The Relationship Satisfaction of Parents to Children With Congenital Heart Disease

Articles The Relationship Satisfaction of Parents to Children With Congenital Heart Disease Anni Riikonen*a, Anna Liisa Ahob, Anja Rantanenc [a] Satakunta University of Applied Sciences, Welfare and Health, University of Tampere, Faculty of Social Sciences, Nursing Science, Tampere, Finland. [b] University of Tampere, Faculty of Social Sciences, Nursing Science, Tampere, Finland. [c] University of Tampere, Faculty of Social Sciences, Nursing Science, Tampere, Finland. Abstract The purpose of the research is to describe the marital satisfaction of parents with a child with congenital heart disease, and the factors associated with it. The data were collected using an electronic questionnaire from applicable parents (n = 104) via the website of the Finnish Association for Heart Children and Adults and a closed Facebook forum where such parents are members. Marital satisfaction was measured using the ENRICH Marital Satisfaction (EMS) scale. The data were analysed using statistical methods. The variables were described by frequencies, percentages, and dispersion measures (Md = median, Q1= lower quartile, Q3 = upper quartile). Associations between the background variables and relationship satisfaction were examined using Mann-Whitney U test and Kruskall-Wallis test. Most of the surveyed parents were quite satisfied with their relationships. Parental factors associated with marital satisfaction were the gender of the parent, current health situation, support received from the spouse, problems with the spouse, and remarkable changes in economic situation during last year. The age of the child with a congenital heart disease was a factor associated with marital satisfaction. The interaction skills of the parents must continue to be supported and strengthened, because good interpersonal skills increase marital satisfaction and help resolve the conflicts that may arise in a relationship. Keywords: child with a congenital heart disease, parents, marital satisfaction Interpersona, 2019, Vol. 13(1), 57–71, https://doi.org/10.5964/ijpr.v13i1.325 Received: 2018-10-02. Accepted: 2019-05-08. Published (VoR): 2019-07-19. *Corresponding author at: Satakunnankatu 23, 28130 Pori, Finland. E-mail: [email protected] This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The marital between parents forms the basis of a family (Paajanen, 2007). Several studies have suggested that embarking on parenthood decreases marital satisfaction (e.g. Lawrence, Rothman, Cobb, Rothman, & Bradbury, 2008; Salmela-Aro, Aunola, Nurmi, Saisto, & Halmesmäki, 2003; Twenge, Campbell, & Foster, 2003). In today’s world, neither shared possessions nor children no longer guarantee the continuation of a relationship. Instead, people value the quality of the marital relationships they have (Malinen, 2011). Forming and maintaining a high-quality marital relationship has emerged as a special life goal (Kontula, 2013). However, such relationships are hard to sustain (Rosen-Grandon, Myers, & Hattie, 2004). The marital relationship between parents is not only about interaction between two spouses. On the contrary, the well-being or suffering of any family member affects the other members of the family as well. The quality of the parents’ marital relationship is a significant factor for a child’s mental well-being (Salo, 2011). Marital satisfaction has an impact on parenthood – a happy spouse is often a happy parent as well (Malinen, 2011). In addiInterpersona | An International Journal on Personal Relationships interpersona.psychopen.eu | 1981-6472 tion, a satisfactory relationship and support from one’s spouse can provide protection against emotional exhaustion and hopelessness (Murphy, Christian, Caplin, & Young, 2007). Every year, over 500 children with congenital heart disease (CHD) are born in Finland (Rovamo & Rautiainen, 2014). No known research exists in Finland on the marital satisfaction of parents to heart children, and very few international studies have been carried out on the topic. Thus, it is an important focus of study. Marital Relationship The term marital relationship refers to an emotional relationship between two people. The quality of this relationship is the basis for marital satisfaction (Rosen-Grandon, Myers, & Hattie, 2004). A good marital relationship is considered to be one of the most important aspects of life, in addition to good parenting