Aim: The purpose of this study was to develop a scale, “parental anxiety about pediatric emergency medical care services” (PAPEMCS), and to evaluate its psychometric properties. Methods: Participants were 14,510 parents with children 6 years old or younger in Kagawa Prefecture. Using each half of the participants, exploratory factor analysis was performed to generate items and factors for the PAPEMCS, and confirmatory factor analysis (CFA) was used to establish the construct validity. The generalizability of the PAPEMCS was evaluated by congruence tests and multigroup CFA. The usefulness of the PAPEMCS was established by the relationship between the PAPEMCS and non-urgent usage of pediatric emergency medical care services (PEMCS). Results: The PAPEMCS compromised 4 factors: “anxiety about quality of PEMCS”, “anxiety about PEMCS system”, “anxiety about public support”, and “anxiety about private support”. All reliability estimates (polychoric ordinal alpha coefficients, item-rest correlations), the item discrimination, 5 fit indices for CFA, the convergent validity (indicator reliabilities, composite reliabilities, average variance extracteds), and the discriminant validity fulfilled the acceptability thresholds. All generalizability estimates fulfilled the predetermined levels of acceptability (Tucker’s congruence coefficients, congruence tests, strict factorial invariance). The usefulness of the PAPEMCS was established by the higher scores of the PAPEMCS being related to non-urgent usage of PEMCS. Conclusions: The PAPEMCS demonstrated satisfactory reliability, validity, generalizability and usefulness. The PAPEMCS is useful to quantify the contents and extent of parental anxiety about PEMCS, and to clarify the mechanisms of non-urgent PEMCS usage.
The appropriate enforcement of pediatric emergency medical care service (PEMCS) is a vital component of pediatric health services. However, around the world, especially in developed nations, pediatric emergency department (PED) crowding due to PED visits for non-urgent health concerns prevents the efficient and efficacious use of health services. The overcrowding threatens the quality (treatment delays for children requiring attention and urgent medical care), wastes resources, and is a financial burden to parents and to society [
A lot of previous studies have demonstrated that non-urgent PED users are characterized by high levels of social, educational, and financial disadvantages, and include parents with only one child, young mothers, single parents, and parents with a low education and low income that receive public insurance or have no insurance [
Regarding the reasons of PED usage, parents, especially those engaging in non-urgent PED usage, have the sense of anxiety over child’s illness [
In addition, parents are full of anxiety about PEMCS systems, such as convenience of 24-hour accessibility [
However, no studies have been conducted to clearly explain what aspects of parental vulnerability or PEMCS systems are related to what kind of anxiety about PEMCS [
To provide suitable PEMCS that eliminate parental anxieties with limited health resources, it is firstly essential to investigate the multifarious parental anxieties about PEMCS. If a scale for quantifying the contents and extent of multifarious anxieties about PEMCS could measure specific anxieties caused by specific risks, as well as comprehensive anxieties integrating individual anxieties, the scale would be useful to examine multifarious risks of PEMCS. This study aims to develop a scale to quantify the contents and extent of parental anxiety about PEMCS, and to examine the reliability, validity, generalizability and usefulness of the scale.
In order to ensure the generalization of the scale, Kagawa Prefecture was selected as an area that fulfills the research requirements: multifarious family structure, PEMCS systems, and diverse geographical features. The population of Kagawa Prefecture is 995,842 [
The PEMCS systems in Kagawa Prefecture represent multiple PEMCS available in Japan. For example, the PEMCS system of the Takamatsu secondary medical region (Takamatsu) is constituted of typical systems of PEMCS in Japan: primary (a pediatric emergency night clinic), secondary (a group of hospitals on rotational duty) and tertiary (Kagawa University Hospital) [
Although the PEMCS system in Chusan is rare in Japan, it is important in the future development of PEMCS to examine not only other PEMCS systems, but also the PEMCS system itself. Therefore, as an area to ensure the generalization of the scale, Kagawa Prefecture was selected.
