University of Ghana Department of Psychology THE USE OF KANGAROO MOTHER CARE: COPING AND PSYCHOLOGICAL DISTRESS AMONG MOTHERS WITH PRETERM BABIES IN GHANA BY CRESCENS OSEI BONSU OFORI (10521385) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PHILOSOPHY IN CLINICAL PSYCHOLOGY JANUARY, 2022 University of Ghana http://ugspace.ug.edu.gh Page | ii DECLARATION I CRESCENS OSEI BONUS OFORI, hereby declare that this thesis is the result of my own research work and no part of it has been submitted for any academic award. 11th January, 2022 …………………………………. ……………………….. CRESCENS OSEI BONUS OFORI DATE (10521385) 12th January, 2022 ………………………… ………………………. MABEL OTI-BOADI (PHD) DATE (Principal Supervisor) 12th January, 2022 ………………………………………………. ……………………. CHARITY AKOTIA (Ph.D.) DATE (Co. Supervisor) University of Ghana http://ugspace.ug.edu.gh Page | iii Page | DEDICATION This work is dedicated to Almighty God for the gift of life and strength through the writing of this thesis. To my family and friends. University of Ghana http://ugspace.ug.edu.gh Page | iv ACKNOWLEDGEMENT I do express my heartfelt gratitude to my supervisors, Dr. Mabel Oti-Boadi and Prof. Charity Akotia for their guidance, scrutiny, support and best wishes that helped me complete this thesis. Grateful to the management of Eastern Regional Hospital especially the Kangaroo clinic for their support and cooperation. Many thanks to friends and loved ones (i.e Sam-Nkrumah, Marcus, Juliet and Sakyibea) who assisted in diverse ways. Finally, my sincere gratitude goes to my parents (Mr & Mrs Ofori) for their love, support and prayers throughout this program of study. University of Ghana http://ugspace.ug.edu.gh Page | v TABLE OF CONTENT DECLARATION ............................................................................................................................................... ii DEDICATION ................................................................................................................................................. iii ACKNOWLEDGEMENT.................................................................................................................................. iv LIST OF TABLES ............................................................................................................................................ vii LIST OF FIGURES .......................................................................................................................................... vii ABSTRACT .................................................................................................................................................. viii CHAPTER ONE ............................................................................................................................................... 1 INTRODUCTION ............................................................................................................................................. 1 Background of the study ........................................................................................................................... 1 Problem statement ................................................................................................................................. 10 Research Aim and Objectives ................................................................................................................. 11 CHAPTER TWO ............................................................................................................................................ 13 LITERATURE REVIEW ................................................................................................................................... 13 Theoretical Framework ........................................................................................................................... 13 The Stress Process Model (Pearlin, Mullan, Semple, & Skaff, 1990). ............................................... 13 The Reformulated Theory of Learned Helplessness (Abramson, Seligman & Teasdale, 1978). ....... 14 Transactional Model of Stress and Coping (Lazarus & Folkman, 1984). .......................................... 16 Review of Related Studies ...................................................................................................................... 18 Challenges of Kangaroo mother care among mothers with preterm infants ....................................... 18 Psychological distress (parental stress, anxiety, and depression) among mothers with preterm infants ................................................................................................................................................. 21 Perceived stigma among preterm mothers .......................................................................................... 26 Perceived social support among preterm mothers .............................................................................. 27 Ways of coping among preterm mothers ............................................................................................ 28 Research Hypotheses.............................................................................................................................. 34 Conceptual Framework .......................................................................................................................... 35 Research Rationale ................................................................................................................................. 36 CHAPTER THREE .......................................................................................................................................... 38 University of Ghana http://ugspace.ug.edu.gh Page | vi METHODOLOGY .......................................................................................................................................... 38 Introduction ............................................................................................................................................ 38 Design ..................................................................................................................................................... 38 Study setting ........................................................................................................................................... 38 Participants and Sampling ...................................................................................................................... 39 Inclusion criteria ..................................................................................................................................... 40 Measures/Materials ............................................................................................................................... 40 Demographic Information .................................................................................................................. 40 Parenting Stress: Parenting Stress Scale (PSS) (Berry & Jones, 1995). ............................................. 42 Psychological distress: Brief Symptom Inventory (BSI) (Derogatis & Melisaratos, 1983). .............. 42 Perceived Social Support: Multidimensional Scale of perceived social support (MSPSS) (Zimmert et al., 1988) ............................................................................................................................................. 43 Coping: Brief Cope Inventory (BCI) (Carver, 1997).......................................................................... 43 Perceived Stigma: Perceived Stigma Scale – Revised (PSSR) (based on Mickelson et al., 1999) .... 44 Pilot study ............................................................................................................................................... 45 Procedure ............................................................................................................................................... 46 Ethical considerations ............................................................................................................................. 46 Data analysis ........................................................................................................................................... 47 CHAPTER FOUR ........................................................................................................................................... 49 RESULTS ...................................................................................................................................................... 49 Introduction ............................................................................................................................................ 49 Summary of descriptive analyses ........................................................................................................... 49 Hypotheses testing ................................................................................................................................. 51 CHAPTER FIVE ............................................................................................................................................. 61 DISCUSSION ................................................................................................................................................ 61 Introduction ............................................................................................................................................ 61 Challenges with the practice of KMC on prenatal stress ........................................................................ 61 Psychological distress (depression and anxiety) among preterm mothers ............................................ 63 Mothers’ ways of coping with depression .............................................................................................. 68 Mothers’ ways of coping with anxiety .................................................................................................... 72 Limitations of the study .......................................................................................................................... 76 Recommendations for future study ....................................................................................................... 77 University of Ghana http://ugspace.ug.edu.gh Page | vii Conclusion .............................................................................................................................................. 78 References .................................................................................................................................................. 79 APPENDICES ................................................................................................................................................ 93 LIST OF TABLES Table 1: Summary of demographic characteristics of participants in the study (N =120) ..........................41 Table 2 Summary of descriptive statistics of study variables .................................................................... 50 Table 3 Summary of multiple regression of ways of coping on psychological distress (depression and anxiety) ....................................................................................................................................................... 51 Table 4 Summary of the multiple regression of perceived stigma and perceived social support on parental stress ............................................................................................................................................................ 53 Table 5 Summary of ANCOVA showing the significant differences of maternal age, marital status, and number of children on psychological distress (depression and anxiety) ..................................................... 