ABSTRACT

Background:

Child accidents are the most important preventable cause of morbidity and mortality in pediatric age. The degree of parental supervision is a factor that can influence, among others, in these accidents. The aim of this study was to validate and cross-culturally adapt to Spanish the questionnaire Parental Supervision Attributes Profile Questionnaire (PSAPQ) as a method of measuring the degree of parental supervision.

Methods:

Forward and back-translation methodology was applied using 4 bilingual spanish-english people to obtain version 1.0 of the questionnaire. Subsequently, the questionnaire was reviewed by a committee of experts, obtaining version 1.1, which was provided to 149 parents of children between 2-5 years old, randomly obtained, who attended consultation for the well child visits in several health centers in the province of Valencia. For the statistical study, the internal consistency was analyzed using Cronbach’s α test and the test-retest reliability using Pearson correlations.

Results:

A very good internal consistency was obtained, with Cronbach’s α values greater than 0.7 in three of the four subscales that make up the test, with the remaining being 0.68. The reliability obtained was excellent, with values with Pearson correlations close to or higher than 0.7 for all subscales.

Conclusions:

The PSAPQ translated and validated into spanish shows very good psychometric results with respect to the original, so it can be said that an adequate instrument has been obtained to objectively measure one of the possible risk factors of child accidents

Key words:
Child accidents; Cross-cultural adaptation; Prevention; Parental supervision; Validation

INTRODUCTION

Currently, child accidents are a serious public health issue, since they represent the third-leading cause of pediatric mortality in the European Union¹1. Jiménez de Domingo A, Rubio García E, Marañon Pardillo R,et al. Epidemiología y factores de riesgo de las lesiones por caídas en niños menores de un año. An Pediatría. 2017;86(6):337-343.^,22. European Child Safety Alliance. Child safety report card 2012. Disponible en: http://www.childsafetyeurope.org/reportcards/.
http://www.childsafetyeurope.org/reportc... . In Spain, they are the second-leading cause after cancer, making them the leading cause among previously healthy children³3. Instituto Nacional de Estadística (INE). Mortalidad por causas 2017: Disponible en: https://www.ine.es/jaxi/tabla.do?type=pcaxis&path=/t00/mujeres_hombres/tablas_1/l0/&file=d09003.px.
https://www.ine.es/jaxi/tabla.do?type=pc... .

These unintended injuries are preventable, so if we know and act on the risk factors that promote them, we can reduce their incidence and, therefore, the serious consequences resulting from them. Among these risk factors, there are various studies that indicate the Degree of Parental Supervision⁴4. Morrongiello B, Corbett M, McCourt M. Understanding unintentional injury risk in young children II. The contribution of caregiver supervision, child attributes, and parent attributes. J Pediatr. 2006;31(540-551).^,55. Saluja G, Brenner R, Morrongiello BA, et al. The role of supervision in child injury risk: definition, conceptual and measurement issues. Inj Control Saf Promot. 2004;11:17-22. as a decisive factor. Deficiencies in parent/caregiver supervision of minors contribute to the occurrence of accidents⁶6. Morrongiello BA, Corbett M, Brison RJ. Identifying predictors of medically-attended injuries to young children: do child or parent behavioural attributes matter? Inj Prev. 2009;15(4):220-225.^,77. Damashek A, Kuhn J. Toddlers' unintentional injuries: the role of maternal-reported paternal and maternal supervision. J Pediatr Psychol. 2013;38(3):265-275.^,88. Peterson L, Ewigman B, Kivlahan C. Judgments regarding appropriate child supervision to prevent injury: The role of environmental risk and child age. Child Dev. 1993;64(3):934-950.^,99. Schnitzer PG, Dowd MD, Kruse RL, Morrongiello BA. Supervision and risk of unintentional injury in young children. Inj Prev. 2015;21(e1):e63-70., and are proportional to the degree of severity¹⁰10. Finkelstein EA, Corso PS, Miller TR. Incidence and Economic Burden of Injuries in the United States. Oxford: Oxford University Press; 2006.^,1111. Ministerio de Sanidad, Consumo y Bienestar Social. Campañas 2007 - Prevención de accidentes infantiles. Disponible en: https://www.mscbs.gob.es/campannas/campanas07/seguridadInfantil.htm.
https://www.mscbs.gob.es/campannas/campa... . Furthermore, it has been shown that children have more accidents when they are not under any type of supervision¹²12. Morrongiello B, Ondejko L, Littlejohn A. Understanding toddlers´in home injuries: II.Examining parental strategies, and their efficacy,for managing child risk injury. J Pediatr Psychol. 2004;29:433-436. or, on the other hand, when the supervision is excessive¹³13. Wills KE, Christoffel KK, Lavigne JV, et al. Patterns and correlates of supervision in child pedestrian injury. The Kids 'N' Cars Research Team. J Pediatr Psychol. 1997;22:89-104..