The inclusion criteria were as follows: the family who has a child six years old or younger because many of such children visit PED [
In order to fulfill the inclusion criteria, the selected participants were parents of children attending kindergartens or nursery schools, or those undergoing a health examination at a health center (one and a half years old or three years old) in Kagawa Prefecture.
First, based on literature review, three pediatric and four community nursing researchers developed 43 questionnaire items that depict parental anxiety about PEMCS: information, system, or quality of PEMCS; public support; private support; and parental care ability [
Third, the preliminary research was performed for parents who only had children of seven years old or older, because the main research was intended to secure families with children of six years old or younger as much as possible. In addition, if both the preliminary research and the main research participants are parents whose children are the same age, when the investigation institutions handed a questionnaire to parents, it was considered to be difficult to exclude the participants of the preliminary research from the main research. By using quantitative research, items were selected in which at least 23 respondents (57.5%) expressed high anxiety. Finally, 31 items were selected to constitute the questionnaire from the initial pool of 43 items. Final items included both the information of PEMCS, such as telephone consultation, and public support, such as Kagawa Emergency Support Network. The emergency support network is conducted by 47 municipalities to care for sick children of parents, such as a nuclear family with two-income or single mother [
The questionnaire also included demographic variables and the situation in which participants used a pediatric emergency institution most recently.
This survey was performed as part of a research project entitled “Pediatric Emergency Medical Care in Kagawa Prefecture”. Between January and February 2009, the survey was conducted [
In order to avoid duplication in replying to the questionnaire and confirm the number of participants, the survey was conducted as follows: parents with two or more children attending the same kindergarten or nursery school were each handed one questionnaire; the institution maintained a record of the number of questionnaires distributed and the number of remaining questionnaires, and made a report of these figures; and when a guardian had already replied to the questionnaire, she/he was asked to mark in the subsequent questionnaire that she/he had already replied, provide a signature, and return it.
Approval of this study was obtained from the ethical review board of the author’s institution (Heisei 20 - 25). This study was administered after obtaining informed consent from the Kagawa Prefectural Government, 17 municipal offices, the principal organization of national and public kindergartens, a private kindergarten federation, and 21 health centers.
To maintain the quality of the data, all missing data were excluded from the candidate data of the scale. All participants were randomly divided into two groups using an odd-even splitting method. First, using one half of the participants, which were assigned an odd number identification (odd number group), exploratory factor analysis (EFA) was performed to generate items and factors for parental anxiety about PEMCS, and the factor structure and reliability of the scale were examined. Second, using the second half of the sample, which was assigned an even number identification (even number group), confirmatory factor analysis (CFA) was performed to test the generality of the extracted factor structure by EFA, and reliability and construct validity for the scale were examined.
All statistical analyses were carried out with SAS 9.2, EFA was conducted by the FACTOR procedure, and CFA was performed by the CALIS procedure.
If a high proportion (≥50%) scored the highest (ceiling) or lowest (floor) possible score on an item, this item was excluded as a floor or ceiling effect [
Because unweighted least squares on EFA makes no assumptions of normality [
The reliability assessments of the scale extracted by EFA were conducted using the polychoric ordinal alpha coefficient, item-rest correlation, and good-poor analysis [
In order to evaluate fit of the scale structure based on EFA (factorial validity), CFA was conducted using the unweighted least squares estimation method and polychoric correlation matrix. The unweighted least squares estimation method for CFA provides more accurate and less variable parameter estimates, more precise standard errors, and better coverage rates [
The reliability and validity of the proposed model, and the quality of the individual items were evaluated using component fit results. As the chi-square difference test is highly sensitive to the sample size, model fit was assessed using a combination of fit indices [
In order to assess convergent validity, indicator reliability, composite (construct) reliability, and average variance extracted were examined [
Average variance extracted estimates above 0.5 were treated as indications of convergent validity, which means that at least 50% of the variance in a measurement was due to the hypothesized latent factor [
It is essential for generalizability of scale to demonstrate measurement invariance. Tucker’s congruence coefficient, congruence test, and multigroup CFA were conducted to examine measurement invariance of the scale. Tucker’s congruence coefficient index assessed the similarity of two factor-loading patterns. Tucker’s congruence coefficient exceeding 0.95 suggested that the two factors compared could be considered equal [
Because little is known about the relationship between parental anxiety about PEMCS and the risks of non-urgent PED usage, a suitable scale for verifying concurrent validity of the scale could not be found by literature retrieval. On that account, in order to verify usefulness of the scale, using a Cochran-Mantel-Haenszel test and generalized linear model, the relationship between the scale and vulnerable factors or PEMCS systems was examined.