55 Table 6 Summary of mediations result of relationship between parental stress, perceived stigma, perceived social support, depression and anxiety ....................................................................................... 57 LIST OF FIGURES Figure 1 Hypothesised conceptual model ................................................................................................... 35 Figure 2 Observed model for the mediating influence of parental stress on the relationship between perceived stigma and psychological distress (depression and anxiety) ...................................................... 59 Figure 3 Observed model for the mediating influence of parental stress on the relationship between perceived social support and psychological distress (depression and anxiety) ........................................... 60 University of Ghana http://ugspace.ug.edu.gh Page | viii ABSTRACT This study investigated the challenges associated with the practice of Kangaroo Mother Care (KMC) at home and its impact on mothers' psychological distress (parental stress, depression and anxiety) and they a coping. The study employed a cross-sectional design with 120 preterm mothers from Koforidua as study participants. Participants were recruited by using purposive sampling and convenient sampling. Questionnaires (i.e., Parental Stress Scale, Perceived Stigma, Multidimensional Scale of Perceived Social Support, Brief Symptom Inventory and Brief Cope Inventory) were administered to participants. Multiple regression, One-way ANCOVA and regression (Process Marco) was used to analyze the data. Findings of the study showed that perceived stigma positively predicted parental stress. Perceived social support had a negative impact on parental stress. Additionally, parental stress mediated the relationship between perceived stigma, perceived social support and psychological distress (depression, and anxiety). Finally, preterm mothers used avoidant coping to cope with their psychological distress. In essence, health professionals, policy makers, family and friends as well as preterm mothers should be educated on the psychological distress preterm mothers experienced when performing KMC and provide support and appropriate ways to cope. University of Ghana http://ugspace.ug.edu.gh Page | 1 CHAPTER ONE INTRODUCTION Background of the study According to the World Health Organization (WHO), preterm birth is all births before 37 weeks of gestational age or fewer than 259 days since pregnancy (WHO, 2012). In 2010, about 15 million babies were born preterm globally (WHO, 2012), which signifies a preterm birth rate of 11.1% (Blencowe et al., 2012). One out of every ten world’s babies are born preterm (Aseidu , et al., 2019). An average of 12% of preterm birth occurs in lower-income countries (WHO, 2018). The rate of preterm birth in Ghana is 14%, with 128,000 babies born preterm per year and 8,400 infants die as a result of preterm complications. In terms of the number of preterm births, Ghana ranks 25th in the world (Liu et al., 2014). Preterm birth is a major factor of low birth weight (LBW) (UNICEF & WHO, 2018) and can be subdivided by gestational age (< 28 weeks extreme preterm, very preterm babies are born between 28 and 32 weeks, and moderate preterm babies are born between 32 weeks and 37 weeks). The exact determinants of preterm infants are unknown but there are several predisposing factors such as hypertensive complications, urinary tract infections, multiple births, maternal age, excessive alcohol intake, and smoking. The development and growth of preterm infants are less than normal neonates, which makes preterm infants’ high-risk newborns (Fraser & Cooper, 2003). Being classified as high-risk newborns increases the chances of mortality or morbidity (Suraju et al., 2013). Since preterm infants are classified as high-risk neonates, they faced several problems which include behavioral University of Ghana http://ugspace.ug.edu.gh Page | 2 (i.e impulsive, disorganized, and easily distractible), physical (respiratory illness, sensory deficits, and cerebral palsy), and psychomotor (such as developmental coordination disorder) (Suraju et al., 2013). As a result of the above problems, preterm infants are managed with optimal care at the Neonatal Intensive Care Unit (NICU) for their survival (Holditch-Davis et al., 2000). Optimal care at the NICU includes establishing and maintaining respiration, maintenance of body temperature, and prevention of infection (Suraju et al., 2013). After NICU, preterm infants are discharged home to continue with optimal care (Rudolph et al., 2002). The birth of preterm infants continues to increase, which causes a significant impact on the economy, society, and family (Suraju et al., 2013). Parents, especially mothers are considered at higher risk for enormous challenges because they are the primary caregivers of their babies (Ballantyne et al., 2013). Such challenges include, psychological (i.e stress, depression, and anxiety), physical (i.e body pains), and economic costs (i.e financial burden) (Ango, 2016). Mothers encounter such challenges when their children have physiological and developmental issues (Auslander et al., 2003), and during the process of providing optimal care for their infants either at NICU (Ango, 2016) or after being discharged from the NICU (Suraju et al., 2013). Kangaroo Mother Care (KMC) is a natural method for caring for preterm infants, which usually begins at the hospital (NICU). This continues after the stability of the infant, where mothers who have demonstrated confidence in handling their infants are discharged to continue the practice of KMC at home. KMC is an early, continuous, and prolonged skin-to-skin contact where a stable LBW preterm infant is placed and carried in skin-to-skin contact of the mother (WHO, 2018). This natural method for caring for preterm infants is an accepted World Health Organization standard of care to decrease mortality and morbidity rates among LBW infants and preterm infants (Baley, University of Ghana http://ugspace.ug.edu.gh Page | 3 2015; Charpak et al., 2005; Nunes et al., 2017). KMC was developed in Bogota, Columbia in the 1970s by Rey and Martinez to help tackle the challenges of inadequate and insufficient incubators to care for preterm infants, overcrowding, and the problem of separation of mother and the baby (WHO, 2003). In 2007, KMC was first introduced in Ghana (Nguah, et al., 2011). It gained much acceptance in the year 2015 and major regional and district hospitals in Ghana included it in their optimal care for preterm infants (Bergh et al., 2013). KMC can be continuous or intermittent (Mohammadi et al., 2021). Practicing KMC continuously is when there is day and night skin-to-skin contact between the mother and the infants for at least 20 hours or more per day. Whereas, intermittent KMC is when there is skin-to-skin contact between the mother and the infant for a shorter period (at least 70 minutes every day) (Mohammadi et al., 2021). KMC involves components such as KMC position, exclusive breastfeeding, early discharge from NICU, and adequate support for mothers at home (Sarfo, 2018). KMC position is where the naked baby is held upright between the mother’s breasts, wearing only a cap, diaper, and socks. Preterm infants are encouraged to be in a kangaroo position for 24 hours a day until the preterm infant weighs at least 2500g (2.5kg) and wriggles to show his or her discomfort. With regards to feeding, mothers ensure exclusive breastfeeding for at least every two hours especially when preterm infants are discharged home. Social support is the provision of adequate support from family, friends, and significant others and a fellow up from health staff for mothers at home. Benefits of KMC include bonding, confidence, stimulation, maintain body temperature, regular breathing pattern, and reduced risk of infection (Amankwaa et al., 2007; Bera et al., 2014; Jones & Santamaria, 2018; Lewis et al., 2019). However, barriers such as social support, family University of Ghana http://ugspace.ug.edu.gh Page | 4 acceptance, maternal age, marital status, and the number of children has impeded the mother’s ability to implement KMC (Lewis et al., 2019). Studies in Sweden and Ghana highlighted the above array of challenges mothers faced when caring for their preterm infant both at the NICU and home (Ango, 2016; Blomqvist, et al., 2012; Lee & Kimble, 2009; Suraju et al., 2013). Thus, studies have shown high levels of stress that led to severe psychological distress among mothers after preterm birth (Witt et al., 2012). This calls for the present study to examine the challenges that mothers faced when practicing KMC at home, its impact on mothers’ psychological distress and how mothers cope with such psychological distress. Psychological distress is a psychological construct that has several dimensions and is characterized by negative functioning such as expression discomfort, harm, alteration of emotional state, and inability to effectively cope with negative situations (Nutsugah, 2019). Ridner defines psychological distress as the unique discomforting, emotional state experienced by an individual in response to a specific stressor or demand that results in harm, either temporary or permanent, to the person” (Ridner, 2004, p. 539). A change in an individual’s stable emotions determines whether an individual has experienced psychological distress or not. Stress, depression, and anxiety are all manifestations of psychological distress that an individual show when there is a change in his or her stable emotions (Massey, 2002). Parental care appears to be linked to the severity of psychological distress (Borghini et al., 2006). This is because parenting is affected by new stressors, which causes mothers to experience some unique discomforting or emotional state (Surkan et al., 2011). Mothers with preterm infants are at serious risk in terms of adverse parenting, which causes mothers to experience high levels of psychological distress (Hall et al., 2017). Anxiety and depression are the commonest University of Ghana http://ugspace.ug.edu.gh Page | 5 (NolenHoeksema & Keita, 2003) and leading psychological distress in women more than men especially during childbearing years (Mayosi et al., 2009). Anxiety is the fear of the future, temporary fear, and uncertainty about a particular event or situation (Barlow, 2004). Causes of anxiety among mothers, especially preterm mothers have been suggested to include behavior and appearance of infants, parental role alteration, social support, financial problems, and the environment of the mother (Ango, 2016; Duarte et al., 2009). A study by Duarte et al. (2009) has shown that clinical symptoms of anxiety decrease when preterm mothers are discharged from the hospital (Duarte et al., 2009). This means preterm mothers are more anxious during hospitalization as compared to the period of discharge. However, other studies have pointed out that mothers who have been discharged for months continue to exhibit high levels of anxiety like those at the hospital (Holditch-Davis et al., 2009). Mothers' levels of anxiety were not significantly different, considering their marital status (Hinz, Finck, & Gomez, 2014). This means the level of anxiety among mothers who are married is equal to the level of anxiety among mothers who are not married. With regards to maternal age, anxiety decreases with increasing age among preterm mothers who perform KC at the NICU (Sweeney et al., 2017). This is because those who have advanced in age have experienced other life events or situations that have caused them to know how to cope better with stress. Therefore, such mothers can handle the stress that comes with the performance of KCM at the NICU. Depression according to the American Psychiatric Association, is a mental