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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 128-133

Validation of the Malayalam version of the parental stressor scale: Pediatric intensive care unit

1 Krishna Maternity Home and Pediatric Centre, Tirunelveli, Tamil Nadu, India
2 Department of Psychiatry, Believers Church Medical College Hospital, Thiruvalla, Kerala, India

Date of Submission27-Feb-2020
Date of Decision07-Apr-2021
Date of Acceptance16-Apr-2021
Date of Web Publication21-May-2021

Correspondence Address:
Dr. Janani Sethuraman
19J/3, Rose Avenue, St. Johns College Road, Palayamkottai, Tirunelveli - 627 002, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcc.jpcc_189_20

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Background: For any research, it is important to ensure that an establish instrument conforms to the culture of the population in focus. The objectives of this study include translation of the Parental Stressor Scale: Pediatric Intensive Care Unit (PSS: PICU) questionnaire into Malayalam and the analysis of its psychometric properties.
Subjects and Methods: This was a cross-sectional study of 201 parents of children admitted to the PICU. The PSS: PICU questionnaire was first translated into Malayalam language using the standard “Forward-Backward” procedure. Following consent, parents completed the demographic sheet and the Malayalam version of PSS: PICU scale within 30 min.
Results: Analysis showed good psychometric properties for the Malayalam PSS: PICU questionnaire when compared to the original English version. The principal component factor analysis with Varimax rotation was used to assess the validity and was found to favor the conceptual dimensions of the original English questionnaire. The Cronbach's alpha coefficient used to assess reliability was 0.865 for the entire scale reflecting good internal consistency.
Conclusion: The PSS: PICU questionnaire was translated to Malayalam and the psychometric properties of the Malayalam version were found to be adequate, albeit requires further exploration before extensive use.

Keywords: Malayalam parental stressor scale, parental distress, parental stressor scale, pediatric intensive care unit

How to cite this article:
Sethuraman J, Venkateswaran C. Validation of the Malayalam version of the parental stressor scale: Pediatric intensive care unit. J Pediatr Crit Care 2021;8:128-33

How to cite this URL:
Sethuraman J, Venkateswaran C. Validation of the Malayalam version of the parental stressor scale: Pediatric intensive care unit. J Pediatr Crit Care [serial online] 2021 [cited 2023 Jun 2];8:128-33. Available from: http://www.jpcc.org.in/text.asp?2021/8/3/128/316594

  Introduction Top

A pediatric intensive care unit (PICU) caters to the critical care of children with serious illness under a notable stressful milieu.[1],[2],[3] Following the admission of children to PICU, there is pronounced interference into the lives of their families.[4],[5],[6] This impact on families, especially parental distress has been previously documented.[4],[7],[8] Evidently, parental distress has an unfavorable effect on care and long-term adjustment of children.[9] Thus lays the significance in identifying parental stress.

Among the several questionnaires formulated to detect parental distress, the most recognized and studied is (Parental stressor scale [PSS]: PICU).[10],[11]

The PSS: PICU was published by Melba C. Carter and Margaret S. Miles in 1989.[11] The conceptual framework behind PSS: PICU was based on Selye's theory on stress and Roy's model of nursing.[12],[13] The theory concentrated on defining the elements contributing to stress at various levels of individual, situational and environmental along with the influence of individual's perception on them.[11] Personal stressors comprise of age, education level, and vulnerable personality of parents while situational stressors are cumulative of contextual factors such as reasons for admission of child, preparedness of parents, and interventions done for the child. PSS: PICU was designed to assess specifically environmental stressors related to the physical and psychosocial environment of the intensive care unit (ICU).[11]

As the first step in the development of PSS: PICU, parents were observed during admission of child to ICU and possible contributing factors to stress were noted down. Following the discharge of children, parents were requested to validate these noted stressors. Combining the observations and the response given by parents, 56 items indicating environmental stress in ICU were identified. Further evaluation on appropriateness of items was done through a small pilot study with 10 parents and 11 nurses at the end of which 44 more items were added. With the help of the members of the Pediatric Nursing Research Section, 100 items were then compressed into a 79-item scale. The 79 items were organized into seven dimensions-Child's appearance, Sights and sounds, Painful procedures conducted on the child, Alteration in the parenting role, Staff's behavior and communication, and Behaviours and emotional responses.[11]

