AKADEMIN FÖR HÄLSA OCH ARBETSLIV
Avdelningen för arbets- och folkhälsovetenskap
Children in play therapy:
what significance does this have for their parent´s perceived health?
Scientific writing C
Sandra Eriksson
2014
Examensarbete, Grundnivå (kandidatexamen), 15 hp Folkhälsovetenskap
Hälsopedagogiska programmet
Folkhälsovetenskap: Teori och metod med tillämpning och examensarbete C Handledare: Leah Emegwa Okenwa
Examinator: Ola Westin, Maria Lennernäs Wiklund
Eriksson, S. (2014) Children in play therapy: what significance does this have for their parent´s perceived health? Bachelor thesis in Public Health science. The Faculty of Health and Occupational Studies. The University of Gävle, Sweden.
Children in play therapy: what significance does this have for their parent´s perceived health?
Abstract
Background: World Health Organization highlights an increasing world-wide problem
regarding mental ill health, disorders and difficulties among children and adolescent.
Research has found that health-related impairments do not only affect the children suffering from it, but their parents as well who report negative influences on their own health and burdens of different kinds. Play therapy is suitable when treating children with mental ill health, disorders and difficulties. To improve the parents´ health as well, there is a need for research looking into which kinds of interventions that is beneficial for both children and their parents. Purpose: The aim with this study was to investigate whether children´s participation in play therapy also could be beneficial for their parent´s perceived health. It was also of interest to investigate if these parents experienced the intervention as stress-reducing and social support increasing. Method: Four parents whose children had been treated or were currently treated in play therapy participated in an individual, semi-structured interview. The collected material was processed through a thematic analysis and interpreted based on the Theory of social support. Result: Four out of four participants considered themselves at better perceived health since the child´s participation in play therapy. All participants also
experienced a stress-reducing effect and three out of four considered the intervention as considerably social support increasing.
Keywords
: play therapy, mental ill health, children, parenting stress, social support,
perceived health.
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Eriksson, S. (2014) Children in play therapy: what significance does this have for their parent´s perceived health? Bachelor thesis in Public Health science. The Faculty of Health and Occupational Studies. The University of Gävle, Sweden.
Sammanfattning
Syftet med denna uppsats var att undersöka om barns deltagande i lekarbetspedagogik även kan vara fördelaktigt och främjande för deras föräldrars upplevda hälsa. Målet med uppsatsen var även att undersöka om föräldrarna upplevde interventionen som stressreducerande och socialt stöttande. I uppsatsen valdes en kvalitativ metodansats med utgångspunkt i teorin om socialt stöd och fyra stycken enskilda, halvstrukturerade intervjuer genomfördes. Deltagarna bestod av föräldrar vars barn deltagit/deltar i lekarbetspedagogik på den verksamhet som författaren var i samarbete med. Det insamlade materialet bearbetades i en tematisk analys och tolkades även utifrån teorin om socialt stöd. Detta resulterade i tre stycken huvudteman;
socialt stöd, empowerment (hanterbarhet) och relationen förälder-barn. Resultatet visade att samtliga deltagare upplevde barnens deltagande i lekarbetspedagogik som hälsofrämjande på deras egna upplevda hälsa och alla beskrev även hur de upplevde interventionen som
stressreducerande. Tre utav fyra deltagare beskrev tydligt hur deras tillgång på socialt stöd ökade signifikant, då de erhöll tröst, bekräftelse, rådgivning och hjälp att hantera
familjesituationen. Slutsatsen drogs således att lekarbetspedagogik för barn även kan vara främjande för deras föräldrar upplevda hälsa. Ytterligare forskning behövs dock för att se om detta gäller specifikt för lekarbetspedagogik, eller om interventioner av liknande slag har samma effekt på föräldrarnas upplevda hälsa. Studier som inkluderar fler deltagare, både mödrar och fäder samt barn med olika upplevelser av lekarbetspedagogiken efterfrågas även, för att resultatet inom detta forskningsområde ska kunna bli representativt och generaliserbart.
Nyckelord: lekarbetspedagogik, mental ohälsa, barn, föräldrastress, socialt stöd, upplevd
hälsa.
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Summary
The purpose of this study was to investigate if children´s participation in play therapy also can be considered beneficial for their parent´s perceived health. The aim was furthermore to explore whether the parents experienced the intervention as stress-reducing and social support increasing. The study design consisted of a qualitative method with a theoretical approach based on the Theory of social support and four personal, semi-structured interviews were conducted. Participants consisted of parents whose children had participated or was currently participating in play therapy at the corporation that the researcher was in cooperation with.