illness that negatively affects an individual cognition, behavior, and emotions. Symptoms of depression include the feeling of sadness, loss of interest, changes in appetite, worthlessness, feeling of hopelessness, guilt, feeling of helplessness, and suicidal thoughts. The rate of depression among preterm mothers University of Ghana http://ugspace.ug.edu.gh Page | 6 is 14% to 27% (Annon , 2008) and depressive symptoms are 63% high during the hospitalization of the preterm infant (Miles et al., 2007). Studies have indicated that increased parental stress, poor social support, single marital status, poor coping skills, perceived parental role alteration, perception of infant’s development, and stay at the NICU are all risk factors that cause preterm mothers to be depressed (Beck, 2001; Rogers et al., 2013). Mothers of preterm infants are at higher risk of depressive and anxiety symptoms than mothers of healthy term infants and fathers (Auslander et al., 2003; Ballantyne et al., 2013). Goodman and Brand (2009) indicated that mothers who are depressed or anxious engage in withdrawal and disengaged interaction behaviors with their infants (Goodman & Brand, 2009). However, in some studies, preterm mothers who are anxious and depressed developed a strong bond with their infant (Borghini et al., 2006). This shows that in some instances, psychological distress strengthens mothers to take proper care of their infants. Parents of preterm infants are more vulnerable to stress especially after being discharged as parents felt overwhelmed, afraid, and unprepared to assume responsibilities (Haemmerli et al., 2000). Additionally, studies have pointed out that high levels of stress led to severe psychological distress such as depression and anxiety (Witt et al., 2012). This is because mothers face challenges when caring for their preterm infant or performing KMC both at the NICU and home (Ango, 2016; Blomqvist et al., 2012; Lee & Kimble, 2009; Suraju et al., 2013). Some challenges include social support, family acceptance, maternal age, marital status, and the number of children of the mother (Lewis et al., 2019). Parenting is often affected by new stressors (Surkan et al., 2011), hence, psychological distress can continue well beyond the time the infant is discharged home (Vigod et al., 2010). This makes it difficult for preterm mothers to create an environment that supports resiliency (Duarte et al., 2009), which negatively affects the development of the infant (Singer, et University of Ghana http://ugspace.ug.edu.gh Page | 7 al., 2007) and the relationships between the child and the parent (Eiser et al., 2005). Thus, understanding the relationship between the level of psychological distress and the challenges that mothers face when performing KMC at home would be relevant in determining the appropriate coping for mothers with preterm infants. Every parent, especially mothers’ dreams of having a normal and healthy infant but when parents lose such a dream, it results in psychological distress such as depression and anxiety. Mothers who appraise KMC as a stressful event but possess inadequate resources to address the stressors may experience high levels of stress and an adverse psychological effect as compared to mothers who possess adequate resources to address her stressors (Greer, 2011). Studies have also shown that individuals cope with psychological distress negatively (Burns et al., 2008). This means an individual with adequate resources can cope properly with stressors that cause psychological distress to decrease and vice-versa. Overwhelming challenges associated with the practice of KMC during NICU or after discharge may cause parental stress among mothers and they need to possess adequate resources to handle such challenges effectively. Mothers’ way of coping may have an impact on their psychological distress and research by Kendall and Terry (2008) has pointed out the ways of coping into three categories. They include emotional-focused coping, problem-focused coping, and avoidant coping (Kendall & Terry, 2008). Problem-focused coping is mostly used when an individual perceives he or she can change stressful environments or situations (Moszczynski & Haney, 2002). This is because problem focused coping includes skills that help individuals change their stressful situations (GueritaultChalvin et al., 2010). Such skills include actively trying to make the situation better, thinking about the positive University of Ghana http://ugspace.ug.edu.gh Page | 8 side of a stressful situation, adjusting to stressful situations and learning to accept stressful situations (Jones et al., 2010). A study by Tuncay et al. (2008) showed that problem-focused coping is related to less psychological distress while emotion-focused coping is positively related to depressed moods. Likewise, an empirical study by Chang et al. (2007) showed that the use of problem-focused coping helped nurses in Australian and New Zealand hospitals handle role stress better than those who used emotional-focused coping. Since nurses can control their workplace stress, they adopted the problem-focused coping approach to change their workplace stress and this benefited the nurses in addressing their stresses. However, studies also showed that the use of problem-focused coping increased an individual's psychological distress even though the individual has control over the stressful situation (Calvete & Lopez de Arroyabe, 2012; Feldman et al., 2002). This occurs when the problem-focused coping approaches become ineffective in trying to control the stressful situation, which causes individuals to be more frustrated and confused and eventually become distressed (Chronister & Chan, 2006). Apparently, the stress surrounding the practice of KMC can either be controlled or not depending on the caregiver and since women mostly used problem-focused coping than men (Chronister & Chan, 2006), this study examines whether preterm mothers would make use of problem-focused coping as a way of coping. Emotion-focused coping on the other hand is used when a stressful situation or condition is uncontrollable especially situations in the health-related field but the individual tries to manage the magnitude of the stress on his or her emotions (Eaton et al., 2011). It includes approaches such as the use of religion, emotional support, expression, self-blame, humor, and cognitive distraction. University of Ghana http://ugspace.ug.edu.gh Page | 9 For instance, if an individual finds a particularly stressful situation as part of everyday life, the individual manages the stressful situation by applying either cognitive distraction or cognitively accepting the stressful situation which helps reduce the stress level the individual experiences. This is because the individual has admitted that stressful conditions are part of his or her life and the level of depression and anxiety the individual experience reduces. A study in Ghana by Suraju et al. (2013) highlighted that, mothers of preterm infants’ cope with challenges by relying on some emotion-focused coping approaches such as support from family, significant others, and religion. Additionally, a study in Bawku Municipality and Korle-Bu teaching hospital showed that regardless of the overwhelming challenges, mothers adopted emotion-focused coping approaches such as understanding their baby's needs, spirituality (such as having faith in God), and collective coping (Ango, 2016; Akum, 2018). Another empirical study by Wartella et al. (2009) showed that the use of emotion-focused coping by family members of neuroscience patients did not affect stress. Since the family members were in a denial state, the use of emotion-focused coping was negated in dealing with stress (Wartella et al., 2009). Avoidant coping is a type of coping in which the meaning of a particularly stressful event or environment is changed, and the individual ignores his or her emotions to alleviate distress (Lu et al., 2016). It includes skills such as denial, substance use, behavioral disengagement, and self- distraction. Several studies have revealed that the use of avoidant coping is related to increase in caregivers’ psychological distress and mental health (Mausbach et al., 2006; Penley et al., 2002). This is because most people who use avoidant coping believe that a particular stressful condition is uncontrollable and therefore it is beyond their abilities to use any behavioral or cognitive actions University of Ghana http://ugspace.ug.edu.gh Page | 10 to address such a condition (Mausbach et al., 2006). The psychological distress associated with the practice of KMC at home may cause preterm mothers to use avoidant coping as a form of coping with anxiety and depression because they might believe they cannot use cognitive and behavioral actions to cope. All coping strategies can be effective (Tuncay et al., 2008) therefore, determining mothers’ ways of coping and their influence on depression and anxiety would be useful for this study. This is because it will help clinical psychologists plan an effective coping way for preterm mothers who practice KMC at home. Problem statement An alternative way to care for preterm infants is the use of Kangaroo Mother Care (Uwaezuoke, 2017). KMC has shown to have multiple benefits to the preterm infant, parents, and the health systems (Bayo et al., 2019). The rate of practice has remained low due to the challenges associated with its practice at home than the robust evidence on the benefits of KMC (Vesel et al., 2015). Thus, the low rate of practice increases the risk of early growth retardation, developmental delays, and early death at childhood (Conde-Agudelo and Diaz-Rossello, 2016) which invariably affect the family. These challenges associated with the practice of KMC do not take a significant psychological toll on mothers when handled well but the reverse has always been true with most reported studies of mothers at the NICU. However, most of the studies reviewed primarily focused on the experiences of mothers’ providing general caregiving to preterm infants. Thus, it becomes a challenge to identify the specific challenges associated with the practice of KMC. Additionally, other studies have similarly looked University of Ghana http://ugspace.ug.edu.gh Page | 11 at the practice of KMC, but the focus has always been on the hospital (NICU) setting. Hence, there is a dearth of studies on how the challenges of practicing KMC at home take a significant psychological toll on mothers at home. It is therefore a rising concern to assess the psychological distress of preterm mothers who faced challenges when practicing KMC at home. Furthermore, there is a paucity of the quantitative literature on how preterm mothers cope with psychological distress when faced with challenges for practicing KMC at home. This creates an opportunity to quantitatively investigate how these mothers will cope with psychological distress when faced with challenges while practicing KMC at home. Research Aim and Objectives The main aim of the study is to investigate the challenges associated with the practice of KMC at home, its impact on mothers’ psychological distress (parental stress, depression, and anxiety) and mothers’ ways of coping with the psychological distress. Specifically, this study seeks to; 1. Investigate the extent to which mothers cope with psychological distress (depression and anxiety). 2. Assess the influence of perceived stigma and perceived support on parental stress 3. Investigate the extent to which demographic variables (i.e., marital status, maternal age and other siblings) influences psychological distress (depression and anxiety). 