and spending time with one’s family (Paajanen, 2005). Most people regard their spouse and other members of their family as their most important source of well-being and happiness in life (Kontula, 2013). Marital satisfaction can be accomplished through love, faithfulness, and good communication (Rosen-Grandon et al., 2004). In a good and long-lasting relationship, spouses have the ability to solve any emerging conflicts through communication and conflict resolution skills (Kiiski, 2011; Pukkala, 2006). A good marital relationship also involves mutual appreciation and respect and having a strong trust in one’s spouse in all matters (Kontula, 2013). The degree of happiness in a relationship affects the degree of happiness in other areas of life, too: research suggests that people who are happy in their marital relationships are also happier overall compared to people are unhappy in their relationships (Dyrdal, Røysamb, Nes, & Vittersø, 2011; Kontula, 2009). Child With a Heart Defect A heart child refers to a child with a congenital heart defect. Heart defects are the most common birth defects in children (Rovamo & Rautiainen, 2014). Nearly all structural heart defects can be treated, and their prognoses have improved substantially during the past twenty years due to developments in diagnosis and treatment (Kaarne, Jokinen, Pesonen, & Leijala, 2008). The parents of a heart child experience constant worry over their child’s illness (Van Horn, DeMaso, Gonzalez-Heydrich, & Dahlmeier Erickson, 2001) and encounter various sources of stress (Karsdorp, Everaerd, Kindt, & Mulder, 2007; Lawoko, 2007), such as challenges related to working while their child is ill (Lawoko & Soares, 2002, 2003) and, as a consequence, potential changes to their financial situation (Karsdorp et al., 2007; Lawoko, 2007; Van Horn et al., 2001). Because of these stress factors, special attention needs to be paid to supporting the marital relationships between the parents of heart children. A good relationship helps parents cope with stress factors (Goldbeck & Melches, 2006) and acts as a buffer against posttraumatic stress, depression, and anxiety, whereas low marital satisfaction has been linked to increased levels of depression and anxiety (Rychik et al., 2013). Factors Associated With Marital Satisfaction There is limited data available on the factors associated with marital satisfaction among the parents of heart children. Mothers of heart children have been shown to experience higher levels of anxiety (Rychik et al., 2013) and emotional exhaustion (Lawoko & Soares, 2002) compared to fathers of heart children. Emotional support has been found to have a positive correlation with marital satisfaction among the parents of heart children (Rychik et al., 2013). The age of a heart child has not been identified as a relevant factor with regard to the level of stress experienced by the family or the mother’s ability to cope (Tak & McCubbin, 2002). A child’s heart The Relationship Satisfaction of Parents to Children with CHD 58 Interpersona 2019, Vol. 13(1), 57–71 https://doi.org/10.5964/ijpr.v13i1.325 defect has nonetheless not been associated with the marital satisfaction of the child’s parents: already during pregnancy, mothers expecting children with heart defects have been found to have lower levels of marital satisfaction compared to mothers expecting healthy children (Rychik et al., 2013). Having children with serious heart malformations reflects negatively on the mental health of mothers (Solberg, Dale, Holmstrøm, Eskedal, Landolt & Vollrath, 2012). By contrast, other studies have discovered no link between a child’s heart defect, regardless of its severity, and decreased marital satisfaction between parents (Dale et al., 2013) or between a child’s heart defect and parents’ stress levels (Tak & McCubbin, 2002; Uzark & Jones, 2003). It is generally known that several factors, such as the gender of the parent, are linked to the marital satisfaction of parents. Mothers are less satisfied with their relationships compared to fathers (Twenge et al., 2003). The health status of the parents of a newborn has also been associated with marital satisfaction: the higher the level of depression in the parents of a newborn, the lower the level of their marital satisfaction (Salmela-Aro et al., 2003). In addition, the support received from one’s spouse – caring for one’s spouse, providing emotional support, showing appreciation, and