

Wilson et al., 2016). Tonsil surgery is a frequently performed surgical procedure among 17

children, and behavioral disturbance has been reported as a common complication (Karling et 18

al., 2007; Sathe, Chinnadurai, McPheeters, & Francis, 2017; Stanko, Bergesio, Davies, 19

Hegarty, & Ungern-Sternberg, 2013; Wilson et al., 2016). The most frequent behavioral 20

changes were apathy and separation anxiety (Fortier, Del Rosario, Rosenbaum, & Kain, 21

2010; L. Kotiniemi, Ryhänen, & Moilanen, 1997; L. H. Kotiniemi, Ryhänen, & Moilanen, 22

1996), eating disturbances (Eriksson et al., 2017; Karling et al., 2007; L. Kotiniemi et al., 23

1997; L. H. Kotiniemi et al., 1996; Sathe et al., 2017), and sleep disturbance (Eriksson et al., 24

2017; Karling et al., 2007; L. Kotiniemi et al., 1997; L. H. Kotiniemi et al., 1996), “making a 25

fuss about eating,” and “temper tantrums” (Beringer, Segar, Pearson, Greamspet, & 26

Kilpatrick, 2014). Preoperative anxiety has been found to be a risk factor for, for example, 27

postoperative pain, sleeping problems, and eating problems after surgery (Kain, Mayes, 28

Caldwell-Andrews, Karas, & McClain, 2006). Young age (Fortier et al., 2010; Karling et al., 29

2007; Stargatt et al., 2006) and being a boy (Beringer et al., 2014) have also been reported as 30

risk factors for behavioral changes postoperatively. Even long-lasting problematic behavior 31

persisting for up to four weeks after surgery has been found in 16%–32% of children (Pearson 32

& Hall, 2017; Stargatt et al., 2006). Day-case tonsil surgery plays a prominent role in 33

pediatric practice in many countries (Hallenstål et al., 2017). 34

In 1966, Vernon, Schulman, and Foley developed a parent-rated instrument, the Post Hospital 35

Behavior Questionnaire (PHBQ), to quantify behavioral changes in children who undergo 36



hospitalization due to surgery or illness in the United States (Vernon, Schulman, & Foley, 37

1966). The PHBQ comprises 27 items in six subscales: general anxiety and regression, 38

separation anxiety, eating disturbance, aggression toward authority, apathy/withdrawal, and 39

anxiety about sleep. For each item, parents are asked to compare their child’s behavior before 40

hospitalization to the child’s current behavior (post-hospitalization) on a Likert-type scale 41

(Vernon et al., 1966). The PHBQ has been translated into Swedish, and its psychometric 42

properties were found to be acceptable (Karling, Stenlund, & Hägglöf, 2006). The Swedish 43

PHBQ includes 25 items. Two items, Does your child need a lot of help doing things? and Is 44

it difficult to get your child to talk to you?, loaded poorly on any factor (<0.4), and when this 45

was evaluated by an expert panel these questions were omitted (Karling et al., 2006). 46

In 2015, Jenkins and colleagues (Jenkins et al., 2015) reduce the number of items from 27 to 47

11, creating the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-48

AS). The PHBQ-AS demonstrated good internal consistency, reliability, and concurrent 49

validity (Jenkins et al., 2015). Since most of the tonsil surgeries among children are 50

performed on a day surgery basis (Alm, Stalfors, Nerfeldt, & Ericsson, 2017), we created a 51

modified version of the PHBQ-AS to test construct validity and internal consistency and to 52

measure behavioral changes in children undergoing tonsil surgery. 53

The instrument Postoperative Recovery in Children (PRiC) was recently developed and tested 54

in Sweden as a questionnaire aiming to measure self-reported postoperative recovery after 55

tonsillectomy in children aged 4–12 years. The results of the study provided evidence of the 56

reliability and validity of the PRiC as a measure of postoperative recovery among children 57

after tonsil surgery. Cronbach’s alpha for the total questionnaire was 0.83. The parents 58

reported in 59% of the cases that the children participated very much in answering the 59

questions (Bramhagen et al., 2016). However, continued psychometric testing of 60



questionnaires measuring postoperative recovery and post hospital behavior are needed, as 61

well as an assessment of these outcomes. 62




The study objectives were to (1) examine the psychometric properties of the modified 65