For example, the relationship between the scale and a certain vulnerable variable, such as single mother, was assessed by means of Cochran-Mantel-Haenszel test, stratified according to other demographic variables. In each vulnerable variable, the common relative risk was calculated in Cochran-Mantel-Haenszel test as the ratio of the proportion of the higher score group (≥median) in the other demographic group, versus the higher score group (≥median) in the particular demographic group, such as single mother, as a reference group that was inferred with the highest risk of non-urgent usage of PED in a previous study [
To clarify the usefulness of the scale on the mechanism clarification for non-urgent usage of pediatric emergency institutions, the relationship among the risk factors of non-urgent usage of the PEMCS, the scale and 8 pediatric emergency institutions that participants used in the immediate past were analyzed. In addition, to analyze certain structural aspects of the scale through the risk factors and non-urgent usage of pediatric emergency institutions, a multiple correspondence analysis was employed as a statistical multivariable analysis that allows the joint study of relational and attributive data [
Among participants who received a questionnaire, 34,606 questionnaires were evaluated after excluding 5,847 questionnaires (5,256 incomplete questionnaires and 591 duplication questionnaires) from 40,453 distributed questionnaires. Among the 18,043 questionnaires that were returned, 17,452 questionnaires (50.4%) were evaluated after excluding 591 duplication questionnaires. To constitute the scale, a complete database was constructed from 14,510 (83.1%) respondents who responded to all 31 items. The demographical variables of the odd number group were not different from those of the even number group (
First, EFA was performed to generate items and factors for parental anxiety about PEMCS.
Demographic variable | Item | Odd number group n = 7255 n | Even number group n = 7255 n | P-value |
---|---|---|---|---|
Respondent | Mother | 6951 | 6951 | 0.994a |
Father | 242 | 240 | ||
Grandparent | 34 | 32 | ||
Other | 6 | 6 | ||
Age of respondent | 15 - 19 | 3 | 1 | 0.776b |
(Years old) | 20 - 24 | 107 | 130 | |
25 - 29 | 916 | 845 | ||
30 - 34 | 2697 | 2725 | ||
35 - 39 | 2550 | 2614 | ||
40 - 44 | 817 | 780 | ||
45 - 49 | 105 | 103 | ||
≥50 | 41 | 39 | ||
Family structure | Nuclear family, father working | 2373 | 2421 | 0.120c |
Nuclear family, two incomes | 2817 | 2815 | ||
Living together with grandparents, father working | 466 | 474 | ||
Living together with grandparents, two incomes | 911 | 852 | ||
Single mother | 176 | 193 | ||
Single father living together with grandparents | 46 | 25 | ||
Single mother living together with grandparents | 186 | 171 | ||
Number of children | One | 1485 | 1541 | 0.777b |
Two | 3994 | 3904 | ||
Three | 1515 | 1546 | ||
Four or more | 226 | 227 | ||
Medical region | Chusan | 2158 | 2191 | 0.661c |
Takamatsu | 3283 | 3204 | ||
Okawa | 639 | 637 | ||
Mitoyo | 990 | 1012 | ||
Shozu | 145 | 162 | ||
Naoshima (remote island in the Takamatsu medical region) | 18 | 24 |
aFisher’s exact test. bWilcoxon rank-sum test. cChi-square test. The total number is different for the missing values.
Then, CFA was performed to evaluate fit of the scale structure based on EFA.