offering help – is related to communication and happiness in a relationship (Kontula, 2013). The age of the child has also been shown to play a role in marital satisfaction: mothers of small children have been found to be more dissatisfied with their relationships compared to mothers of older children (Twenge et al., 2003). Aim of the Study The aim of this study was to describe the marital satisfaction of parents to children with heart defects and the factors associated with it. The goal was to produce knowledge that can be utilized while planning and developing support schemes for the parents of heart children. Research questions: 1. What is the level of marital satisfaction among the parents of heart children? 2. Which parent and heart child background factors are associated with marital satisfaction among the parents of heart children? Methods Participants and Procedure The study focuses on the parents of heart children, and it is a quantitative cross-sectional study. The data for the study was collected between 2015 and 2016 through a link to an electronic form on the website of the Finnish Association for Heart Children and Adults (www.sydanlapsetja-aikuiset.fi) as well as through a closed Facebook group where the parents of heart children were members. To participate to this study there was one inclusion criterion: having a heart child in the family was a prerequisite for participating in the study. Both parents of a heart child could participate in the study, responding to the questionnaire separately. Each stage of the study was guided by the principles of good scientific practice (Polit & Beck, 2012). Participation in the study was entirely voluntary, and the introduction to the questionnaire stated that the parents may Riikonen, Aho, & Rantanen 59 Interpersona 2019, Vol. 13(1), 57–71 https://doi.org/10.5964/ijpr.v13i1.325 terminate their participation in the study at any stage. The Finnish Association for Heart Children and Adults, as well as the administrators of the Facebook group, gave their consent to carrying out the study. By responding to the questionnaire, the parents gave informed consent to participate in the study. Participation was anonymous (Burns & Grove, 2005). The data comprises the answers of 104 parents of heart children. The questionnaire contained structured questions concerning parents and their heart children. The questions solicited background variables (Table 1) and parents’ views on their marital satisfaction (ENRICH). The background variables were chosen based on existing research (Goldbeck & Melches, 2006; Lawoko & Soares, 2003; Rychik et al., 2013; Solberg et al., 2012). Table 1 Parent’s And Children’s Demographic Characteristics (N = 99–104) Variable n% Parents Mother 86 82.7 Father 18 17.3 Age 22–30 year 26 25.0 31–35 year 27 26.0 36–40 year 32 30.8 41–53 year 19 18.3 Marital status Partnered 96 92.3 Not partnered 8 7.7 Family structure Nuclear family 76 73.1 Blended family 20 19.2 Others 8 7.7 Education No education 13 12.5 Vocational education 42 40.4 College or polytechnic degree 27 26.0 University degree 22 21,2 Employment status Employment 65 62.5 Not employment or working 39 37.5 Religious community Yes 78 75.0 No 26 25.0 Parent’s health status Very poor, quite poor or satisfactory 16 15.4 Quite good 69 66.3 Very good 19 18.3 Support amount from a spouse Not at all, very little, little or moderately support 13 13.1 Much support 23 23.2 Very much support 63 63.6 Significant illness or injury during the last year No 87 83.7 Yes 17 16.3 Problems with a spouse during the last year No 72 69.2 Yes 31 29.8 Sicnificant change in economic status No 61 58.7 Yes 43 41.3 The Relationship Satisfaction of Parents to Children with CHD 60 Interpersona 2019, Vol. 13(1), 57–71 https://doi.org/10.5964/ijpr.v13i1.325 Variable n% Adaptation to the child’s heart decease Very poor, quite poor or moderately 18 17.3 Quite good 57 54.8 Very good 29 27.9 Got advance information about the child’s heart disease No advance warning 77 74.0 Advance warning before birth 27 26.0 Number of children in the family 1 19 18.3 2 44 42.3 3 19 18.3 4 or more 22 21.2 Age of the child 0 – ≤ 12 month 18 17.3 > 1 – ≤ 3 year 20 19.2 > 3 – ≤ 7 year 28 26.9 > 7 – ≤ 12 year 30 28.8 > 12 – ≤ 22 year 8 7.7 Child’s health status Very poor, quite poor, satisfactory 22 21.2 Quite good 50 48.1 Very good 32 30.8 Instrument Marital satisfaction was measured with the ENRICH Marital Satisfaction (EMS) instrument. The