The collected data was processed with a thematic analysis and interpreted on basis on the Theory of social support. Three prominent themes where found which consisted of social support, empowerment and parent-child relationship. Four out of four participants
experienced their children´s participation in play therapy as significant beneficial for their own perceived health. They all also considered the intervention as stress-reducing. Three out of four participants experienced their children´s participation in play therapy as considerably social support increasing since receiving comfort, confirmation, advice and increased
manageability within the family situation. The conclusion was thus that play therapy for children also can be beneficial for their parent´s perceived health. Further research is needed to investigate whether this only applies on play therapy, or if similar interventions has the same health promotion effect on the parents´ perceived health. Studies which include a larger number of participants, both mothers and fathers and also children with different experiences and effects from the play therapy, is considered necessary to regard the results from this research area as representative and generalizable.
Keywords
: play therapy, mental ill health, children, parenting stress, social support,
perceived health.
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Acknowledgement
The author wishes to express her most sincere gratitude and humility towards the parents who participated in this study. Without your stories and honest sharing of your experiences, this research could not be conducted. The author wishes you all the best of luck in the future.
Finally, the author would also like to phrase gratitude and admiration towards the corporation which helped these parents and their children through play therapy. It has come to the
author´s understanding that you are of great importance to these families and have been helpful in their various family situations. You have enabled the children to heal through play and their parents have expressed tremendous gratitude for this.
“Just because an animal is large, does not mean he doesn't want kindness; however big Tigger seems to be, remember that he wants as much kindness as Roo.”
― A.A. Milne, Winnie-the-Pooh
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Table of contents
Introduction ... 1
Background ... 2
Global perspective – children´s mental health ... 2
The impact on their parents ... 2
Children and parents in Sweden ... 2
Parental access to social support – a stress reducing factor? ... 3
Theoretical framework ... 4
Parental health on a public health level ... 4
What is play therapy? ... 5
Purpose ... 6
Research questions ... 6
Method ... 7
Study design ... 7
Participants ... 7
Study setting ... 8
Data analysis ... 8
Ethical considerations ... 9
Results... 10
Introduction ... 10
Four different families ... 11
Social support - I am taken seriously! ... 12
Empowerment – Managing the family situation ... 12
Parent-child relationship – A happy child makes a happy parent ... 13
The research questions ... 14
Discussion ... 15
The key findings in relation to the background ... 15
The result in relation to previous research ... 15
The study´s methodology – appropriate or not ... 16
Strengths and weaknesses ... 16
Conclusion and future research ... 17
References ... 19 Appendix 1 ...
Appendix 2 ...
Appendix 3 ...
Appendix 4 ……….
1
Introduction
The prevalence of mental ill health, disorders and difficulties among children and adolescents is a global increasing problem. Research presented by the World Health Organization shows that as many as 20 percent of children and adolescents world-wide are suffering from ill health of this kind (1). Most probably is this percentage not accurate but should be even higher, since for example ADHD and learning difficulties are not included. World Health Organization points to the importance of interventions aiming to prevent and counteract mental ill health, disorders and difficulties among the younger population. Partly to reduce suffering among children and adolescents caused by mental ill health, disorders and difficulties, but also to prevent the negative impacts that this kind of ill health brings into adulthood (1,2,3). Studies have been conducted looking into how parents are affected by their child´s ill health or disabling difficulties. The World Health Organization contributes within this research area as well, with research showing that a significant proportion of these parents are suffering from worry, anxiety, burdens of various kinds as well as stress-related
conditions, among others (4,5). Parents whose child is suffering from mental ill health also reports more embarrassment and alienation, compared to parents with a child suffering from, for example, cancer or heart decease (4). To enable the parent´s coping of the child´s ill health, they are requesting support, information and confirmation. Several studies have come to the conclusion that access to social support has a stress-reducing effect when going through difficult situations in life (6,7). The theory of social support is well-known and commonly used within interventions, and also composes a suitable base when trying to help these parents and prevent parental ill health caused by their children´s mental ill health, disorders and difficulties. The prevalence of mental ill health among children and adolescents below the age of 17 has increased in Sweden since to 90´s (8). In 2011 turned 4 percent of girls and 3
percent of boys to health care seeking help and treatment for this kind of ill health. Due to this increasing public health problem among children and adolescents in Sweden, another risk group for ill health arises: their parents. There is thus a need for interventions targeted
towards both these children and their parents. Play therapy is a therapeutic method used since
several years back to help and treat children with mental ill health, disorders and difficulties
(9). The health promotion effect from play therapy on children is thus already known. But
there is no research on how parents to these children are experiencing the intervention, and if
the children´s participation in play therapy has a beneficial effect on the parent´s perceived
health as well. If play therapy for children has a significant positive effect on the parent´s
perceived health as well, an opportunity opens up for a possible and appropriate intervention
to help both children affected by the increasing incidence of mental ill health, and their
parents, who also represents a growing group at risk of ill health.