4. Examine the impact of parental stress on preterm mothers’ psychological distress (Depression and anxiety). University of Ghana http://ugspace.ug.edu.gh Page | 12 Relevance of the study The study is of relevance to academia, mothers of preterm infants, and the health sector. The study will contribute to the existing understanding of the challenges associated with the practice of KMC, the contribution to preterm mothers’ psychological distress, and ways these mothers cope with the psychological distress when at home. This would aid in developing appropriate intervention models to improve mothers’ psychological well-being while taking care of their preterm infants at home. Additionally, results from this study would be of help to health professionals working with preterm infants and their mothers in the clinical setting. This is where health professionals would get to know the challenges faced when practicing KMC at home, its impacts on mothers’ psychological distress, and how effectively mothers can cope with their psychological distress. Thus, health professionals would specifically focus on how well they can assist preterm mothers to cope with their psychological distress. This can be achieved when clinic reviews do not focus only on the preterm infant but include their mothers as well. Lastly, findings from this study will give insight to preterm mothers about how well they can cope with their psychological distress and recognize any psychological distress in their life. This is where preterm mothers get to understand the challenges that affect their psychological wellbeing and be willing to seek psychological consultation. University of Ghana http://ugspace.ug.edu.gh Page | 13 CHAPTER TWO LITERATURE REVIEW The present chapter presents theories that have been used to explain psychological distress and ways of coping. Additionally, this chapter reviews empirical research in the area. The review of literature focused more on variables such as psychological distress (depression, anxiety, and parental stress), perceived stigma, perceived social support, and ways of coping. Theoretical Framework The Stress Process Model (Pearlin, Mullan, Semple, & Skaff, 1990). The stress process model was introduced as an attempt to conceptualize how informal family caregivers experienced stress as a process. From the theory, caregivers provide specific types or amounts of care within the context of other roles (i.e parenting, employment and marital). Within this context, Pearlin and colleagues came up with four factors that contribute to caregiving stress, which include caregiver’s background and context, stressors, mediators or moderators, and outcomes. According to the theory, the caregiver’s background and contexts such as marital status, age, and religion influence the caregiver’s level of stress. Stressors were grouped into primary stressors and secondary stressors. Primary stressors such as providing support and supervising the care receiver influence caregivers' level of stress. Economic or social burdens were also considered secondary stressors that contribute to caregiver’s stress. Coping strategies, personal responses, and social support were part of the mediators or moderators that influence the effect of stress among caregivers (Pearlin et al., 1990). University of Ghana http://ugspace.ug.edu.gh Page | 14 Outcome, which is the last contributing factor of caregiver stress, is the effects of caregiver’s abilities to maintain social roles or themselves. Therefore, failure to maintain themselves or social roles leads to decisions to end providing care, physical health problems, depression, cognitive disturbance, and anxiety. From the theory, preterm mothers who are not able to maintain themselves or social roles will experience high levels of depression and anxiety when faced with factors or challenges that contribute to their stress while practicing KMC at home. The present study focused on the direct relationship between preterm mothers’ background and context, their stressors, and the mediators of stress on preterm mothers’ outcomes such as depression and anxiety. The Reformulated Theory of Learned Helplessness (Abramson, Seligman & Teasdale, 1978). Seligman (1975) originally developed the learned helplessness theory, which explains how humans or animals are unwilling and unable to escape stimulus events or situations that lead to discomfort, suffering, or pain when subsequently exposed to the stimulus events or situations. Meaning, when individuals understand and perceive that they cannot control events or situations that lead to discomfort and pain, the individual begins to act and feel helpless. This act of helplessness occurs after the individual experiences such a stimulus event or situation. Abramson et al. (1978) identified some flaws in Seligman’s original learned helplessness theory by coming up with the reformulated theory of learned helplessness to address these flaws. Cognitive thinking was included in the reformulated theory of learned helplessness, to help determine whether individuals would be willing or unwilling to escape stimulus events that lead to individuals’ discomfort or pain. Thus, Abramson and colleagues used the theory to elaborate on why some individuals are not anxious or depressed when faced with an unpleasant event. University of Ghana http://ugspace.ug.edu.gh Page | 15 According to the reformulated theory, individuals faced with a draining situation which they do not have control over may end up with cognitive deficit, emotional deficit, and motivational deficit (Abramson et al., 1978). The situation whereby an individual perceives a particular situation as uncontrollable is termed the cognitive deficit, whereas emotional deficit is the feeling associated with helplessness when an individual experiences a negative event as uncontrollable and such feeling includes depression and anxiety. An individual failure to avoid or escape a negative situation results in a motivational deficit. Universal helplessness and personal helplessness were introduced by Abramson and colleagues to elucidate the relationship between depression and learned helplessness. A sense of helplessness whereby an individual believes that nothing can be done about the circumstances he or she is referred to as universal helplessness. This is where the person believes that no one is in the capacity to alleviate his or her discomfort or pain. Therefore, people use external attributions to their failure to solve problems and to their problems, under universal helplessness. However, under personal helplessness, people use internal attributions for their problems and failure to solve their problems. This is because, with personal helplessness, the individual perceives that he or she is unable to provide solutions to negative situations he or she is experiencing but rather believes that the solution to the negative situation lies in the hands of others. Since they believe others can solve a negative situation, they become more prone to low self-esteem which leads to depression. Additionally, higher forms of emotional deficit are experienced by people who believe others are capable than themselves. Preterm mothers may encounter difficult or negative situations they do not have control over in their daily lives when practicing KMC at home. Such difficult and uncontrollable situations University of Ghana http://ugspace.ug.edu.gh Page | 16 include infants’ appearance, infant behavior, practicing KMC, community acceptance, and support. Preterm mothers may use the universal helplessness by making external attribution to the difficult situation. They make external attributions by believing that no one can control the behavior of their preterm infant. Personal helplessness may be used by preterm mothers by making use of internal attribution to the above difficult situations. For instance, preterm mothers may say they are unable to control others to accept their practice of KMC. Therefore, the difficult situation of the community not accepting preterm mothers because they are practicing KMC lies in the willingness of the community to control the difficult situation by making an effort to accept these mothers. This may lead to anxiety anytime mothers think of practicing KMC and depression may set in due to the feeling of helplessness. Transactional Model of Stress and Coping (Lazarus & Folkman, 1984). The Transactional Model of Stress and Coping is a framework for assessing the processes of coping with stressful events. It proposes that stress is experienced as an evaluation (appraisal) of situations individuals find themselves in. When an individual faces a potential or perceived stressful event, he or she engages in a cognitive process that includes primary and secondary appraisal. Primary appraisal means evaluating a situation to decide whether it affects one’s wellbeing positively, irrelevantly, or negatively (Wood et al., 2007). The situation or event could be harmful, threat and challenge especially if the situation or event is evaluated as stressful (Lazarus & Folkman, 1984). When damage (psychological) has already occurred, it is called harm. Anticipation of harm as a result of an event is termed as a threat while challenges refer to demands which make an individual feel confident about overcoming or mastering. An individual elicits negative emotions such as fear, anxiety, and anger when they evaluate an event as harmful or a University of Ghana http://ugspace.ug.edu.gh Page | 17 loss. However, individuals will experience positive emotions (i.e eagerness, excitement, and hopefulness) when they evaluate an event as challenging (Wood et al., 2007). The secondary appraisal is where an individual cognitively evaluates the available options and resources to decide if the individual can cope with the event or stressor (Wood et al., 2007). Adequate resources to cope with the event or stressor decreases an individual levels of stress. On the other hand, inadequate resources to cope with the stressor leads to higher stress levels. Lazarus and Folkman identified two major coping strategies which include emotion-focused coping and problem-focused coping. Emotion-focused coping and avoidant coping, involves reducing and managing emotional distress. This is where the individual changes or reappraises the meaning of a particular event or stressor to reduce the stress it causes. Problem-focused coping consists of situation-specific, instrumental, and task-oriented actions or resources that an individual acquires to handle a fundamental problem (Folkman and Moskowitz, 2004). This is where individuals try to deal with the event itself or try to change the event into something more pleasant. With the present study, mothers appraised the practice of KMC to determine whether it is a threat or challenge to their well-being and determine whether they can cope with the stressor or not. University of Ghana http://ugspace.ug.edu.gh Page | 18 Review of Related Studies Challenges of Kangaroo mother care among mothers with preterm infants Mothers’ general awareness of KMC serve as either barrier or enabler to the practice of KMC (Parmar et al., 2009). Study by Solomons and Rosant (2012) reported that mothers who had full knowledge in KMC were adherent to the practice of KMC in South Africa. However, studies (Abul-Fadi et al., 2012; Bazzano et al., 2012; Blomqvist et al., 2013; Bramson et al., 2010; Lemmen, Fristedt and Lundqvist 2013; Kumar et al., 2008; Vesel et l., 2013) showed non- adherent to KMC because preterm mothers had limited or no information about KMC. Quasem et al. (2003) identified fatigue as a major challenge preterm mother’s encounter when practicing KMC. Additionally, preterm mothers continually expressed challenges such as discomfort on the chest, difficult sleeping with the infant on the chest, difficult with breastfeeding and discomfort associated with the infant temperature. Preterm mother’s medical issues such as pain from episiotomy repair (Brimdyr et al., 2012), pain from caesarean section (Kymre & Bondas, 2013), maternal