EMS instrument consists of 15 statements that are used to evaluate marital satisfaction (10 statements) and idealistic distortion (5 statements). The statements about marital satisfaction addressed personality issues, communication, conflict resolution, financial management, leisure activities, sexual relationships, children and parenting, family and friends, role relationships, and spiritual beliefs. The statements used to measure idealistic distortion describe the relationship in an exaggeratedly positive manner. The idealistic distortion scores are used to correct for the potential bias in the marital satisfaction scores. The statements are answered with a 5-point Likert scale (ranging from strongly agree to strongly disagree) (Fowers & Olson, 1993). No known Finnish study has previously used the instrument, making this study a pilot for the instrument in the Finnish context. The instrument was double translated for the purpose of this study, and the response scale was expanded to a 7-point scale to increase precision for further inquiry. The background variables were examined individually in relation to both sum variables since the idealistic distortion scale could not be used for score adjustment due to altering the original response scale. An existing statistical instrument, established as a reliable measure of marital satisfaction, was used in the data collection (Fowers & Olson, 1993). The developers of the instrument consented to its use in this study. The Cronbach alpha values of the sum variables created (marital satisfaction α = 0.850; idealistic distortion α = 0.854) exceeded 0.7 and can thus be considered internally consistent (Polit & Beck, 2012). The comparability of the results to previous results based on the instrument’s mean sum variables is weakened by the fact that points were added to the scale. Data Analysis The variables were described by frequencies, percentages, and dispersion measures (Md = median, Q1 = lower quartile, Q3 = upper quartile). Background variables were recategorized based on frequencies. The EMS instrument includes both positive and negative statements, and they were translated following the instrument guideRiikonen, Aho, & Rantanen 61 Interpersona 2019, Vol. 13(1), 57–71 https://doi.org/10.5964/ijpr.v13i1.325 lines prior to the analysis (Fowers & Olson, 1993). Next, two sum variables were created: marital satisfaction (10 statements) and idealistic distortion (5 statements), whose internal consistency was tested by Cronbach’s alpha. Since the group sizes were small, the links between the background variables and relationship satisfaction were examined through nonparametric tests (the Mann-Whitney U test / the Kruskall-Wallis test). If a qualitative variable had more than two values, the Mann-Whitney U test with a corrected p-value was applied in the paired comparison. The limit of statistical significance was p < .05 (Polit & Beck, 2012). The data were analyzed using the IBM SPSS 23.0 program. Results Background Information on Heart Children and Their Parents The parents (N = 104) were on average 35 years of age (SD = 6.6, range 22–53). 83 per cent of the respondents were mothers of heart children. The majority were living in a marital relationship (92%) and in a nuclear family (73%). 40 per cent of the parents had a vocational degree, 26 per cent had an applied sciences degree, and 21 per cent an academic degree. The majority of the parents were working (63%), and belonged to a religious community (75%). The parents of heart children mostly considered themselves healthy (85%). The heart children were on average 6 years of age (SD = 4.5, range 0–22). The current health status of the heart children varied between very good (31%), fairly good (48%), and satisfactory or worse (21%; Table 1). The three most common heart defects among the respondents’ children were ventricular septal defect (VSD), atrial septal defect (ASD), and coarctation of the aorta (CoA). 