A floor effect or ceiling effect was not observed for all items. As five elements of 465 elements had a variance inflation factor value of more than five, four items were omitted from the polychoric correlation matrix in order to exclude multicollinearity (Appendix 1).
The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.925, which was a clear indication that it was a high factorability for the sample. On the basis of Cattell’s scree test, it was decided to extract four factors, as the decrease of plotted eigenvalues appeared to level off after factor four. Likewise, a four-factor structure was obtained in accordance with the final eigenvalues (11.03, 2.85, 1.69, 1.19), which were higher than 1.0, the reference value set by the Kaiser rule. A four-factor solution accounted for 92.29% of the total variance in the items before rotation.
On the basis of these criteria, a second EFA was conducted, and 15 items out of the original 27 items were retained in the end. Following a promax rotation, loadings of the items on the respective factors all exceeded 0.674, and there was no item having a cross-loading exceeding 0.195 on the other factors (
The polychoric ordinal alpha coefficient on each factor and scale was above the acceptable threshold of 0.7, which indicated internal consistency reliability (
Based on findings from the EFA, CFA was conducted using unweighted least squares as the estimator. To confirm the integrity of the model, the four-factor model was compared with the other two models: the three-factor model which excluded the fourth factor (two items), and the second-order factor model that was selected as the factor model explaining the four first-order factors. Because the combination of fit indices of the four-factor model fulfilled the predetermined level more than those of the other two factor models, the four-factor model was selected as the most acceptable model (
For the four-factor model, all the indicator reliabilities, composite reliabilities, and average variance extracted estimates exceeded the recommended thresholds (0.5, 0.7, and 0.5, respectively). Hence, the convergent validity was demonstrated. For all four factors, the average variance extracted estimates were greater
N | Factor (Item) | Exploratory factor analysisa | ||||
---|---|---|---|---|---|---|
F1 | F2 | F3 | F4 | C | ||
Anxiety about quality of pediatric emergency medical care services (F1) | ||||||
29 | There is no reasonable explanation of the disease and treatment. | 0.956 | −0.059 | −0.032 | 0.040 | 0.87 |
31 | No indication regarding the patient’s next consultation is given. | 0.898 | −0.064 | 0.032 | 0.010 | 0.76 |
26 | Pain and symptoms are not relieved appropriately. | 0.875 | 0.061 | −0.032 | 0.008 | 0.83 |
28 | There is no support for a parent’s insufficient experience/knowledge, anxiety, and concerns. | 0.851 | 0.001 | 0.051 | 0.039 | 0.78 |
27 | In the emergency consultation hospital, there is no facility to stay at. | 0.760 | 0.195 | −0.033 | −0.040 | 0.75 |
23 | Examinations including X-ray, CT, or blood or urine tests are not available. | 0.683 | 0.187 | 0.058 | −0.067 | 0.64 |
Anxiety about pediatric emergency medical care service system (F2) | ||||||
17 | Emergency facilities available change day by day. | −0.023 | 0.860 | 0.099 | −0.086 | 0.73 |
18 | The locations of emergency facilities available are unclear. | 0.045 | 0.825 | −0.012 | 0.058 | 0.77 |