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Background
Global perspective – children´s mental health
World Health Organization highlights the expanding world-wide problem with disabling mental ill health, disorders and difficulties among children and adolescents (1). Up to 20 percent of all children today suffer from psychological difficulties such as trauma, depression, anxiety, communicating and social barriers, among others. The real percentage of children and adolescents suffering is probably even higher since for instance ADHD, mood disorders and learning difficulties are not included (1). These difficulties are however also important to highlight since they create obstacles and problems regarding children and adolescent’s
schooling, family life, maturity and social conditions. The prevalence of behavioral disorders has increased significantly among children and research shows that these individuals has a greater risk of drug abuse, lower occupational status and disabled social relationships in adult life if not helped and treated efficient (2). Bipolar disorder, which consists of recurring depression and mania, is becoming more common among the younger population and research post to the fact that this disorder has its roots in early life and can be prevented (3).
Interventions specially targeted at children are seen as increasingly significant and studies attest to its importance improving mental health among young individuals, as well as prevent further psychological suffering in adulthood (1, 3).
The impact on their parents
The family as a unit has a central position in all cultures and its form of cohabitation offers an opportunity for both children and adults to get their primary needs satisfied (10). These needs consist of affirmation, social protection and affection, among others. A family is thus a form of coexistence in which the individuals are closely related to each other and has great
significance for one another. In this social context have all family members influence on each other and that which significant influence one of these individuals, also affects the rest of the family. A child´s suffering from illness has thus an influence on the rest of the family
members, such as their parents, as well. Research from 2013, based on World Health Organization´s World mental health survey, shows that caregivers to a mental or physical disabled child, who most commonly consist of their parents, are dealing with burdens such as depression, reduced quality of life and stress-related conditions because of the child´s illness (4,5). The inability to help the child causes frustration and worries, and along with concerns regarding its future wellbeing and life, causes high levels of parenting stress. Families with children suffering from ill health and disorders of this kind also reports devoting time, financial burden, embarrassment and psychological distress (5).Parents dealing with a child with mental ill health, disorders or difficulties report higher levels of embarrassment and alienation than those having a child with, for example, cancer or heart disease (4). The stigma surrounding mental ill health remains widespread and often puts the whole family in
perceived exclusion. The expanding problem regarding mental ill health, difficulties and disorders among children and adolescent thus means a problem of importance among parents health as well. These parents constitute a risk group and interventions which can ease their burdens and therefore prevent ill health are of significance.
Children and parents in Sweden
The mental ill health among children in Sweden at the age of 17 or younger has increased since the 1990`s (8). It is primarily the occurrence of stress, anxiety and depression which has enhanced and the use of psychotropic drugs has also increased. Concentration and
hyperactivity disorders are also becoming more common and the use of ADHD-medication
increases rapidly. In 2011 were 4 percent of girls and 3 percent of boys below 17 years of age
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in contact with medical care seeking help and treatment for mental ill health (8). Mental and emotional difficulties are however at a greater percentage than that, since many don´t turn to medical care when experiencing psychological problems (5). An increasing share of Sweden´s children and adolescents suffer thus from mental ill health, difficulties and disorders. This also means that there are a growing proportion of parents within the country affected by their child´s mental ill health. Parenthood can be stressful itself due to the demands and
responsibilities of being a parent, even though not having to deal with a child suffering from mental ill health or difficulties. A study which aimed to look into parental stress among Swedish mothers and fathers in early parenthood concluded that there were several factors which could eventuate in stress (11). The experience and worry of being a dissatisfaction parent and lack of support were two of the prominent issues which could cause stress. The conclusion from this study pointed to the importance for healthcare professionals to be aware of which factors that can cause parental stress, and there for give better support to the parents within their parenthood. Another Swedish study report how parents with children born with a lifelong disability report unanswered needs for information and support (12). The information requested is wished to be helpful for these parents and their understanding of the child's illness. Counseling is also desired by these parents and described as important for their perceived ability to deal with the family situation which has arisen. Support, such as comfort, encouragement and understanding, are also important for these parents when dealing with the fact of having a lifelong disabled child (12). Research shows the same parental need when a previously healthy child is being admitted to hospital. A Swedish study found that if parents´
needs were fulfilled, they were better able to cope with the child´s illness (13). The
perception of being trusted, confidence towards health care providers, access to information, supportive surroundings and guidance, are all examples of needs reported by these parents.