One of the major current problems in evaluating this factor has been how to quantify it, since there is no validated instrument for such purpose. If you needed to measure the degree of parental supervision, it was done using very different methods; in some cases, it was a simple interview in which parents were asked how they supervised their children¹⁴14. Simon H, Tamura T, Colton K. Reported level of supervision of young children while in the bathtub. Ambul Pediatr. 2003;3(2):106-108.^,1515. Petrass L, Finch C, Blitvich J. Methodological approaches used to assess the relationship between parental supervision and child injury risk. Inj Prev. 2009;15(2):132-138., while in others audio or videos of children at risk of unintentional accident were shown and they were asked how they would react to the situation¹⁶16. Morrongiello B, Dawber T. Mothers' responses to sons and daughters engaging in injury-risk behaviors on a playground: Implications for sex differences in injury rates. J Exp Child Psychol. 2000;76(2):89-103., or caregivers were asked to describe situations in which they should supervise children and how they would do it⁸8. Peterson L, Ewigman B, Kivlahan C. Judgments regarding appropriate child supervision to prevent injury: The role of environmental risk and child age. Child Dev. 1993;64(3):934-950.^,1717. Gärling A, Gärling T. Mothers' supervision and perception of young children's risk of unintentional injury in the home. J Pediatr Psychol. 1993;18(1):105-114.. This means that the methodology used was quite varied, not very regulated and, therefore, it was very difficult to assess the implication of the degree of parental supervision¹⁸18. Morrongiello BA. Caregiver supervision and child-injury risk: I. Issues in defining and measuring supervision; II. Findings and directions for future research. J Pediatr Psychol. 2005;30:536-552..

On the other hand, it has been demonstrated that questionnaires are a reliable and valid tool for the study of parental behavior¹⁹19. Kochanska A, Kuczynski L, Radke-Yarrow M. Correspondence between mothers´self-reported and observed child-rearing practices. Child Dev. 1989;69(1):56-63.^,2020. Morrongiello B, Dayler L. A community-based study of parents' knowledge, attitudes and beliefs related to childhood injuries. Can J Public Health. 1996;87:383-8.. In 2006, B.A. Morrongiello and M. Corbett designed and validated, in English, the Parental Supervision Attributes Profile Questionnaire (PSAPQ)²¹21. Morrongiello BA, Corbett M. The Parent Supervision Attributes Profile Questionnaire: A measure of supervision relevant to children's risk of unintentional injury. Inj Prev. 2006;12(1):19-23., a 29-item questionnaire that is evaluated using a 5-point Likert scale, divided into 4 subscales (protectiveness, supervision, risk tolerance, belief in fate), for children 2 to 5 years of age. Many of these items measure actions that would increase or decrease the likelihood of occurrence of child injuries.

Currently, in addition to the PSAPQ there are other questionnaires, such as the one designed by W. Harrell²²22. Harrell W. Effect of two warning signs on adult supervision and risky activities by children in grocery shopping carts. Psychol Rep. 2003;92(3):889-898.^,2323. Harrell W. Dangerous activities by children in grocery carts: is adult supervision important? Psychol Rep. 2003;92(3):957-962., the purpose of which is also to measure parental supervision. However, in general, they have the limitation that they take a lot of time to complete and, therefore, cannot be used in all settings.

Due to its dissemination and simplicity, it seems that the PSAPQ is currently the best method for measurement of parental supervision. This questionnaire was validated in Portuguese in 2013²⁴24. Andrade C, Carita AI, Cordovil R, et al. Cross-cultural adaptation and validation of the Portuguese version of the Parental Supervision Attributes Profile Questionnaire. Inj Prev. 2013;19(6):421-427.. It should be pointed out that Spanish is the second most-spoken language worldwide²⁵25. Centro Virtual Cervantes (CVC). Anuario 2012. El español y sus hablantes en cifras. Disponible en: https://cvc.cervantes.es/lengua/anuario/anuario_12/i_cervantes/p01.htm.
https://cvc.cervantes.es/lengua/anuario/... , and is present on all continents, with approximately 550 million speakers, and is the second language in international communication after English; therefore, validation of the PSAPQ questionnaire into Spanish would offer undeniable benefits and breadth of dissemination.