19 | It takes over 30 minutes from home to get to an emergency facility providing consultation. | 0.168 | 0.689 | −0.037 | 0.037 | 0.65 |
16 | There is no facility providing consultation at any time. | 0.124 | 0.674 | −0.020 | 0.105 | 0.64 |
Anxiety about public support (F3) | ||||||
3 | Use telephone consultation. | −0.014 | −0.041 | 0.940 | 0.013 | 0.86 |
5 | Use Kagawa Emergency Support Network. | 0.016 | 0.006 | 0.731 | 0.014 | 0.55 |
2 | Judge the disease state and take action via the Internet or by cellular phone. | 0.025 | 0.077 | 0.727 | −0.012 | 0.58 |
Anxiety about private support (F4) | ||||||
9 | There is no family member or friend with whom you can consult about your child’s diseases and injuries. | 0.020 | −0.004 | 0.028 | 0.953 | 0.93 |
10 | There is no family member or friend whom you can ask to take care of your child. | −0.005 | 0.050 | −0.014 | 0.850 | 0.75 |
N | IRCa,c | Good-poor analysisa,d | Confirmatory factor analysisb | Odd number group | Even number group | P-valuee | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
<25% | >75% | SL | RS | Error variance | ||||||||||
Mean | SD | Mean | SD | Mean | SD | Mean | SD | |||||||
F1 | ||||||||||||||
29 | 0.70 | 1.67 | 0.73 | 3.77 | 0.50 | 0.895 | 0.801 | 0.199 | 2.86 | 1.04 | 2.84 | 1.04 | 0.286 | |
31 | 0.67 | 1.50 | 0.63 | 3.52 | 0.69 | 0.849 | 0.721 | 0.279 | 2.58 | 1.02 | 2.55 | 1.03 | 0.124 | |
26 | 0.71 | 1.62 | 0.72 | 3.80 | 0.45 | 0.902 | 0.814 | 0.186 | 2.85 | 1.05 | 2.84 | 1.06 | 0.392 | |
28 | 0.71 | 1.68 | 0.64 | 3.69 | 0.54 | 0.892 | 0.795 | 0.205 | 2.75 | 0.98 | 2.74 | 0.98 | 0.356 | |
27 | 0.70 | 1.48 | 0.62 | 3.67 | 0.58 | 0.872 | 0.761 | 0.239 | 2.68 | 1.06 | 2.65 | 1.06 | 0.132 | |
23 | 0.65 | 1.66 | 0.72 | 3.60 | 0.62 | 0.819 | 0.671 | 0.329 | 2.74 | 1.00 | 2.71 | 1.00 | 0.092 | |
F2 | ||||||||||||||
17 | 0.59 | 1.66 | 0.71 | 3.42 | 0.75 | 0.778 | 0.605 | 0.395 | 2.55 | 0.99 | 2.53 | 0.99 | 0.145 | |
18 | 0.66 | 1.59 | 0.71 | 3.65 | 0.62 | 0.861 | 0.741 | 0.259 | 2.65 | 1.06 | 2.64 | 1.07 | 0.336 | |
19 | 0.64 | 1.54 | 0.73 | 3.60 | 0.66 | 0.848 | 0.719 | 0.281 | 2.59 | 1.07 | 2.59 | 1.08 | 0.941 | |
16 | 0.63 | 1.65 | 0.81 | 3.74 | 0.55 | 0.838 | 0.703 | 0.297 | 2.75 | 1.10 | 2.73 | 1.10 | 0.280 |
F3 | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
3 | 0.33 | 1.57 | 0.73 | 2.54 | 0.95 | 0.834 | 0.696 | 0.304 | 2.06 | 0.89 | 2.05 | 0.89 | 0.715 | |||
5 | 0.31 | 1.71 | 0.77 | 2.63 | 0.93 | 0.747 | 0.558 | 0.442 | 2.18 | 0.89 | 2.17 | 0.89 | 0.431 | |||
2 | 0.36 | 1.71 | 0.77 | 2.78 | 0.92 | 0.826 | 0.683 | 0.317 | 2.26 | 0.92 | 2.24 | 0.93 | 0.190 | |||
F4 | ||||||||||||||||
9 | 0.47 | 1.22 | 0.48 | 2.84 | 1.12 | 0.935 | 0.875 | 0.125 | 1.91 | 1.05 | 1.89 | 1.03 | 0.579 | |||
10 | 0.44 | 1.38 | 0.70 | 3.04 | 1.08 | 0.890 | 0.792 | 0.208 | 2.12 | 1.13 | 2.11 | 1.13 | 0.742 | |||
PAPEMCS: Parental anxiety about pediatric emergency medical care services, N: Number, C: Communality, IRC: Item-rest correlation, SL: Standardized loading, RS: R-squared. SD: Standard deviation. aOdd number group n = 7255 Exploratory factor analysis was conducted using unweighted least squares with promax rotation. bEven number group n = 7255 Confirmatory factor analysis was conducted using unweighted least squares. cSpearman’s correlation coefficient; all of the probability values showed P < 0.001. dWilcoxon rank-sum test; all of the probability values showed P < 0.001. eWilcoxon rank-sum test.