illness (Lee, Martin-Anderson & Dudley, 2012; Quasem et al., 2003) and among others was emphasized as a challenge for preterm mothers when practicing KMC. Thus, this study seeks to understand the challenges of KMC among mother with preterm infants in Ghana. Studies have shown various challenges mothers with preterm infants’ encounter when caring for their preterm infants especially with the use of KMC. A study by Suraju (2013) explored mothers care at home for their preterm infants within the Accra Metropolis and the study found that most mothers use KMC as a special way to care for their infants. Participants faced challenges such as sleep deprivation, inability to maintain personal hygiene and being cut off from social gatherings University of Ghana http://ugspace.ug.edu.gh Page | 19 because of the tedious and constant care of their infants. Siblings of the preterm infants were not given much attention, and this caused displeasure to mothers. Another study by Gabriels et al. (2015) reviewed the experiences and needs of parents with infants within the NICU. Literature was searched through the following databases, PubMed, Cochrane Library, CINAHL, and PsychINFO. The study showed that parents’ own physical needs (such as needs to eat, drink, sleep and shower) were seen as irritating and difficult when practicing KMC. Parents had other obligations at work or home but the practice of KMC both at the hospital and home impeded parents’ ability to honor their obligations. In addition, parents complained of inappropriate and uncomfortable furniture and rooms for KMC at the NICU, which made it difficult to perform KMC for a longer period because of backache. Inadequate information and communication concerning caregiving activities is a challenge for parents in monitoring their child’s condition when practicing KMC. Mu et al. (2019) reviewed qualitative studies on the experiences of parents who have used kangaroo care for preterm infants in neonatal intensive care. By searching through English and Chinese databases for relevant studies and the use of the Joanna Briggs Institute, qualitative assessment and review instruments were used to extract the findings. The study pointed out that parents who practiced KMC faced challenges such as parental stress and role strain. These challenges become pressure points that make parents (especially mothers) feel as though they cannot cope with parental roles when practicing kangaroo care, which causes parents to experience a sense of emptiness and uncertainty about their parental role. This present study assessed the impact of the practice of KMC on mothers’ level of psychological distress and their coping University of Ghana http://ugspace.ug.edu.gh Page | 20 strategies. That is to determine whether the challenges associated with the practice of KMC at home affect mothers’ level of parental stress, depression and anxiety, and ways of coping. Purbasary et al. (2017) conducted a study to investigate the effect of education about kangaroo mother care on young mothers’ confidence and ability to implement KMC. The study employed a randomized controlled trial and equivalent groups of 13 mothers for each pre-test (control group)- post-test (intervention group). Mothers who were < 25 years participated in this study. Questionnaires were used to measure mothers’ confidence and mothers’ ability to implement KMC was measured by the KMC observation sheet. The study pointed out the young mothers’ confidence and ability to implement KMC increased after education about KMC. This means that before KMC education, young mothers had low confidence and were not willing to implement KMC because they lack knowledge and experience to handle family responsibilities together with the practice of KMC. Present study examines whether maternal age is a challenge to practice of KMC at home and its impact on mothers’ psychological distress. Kurniawati et al. (2019) did a study to investigate the effect of peer support on KMC implementation, infant’s weight, and maternal self-confidence among four hospitals (Jakarta, Bekasi, Tangerang and Bogor). Twenty-four participants were grouped into an intervention group and a control group. The intervention group had their peers educating them on KMC while the control group did not have their peers educating them on KMC. Peers engaged in activities such as sharing their experience on KMC and demonstration of KMC in practice. A maternal self- confidence questionnaire was used to measure maternal self-confidence and observation for infant weight gain. Results have shown that infant weight gain, KMC implementation, and maternal self- University of Ghana http://ugspace.ug.edu.gh Page | 21 confidence have improved effectively as a result of peer support. This current study focused on how social support impacted mothers' psychological distress when practicing KMC at home. Psychological distress (parental stress, anxiety, and depression) among mothers with preterm infants Ango (2016) conducted a cross-sectional survey to examine the psychological distress and coping styles among mothers with preterm infants at Korle-Bu-Teaching hospital. The study sampled 150 preterm and term mothers (50 term mothers and 100 preterm mothers) at Korle-Bu-Teaching hospital. Results revealed less depression and anxiety among mothers with term infants at the NICU than preterm mothers. The NICU environment predicted depression and anxiety. Additionally, mothers’ psychological distress was influenced by parental role, support from family, spiritual and collective coping styles. The current study examines how a specific caring giving approach or intervention (i.e KMC) influences mothers’ level of depression and anxiety since the hospital environment might naturally have an impact on the mother’s level of depression and anxiety. It seems appropriate for this study to examine mothers whose preterm infants have been discharged from the NICU. Moreover, the socio-economic background of mothers with preterm infants might cause mothers to differ in the way they perceive psychological distress. Mothers in Accra may experience different challenges when practicing KMC and this might cause them to perceive depression and anxiety differently from mothers in the Eastern Region. Therefore, the present study focused on preterm mothers in the Eastern Region and their level of depression and anxiety when practicing KMC at home. Another empirical study by Rao et al. (2019) assessed anxiety and depression among postnatal mothers of preterm babies and evaluated whether Kangaroo Mother Care reduces mothers’ University of Ghana http://ugspace.ug.edu.gh Page | 22 anxiety. Participants of 50 were grouped into two, the pre-kangaroo mother care and the post kangaroo mother care. This descriptive study showed that the total mean of the hospital anxiety and depression scale score was significantly less in the post kangaroo care group while mothers in the pre-kangaroo experience significant anxiety and depression. This means, kangaroo mother care can reduce mothers’ stress level, which would affect the mother's level of depression and anxiety. Since mothers in the post kangaroo mother care used KMC for just one week, they might not have experienced the full challenges associated with the practice of KMC. Therefore, this research examines mothers who have used KMC for more than a week and how the stressful challenges influence their level of depression and anxiety. Rogers et al. (2013) conducted a study to investigate the most useful factors which make mothers at risk for postpartum depression or anxiety when discharged from the NICU. Prospective cohort design was used to recruit 73 Caucasian and African-American preterm mothers for three years. At the time of discharge, comprehensive questionnaires were completed by participants to assess postpartum depression, anxiety, and demographic and psychosocial factors. The findings of the study showed clinically significant levels of depression among 20% of preterm mothers and moderate to severe anxiety among 43% of preterm mothers. Additionally, the study indicated that factors such as prolonged ventilation, parental role alteration, and being married contributed to the increase in depressive symptoms. Demographics and psychosocial factors did not contribute to the mother’s anxiety levels. This means that few risk factors lead to anxiety among preterm mothers at the time of discharge. The current study examines the identified risk factors and their relationship with parental stress when practicing KMC at home among Ghanaian preterm mothers. University of Ghana http://ugspace.ug.edu.gh Page | 23 Scime et al. (2019) did a study to investigate the impact of skin-to-skin care on postpartum depression among preterm mothers or mothers with low-birth-weight infants. The study was conducted through a meta-analysis and systematic review at the neonatal intensive care units (NICU). Results of the mate-analysis indicated that continuous practice of skin-to-skin care thrice daily from 15 minutes to an hour was associated with a 1.04% reduction in depression. This is because, at the NICU, infants are separated from their mothers which causes mothers to be psychologically vulnerable therefore, the practice of skin-to-skin care helps alleviate mothers’ psychological vulnerability. This study focused on the impact of the practice of KMC on mothers' psychological distress at home. A study conducted by Soghier et al. (2020) investigated the risk factors and prevalence associated with parental depressive symptoms at neonatal intensive care unit (NICU) discharge and determined the relationships among social support, stress, and depressive symptoms. Standardized questionnaires (such as Center for Epidemiological Studies Depression Scale, Parental Stressor Scale: Neonatal Intensive Care Unit, Perceived Stress Scale, and Multidimensional Scale of Perceived Social Support) were shared among participants in Washington, DC who engaged in giving parental support trial two weeks before NICU discharged. Findings of the study indicated that at NICU discharge, there were high depressive symptoms and increased perceived stress among parents. Younger parents reported higher depressive symptoms and the study showed a positive association between depressive symptoms and parental stress. This is because infants' appearance and parental role alteration became constant stressors for parents to handle. In addition, social support was negatively associated with depressive symptoms. The current study examines mothers' psychological distress after a week of being discharged from the NICU. University of Ghana http://ugspace.ug.edu.gh Page | 24 A cohort study conducted by Herizchi et al. (2017) evaluated the effect of kangaroo mother care on the incidence of postpartum depression in mothers of preterm infants. With a sample of 60 mothers of preterm infants who were hospitalized in the NICU at Tabriz Al-Zahra hospital. Mothers were divided into two groups, mothers with three or more times or days of KMC and those with less KMC. Findings showed that there were no obvious differences at the beginning of KMC, which is the 10th day, but there was a significant difference in the 20th and 30th days. Depression in mothers with KMC decreased during follow-up times. At the NICU, mothers are separated from their infants and this mostly increases mothers’ level of depression therefore, the intervention of KMC would reduce mothers’ level of depression because it is an opportunity to get closer to their babies. The mother’s level of depression will not necessarily be based on the stressful challenges of practicing KMC but rather the challenges at the NICU. Hence, this current study assessed mothers who have been discharged from the NICU and have full access to their preterm infants on any given day while practicing KMC more than three