For all of these reasons, the objective of this study was the adaptation, validation and evaluation of the psychometric properties of the PSAPQ questionnaire for its use in Spanish.

SUBJECTS AND METHODS

Instrument

The PSAPQ questionnaire is a questionnaire that consists of 29 questions, in random order, divided into 4 subscales created from factors that, according to the authors of the questionnaire, affect the degree of parental supervision: protectiveness (9 questions), supervision (9 questions), risk tolerance (8 questions), belief in fate (3 questions). Each of these questions is evaluated on a 5-point Likert-type scale (from 1: strongly disagree, to 5: strongly agree), according to the degree of agreement, or not, with each of them.

Procedure

The following steps were used for the validation of this questionnaire:

After completing all of these phases, the final version of the PSAPQ questionnaire adapted to Spanish was obtained (annex I).

The study of socio-epidemiological factors was carried out by means of an observational analysis. It should be noted that for classification of the family socioeconomic status, the Goldthorpe classification modified by Feito²⁹29. Feito R. Estructura social contemporánea. Las clases sociales en los países industrializados. Madrid: Siglo XXI Editores SA; 1995. was used.

RESULTS

Characteristics of the participants of the observational study

A total of 149 participants were recruited, parents/caregivers of 77 girls and 72 boys, with a mean age of 4 years. Of the participants, 88% were Spanish, 6.7% Latino, 3.3% non-Spanish Europeans and the remaining percentage were African and Asian.

The socio-epidemiological data studied found that 30.7% of the patients were single children, 38.7% had one sibling and the others had more than two siblings.

With regard to the education level of the parents, 66% of mothers and 51.3% of fathers had a university education; 22% of mothers and 29.3% of fathers had a secondary education, and the rest only had primary or no type of education.

In terms of family socioeconomic status, calculated according to the type of occupation of each of the parents using the Goldthorpe-Feito classification, 45.3% of mothers and 31.3% of fathers belonged to upper classes (I, II of the classification), 36% of mothers and 59.3% of fathers middle class (III, IV, V, VI of the classification) and the rest lower class (VII).

Identification of factors

The confirmatory factorial analysis identified up to 8 possible factors or dimensions, which explained 65.7% of the variance. When we forced identification of 4 components, like the original scale, 47.9% was explained and after rotation of these components, the factorial matrix was obtained (table 1).

Furthermore, the description of the 4 dimensions of the questionnaire presented a relatively heterogeneous distribution of them, with greater values for "protectiveness" and "risk tolerance" and smaller for "supervision," and especially for "fate" (table 2).

Internal consistency

Through study of Cronbach’s α, we obtained values that varied from 0.684 for the dimension "risk tolerance" to 0.866 for "fate" (table 3).

External consistency or reliability

Reliability or stability of responses was verified in 30 subjects, to whom the questionnaire was re-administered (re-test) 3 months after the first consultation (test); then the statistical study was done through analysis of the Pearson correlation coefficient. Table 4 compares the results obtained in the different validation studies of the PSAPQ.

Values greater than 0.6 were obtained in the risk tolerance (r=0.665) and fate (r=0.651) subscales, and greater than 0.7 in the protectiveness (r=0.814) and supervision (r=0.787) subscales (table 5).

DISCUSSION

The results demonstrate that we have obtained a reliable Spanish-language tool for the objective measurement of the degree of parental supervision, allowing its use in various Spanish-speaking populations.

Unintentional child injuries are a serious public health issue, since they represent one of the leading causes of morbidity and mortality worldwide in pediatric patients, in addition to their high psychological impact on the child and his/her family members.

There is no single factor that favors the occurrence of unintentional injuries; rather there are multiple factors, or the sum of them, as well as the presence of various intra- and interpersonal variables responsible for increasing the likelihood of their occurrence. Knowledge of these variables is very important for their prevention, since if we act on them, we can decrease the risk of accidents due to this.

The degree of parental supervision is considered to be a decisive risk factor⁷7. Damashek A, Kuhn J. Toddlers' unintentional injuries: the role of maternal-reported paternal and maternal supervision. J Pediatr Psychol. 2013;38(3):265-275.^,1414. Simon H, Tamura T, Colton K. Reported level of supervision of young children while in the bathtub. Ambul Pediatr. 2003;3(2):106-108., so it is very important to have an objective and reliable tool to be able to evaluate and thus act on it. With this purpose in mind, in 2006, the PSAPQ questionnaire was validated in English²¹21. Morrongiello BA, Corbett M. The Parent Supervision Attributes Profile Questionnaire: A measure of supervision relevant to children's risk of unintentional injury. Inj Prev. 2006;12(1):19-23. and then, in 2013, in Portuguese²⁴24. Andrade C, Carita AI, Cordovil R, et al. Cross-cultural adaptation and validation of the Portuguese version of the Parental Supervision Attributes Profile Questionnaire. Inj Prev. 2013;19(6):421-427..