Factor | Correlation matrixa,d | Polychoric ordinal alpha coefficienta | Good-poor analysisa,e | Fornell-Larcker criterionb,f | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
F1 | F2 | F3 | F4 | <25% | >75% | F1 | F2 | F3 | F4 | ||||
Mean | SD | Mean | SD | ||||||||||
F1 | 0.949 | 1.60 | 0.49 | 3.67 | 0.34 | 0.761 | |||||||
F2 | 0.60 | 0.896 | 1.61 | 0.52 | 3.60 | 0.43 | 0.404 | 0.692 | |||||
F3 | 0.24 | 0.32 | 0.847 | 1.66 | 0.61 | 2.65 | 0.77 | 0.062 | 0.106 | 0.645 | |||
F4 | 0.36 | 0.40 | 0.19 | 0.912 | 1.30 | 0.51 | 2.94 | 1.01 | 0.133 | 0.170 | 0.037 | 0.833 | |
Scale | 0.87 | 0.83 | 0.48 | 0.58 | 0.922 | 1.58 | 0.29 | 3.35 | 0.24 |
Factor | Composite reliabilityb | Tucker’s congruence coefficientc | Congruence testc | Odd number groupg | Even number groupg | P-valueh | ||
---|---|---|---|---|---|---|---|---|
Mean | SD | Mean | SD | |||||
F1 | 0.950 | 0.9996 | 0.015 | 2.74 | 0.87 | 2.72 | 0.88 | 0.143 |
F2 | 0.900 | 0.9995 | 0.014 | 2.64 | 0.88 | 2.62 | 0.89 | 0.317 |
F3 | 0.845 | 0.9996 | 0.010 | 2.17 | 0.75 | 2.15 | 0.75 | 0.353 |
F4 | 0.909 | 0.9990 | 0.015 | 2.01 | 1.01 | 2.00 | 1.01 | 0.682 |
Scale | 0.976 | 2.50 | 0.66 | 2.49 | 0.67 | 0.139 |
PAPEMCS: Parental anxiety about pediatric emergency medical care services. F1: Anxiety about quality of pediatric emergency medical care services, F2: Anxiety about pediatric emergency medical care service system, F3: Anxiety about public support, F4: Anxiety about private support, SD: Standard deviation. aOdd number group, bEven number group, cOdd number group and even number group. dSpearman’s correlation coefficient; all of the probability values showed P < 0.001. eWilcoxon rank-sum test; all of the probability values showed P < 0.001. fThe squared correlations between the factors (Spearman’s correlation coefficient). Average variant extracted estimates are presented in bold-faced italic type diagonally. gThe mean factor score significantly differed among all 4 factors both in the odd number group and even number group (P < 0.001) (Wilcoxon signed-rank test). hWilcoxon rank-sum test, Odd number group vs Even number group.
than the squared correlation between all pairs of factors. The Fornell-Lacker criterion of discriminant validity was fulfilled for all factors in the model.