101 of the respondents’ children were born with their condition (Table 1). Marital Satisfaction Among the Parents of Heart Children The vast majority of the parents surveyed were at least fairly satisfied with their marital relationships. Nearly a third of the respondents (31%) were very happy with their relationships. About a quarter (28%) were happy with their relationships, while a little over a quarter (30%) were fairly satisfied with their relationships. Among the parents surveyed, 12 per cent were dissatisfied or not satisfied/dissatisfied with their relationships. The parents were predominately fairly satisfied with their marital relationships (Md = 48.5, Q1 = 39.3, Q3 = 56.8). Over half of the parents (53%) were satisfied with the communication they had with their spouses and felt understood by their spouses. Over two thirds (70%) of respondents were satisfied with decision-making and conflict resolution in their relationships. More than a third (40%) were dissatisfied with their financial situation and the way financial decisions were made in the household. A third (33%) of the parents were satisfied with the time they shared with their spouses, and over half (52%) were satisfied with the way both spouses regarded their responsibilities as parents. Half (50%) of the respondents were happy with the way spirituality and values were expressed in the household, but it is worth noting that 28 per cent of the respondents had no opinion on the matter. Some of the parents of heart children surveyed presented an idealistically distorted view of their relationships (Md = 23.0, Q1 = 16.0, Q3 = 27.0). Almost half of the respondents (46%) stated they and their spouses understand each other almost perfectly, and 10 per cent saw their relationships as perfect successes. Nearly a fifth of the parents (17%) fully agreed that they had never, not even for a moment, regretted their relationship with their The Relationship Satisfaction of Parents to Children with CHD 62 Interpersona 2019, Vol. 13(1), 57–71 https://doi.org/10.5964/ijpr.v13i1.325 spouses. However, almost half of the respondents (48%) felt that some of their needs were not met in their relationships. The Parent and Heart Child Background Factors Associated With the Marital Satisfaction of the Parents of Heart Children Among the parental background factors included, the gender of the parent, the current health status of the parent, the degree of support received from one’s spouse, problems with one’s spouse, and significant changes in one’s financial situation were found to have a statistically significant link to the marital satisfaction of the parents. The fathers of heart children (Md = 52.2, Q1 = 46.8, Q3 = 59.5) rated their relationships higher compared to the mothers (Md = 46.5, Q1 = 38.0, Q3 = 56.0). The parents who regarded their current health status as very good (Md = 51.0, Q1 = 41.0, Q3 = 57.0) were more satisfied with their relationships compared to the parents who regarded their health as satisfactory or worse (paired comparison p = .027). The parents who received a high degree of support (Md = 49.0, Q1 = 39.0, Q3 = 51.0) (paired comparison p = .045) or a very high degree of support (Md = 51.0, Q1 = 43.0, Q3 = 58.0) (paired comparison p < .001) were more satisfied with their relationships compared to the parents who received a moderate or lower degree of support from their spouses (Md = 34.0, Q1 = 28.5, Q3 = 45.0). The parents who had experienced problems with their spouses over the previous year were less satisfied with their relationships (Md = 38.0, Q1 = 33.0, Q3 = 46.0) compared to the parents who had not faced problems during the same time period (Md = 51.0, Q1 = 44.0, Q3 = 58.0). The parents who had seen a significant change in their financial situation during the previous year were less satisfied with their relationships (Md = 45.0, Q1 = 33.0, Q3 = 46.0) compared to the parents whose financial situation had remained similar during the same time period (Md = 50.0, Q1 = 44.0, Q3 = 58.0). There was no link between other background factors and marital satisfaction (Table 2). Table 2 The Factors Associated With the Marital Satisfaction of Parents (N = 99–104) Demographic Marital satisfaction nMd Q1Q3p-value Parent .038* Mother 86 46.5 38.0 56.0 Father 18 52.2 46.8 59.5 Age .830 22–30 year 26 47.5 41.5 51.8 31–35 year 27 46.0 43.0 60.0 36–40 year 32 49.5 35.5 56.8 41–53 year 19 49.0 41.0 55.0 Education .063 No education 13 50.0 43.5 59.0 Vocational education 42 43.5 35.0 52.3 College or polytechnic degree 27 50.0 40.0 56.0 University degree 22 54.5 43.8 60.3 Employment status .835 Employment 65 49.0 40.0 56.0 Not employment or working 39 47.0 38.0 58.0 Riikonen, Aho, & Rantanen 63 Interpersona 2019, Vol. 13(1), 57–71 https://doi.org/10.5964/ijpr.v13i1.325 Demographic Marital satisfaction nMd Q1Q3p-value Parent’s health status .034* Very poor, quite poor or satisfactory 16 42.0 33.3 49.0 Quite good 69 49.0 40.5 58.0 