This study also highlighted the significance that healthcare professionals acknowledge the children and parents´ importance towards each other. Support is thus not only needed by the children being ill but by their parents as well. The research within Sweden is quite limited regarding experiences and health among parents with children suffering from mental ill health, difficulties and disorders. Research has to some extent been done aimed to get a better understanding regarding parents´ perspective and health when having children with
concentration and hyperactivity disorders. This research shows that these parents suffer from perceived powerlessness and loss of control (14). With the increasing prevalence of mental ill health and disorders among Swedish children and adolescents, a need occurs to also
understand how this affects their parents´ health. It is also important to learn more about which interventions that can be health promoting and helpful for these parents.
Parental access to social support – a stress reducing factor?
When experiencing difficult times in life, studies show that access to social support and supportive social networks has a reducing effect on the vulnerability to develop stress-related conditions (6,7). Such a situation in life could consist of a parent having to deal with their child´s mental ill health, disorders or difficulties. Many parents who is going through this, experience high levels of stress caused by worries for the child, embarrassment, psychological distress and lack of information (4, 5, 12, 13). Among these mothers and fathers, there is also common with a need for support (11, 12, 13). Studies have shown that the best way to satisfy parental need and support families is by providing services and interventions based on social support (15, 16). To help the increasing amount of parents in Sweden having to cope with their children´s mental ill health, difficulties and disorders, and prevent parental ill health such as stress-related conditions, an intervention which could increase the social support and
reduce the parental stress seems appropriate. If this intervention also could be beneficial for
the children’s mental disorders or problems, you could kill two birds with one stone.
4 Theoretical framework
The theory about social support is a concept which involves an individual´s ability to get help and support in social relationships and networks (6). The social support received from one-to- one interactions is divided into four different categories: emotional, informational,
instrumental and appraisal. Affection, empathy, intimacy, love, trust, concern and caring are some of the components representing the emotional support. The relationships providing this kind of support are sources of emotional warmth and are important for the individual´s sense of self-worth. Informational support consists of relationships providing advice, knowledge and guidance. This information is important for the individual´s ability to understand and cope within different situations in life. Instrumental support encompasses acts which directly assist a person in need, for example financial assistance and material contribution. When self- evaluating and for example dealing with a process of change, relationships providing
constructive feedback and confirmation are important and represent the appraisal support.
Social networks consist of several relationships surrounding the individual which together compose a close and supportive social environment (6). Family and relatives, friend circles, work colleagues and classmates could compose such a social network. Access to some kind of social support or a social supportive network can become a suitable base when composing interventions aimed to help children suffering from mental ill health and their parents. An interest arises whether interventions already available and which have a health promotion effect on these individuals, offers social support of some kind and that it is this fact which has a positive effect on their health. The theoretical framework in this study will thus be the Theory of social support, which has influenced the study´s purpose, research questions, interview guide and interpretation of collected data.