Model | Number | GFI | AGFI | NFI | RMSR | SRMSR |
---|---|---|---|---|---|---|
Factor model (Even number group) | ||||||
Four-factor model (PAPEMCS) | 7255 | 0.996 | 0.994 | 0.995 | 0.033 | 0.033 |
Three-factor model | 7255 | 0.996 | 0.994 | 0.995 | 0.035 | 0.035 |
Second-order factor model | 7255 | 0.996 | 0.994 | 0.995 | 0.034 | 0.034 |
Multigroup CFA for PAPEMCS: Strict factorial invariance | ||||||
Odd number group, Even number group | 14510 | 0.994 | 0.994 | 0.984 | 0.059 | 0.078 |
Number of children | 14468 | 0.993 | 0.993 | 0.980 | 0.065 | 0.084 |
Family structure | 14468 | 0.993 | 0.993 | 0.978 | 0.067 | 0.086 |
Medical region | 14468 | 0.991 | 0.989 | 0.971 | 0.072 | 0.071 |
Demographic variables | 14468 | 0.990 | 0.990 | 0.971 | 0.076 | 0.094 |
PAPEMCS: Parental anxiety about pediatric emergency medical care services. GFI: Goodness of fit index; AGFI: Adjusted goodness of fit index; NFI: Bentler-Bonett normed fit index; RMSR: Root mean square residual; SRMSR: Standardized root mean square residual. Demographic variables included number of children, family structure, and medical region.
Between pairs of parallel factors corresponding to EFA of the odd number group and EFA of the even number group, all the Tucker’s congruence coefficient indices were 0.999 or greater, and all the congruence tests were 0.015 or less. The results confirmed that both halves were almost identical.
In order to test measurement invariance, multi-group CFA were performed. The level of measurement invariance was assessed through model fit of a hierarchical set of nested multiple group models: configural invariance, metric invariance, scalar invariance and strict factorial invariance. After excluding Naoshima from a multigroup CFA due to small sample size, all the fit indices for strict factor invariance across each of the demographic variables, and all demographic variables, which included number of children, family structure, and medical region, fulfilled the predetermined levels of acceptability.
In summary, the generalizability of the PAPEMCS was demonstrated by the Tucker’s congruence coefficients, congruence tests, and strict factorial invariance.
Because the generalizability of the PAPEMCS was demonstrated, its usefulness was examined by common relative risk, which was calculated in Cochran-Mantel-Haenszel test as the ratio of the proportion of the higher score group in the other demographic group, versus single mother, parents with only one child, or parents in the Shozu region as reference group, which was inferred with the highest risk of non-urgent usage of PED.
After adjustment for the other demographic variables, a single mother had significantly higher risks of “anxiety about public support” or “anxiety about private support” versus a family living together with grandparents (
Demographic variable | Anxiety about quality of pediatric emergency medical care services | Anxiety about pediatric emergency medical care service system | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