Swedish version of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery 66

(PHBQ-AS), (2) describe post-hospitalization behavior and postoperative recovery in children 67

undergoing tonsil surgery, and (3) explore any gender or age differences in connection with 68

these aspects. 69



Study Design and Population 71

The study employed a prospective, comparative cross-sectional survey. A sample of 390 72

children undergoing tonsil surgery (tonsillectomy or tonsillotomy/partial tonsillectomy) and 73

their parents were invited to participate in answering one questionnaire each on day 10 after 74

surgery. The children were consecutively recruited from five different settings, four hospitals 75

and one private day surgery clinic, in Sweden in 2012–2014. The inclusion criteria were as 76

follows: healthy children without any chronic disease between the ages of 4 and 12 years, 77

who were selected for day surgery and whose parents could read, understand, and speak 78

Swedish. 79

Questionnaires 80

Post Hospitalization Behavior Questionnaire for Ambulatory Surgery 81

The modified version of the PHBQ-AS consisted of nine items, that is, the two items excluded 82

in the Swedish version of PHBQ was also excluded in the PHBQ-AS version. The two 83



excluded items were Is it difficult to get your child to talk to you? and Does your child need a 84

lot of help doing things? The nine items were answered by the parents on a five-point scale: 1 85

= much less than before, 2 = less than before, 3 = same as before, 4 = more than before, and 5 86

= much more than before. 87

Postoperative Recovery in Children 88

Postoperative recovery was measured with the PRiC, by the children themselves or with help 89

from the parents. The PRiC includes 23 items, 21 items about different aspects of recovery in 90

general and 2 items that are specific to tonsil surgery (ear ache and blood in the mouth). The 91

items concern the previous 24 hours and are assessed on a four-grade scale: 1 = not at all, 2 = 92

a little, 3 = much, and 4 = very much, where “very much” indicates the lowest level of 93

recovery. The PRiC also includes one item of a more general nature that addresses the 94

children’s present general health, to be answered with: 4 = very good, 3 = pretty good, 2 = 95

pretty bad, or 1 = very bad. 96

Background data were collected from the child’s medical journal using a protocol developed a 97

priori, concerning gender, age, surgical procedure, and type of anesthesia. 98

Procedure 99

The invited children and their parents received verbal and written information about the study. 100

At discharge from the hospital, the children received the PRiC questionnaire for assessing 101

postoperative recovery on the 10th day postoperatively. Their parents received the Swedish 102

version of the PHBQ-AS, also to be answered on the 10th day postoperatively, along with 103

prepaid envelopes. No reminder was sent out. 104

Ethical Approval 105



The study was approved by the Research Ethics Committee in Uppsala (No. 2012/106). 106

Parents provided written informed consent for the study, and the children provided assent. 107

The children could either write their name or draw a picture on the consent form. The 108

researcher stated that children could withdraw from the study at any time. Data sheets were 109

stored in a locked cabinet and no identifying information was collected. 110

Statistics 111

Power Calculation 112

Based on the suggestions by Ferketich (1991)of a five-to-one ratio (five individuals per scale 113

item) for examining psychometric properties in a nine-item instrument, a minimum of 45 114

participants would be needed to conduct principal components analysis (Ferketich, 1991). 115

Therefore, our sample size provided sufficient power to conduct psychometric testing of the 116

Swedish modified version of PHBQ-AS. 117

Validity to evaluate the accuracy was assessed as follows: 118

1. Principal components analysis: Although the PHBQ-AS (Jenkins et al., 2015) was 119

developed during the time of data collection of the present study, a decision was made 120

to determine construct validity of the Swedish version of the PHBQ-AS, using a 121

principal components analysis with varimax rotation rather than presenting all 25 items, 122

that is, the Swedish version of the PHBQ. 123

2. Construct validity is the degree to which the scores of a questionnaire are consistent 124

with hypotheses based on the assumption that the questionnaire validity measures the 125

construct to be measured. For a correlation coefficient 0.3 < r < 0.7, moderate 126

correlation was assumed. 127



3. Hypothesis testing: To analyze construct validity, a priori hypotheses were set up, 128

hypothesizing that the PHBQ-AS would correlate moderately positively with the PRiC 129

and with general health measured with Spearman rank (rho) correlation coefficients. 130