times. Cekin and Turan (2017) conducted a study to determine the stress level of parents whose premature babies are hospitalized in the neonatal intensive care unit and to determine the factors affecting their stress. One hundred and one parent were sampled for this study. The researcher used face-to face interviews and filling of questionnaires to assess parents’ level of stress and the factors that affect the stress levels in parents. The findings of the study show the highest rate of stress on the infants’ appearance and behavior. In addition, parents who had children other than their babies in the NICU had high levels of stress. The mean score on the parental role alteration subscale shows that mothers had higher levels of stress than fathers. It could be the case that being admitted at the hospital alone can contribute to mothers’ rate of stress because mothers cannot bring other siblings to the hospital to take care of them. This would be a challenge for mothers especially when they University of Ghana http://ugspace.ug.edu.gh Page | 25 do not have anyone around to support them. Hence, this current study determines whether other siblings of the discharged preterm infant influence mothers’ level of stress when practicing KMC at home. Since mothers are the primary caregivers of preterm infants, the current study examines whether being married or not influences mothers’ level of stress when practicing KMC at home. Gray et al. (2013) conducted a longitudinal study to explore factors associated with parenting stress among preterm mothers. Participants of 105 preterm mothers and 105 term mothers were enrolled in the study between 2007 to 2009. Standardized questionnaires, such as Parenting Stress Index, the Short Temperament Scale for toddlers, and the Edinburgh Postal Depression Scale were completed by the participants at the age of one of their preterm infants. After comparing preterm and term mothers, the findings showed greater parenting stress among preterm mothers and less parenting stress among term mothers. Infant temperament and depressive symptoms were found as contributing factors for higher levels of parenting stress. The present study examines whether the practice of KMC at home is a risk factor for higher levels of parental stress in preterm mothers and its impact on the mother's psychological well-being. Howe et al. (2014) examined the type and degree of parenting stress among families with very low birth weight infants for the first two years of life. It’s an exploratory study with participants of 505 mothers (297 preterm mothers and 208 full-term mothers) from Tainan-Taiwan. Participants were assessed on the Neonatal Medical Index, Parenting Stress Index, and Behavior-based Feeding Questionnaire. Findings from the study showed that preterm mothers’ levels of stress increases even though it was not statistically significant. Clinical intervention was warranted because preterm mothers demonstrated 13.1% of stress levels. Additionally, preterm mothers demonstrated different parenting stress and health difficulties such as more depression, role restriction, less University of Ghana http://ugspace.ug.edu.gh Page | 26 support from spouses, and social isolation. The present study focused on how the challenges of performing KMC affect parental stress among mothers. Perceived stigma among preterm mothers Murjuki (2017) did a study to determine health workers' perceptions on the factors that would affect KMC implementation in one rural country in Kenya. Participants of service providers and health facility managers engage in focus group discussions and in-depth interviews. Findings indicated that community perception of KMC and stigma served as barriers to the implementation of KMC by the mothers. Since the sociocultural background of Kenya is different from Ghana, the current study uses quantitative methods (questionnaires) to examine whether mothers with discharged preterm infants perceive stigma as one of the challenges when practicing KMC at home in the Ghanaian context. Kampekete et al. (2018) investigated factors that influence the acceptance of KMC in the care of premature babies at the university teaching hospital, Lusaka Zambia. The study used a cross sectional analytical design with a mixed-method approach. Sixty mothers participated in the study. Results showed that 96.7% of the mothers did not agree that it was wrong to place a naked baby skin-to-skin between the breasts while 3.3% were not sure. Additionally, 45% observed the traditional beliefs of caring for a preterm infant while 55% did not. That is the 45% felt it was strange to practice KMC therefore, the mothers were stigmatized against the practice themselves. Since the sociocultural background differs from country to country, this present study assesses the acceptance of KMC from the mothers’ environment (partner, family, friends, and community) and not just the mother. The present study focused on how acceptance of KMC influences mothers’ psychological distress. University of Ghana http://ugspace.ug.edu.gh Page | 27 Mickelson (2015) conducted a study to examine the effects of perceived stigma on perceived support availability, negative interactions, and depression among parents of special needs children such as mental retardation, autism, and developmental delays. A short-term longitudinal method was used with participants from 109 parents of special needs children. Two interviews were conducted over four months among the parents. The study found that perceived stigma was consistently related to less perceived support availability from the respondent’s parents, negative interactions with grandparents and spouse, and increased depressive symptomatology. Structural equation modeling suggested that perceived support availability of grandparents partially mediated the longitudinal relation between perceived stigma and depression. Since the population is different from the current study, it can be possible that mothers of preterm infants would have enough support from family and others. Which can affect mothers’ perceived stigma. The present study would use mothers with preterm infants discharged from the NICU to know how parental stress would mediate the relationship between perceived stigma and psychological distress (depression and anxiety). Perceived social support among preterm mothers Opeara and Okonie (2017) did a study to explore mothers’ knowledge and experiences with KMC at home after discharge from the University of Port Harcourt Teaching Hospital (UPTH). A simple structured interview and questionnaire were used to collect the data among 402 participants in Nigeria. The results of the study revealed that one of the commonest reasons for the termination of KMC was lack of support for domestic chores. Participants described KMC as both a restorative and energy-draining experience. Therefore, a supportive environment facilitates restorative experience while obstacles in the environment make the provision of KMC energy-draining for University of Ghana http://ugspace.ug.edu.gh Page | 28 parents. Thus, this current study examines mothers’ level of perceived support from their environment and how it affects their psychological distress. Since support for domestic chores was the commonest reason for the termination of KMC in Nigeria, this study looked at the contributing factors for parental stress among preterm mothers at home. In a related study, Gold et al. (2013) conducted a study to examine risk factors and the prevalence for depression among mothers with high-risk ill neonates in Ghana. Data were collected through a semi-structured interview among 153 participants at Komfo Anokye Teaching Hospital (KATH). The outcome of the study showed that several symptoms of depression were present among more than two-thirds of the mothers who have an infant(s) at the hospital. Subsequently, lack of perceived social support was indicated among the risk factors of postpartum depression among mothers with sick infants in Ghana. Hence, the study looked to quantitatively investigate the role of perceived social support on psychological distress among mothers with preterm infants who have been discharged from the NICU. Ways of coping among preterm mothers A study by Madu and Roos (2006) investigated maternal levels of symptoms of depression and ways of coping between preterm and full-term mothers in a hospital in Pretoria (South Africa). Convenient sampling was used to select 150 participants (50 preterm mothers and 50 term mothers) at Pretoria academic hospital. The study used the Edinburgh Postnatal Depression Scale (EPDS) and Ways of Coping Questionnaire to collect data from participants. The results of the study demonstrated that preterm mothers’ highest levels of depression were positively related to them seeking for social support. This means that preterm mothers in this study cope with their challenges by depending solely on seeking social support. Hence, their inability to get this social University of Ghana http://ugspace.ug.edu.gh Page | 29 support or when these needs are not met sufficiently increases mothers’ levels of depression. Since the study focused on how coping strategies contribute to depression, this recent study assesses how mothers cope with their psychological distress as a result of the challenges they face when performing KMC at home. Rowe and Jones (2010) conducted a study to compare mothers' and fathers’ patterns of stress, coping, and parenting efficacy for having low-risk preterm infants. The study applied to a longitudinal study. Participants of 25 couples from three special care nurseries in South East Queensland (Australia) completed a survey about their perception of their stress, coping, social support, and parenting efficacy just before their infant’s discharge from hospital and three months later. Results of the study showed that both fathers' and mothers' appraisals of negative stress decreased three months after being discharged. Additionally, there were changes in mothers' and fathers' coping strategies and social support. This is where after transitioning from hospital to home, family routines and life gets established which causes extended support networks (such as support from kinship and informal kinship) to diminish. Thus, parents cope by consulting other parents and medical staff. It is difficult to generalize the above findings because of its small sample size and the different sociocultural background that exists between Australia and Ghana. Therefore, the present study focuses on how mothers’ cope after being discharged. Linden et al. (2015) examined factors that predict parenting stress in a longitudinal cohort of children born very prematurely at age seven years. Participants were 100 parents with preterm infants and a control group of 50 parents with term-born infants between 2001 and 2004 with follow-up at seven years. Parenting Stress Index, Ways of Coping Questionnaire, Child Behavior Checklist, Beck Depression Inventory, and the State-Trait Anxiety Inventory questionnaires were University of Ghana http://ugspace.ug.edu.gh Page | 30 used to assess participants. From the findings, it was found that parents' use of avoidance coping predicted higher parenting stress. Once a particular way of coping can predict parenting stress, then it will be more suitable for this present study to investigate the kind of coping mothers used when faced with higher psychological distress as a result of the challenges associated with the practice of KMC at home. Another study by Awah and Bimerew (2016) explored and described the coping strategies and support needs of mothers with preterm infants admitted to a neonatal care unit in one hospital in Cape Town. The study adopted descriptive and exploratory design to elicit information from participants using semi-structured interview techniques. Purposive sampling