To date, there is no validated method in Spanish, even though it is the second most-spoken language worldwide and in scientific communication; therefore, the cross-cultural adaptation and validation of the PSAPQ was considered to be important. For all of these reasons, our objective in this study was to validate and cross-culturally adapt the PSAPQ questionnaire to Spanish and thus make available a tool that can be used clinically or epidemiologically when objective measurement of the degree of parental supervision is required. Furthermore, the use of a single questionnaire in this field allows comparison of different studies carried out in different countries.

To carry out the validation and cross-cultural adaptation of the PSAPQ questionnaire to Spanish, a regulated process was used²⁶26. Bullinger M, Alfonso J, Apolone G,et al. Translating Health Status Questionnaires and Evaluating Their Quality: The IQOLA Project Approach. J Clin Epidemiol. 1998;51(11):913-923.^,2828. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25:3186-91., including a population sample with different socioeconomic and cultural statuses, so as to increase the representativeness.

In addition, an analytical study of the results was carried out. It revealed, in terms of internal consistency, Cronbach’s α values greater than 0.7 in three of the four subscales of the questionnaire (protectiveness, supervision and fate), with a very similar value in the remaining subscale.

These results indicate that the Spanish version of the questionnaire has an acceptable internal reliability, demonstrating that the items that form each subscale are related and evaluate the same construct.

With regard to reliability, a Pearson correlation coefficient > 0.7 was obtained for the supervision and protectiveness subscales, and values very similar to this were found for risk tolerance and fate; the latter was greater than the work of Andrade et al.24 in Portugal, and these results were very similar to those obtained in the questionnaire carried out by the Canadian authors.

Given these results, we can confirm that our study has good consistency, which is positive between the responses obtained separately over time in the test-retest.

Furthermore, our study also evaluated socio-epidemiological variables such as participants’ number of siblings, country of origin of the parents, family socio-cultural status, etc., with the purpose of, in subsequent works, studying the relationship of these factors to the degree of parental supervision.

The first of this work’s limitations is the sample size, which, although the results are statistically significant, may have required a larger size; however, the inclusion and exclusion criteria of the participants were very strict. Furthermore, data collection was carried out simultaneously with well child visits at the various health centers, with the cooperation of pediatricians, who assessed children who met the inclusion criteria, explained the project and, if the parents signed the informed consent form, carried out the interview and proceeded to fill out the questionnaire. This translated into a work overload, added to the high care pressure that these professionals face, so after obtaining a sufficient sample size to achieve statistically significant results, data collection was concluded.

The number of patients to whom the questionnaire was administered for the internal consistency study is limited. Although it is sufficient to obtain a significant Cronbach’s α, it would have been interesting to be able to collect a larger sample size; however, it was very complicated since out of all of the participants to whom the questionnaire was re-sent, only 24 responded by e-mail and 6 by phone.

The third limitation was the inability to find a scale similar to the PSAPQ test to be able to study the criteria validity. However, this variable is also not considered in the Canadian and Portuguese studies, presumably due to this same limitation.

Although in the confirmatory factorial analysis there are variables that do not exactly match those of the initial test, this can be explained because the population of our study is different from the Canadian population and the idiomatic meanings of words vary; in addition, there may be errors when interpreting or answering questions.

In conclusion, we can confirm that a useful and cross-culturally adapted tool has been obtained for measurement of the degree of parental supervision, to allow action against one of the risk factors that favor child accidents, the second-leading cause of morbidity and mortality in pediatric patients in Spain. Thus, it allows the start of campaigns for prevention of this type of accident by means of awareness and education of parents/caregivers, in order to be able to decrease the incidence these accidents.

Moreover, this questionnaire can be used in all other settings in which it is necessary to objectively and reliably know the degree of parental supervision for different purposes, such as: primary care pediatrics, legal services, social services, etc.; therefore, this validation takes on an even greater importance.

Annex I.   Version translated and transculturally adapted to the Spanish from the PSAPQ questionnaire

References

Publication Dates

History