Internal consistency (reliability) describes consistency and was assessed based on the 131

following: Cronbach’s alpha coefficient was calculated to determine the homogeneity of each 132

factor among the items in the PHBQ-AS. 133

Analysis of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery and 134

Postoperative Recovery in Children 135

1. Parent-reported behavioral changes, PHBQ-AS, are presented as frequencies and 136

proportions. 137

2. The self-reported items of the PRiC are presented with mean and standard deviation 138

(SD) and with the frequencies for all answers in each item. 139

3. Age was categorized dichotomously as younger children (<6 years) or older children 140

(≥6 years), guided by the mean age 6.5 years of the included population. Ages were 141

compared using the Mann Whitney U-test. 142

4. Differences between genders were analyzed with Mann Whitney U-test. 143

All statistical analyses were conducted with SPSS 23.0 (SPSS Inc., Chicago, IL, USA). 144

Descriptive statistics are presented as numbers and percentages, arithmetic means, and 145

medians. A p-value less than 0.05, two-tailed, was considered statistically significant. 146



On the 10th day after the surgical procedure a total of 37% (n = 143) of the included children 148

answered the PRiC, while their parents answered the PHBQ-AS. The mean age of the 149

responding children was 6.5 years (SD 2.3); 58% were girls (n = 82) and 42% boys (n = 61). 150



Half of the children underwent adenotonsillotomy (n = 60) or tonsillotomy (n = 7), and the 151

other half underwent adenotonsillectomy (n = 41) or tonsillectomy (n = 35). The main 152

indications for the procedures were airway obstruction/hypertrophic tonsils (n = 112), 153

infection/inflammation such as recurrent tonsillitis (n = 16), and “chronic” tonsillitis (n = 15). 154

The types of anesthesia were inhalation (78%, n = 112) and total intravenous anesthesia 155

(22%, n = 31). 156

Psychometric Properties 157

A principal components factor analysis with varimax rotation was conducted, using the nine 158

remaining items of the PHBQ-AS to determine whether the Swedish version was 159

unidimensional. The principal components analysis resulted in a one-factor solution 160

explaining 50.8% of the total variance (Table 1). The Cronbach’s alpha was 0.86. Construct 161

validity showed a low positive correlation between the PHBQ-AS and PRiC, rho = -0.25, 162

P = 0.003 and a moderate correlation between PHBQ-AS and general health, rho = -0.30, 163

P = 0.000. On item level, low positive correlations were found between seven PHBQ-AS 164

items and 13 PRiC items. The strongest correlation was found between the items PHBQ-AS 165

Does your child make a fuss about eating? and the PRiC items difficulty eating (rho = 0.31, 166

P = 0.000) and sore throat (rho = 0.30, P = 0.000). The highest frequencies of correlations 167

were found in the two PHBQ-AS items measuring fuss about eating and poor eating. No 168

correlations were found between two of the PHBQ-AS items, Does your child have bad 169

dreams at night or wake up and cry? and Does your child get upset when you leave him (or 170

her) alone for a few minutes?,and any of the PRiC items (Table 2). 171

Behavioral Changes, PHBQ-AS 172

The most frequently reported negative behavioral changes were fuss about eating (17%, n = 173

28) and having a poor appetite (17%, n = 28) (Figure 1). There were no significant differences 174



in younger children compared to children from 6 years and older in the PHBQ-AS or on item 175

levels. No differences were seen between genders. 176

Postoperative Recovery (PRiC) 177

The item general health was scored to be rather good, 3.7 (SD 0.5), and the majority of the 178

children had a relatively high quality of recovery on postoperative day 10, with 61%–98% 179

reporting no symptoms or difficulties. The most frequently reported symptoms were sore 180

throat (39%), difficulties with eating (28%), feeling sad (20%), and feeling cold (18%). 181

Twenty percent of the children reported difficulties with attending daycare or school (Table 182

3). Younger children reported more difficulties with dizziness, 1.3 vs 1.1 (P = 0.009), and 183

sleep 1.3 vs 1.1 (P = 0.042), compared to the older children. There were no differences in the 184

other 21 items. Girls suffered more from nausea, 1.1. vs 1.0 (P = 0.048); dizziness, 1.2 vs 1.0 185

(P = 0.009); coldness, 1.4 vs 1.1 (P = 0.001); and headache, 1.2 vs 1.0 (P = 0.002), compared 186

to the boys. There were no differences in the other 19 items. A difference in age was also seen 187

in the item general health, in which younger children assessed lower levels of health 188

compared to the older ones, 3.6 vs 3.8 (P = 0.021). No differences were observed between 189

genders. 190



The study examined a parent-reported questionnaire about post-hospitalization behavior, 192

PHBQ-AS (Jenkins et al., 2015), together with a child-reported questionnaire about 193

postoperative recovery, PRiC (Bramhagen et al., 2016), in a group of tonsil-operated children. 194