The psychometric evaluation began with the test-retest technique where 17 parents were given the instrument twice at a 48-h gap. The resultant correlation coefficients of all dimensions favored stability of instrument except for Sights and sounds. Further evaluation was done involving another group of165 English-speaking parents who scored the State-Trait Anxiety Inventory (STAI) in addition to this instrument. The Cronbach's alpha coefficient of 0.96 reflected good internal consistency of the instrument thereby indicating its reliability. Pearson correlations computed for establishing the validity of the scale, compared dimensional scores of instrument and state anxiety scores in STAI and appeared statistically significant at P = 0.01. Principle component factor analysis with Varimax rotation applied to assess the adequacy of sampling showed 67% variance with six-factor solutions. With the additional exploration of conceptual clarity of items using factor analysis, the instrument was refined. The revised scale was then administered to a different set of 510 parents along with STAI. The favorable results were an alpha coefficient of 0.95 for the entire scale and Pearson correlation coefficients of 0.29–0.42 (P < 0.0001). Thus, the final outcome of scale contained 37 items categorized into seven dimensions.[11]

Various studies on translation of PSS: PICU have shown good validity and reliability with adequate psychometric properties in other languages including Malay, Spanish and Chinese.[11],[14],[15],[16],[17] Amongst the research with PSS: PICU until now, items found scoring high include loss of parental role with physical separation from child, difficulty understanding medical information on child's outcome, and feeling helpless on seeing child in pain.[18],[19] The stress assessed through PSS: PICU were found correlating to psychological outcomes such as anxiety, depression, and PTSD.[8],[20] Determination of such variables would pave way for strategies for intervention.

Despite substantial literature on PSS: PICU, one of the biggest obstacles for its application is cultural veracity. For ease of administration, the questionnaire has to be translated to the native language of people. Before conforming to large-scale implementation, a detailed analysis of translated questionnaire is required. Thence, the aim of our study to translate PSS: PICU for the Malayalam-speaking population.

  Materials and Methods Top


The PSS: PICU instrument contains 37 items designed specially to assess parental stress in pediatric intensive care settings, scored along a five-point Likert scale of 0 (not experienced) or from 1 (not stressful) to 5 (extremely stressful). The total scores range from 0 to 185. The questions are arranged into 7 dimensions:[11]

  1. Appearance of the child (3 items)
  2. Sights and sounds of alarms and equipment (3 items)
  3. Painful procedures conducted on the child (6 items)
  4. Behavior of staff towards child observed by parents (6 items)
  5. Alteration in parenting role (6 items)
  6. Communication with parents about child's condition by Staff (5 items)
  7. Behaviors and emotional responses of child in an intensive care setting (10 items).

Ethical consideration

Following approval from the Research Ethics Committee of the University (IEC-AIMS-2017-PSYCH-308), the original PSS: PICU was procured from the University of Kansas, School of Nursing, which holds the copyright for the questionnaire along with permission to translate it. Before giving questionnaire, all parents were given written information about the nature of study with assured confidentiality, and written consent was obtained.


The standard “forward-backward” procedure was applied to translate PSS: PICU from English into Malayalam. Two bilingual staff members translated the original scale into Malayalam followed by two independent translators who back-translated the translated versions into English. The translators were not connected to the study and hence comparability and equivalence were ensured. With the help of different versions, the authors then created a provisional Malayalam version of the scale. After few rounds of iterative checking, minor differences between different translations were corrected and the final version was finalized for this study.

Sample and setting

Parents of children admitted in PICU were included in this study. Parents selected were those whose children were admitted within the last 72 h, native of Kerala who could read and understand the Malayalam language and willing to take part in the study. A total of 201 parents of 133 children participated in this study. If both father and mother participate, each of them was given separate questionnaire. Exclusion criteria were children admitted <24 h, parents with a history of mental health issues, and difficulty in communication.