Very good 19 51.0 41.0 57.0 Support amount from a spouse < .001*** Not at all, very little, little or moderately 13 34.0 28.5 45.0 Much 23 49.0 39.0 51.0 Very much 63 51.0 43.0 58.0 Problems with a spouse during the last year < .001*** No 72 51.0 44.0 58,0 Yes 31 38.0 33,0 46,0 Sicnificant changes in a economical situation .010* No 61 50.0 44.0 58.0 Yes 43 45.0 33.0 46.0 Adaptation to the child’s heart disease .157 Very poor, quite poor or moderately 18 46.5 33.8 51.0 Quite good 57 47.0 40.0 56.0 Very good 29 51.0 40.0 58.5 Got advance information about the child’s heart disease .470 No advance warning 77 49.0 38.5 56.0 Advance warning before birth 27 48.0 41.0 59.0 Number of children in the family .318 1 19 47.0 39.0 56.0 2 44 48.5 40.5 56.0 3 19 44.0 34.0 53.0 4 or more 22 50.5 40.3 59.3 Age of the child .047* 0 – ≤ 12 month 18 47.0 38.0 56.5 > 1 – ≤ 3 year 20 39.0 33.0 50.0 > 3 – ≤ 7 year 28 52.5 44.3 59.8 > 7 – ≤ 12 year 30 50.0 41.8 56.0 > 12 – ≤ 22 year 8 45.0 40.3 55.8 Child’s health status .550 Very poor, quite poor, satisfactory 22 46.5 35.0 54.0 Quite good 50 46.5 38.8 58.0 Very good 32 50.5 41.0 57.0 *p < .05. **p < .01. ***p < .001. Among the heart child background factors included, the age of the child had a significant link to the relationship satisfaction of the parents. The parents of children above the 3 – 7 years age group (Md = 52.5, Q1 = 44.3, Q3 = 59.8) were on average more satisfied with their relationships. However, the paired comparison showed no differences in the relationship satisfaction of the parents between children in different age groups. The current health status of heart children was not identified as a significant factor for the marital satisfaction of the parents (Table 2). The parental background factors that were statistically significant in relation to idealistic distortion were the gender of the parent, the degree of support received from one’s spouse, and problems with one’s spouse over the previous year. The fathers of heart children (Md = 26.5, Q1 = 23.0, Q3 = 28.0) idealized their relationships more The Relationship Satisfaction of Parents to Children with CHD 64 Interpersona 2019, Vol. 13(1), 57–71 https://doi.org/10.5964/ijpr.v13i1.325 compared to the mothers (Md = 22.5, Q1 = 15.8, Q3 = 27.0). The parents who received a very high degree of support from their spouses (Md = 25.0, Q1 = 20.0, Q3 = 29.0) idealized their relationships more compared to the parents who received a moderate or lower degree of support from their spouses (Md = 14.0, Q1 = 9.0, Q3 = 23.5) (paired comparison p = .003). The parents who had experienced problems with their spouse over the previous year perceived their relationships less idealistically (Md = 15.0, Q1 = 13.0, Q3 = 20.0) compared to the parents who had not experienced problems with their spouses during the same time period (Md = 25.0, Q1 = 22.0, Q3 = 28.0). Other parental background factors had no significant statistical link to idealistic relationship positions. The data showed no association between the heart child background factors and the parents’ idealistic views about their marital satisfaction (Table 3). Table 3 The Factors Associated With the Idealistic Distortion of Parents (N = 99-104) Demographic Idealistic distortion nMd Q1Q3p-value Parent .047* Mother 86 22.5 15.8 27.0 Father 18 26.5 23.0 28.0 Age .817 22–30 year 26 21.5 14.8 25.8 31–35 year 27 23.0 18.0 29.0 36–40 year 32 23.0 14.5 28.0 41–53 year 19 24.0 19.0 27.0 Education .633 No education 13 25.0 16.0 26.5 Vocational education 42 22.0 13.8 28.0 College or polytechnic degree 27 24.0 17.0 27.0 Academic degree 22 23.0 18.5 28.3 Employment status .901 Employment 65 23.0 17.0 27.0 No employment or working 39 23.0 15.0 28.0 Parent’s health status .235 Very poor, quite poor or satisfactory 16 21.0 11.5 26.5 Quite good 69 24.0 16.5 28.0 Very good 19 23.0 20.0 28.0 Support amount from a spouse < .001*** Not at all, very little, little or moderately 13 14.0 9.0 23.5 Much 23 22.0 16.0 25.0 Very much 63 25.0 20.0 29.0 Problems with a spouse during the last year < .001*** No 72 25.0 22.0 28.0 Yes 31 15.0 13.0 20.0 Sicnificant changes in a economical situation .127 No 61 23.0 18.0 28.0 Yes 43 21.0 14.0 27.0 Adaptation to the child’s heart decease .084 Very poor, quite poor or moderately 18 19.0 12.5 28.0 Quite good 57 23.0 16.0 27.0 Very good 29 26.0 21.5 28.5 Riikonen, Aho, & Rantanen 65 Interpersona 2019, Vol. 13(1), 57–71 https://doi.org/10.5964/ijpr.v13i1.325