Our findings from the psychometric testing suggest that the modified Swedish version of the 195

PHBQ-AS has good construct validity and internal consistency. The Swedish version of 196

PHBQ-AS consists of 9 items, instead of 11 items as in the original PHBQ-AS (Jenkins et al., 197

2015), due to two items being excluded in the Swedish version of PHBQ (Karling et al., 198



2006). The Swedish 9-item version of PHBQ-AS cannot be compared with the original 199

American 11-item version of PHBQ-AS. We also assume that there could be cultural 200

differences between Sweden and the United States that also might influence items on the scale 201

and the psychometric properties. Assessment of construct validity should include testing 202

hypotheses that can demonstrate the proposed construct. We expected and found a positive 203

correlation between the PHBQ-AS and the PRiC and general health, because they measure 204

related concepts (behavior vs recovery/health), and children with behavioral changes are 205

expected, to some extent, to have lower quality of recovery and general health. Jenkins et al. 206

(2015) found a moderate positive correlation, r 0.49, between the PHBQ-AS and the 207

Functional Disability Inventory (FDI). The FDI is a 15-item instrument that assesses 208

limitations in psychosocial and physical functioning as a function of children’s physical 209

health (Walker & Greene, 1991). In the present study we also found some positive 210

correlations on item level between PHBQ-AS items and PRiC items. The strongest correlation 211

was noticed between the PHBQ-AS item Does your child make a fuss about eating? and 212

PRiC items difficulty eating (rho = 0.31, P = 0.000) and sore throat (rho = 0.30, P = 0.000). 213

Highest frequencies of correlations were found in the two PHBQ-AS items measuring fuss 214

about eating and poor eating. However, we strongly suggest that the results from both PHBQ-215

AS and PRiC should be analyzed on item level, not as total scores. The reason behind this is 216

that we believe it is important to study each item separately when evaluating the child’s 217

postoperative behavior and recovery. To merge all items (symptoms and signs) into a sum 218

score can dilute or blur the results and thus diminish the external validity. 219

The present study also aimed to describe both post-hospitalization behavior and postoperative 220

recovery 10 days after tonsil surgery. The results showed that 61%–98% of the children 221

reported no symptoms in the different PRiC items and also scored general health as high. 222

However, 39% reported a sore throat and 28% had difficulties eating on day 10 after surgery. 223



This is in line with other studies showing that children experienced pain up to 14 days after 224

tonsil surgery (Stanko et al., 2013; Stewart et al., 2012). Regarding the eating factor in the 225

behavioral changes instrument (PHBQ-AS), the parents reported that only 15% had poor 226

appetite. One explanation for this discrepancy could be that the appetite was considered to be 227

normal, but the pain from the sore throat made it difficult for the children to eat. 228

Previous research has shown that pain medications are underused in pediatric populations 229

(Baugh et al., 2011). This underutilization can be attributed to several factors, including 230

parental concerns. A behavioral measurement can provide information to parents about the 231

distress and behavioral changes that children exhibit following surgery, indicative of pain. An 232

advantage of creating a short form of PHBQ is that it would increase the utility of the tool, 233

making it faster to complete and possibly increase compliance, with repeated use during the 234

child’s postoperative recovery. Pain and post-operative recovery are individual and subjective 235

experiences and should be measured with self-assessment in children, as is standard practice 236

in adults. The PHBQ-AS could assist parents and serve as a supplement to the children’s 237

recovery self-reports. Parents play a crucial role in pain management after hospital discharge, 238

particularly given the increases in day surgery and brief hospitalization. 239

We did not find any gender differences in behavioral changes or general health, but the PRiC 240

results revealed that girls reported more nausea, dizziness, coldness, and headache compared 241

to the boys. No differences were found in the other 19 items of the PRiC. Gender differences 242

reported in other studies include a higher incidence of postoperative nausea and vomiting in


girls, following outpatient tonsillectomy (Sadhasivam et al., 2015), and less postoperative


pain in boys (Chieng et al., 2013). A Swedish registry of 32,225 tonsil surgeries on children


reported no clinically relevant difference between genders in patient-reported pain-related 246

outcome measurements, except for days to regular food intake, which was somewhat higher in 247

the girls after tonsillectomy. One factor was that the girls tended to be older at the time of 248



surgery, which could influence patient-reported outcome measures for pain (Alm et al., 2017). 249