Data collection

Firstly, consent was taken after providing information about the study. Parents were approached only 24 h after admission to give them time for acclimatizing to PICU. Following consent, parents were asked to fill in the demographic sheet and PSS: PICU questionnaire. Demographic data collected included age, education, occupation, income, socioeconomic status and previous experience of PICU. Information about child included age, gender and reason for admission. The investigator remained in the vicinity to clarify doubts during the process of answering the questionnaire. Parents finished the questionnaire within 30 min. A retest with parents could not be planned in this study as a child's condition is unpredictable in intensive care settings.

Statistical analysis

The IBM SPSS version 20.0 software (Kochi, Kerala, India) was employed for analyzing statistics in this study.


Validity is an important measure to certify the soundness of this instrument for the purpose it was designed, i.e., identifying parental distress. At first, the Kaiser-Meyer-Olkin measure of sampling adequacy was done to show the proportion of variance among variables to decide if this study was satisfactory for principal component analysis. The principal component analysis aids in examining large data by reducing variables into smaller groups yet intact with the same information. The homogeneity among those variances was checked with Bartlett's test of sphericity before advancing to further analysis.

Factor analysis

Factor analysis was used to assess the construct validity of the instrument. Principal component factor analysis with Varimax rotation was performed on the data. This was the same statistical approach used by the originators of the instrument.


Reliability infers the ability of this questionnaire to produce the same results when repeatedly administered. Cronbach's method reflects the connectedness among the items in the tool. The Cronbach's alpha coefficients were calculated for each subscale and for the total instrument.

  Results Top

A total of 201 completed Malayalam versions of PSS: PICU questionnaires were collected over a 6-month period of study. Among the 228 parents approached, 27 (12%) of them returned questionnaire for reasons including poor matching of the timing of visiting hours of parents with that of investigator and outright refusal of participating in the study. Once parents refused to take part in this study, they were not contacted the second time.

In this study, 201 parents participated comprising of 95 fathers and 106 mothers. The mean parental age was 35 years. With the help of the Modified Kuppusamy scale, based on education, occupation, and income information, socioeconomic class was determined and included an upper class of 4%, upper-middle 50.2%, lower-middle 27.9% and upper-lower 17.9% among the participants.

Out of 133 children, 12.4% were between 1 month and 1 year of age, 37.3% 1–5 years, 38.3% 6–10 years and 11.9% 11–15 years of age. The mean age of children was 5.9 years. The reasons for admission included neurological (40% mainly seizure disorder), respiratory (31%), cardiac (9%), gastrointestinal (17%), and orthopedic disorders (3%).

The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.767, indicating that the data of this study was suitable for subsequent principal component analysis. Bartlett's test of sphericity was significant (P < 0.001) indicating sufficient correlation among variables to further proceed with the analysis.

The initial factor analysis provided 10 factors with eigenvalues >1, which collectively accounted for 70.54% of the variance. The application of a screen test showed that 7 factors could be retained. The rotated factor matrix for the 7-factor solution explained 60.7% of the variance in the data [Table 1]. These factors were in congruence with the conceptual dimensions of the original instrument.
Table 1: Rotated component matrix

Click here to view

The Cronbach's alpha coefficients were acceptable (>0.70) for all the subscales except “Child's behavior and emotions” (0.58) as shown in [Table 2]. The internal consistency for the entire scale (0.865) was good, indicating that the instrument measures the characteristics relevant to the construct of stress in each dimension.
Table 2: Alpha coefficients for subscales

Click here to view

  Discussion Top

India is a country with 22 languages and diverse culture. The most challenging task is to overcome this varsity in language and culture while administering self-reporting questionnaires. It is not only the native language that should be considered but also other socioeconomic factors which can affect merely participation in the studies.

With existing literature, this is the first of validation studies in India on PSS: PICU with copyrights under the University of Kansas, School of Nursing.