Parental health on a public health level
The public health agency of Sweden has a national responsibility for the population´s health and the issues which influence the public health. Eleven target areas have been identified to promote the health among the population. Target area number two concern economic and social conditions and how this is essential for good health (17). The social aspect consists of the individual´s safety and equality in social contexts. Alienation, anxiety and inequality at home, at work or in the community are all examples of social conditions that can cause illness. Children and adolescents’ upbringing represents the third target area and it highlights the importance of the environment and conditions during childhood on mental and physical health throughout life (17). The parent – child relationship, school environment and physical lifestyles are some examples of such of importance within this area. The sixth target area regards a health promotion health care (17). Some of the aims within this target are
comprehensive preventive and treatment interventions, health promotion actions and active
dissemination of knowledge regarding diseases and ill health. The increasing prevalence of
mental ill health, disorders and difficulties among children and adolescents (8), and its further
health impairment consequence within their parents is a public health issue which should be
impeded according to these three target areas. The parents are at risk for decreased social
conditions when experiencing embarrassment, alienation and lack of support, which makes
this a public health issue in line with target area number two. The mental ill health or
hardships which the children suffer from increases the risk of health problems later in life,
which points to its importance to prevent in obedience with target area number three. The
parents´ need for significant information and health promotion interventions makes the
problem even important due to target area number six. Swedish population statistics from
2012 regarding different kinds of households shows following percentages: single parents
with children 0-24 years of age represent 5, 9 %, cohabiting parents with children 0-24 years
of age represent 22,2 % and other households with children 0-24 years of age represent 2,9 %
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(18). A total of 31 percent of Swedish households thus includes children and adolescents. This means that a significant part of the population in Sweden consists of households with children and caregivers, most common parents. This further means that a significant amount of parents are at risk for ill health. With an expanding problem, which should be prevented according to three of The public health agency´s target areas, regarding children and adolescent´s mental health and the health impairment affect this could have on their parents, there is a need for research investigating which kind of interventions are suitable to help both children and parents. In addition to the suffering among these children and their parents, there is another reason to investigate how to prevent and diminish this public health problem. Ill health composes a significant financial burden within the Swedish society. A report from 2010 conducted by the public health agency of Sweden reveals how ill health costs the society 120 billion a year (19). The report further state how these numbers probably only composes the top of an iceberg, which means that the ill health is an even higher financial burden for the society. This fact lays even more importance to the need for interventions aiming to prevent and reduce mental ill health among children and their parents.
What is play therapy?
The distinct use of play within therapy first occurred in the early 1900´s when psychoanalyst
Sigmund Freud saw the act of play as a possible therapeutic method (9). This new kind of
therapeutic setting was considered suitable for young children´s need to express feelings,
experiences and thoughts. Therapists such as Anna Freud and Melanie Klein continued the
sequent development of children´s play as a stimulating and therapeutic process. In the mid
1900´s were play therapy heralded to the next development in the therapeutic field by
psychologist Virginia Axline (9, 20). Axline was a pioneer within play theory and founded
therapeutic principles based on the belief that children hold possibilities to heal themselves
within ideal therapeutic settings (20). During the following decades, play theory developed
into a well-known and widely used method when treating and helping children suffering from
mental and emotional difficulties, behavioral problems and trauma (9). Today, play therapists
are helping children expressing themselves all over the world and this kind of intervention is
commonly used (20). This therapeutic method currently exists of many different types of use
of play, but they´re all based in the beliefs that play is a possible tool when helping young
children. Most children under the age of eleven are unable to verbalizing their problems and
inner thoughts, whereby the act of play becomes an important possibility for the child to
express itself. When playing, the child explores the surroundings, processes experiences and
practice problem solving. The ability to play is also necessary for the child´s personal and
social development (21). Play therapy is today used to alleviate and treat young children with
mental ill health such as anxiety, depression and trauma, behavioral problems such as anger
and irritability and difficulties regarding coping, social interaction and emotions (9). This kind
of therapy is therefore a suitable intervention to decrease the problem of today regarding
Swedish children and adolescent´s mental ill health, disorders and difficulties. It is currently
common used within children´s ward within Swedish hospital care. However, there is no
research on how parents whose children being helped by and treated in play therapy are
experiencing this intervention, and if they consider it health promotion on their own perceived
health. By investigating the significance of children´s participation in play therapy for their
parent´s perceived health, an opportunity opens up to consider play therapy as an intervention
not only health promotion for the participating children but for their parents as well. This kind
of intervention could thus become one appropriate solution regarding the increasing mental ill
health, disorders and difficulties among children and the health impairment consequences this
could have on their parents.
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Purpose
The purpose of this study was to explore if play therapy is beneficial not only for the children taking part of it but also for their parents´ perceived health. The aim with this study was furthermore to increase the understanding regarding if children´s participation in play therapy has a stress reducing and social support increasing effect within their parents.
Research questions
1. Has the child´s participation in play therapy had any significant effect on the parent´s perceived health?
2. Has the parent perceived their child´s participation in play therapy as a stress reducing intervention?
3. Has the parent perceived their child´s participation in play therapy as a social support
increasing intervention?