was used for sample selection. The study showed that mothers cope by praying, attachment to the baby, acceptance of the situation, and support from others. Since the study focused on how mothers’ ways of coping at the NICU, it will be appropriate for this current study to quantitatively focus on how mothers cope at home after being discharged from the hospital. Al-Maghaireh et al. (2020) conducted a study to investigate how emotional support training programs impact acute stress disorder levels among mothers of preterm infants admitted at the neonatal intensive care unit at a public teaching hospital in Amman at Jordan. The study used a pretest-posttest experimental randomized controlled trial design with 24 participants in each group (control and intervention). Participants in the intervention group were introduced to the emotional support training program. The emotional support training program is where participants in the intervention group had the opportunity to express their feelings and share their experiences with other preterm mothers at the NICU. Also, participants in the intervention group were given psychological training on how to handle their acute stress disorder. It was revealed that there were University of Ghana http://ugspace.ug.edu.gh Page | 31 statistically significant differences between the control group and the intervention group. This means that emotional support helps reduce the amount of acute stress that mothers experience while at the NICU. Hence, the present study investigates how preterm mothers cope with psychological distress while in the house and how effectively it influences mothers’ psychological distress. Schreuder et al. (2012) explored styles of coping relating to work environment and health status among nurses in both Dutch and Norwegian hospitals. A comparative study design was used and questionnaires were used to assess nurses' work environment, health, and coping styles. Findings from the study indicated that Norwegian nurses made use of active problem coping which correlates with good general health. However, the use of emotion-focused coping by both the Dutch and Norwegian nurses was associated with poor mental health, low job control, and poor general health. This shows that cultural differences did not influence the outcome of the use of emotionally focused coping therefore, the current study seeks to establish how preterm mothers cope and its outcome on depression and anxiety within the Ghanaian context. A pilot study conducted by Jones et al. (2010) investigated factors that led to stress among medical students when caring for cancer patients and identified how the medical students cope with these stresses. Self-administered questionnaires such as brief cope inventory was given to 80 medical students from the University of Birmingham, UK. The findings of the study showed that males experienced lower levels of stress than the females and factors such as breaking bad news, patients' condition, and biopsychosocial effects of cancer contributed to the stress. Additionally, it was reported that most students used problem-focused coping and those who experienced higher levels of stress used both problem-focused coping and emotion-focused coping. The study indicated a University of Ghana http://ugspace.ug.edu.gh Page | 32 positive relationship between the two coping styles (emotion-focused coping and problem-focused coping) and stress. This means that both coping styles were not effective in handling stress among the medical students. Cultural differences and the type of stress the medical student encounters may be the reason why the coping strategies were not effective therefore, the present study examines effective coping styles that preterm mothers used when depressed and anxious. Another empirical study by Gueritault-Chalvin et al. (2014) examined how nurses cope with occupational burnout and work-related stress when providing care for people with AIDS. Four hundred and forty-five (445) nurses completed self-administered questionnaires such as the ways of coping scale, rotter’s internal-external locus of control scale, and Maslach burnout inventory. The outcome of the study showed that emotion-focused coping positively correlated with burnout. This means that frequent use of emotion-focused coping did not decrease nurses’ burnout during caretaking. However, the findings also showed a negative correlation between problem-focused coping and burnout. Nurses who used problem-focused coping experienced lower levels of burnout therefore, the use of problem-focused coping becomes a protective factor for nurses. Contrary to the above study Cooper et al. (2008) conducted a study to examine how caregivers of people with Alzheimer’s disease cope with caregivers' burden, anxiety, and depression. The study employs a longitudinal study design with all participants sampled from the UK. The findings of the study showed that more caregivers used problem-focused coping with fewer participants using emotion-focused coping. Further findings showed that the use of emotion-focused coping decreased the levels of anxiety whilst more use of the problem-focused coping led to an increase in anxiety a year later. This is because caregivers perceive the problems of caring for people with Alzheimer's disease as intractable thus, the use of problem-focused coping becomes ineffective University of Ghana http://ugspace.ug.edu.gh Page | 33 and frustrating for caregivers. Since the problems associated with the practice of KMC at home are not intractable, this present study examines the kind of coping ways preterm mothers adopt when depressed and anxious. Summary of Relate Studies Literature have showed that preterm mothers faced challenges such as sleep deprivation, inability to maintain personal hygiene, being cut off from social gatherings, neglect of other siblings of the preterm infants, other obligations at work or home, inappropriate and uncomfortable furniture, family acceptance, maternal age, lack of knowledge about the practice of KMC and lack of social support when practicing KMC (Gabriels et al., 2015; Gold et al., 2013; Lewis et al., 2019; Mu et al., 2019; Opeara & Okonie, 2017; Purbasary et al., 2017; Suraju, 2013). Studies indicated that factors such as prolonged ventilation, parental role alteration, being married, lack of support from family and lack of coping strategies contributed to the increase in depressive, stress and anxiety symptoms at the NICU environment (Ango, 2016; Cekin & Turan, 2017; Gray et al., 2013; Rogers et al., 2013; Soghier et al., 2020). Additionally, the practice of kangaroo or skin-to-skin care predicted both anxiety and depression (Rao et al., 2019; Scime et al., 2019; Herizchi et al., 2017). Perceived stigma was found to be associated with the practice of KMC by increasing depressive and anxiety symptomatology (Kampekete et al., 2018; Mickelson, 2015; Murjuki, 2017). Parents cope with their psychological distress by seeking for social support, consulting other parents and medical staffs, seeking emotional support, avoidance, praying, attachment to the baby, acceptance of the situation and problem-focused coping (Awah & Bimerew; 2016; Al- University of Ghana http://ugspace.ug.edu.gh Page | 34 Maghaireh et al., 2020; Cooper et al., 2008; Linden et al., 2015; Madu & Roos, 2006; Rowe & Jones,2010) Research Hypotheses 1. a. There will be a significant negative association between problem-focused coping and psychological distress (i.e., depression and anxiety) 1b. There will be a significant negative association among emotion-focused coping and psychological distress (i.e., depression and anxiety). 1c. There will be a significant positive association among avoidant coping and psychological distress (i.e., depression and anxiety). 2. There will be a significant positive relationship between perceived stigma and parental stress. 3. There will be a significant negative relationship between perceived social support and parental stress. 4. There will be differences in psychological distress (i.e depression and anxiety) concerning having other siblings, marital status, and maternal age. 5. Parental stress will mediate the relationship between perceived stigma, perceived social support and psychological distress (i.e depression, and anxiety) University of Ghana http://ugspace.ug.edu.gh Page | 35 Conceptual Framework Figure 1 Hypothesised conceptual model In this model, we assumed that perceived stigma and perceived social support would have a direct influence on parental stress. In addition, parental stress is assumed to mediate the relationship between perceived stigma, perceived social support and psychological distress (depression and anxiety). Lastly, demographic variables (i.e., other siblings, marital status and maternal age) and ways of coping are assumed to have a direct influence on mothers’ level of psychological distress (depression and anxiety). Hence, the present study assessed the role of the independent variables (perceived stigma, perceived social support, others siblings, marital status, maternal age and ways of coping) on the dependent variable psychological distress (depression and anxiety). Additionally, to assessed the potential mediating effect of parental stress on the relationship between perceived stigma, perceived social support and psychological distress (depression and anxiety) Perceived Stigma Perceived social support Psychological distress (i.e depression and anxiety) Parental Stress Ways of coping Demographic variables ( i.e, other siblings, marital status and maternal age) University of Ghana http://ugspace.ug.edu.gh Page | 36 Definition of terms Kangaroo Mother Care: Prolonged skin-to-skin contact where a stable LBW preterm infant is placed and carried in skin-to-skin contact of the mother. Psychological distress: An individual expression of parental stress, depression and anxiety in response to a specific stressor. Perceived stigma: The fear of being discriminated against by family, friends, significant others and society. Perceived social support: Is when an individual perceive sources available to provide material, psychological and overall support during times of need. Problem-focused coping: Is when an individual perceives he or she can change a stressful situation Avoidant coping: Is when an individual ignores his or her emotions to alleviate distress by changing the meaning of a particular stressful event. Emotion-focused coping: Is when an individual tries to manage the magnitude of stress on his or her emotions. Research Rationale There are studies of mothers with preterm babies in Ghana, yet, there is sparse literature in Ghana about KMC after discharge from the NICU. The majority of studies on preterm mothers focus on the experiences, detriments, psychological distress, and coping at the NICU (Adu-Bonsaffoh, et al., 2019; Ango, 2016; Aseidu, et al., 2019). Fewer studies, for instance (Akum, 2018; Suraju, 2013) focus on the care of preterm infants at the home or after discharge. But there is limited University of Ghana http://ugspace.ug.edu.gh Page | 37 knowledge about challenges related to the practice of KMC at home and its impact on mothers’ psychological distress and how mothers cope after being discharged from NICU. Hence, to fill the gap, this study seeks to investigate the challenges associated with the practice of KMC at home, its impact on mothers’ psychological distress (parental stress, depression, and anxiety), and how mothers cope with the psychological distress. University of Ghana http://ugspace.ug.edu.gh Page | 38 CHAPTER THREE METHODOLOGY Introduction The chapter presents comprehensive information on the study design, settings, participants and sampling, measures of the study, procedures, ethical considerations and analysis of the data. Design The study employed a cross-sectional research design, because