One possible explanation in our study is that the girls’ symptoms were related to dehydration 250

from the influence of diet in the postoperative recovery. 251

Our study showed that younger children scored lower in the item general health compared to


older children. Younger children reported more dizziness and more problems going to sleep


on day 10 after surgery. This is in line with other studies that have reported that younger


children are at higher risk of behavioral changes after surgery (Fortier et al., 2010; Karling et


al., 2007; Stargatt et al., 2006). Karling and colleagues (2007) considered that the items in the


original subscale of the PHBQ better reflect behaviors in younger children. There was no


difference in age in the item “sore throat” to explain untreated pain in our study. Alm and


colleagues (2017) found that older children generally reported higher pain in patient-reported


outcome measures. It might be speculated that older children need more support for coping


with the pain and that they also are more aware that the parents are responsible for the pain




One limitation in the present study is the chosen follow-up time. The pain after tonsil surgery 263

increases a few days after surgery before gradually decreasing, and is often most pronounced 264

on days 3 to 5 after tonsillectomy (Ericsson, Brattwall, & Lundeberg, 2015) We might have 265

seen a stronger correlation between behavior (PHBQ-AS) and recovery (PRiC) if data 266

collection had been performed during that period. 267


Implications for Clinical Practice and Further Research


It has previously been shown that the family structures one-parent families (Karling et al.,


2007), two or more older siblings (Stargatt et al., 2006), area of residence, and parental


education (Karling et al., 2007) are risk factors for developing negative behavioral changes



postoperatively. This was not the focus of our study, but is perhaps something worth studying


in the future, together with other sociodemographic factors that possibly could influence


postoperative recovery and post-hospitalization behavioral changes.


This study is limited in terms of generalizability and whether the sample size is enough for a 276

subgroup analysis of gender and age. Furthermore, this study was conducted in Swedish- 277

speaking children and their parents. Further studies including all types of anesthesia and 278

surgeries should be conducted, as well as studies including non-Swedish-speaking participants 279

answering in their own languages. Another limitation to be acknowledged which may 280

influence the results, is that we had no information about if the children had any earlier 281

experiences of undergoing surgery or any siblings with experience of it. 282


The modified Swedish PHBQ-AS seems to be relevant for measuring parent-reported 284

behavioral changes in children undergoing tonsil surgery. However, there is a difference 285

between the child’s perspective and, for example, the health care system that defines what is 286

good for them (Nilsson et al., 2015). Children’s own views should be considered when 287

measuring children’s postoperative recovery and care (Bramhagen et al., 2016). Furthermore, 288

to ensure that important and relevant outcomes are measured in clinical practice and future 289

studies, a core outcome set developed specifically for this purpose would be highly desirable. 290

Such a core outcome set would also help limit heterogeneity in outcome reporting. There is a 291

lack of core outcome sets within pediatric anesthesia and surgery, both parent-reported and 292

self-reported among children (Pearson & Hall, 2017). We therefore suggest that parent proxy 293

PHBQ-AS reporting should be supplemented with children’s self-reported symptoms during 294

the postoperative phase, as assessed with the PRiC (Bramhagen et al., 2016) This would 295

identify both children with behavioral changes due to anesthesia and surgery and those 296

children who currently experience low-quality postoperative recovery, such as girls and 297



younger children, as well as measure differences in behavior and postoperative recovery in 298

clinical trials. The availability of the PHBQ-AS and the PRiC will be valuable in research and 299

clinical practice with children experiencing pain at home following medical care. 300

Conclusion 301

Our findings from the psychometric testing suggest that the modified Swedish version of the 302

PHBQ-AS has good construct validity and internal consistency, and it reflects aspects of the 303

postoperative period measured by PRiC. Both instruments have their value and should be 304

implemented in the postoperative follow-up. Postoperative recovery seems to differ between 305

genders and ages, presented as lower quality of recovery in girls and younger children. 306

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Figure 1. Graph representing the frequency of negative behavioral changes (n = 140) on postoperative day 10.

28 28 20 16 12 10 10 9 7 F U S S A B O U T E A T I N G P O O R A P E T I T E G E T T I N G T O T R O U B L E S L E E P B A D D R E A M S U P S E T L E A V I N G D I F F I C U L T I N T E R E S T E D A N T R U M S T E M P E R D O I N G N O T H I N G U N I N T E R E S E D


Figure 1. Graph representing the frequency of negative behavioral changes (n = 140) on postoperative day 10

Figure 1.

Graph representing the frequency of negative behavioral changes (n = 140) on postoperative day 10 p.17


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