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Method Study design
The purpose of this study was to investigate if children´s participation in play therapy also could be beneficial for their parents, by increasing the knowledge and understanding about which effect this kind of intervention has on the parent´s perceived health. It was also of interest if the parents perceived the children´s participation in play therapy as something stress-reducing and social support increasing. The aim was thus to comprehend the parent´s point of view and answer questions like “How?”, “In what way?” and “Why?”. To
accomplish this was a qualitative method with an inductive approach chosen and collecting of data consisted of private interviews. This study design is appropriate when aiming to describe, explain and understand (22). Qualitative methods most commonly consist of a research
process where texts are analyzed with the purpose to understand contexts and experiences within the chosen area. The texts which are used either consist of data who the researcher has collected from interviews or video recordings and thereafter transcribed, or from textual sources written by others such as books, diaries or articles (22). In this study were texts used which consisted of transcribed material collected in the interviews. The private interviews in this study were semi-structured and based on an interview-guide with three themes: before and after the child´s participation in play therapy, the parent´s perceived health and perceived stress and social support. The interview guide and it´s questions were developed based on the Theory of social support. For more details regarding the interview guide, please go to
appendix one and two. The first theme consisted of questions regarding the family situation:
what led the family to seek help and which changes the parent had noticed within the family since the intervention. Focus within this theme was on the whole family situation and this was chosen to make the participant comfortable with the situation and answering questions, before moving on to personal issues (23). The following theme was based on questions regarding if and how the parent´s perceived health had changed and if so, if this change had been
influenced by the child´s participation in play therapy. This was done, for example, by asking the participant to describe their general health status on the basis of a scale which ranged from very good to very poor. The interview guide´s last theme concerned the participant´s
perceived stress and social support. Questions asked concerned if the level of stress had changed and if so, if this had been affected by the child´s participation in play therapy. The parent was also asked to describe if their access to social support had increased and to which importance this kind of support could be for parents.
Participants
The method used to find participants in the study was purposive sampling. This sampling
method is suitably in qualitative research (24 ). Purposive sampling is characterized by the
aim to select and identify certain participants most appropriate to answer the research
questions, which in qualitative research has the intention to get a greater understanding and
knowledge within a specific population or situation. Selection of participants is thus not
randomized or representative of the larger mass of the population. Purposive sampling is
further divided into different and more specific kinds of sampling methods. The one used in
this study is criterion sampling which consist of a selection of participants based on particular
characteristics (24). The particular criterions are based on the study´s purpose and specific
research questions and are done so to accomplish the most suitable basis in the research. The
criteria decided to be fulfilled for the participants in this study were that they had to be parents
whose children had been/were currently attending in play therapy at the corporation in which
the researcher were in cooperation with. No further preferences were given such as sex, age,
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ethnicity or profession. Sex possible participants were found who fulfilled the criteria and they were all asked to participate. Of these it was four who chose to participate in the study.
Study setting
The study took place in the southern part of Norrland in Sweden during the first half of 2014 and was conducted by a student graduating from a college in the area. The research was done in cooperation with a corporation that operates health promotion with children and families in the middle of Sweden. This corporation has been operative during a number of years back helping families and children with various problems, and works for example with cooking groups, drug-free youth activities and therapy sessions. One of the interventions offered in the corporation is play therapy for children. The search for participants was first made by the corporation´s personnel who handed out covering letters to parents who had children being attending in their play therapy. For more details regarding the covering letters, please go to appendix three and four. Those parents being interested in further information and
participation contacted the researcher by mail or telephone. The participant´s rights and the basis of the study were ensured during this time of contact, followed by the determining of time and place for the interviews according to the participant´s preferences. Two interviews were conducted in the participants’ home, one at the corporation where the children
participate in play therapy and one took place at the participant´s workplace. All interviews were hold in personal meetings between the researcher and one participant at a time. Two of them were to some extent accompanied by the participant´s child who was in the vicinity at some of the time. The interviews lasted between 35-50 minutes and were recorded with a Dictaphone or the researcher´s cellphone. The interview guide was also available at each interview by the researcher´s laptop.