it draws conclusions or inferences about a population of interest at one point in time and examines a large number of variables (Wang & Cheng, 2020). Thus, this helped determined varying views of the participants regarding the issues under investigation concerning the use of KMC among mothers with preterm infants as well as accommodating different characteristics such as age, number of children and marital status. The instrumentation for the research was the distribution of questionnaires to obtain information. Study setting This current study was conducted in the Eastern Region of Ghana specifically at the Eastern Regional Hospital in the New Juaben South Municipality in Koforidua. According to the Ghana Health Service report (Ghana Health Service, 2016), 25, 285 teenage girls were impregnated over the past two years and since teenage pregnancy is a high-risk factor of preterm birth it is more appropriate to conduct the study at the Eastern Region (especially at the Eastern Regional Hospital). Moreover, a study by Sarfo (2018) showed that because of the increase in numbers of preterm delivery, the Eastern Regional hospital has a well-structured Kangaroo clinic for preterm University of Ghana http://ugspace.ug.edu.gh Page | 39 infants and their mothers aside from the NICU. That is, the clinic provides both in-patient and outpatient KMC (Sarfo, 2018). With an in-patient Kangaroo clinic, caregivers are introduced to KMC and allowed to practice intermittent skin-to-skin contact with their infants, before being discharged from the NICU. Out-patient kangaroo clinic is where the clinic follows-up care after being discharged. This is where caregivers have to come for reviews after being discharged. Participants and Sampling Sample participants were recruited from the Eastern Regional Hospital through the use of purposive sampling and convenient sampling techniques. Purposive sampling was used because the population (mothers with preterm infant) consists of specific individuals who bare the relevant information considering the research. Convenient sampling was used because these individuals must be available, accessible to the researcher and be willing to give consent to participate in the study. In addition, the study was open to all persons irrespective of their religious and educational background. Since teenage pregnancy is one of the major risk factors for preterm delivery, it was appropriate to include mothers from 15 years old and above. The convenient sampling technique allowed the population an opportunity to participate without any discrimination. For this research, one hundred and twenty (120) participants were sampled from the population to participate in the study. Minimum sample size determination (N > 50 + 8m where m=number of variables) offered by Tabachnick and Fidell (2013) for regression-based analysis was used to determine the sample size selection. Therefore, the study with 8 variables will need a minimum sample of 114 participants. Hence, a sample size of 120 was adequate for this study. Informed consent was sought from participants themselves, assent from guardians where the participants University of Ghana http://ugspace.ug.edu.gh Page | 40 were below 18 years and consent from the participants themselves after the assent. Withdrawal from this study was acceptable at any point during this study. Inclusion criteria Inclusion criteria for the study, (a) mothers with preterm infants who have been discharged home for more than a week and are 15 years and beyond, (b) mothers with preterm infants who could effectively communicate in Twi and English participated in this study. Exclusion criteria Exclusion criteria include; (a) mothers with preterm infants who might be too ill to communicate in English and Twi; (b) mothers whose infants have been discharged from the NICU less than one week. This is because at that point mothers have not experienced much stress in the home. Measures/Materials Demographic Information Participants completed a brief demographic questionnaire in which they were asked to indicate their age, working status, religion, number of children, marital status, and educational level. Table 1 summarizes the characteristics of the study participants. University of Ghana http://ugspace.ug.edu.gh Page | 41 Table 1: Summary of Demographic Characteristics of Participants in the Study (N =120) Variables Frequency Percentage Mean SD Number of children 1.37 2.42 Weeks after discharged 0 .65 0.98 Maternal Age range Teenagers (16-19 years) 12 10.0 Young Adult (20-30 years) 55 45.8 Adult (31-40 years) 41 34.2 Old Adult (41years & above years) 12 10.0 Marital status Single 40 33.3 Married 60 50.0 Divorced 3 2.5 Cohabiting 17 14.2 Educational level Basic Secondary Tertiary Others 43 35 41 1 35.8 29.2 34.2 0.8 Occupation Employed Unemployed Others 46 30 44 38.3 25.0 36.7 Religion Christian Muslim 101 19 84.2 15.8 Type of child delivery Caesarian Self-delivery 85 35 70.8 29.2 Childs corrected Age 0-3 months 4-6 months 7-9 months 10-12 months 53 42 23 2 44.2 35.0 19.2 1.7 University of Ghana http://ugspace.ug.edu.gh Page | 42 Parenting Stress: Parenting Stress Scale (PSS) (Berry & Jones, 1995). It is an 18-item self-report scale, which measures stress due to parenting a child (Berry & Jones, 1995). This scale takes into account positive (emotional benefits, personal development) and negative (demands on resources and restrictions) aspects of parenting. It is on a 5-point scale (1- strongly disagree, 2- disagree, 3- undecided, 4- agree & 5- strongly agree) for participants to indicate the degree to which they agree or disagree with each item. Examples of the items include; “Caring for my child sometimes takes more time and energy than I have to give, it is difficult to balance different responsibilities because of my child and I feel overwhelmed by the responsibility of being a parent”. For scoring, items 1, 2, 5, 6,7,8, 17 and 18 should be reversed before summing up all the items. Thus, possible scores on the scale can range between 18-90. Lower scores signify a low level of stress while high scores signify a high level of stress. The scale has an internal reliability of (.83) and test-retest reliability of (.81) (Berry & Jones, 1995). Psychological distress: Brief Symptom Inventory (BSI) (Derogatis & Melisaratos, 1983). It aims is to demonstrate the clinical psychological symptoms of medical, psychiatric and healthy subject. It a self-report inventory with 53-items. Measures three global dimensions of psychological distress and nine profiles of primary symptom areas. But this study made use of only anxiety and depression subscales. Answers are on a 5-point likert scale (0 = not at all, to 4 = extremely). All items under all the subscales are added and divided by 53 (the total number of items on the scale) in order to obtained the Global severity index (the total score on the scale). Depression has 6 items with sample questions such as “Feeling lonely, feeling sad and Feeling hopeless about the future’’. Anxiety is measured on 6 items with sample questions such as University of Ghana http://ugspace.ug.edu.gh Page | 43 “Suddenly scared for no reason, Feeling fearful and Spells of terror or panic”. The BSI has a high Cronbach's α for all the subscales, which is within 0.71 to 0.85 (Derogatis, & Melisaratos, 1983). In addition, a study among Ghanaian mothers with preterm infants reported a reliability for BSI Depression subscale as 0.74 and BSI Anxiety subscale of 0.81 (Ango, 2016). Perceived Social Support: Multidimensional Scale of perceived social support (MSPSS) (Zimmert et al., 1988) Multidimensional Scale of Perceived Social Support (MSPSS) evaluates people perceptions of social support received from 3 sources. It consists of three subscales which includes Family (4 items), sample question ―My family really tries to help me; Friends (4 items), sample question ―I can talk about my problems with my friends; and Significant Other (4 items), sample question ―I have a special person who is a real source of comfort to me. The scale consists of 12 items, with 4 items for each subscale, rated on a 7- point Likert scale ranging from (1) strongly disagree to (7) very strongly agree. Ango (2016) reported a total consistency of Cronbach alpha 0.88 among mothers with preterm infants. For scoring, calculate the mean score of each subscale and divide it by 4. Therefore, any score low score (i.e 1-2.9) is considered as low support, moderate score (i.e 3-5) is considered as moderate support or support and higher scores (i.e 5.1-7) are considered as high support. Coping: Brief Cope Inventory (BCI) (Carver, 1997) The Brief Cope Inventory is a self-report measure for coping and a short version of the COPE inventory (Carver et al., 1989). This Inventory assesses different coping strategies people would use when they encounter a particular stressful condition. It's made up of 14 subscales that are categorized into adaptive coping and maladaptive coping (Meyer, 2001). Adaptive coping includes University of Ghana http://ugspace.ug.edu.gh Page | 44 seeking social support, emotional support, planning, humor, active coping, reframing, use of religion and acceptance. Maladaptive coping also includes denial, self-blame, substance use, venting, behavior disengagement and self-distraction. These 14 subscales consist of 2 items each which sum up to 28 items on the Inventory with a sampled question of ‘I've been trying to find comfort in my religion or spiritual beliefs’ (religion) and ‘I’ve been trying to get advice or help from other people about what to do’ (instrumental support). The 14 subscales are categorized into three overarching coping ways. It includes the problem-focused coping, emotion-focused coping, and avoidant coping. Responses are rated on a 4-point Likert scale ranging from (1) I haven’t been doing this at all to (4) I’ve been doing this a lot. The Inventory was developed from theoretical models such as behavioral self-regulation and Lazarus’ transactional model of stress (Muller & Spitz, 2003). Additionally, it is used to evaluate trait coping and state coping. The usual way an individual copes with everyday life stressors is term as trait coping while the specific way an individual uses to cope with specific stressful situations is referred to as state coping. Internal consistency for the 14 subscales ranges from α= 0.57 to 0.90 (Carver, 1997). To score the items, each overarching coping ways are summed up and divided by the number of items under each overarching coping ways. Higher scores for each overarching coping ways indicate participates use of such coping way while lower scores indicate less use of such coping way. Perceived Stigma: Perceived Stigma Scale – Revised (PSSR) (based on Mickelson et al., 1999) The Perceived Stigma Scale is a self-report measure, adapted from other measures of perceived stigma (Crandall, 1991; Levinson & Starling, 1981). Mickelson’s Perceived Stigma Scale contains eight items, assessed on a 5-point Likert scale (1=Definitely False; 3=Neither; 5=Definitely True). The eight items have been found to have an internal consistency coefficient of .76 and test-retest University of Ghana http://ugspace.ug.edu.gh Page | 45 reliability of .78 (Mickelson, 2001). This current study will adapt from Mickelson et al. (1999), which assessed perceived stigma among parents of children with special needs. According to Mickelson (2001), the scale has been used with a variety of different populations by changing the wording to match the stigma with which that specific population deals. The current study will reword the items so that the stigma reaction being measured will be in response to practicing of KMC after discharge. The scale will be administered three times in the current study, to assess parenting-related perceived stigma in three different contexts: (a) among family members, (b) fri