The comprehensive examination of psychometric properties of the Malayalam version of PSS: PICU provided favorable outcome in comparison to the original instrument. It is of essence to collate, compare and explore alongside other validation studies of PSS: PICU as well apart from original to augment value to this study.

The translation method adopted in this study was standard “forward-backward” procedure. With validity and reliability well established for original instrument, it was important to ensure that questions in the Malayalam version retained the meaning of the English version. Besides, the Malayalam version had to be in simple language yet grammatically right to aid in easy comprehension. Similar translation method was used in the validation studies of Arabic and Chinese versions of PSS: PICU questionnaire.[16],[17] While Arabic study used standard translators, Chinese study used bilingual nurses for study. In the Spanish study on PSS: PICU, aside from back translation procedure and involvement of bilingual and bicultural committee, bilingual parents were asked to complete both Spanish and English questionnaires aiding in better assessment of equivalency of their instrument.[15]

In this study, 201 parents of 103 children participated following informed consent. During the creation of the original instrument, several groups of parents were involved at various levels of the study.[11] In the subsequent validation studies, the sample size ranged from 20 parents in Spanish study to 350 parents in Arabic study.[15],[17]

This study followed the exploratory factor analysis method similar to that applied during original instrument creation. The analysis began by determining sampling adequacy with Kaiser-Meyer-Olkin measure which came 0.767. This indicated that the data collected was suitable for principal component analysis. Bartlett's test of sphericity showed significant results proving sufficient correlation among variables. Finally, principal component factor analysis with Varimax rotation performed explained 60.7% of the variance in data. Unlike Arabic and Chinese studies where similar detailed exploratory factor analysis was done to ascertain the validity of the translated instrument, the Spanish study had demonstrated only the appropriateness of translated tool.[15],[17] Additionally the Chinese study evaluated convergent validity by comparing Pearson correlation coefficients of translated tool with state anxiety scores.[16]

To establish the reliability of the Malayalam version of PSS: PICU, the Cronbach's alpha coefficients were calculated. Alpha coefficients were more than 0.70 for all subscales except “Child's behavior and emotions” (0.58). The validation study of the Spanish version of PSS: PICU had published disclosing the lower Cronbach's alpha coefficient for two of the subscales – Child's appearance (0.47) and Staff behavior (0.58).[15] In the above paper, the lower alphas were attributed to the application of this questionnaire to an incongruous cultural background as opposed to the American context of the originally created English version. This is pertinent to Indian culture as well and requires further detailed research to modify the subscale.

An alpha coefficient of 0.865 for the instrument as a whole signified good internal consistency of the translated tool. It was observed that other studies including Spanish, Arabic, and Chinese translation of PSS: PICU also scrutinized reliability by computing the alpha coefficients and were able to demonstrate substantial internal consistency of their translated tools.[15],[17]

In our study, the stressor scale revealed a mean score of 2.59 with standard deviation of 0.609 indicating pronounced distress among parents. Out of the seven components in scale, sights and sounds and parental roles scored most stressful although there was no association of distress with the gender of the parent.

In this study, equivalency could have been better established if both Malayalam and English questionnaires were given to same parent. Practically it is difficult to implement this, as it requires population who can read and write both Malayalam and English languages. In addition to this, answering two questionnaires would require twice the time and being already in a stressful situation it is difficult to expect participation in such a study.

This study was organized as one-time contact with parents. Retest for validation was not planned as the condition of the child cannot be predicted in ICU. However, follow up of parents could have aided in understanding and differentiating even better on possible stressors, i.e., personal, situation, and environmental.

The lower alpha coefficient of one subscale directs attention to the background Indian setting, indicating the need for more research appropriate to socioeconomic cultural framework.

On one hand, restricting a study to specific population could hamper applying the findings on large scale basis; while on the other hand, a diverse culture poses challenge for generalizing self-reporting questionnaire.

The above exploration of Malayalam PSS: PICU could be considered as foundation for future work thus promoting progress in this field of interest.

  ConclusioN Top

The psychometric properties of the Malayalam version of PSS: PICU were found to be adequate but limitations warrant additional investigation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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