Data analysis
The data collected in the study was processed in a thematic analysis and interpreted on the basis of the Theory of social support. This process first began with a transcription of the materiel recorded in the interviews. Each recording was listen through and literally
documented as close to the interview as possible. The timeframe was important, so that the researcher who conducted the interview wouldn´t create misunderstandings or forget details when transcribing (23). While literally writing down what was said by the researcher and the participant, it was also noted how they said it. Feelings such as anger, relief and happiness were written within parenthesis so that information expressed in other ways than by words, also could be used in the following steps in the analysis. Sounds from the surrounding were also noted and described in the document to ensure that all collected material were noted, but was no data of importance during the following steps. When all recorded data had been transcribed it was read through to get a comprehensive overlook and a first sense of different categories and themes. The next step in the thematic analysis was to print out the documents with large margins on the paper, which enabled the researcher to make notes while reading through the material a second time. Important statements and information given were
highlighted with a marker. These notes and pick outs consisted of information significant for
the study´s research questions. The selected parts of the material were thereafter read through
and cut out into small pieces of paper only consisting of significant material. On the backside
of each piece of paper was the meaning unit condensed into a short summary, in terms of
codes. This was done to facilitate the following step, when the cutouts with codes were used
to compile a number of categories and recurring themes representing the manifest content
from the interviews (23). These different categories were thereafter summarized into a smaller
number of main categories, from which the prominent themes were identified. The last part of
the thematic analysis consisted of a comparison and analysis of the study´s purpose, the
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research questions, the Theory of social support and the found themes. The outcome of this data analysis engendered the study´s result.
Ethical considerations
To make sure that the study was implemented in an ethic proper way, it was put through according to the guidelines from the Science council. These guidelines are categorized in to fours requirements regarding information, consent, confidentiality and use of collected data (25). Possible participants were first contacted by the therapist helping their children and if interested they received a covering letter. This was made to make sure that no one unwilling to participate would be contacted direct by the researcher and thus experience possible feelings of inconvenience. Due to the study´s delicacy it was seen as a possible ethical problem to cause eventual participants the feeling of violated integrity. Only those comfortable and interested in participation in the study were thus in contact with the
researcher. The covering letter contained information about the researcher, the purpose of the study and to which public health use the collected data could be. It also declared the
participation as voluntary, anonymous and the participant´s right to interrupt the partaking at any time. Those interested of taking part in the study thereafter contacted the researcher and time and place for the interview were decided according to the participant´s wishes and comfort. Further details regarding the interview were also given at this time and participants had the opportunity to ask questions. At the time of the interview ensured the researcher the participant´s consent about participating and the right to discontinue at any time. The
researcher also explained how collected data would not be dealt with by anyone else and that it would be discharged after completion the study. When transcribing, analyzing and
presenting the collected material were personal information, such as names and locations
which could reveal the participant´s identity, removed or replaced with fictitious figment. To
further unable the identification of the participants and their children, were the children´s age
and sex removed when presenting the result from the thematic analysis. The data were not
used during any other circumstances than implementing the study. By doing as described
above was the study planned and fulfilled in consent with ethical guidelines.
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Results Introduction
The thematic analysis resulted in three prominent themes which were social support, empowerment and parent-child relationship. The theme social support consisted of the participants´ parental need for acknowledgement, someone to listen to and give comfort regarding the problematic family situation. Advice and information which enabled the
participants´ to understand and manage the situation within the families composed the second theme, which was empowerment. The parent-child relationship constituted the third theme and consisted of how the parents´ wellbeing was depending on their children´s health, which furthermore made them feel as good or bad parents. For more details, please go to Table 1.
Table 1 Prominent themes from the thematic analysis of data collected in four private interviews.
Codes Categories Main categories Themes
“I was so lonely.”
“.. they didn’t listen.”
“ .. made me feel important.”
“Acknowledged our problem!”
“Comforted me..”
“..support.. help.”
Need to be seen Someone to listen Acknowledgement Given importance Willing to help
Comfort and reassurance
Being heard and seen Taken seriously Confirmation
Social Support
“Didn’t know what to do..”
“Felt so useless!”
“.. the feeling of powerlessness.”
“I didn’t understand why.”
“.. gave me guidance.”
“I couldn´t explain..”
“Helped me with the situation.”
Given information Useful tools Comprehending the situation
Parental confidence Understanding the child´s situation
Explanations
Advise and answers
Manageability
Understanding
Empowerment
“I just wanted to help.”
“It’s a horrible feeling..”
“.. made me feel such a bad parent.”
“It makes you so sad.”
“.. when they´re not happy..”
“.. couldn´t express.”
“ They had problems verbalizing..”
Care for the child Sad child – sad parent Being a good parent Responsibility
Knowing what´s wrong Understanding
Sympathy
Parental satisfaction The child´s wellbeing Communication
Parent-child relationship