n | % | CRR | 95% CI | P-value | BDT | n | % | CRR | 95% CI | P-value | BDT | ||||
Family structurea | |||||||||||||||
Single mother | 201 | 54.5 | 1.00 | Reference | 204 | 55.3 | 1.00 | Reference | |||||||
NFFW | 2604 | 54.3 | 1.03 | 0.9 | 1.1 | 0.538 | 0.280 | 2496 | 52.1 | 0.96 | 0.9 | 1.1 | 0.461 | 0.643 | |
NFDI | 2979 | 52.9 | 0.99 | 0.9 | 1.1 | 0.833 | 0.820 | 2815 | 50.0 | 0.91 | 0.8 | 1.0 | 0.077 | 0.349 | |
LGFW | 492 | 52.3 | 0.96 | 0.8 | 1.1 | 0.480 | 0.166 | 493 | 52.5 | 0.94 | 0.8 | 1.1 | 0.332 | 0.201 | |
LGDI | 844 | 47.9 | 0.92 | 0.8 | 1.0 | 0.129 | 0.846 | 845 | 47.9 | 0.91 | 0.8 | 1.0 | 0.086 | 0.552 | |
SFG | 30 | 42.3 | 0.76 | 0.6 | 1.0 | 0.056 | 0.543 | 32 | 45.1 | 0.84 | 0.6 | 1.1 | 0.195 | 0.875 | |
SMG | 204 | 57.1 | 1.06 | 0.9 | 1.2 | 0.372 | 0.906 | 206 | 57.7 | 1.05 | 0.9 | 1.2 | 0.439 | 0.437 | |
Number of childrenb | |||||||||||||||
One | 1725 | 57.0 | 1.00 | 1636 | 54.1 | 1.00 | |||||||||
Two | 4171 | 52.8 | 0.93 | 0.9 | 1.0 | 0.001 | 0.049 | 4025 | 51.0 | 0.95 | 0.9 | 1.0 | 0.015 | 0.335 | |
Three | 1544 | 50.4 | 0.89 | 0.9 | 0.9 | 0.001 | 0.217 | 1495 | 48.8 | 0.92 | 0.9 | 1.0 | 0.001 | 0.523 | |
Four or more | 212 | 46.8 | 0.84 | 0.8 | 0.9 | 0.001 | 0.002 | 209 | 46.1 | 0.90 | 0.8 | 1.0 | 0.038 | 0.454 | |
Medical regionc | |||||||||||||||
Shozu | 133 | 43.3 | 1.00 | 146 | 47.6 | 1.00 | |||||||||
Okawa | 676 | 53.0 | 1.20 | 1.0 | 1.4 | 0.008 | 0.261 | 792 | 62.1 | 1.32 | 1.2 | 1.5 | 0.001 | 0.295 | |
Takamatsu | 3621 | 55.8 | 1.25 | 1.1 | 1.4 | 0.001 | 0.073 | 3472 | 53.5 | 1.10 | 1.0 | 1.3 | 0.101 | 0.775 | |
Chusan | 2232 | 51.3 | 1.17 | 1.0 | 1.3 | 0.014 | 0.171 | 2013 | 46.3 | 0.97 | 0.9 | 1.1 | 0.632 | 0.454 | |
Mitoyo | 972 | 48.6 | 1.12 | 1.0 | 1.3 | 0.104 | 0.047 | 930 | 46.5 | 0.99 | 0.9 | 1.1 | 0.888 | 0.335 |
Demographic variable | Anxiety about public support | Anxiety about private support | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
n | % | CRR | 95% CI | P-value | BDT | n | % | CRR | 95% CI | P-value | BDT | |||
Family structurea | ||||||||||||||
Single mother | 170 | 46.1 | 1.00 | Reference | 204 | 55.3 | 1.00 | Reference | ||||||
NFFW | 1943 | 40.5 | 0.90 | 0.8 | 1.0 | 0.078 | 0.267 | 2701 | 56.3 | 1.04 | 0.9 | 1.1 | 0.412 | 0.314 |
NFDI | 2463 | 43.7 | 0.95 | 0.8 | 1.1 | 0.352 | 0.390 | 2928 | 52.0 | 0.97 | 0.9 | 1.1 | 0.513 | 0.109 |
LGFW | 355 | 37.8 | 0.80 | 0.7 | 0.9 | 0.004 | 0.740 | 401 | 42.7 | 0.77 | 0.7 | 0.9 | 0.001 | 0.214 |
LGDI | 761 | 43.2 | 0.93 | 0.8 | 1.1 | 0.288 | 0.108 | 752 | 42.7 | 0.78 | 0.7 | 0.9 | 0.001 | 0.307 |
SFG | 34 | 47.9 | 0.96 | 0.7 | 1.3 | 0.786 | 0.793 | 43 | 60.6 | 1.05 | 0.8 | 1.3 | 0.658 | 0.078 |
SMG | 181 | 50.7 | 1.05 | 0.9 | 1.2 | 0.558 | 0.019 | 172 | 48.2 | 0.89 | 0.8 | 1.0 | 0.106 | 0.093 |
Number of childrenb | ||||||||||||||
One | 1365 | 45.1 | 1.00 | 1689 | 55.8 | 1.00 | ||||||||
Two | 3292 | 41.7 | 0.94 | 0.9 | 1.0 | 0.018 | 0.206 | 4022 | 50.9 | 0.90 | 0.9 | 0.9 | 0.001 | 0.011 |
Three | 1300 | 42.5 | 0.95 | 0.9 | 1.0 | 0.096 | 0.827 | 1545 | 50.5 | 0.91 | 0.9 | 1.0 | 0.001 | 0.036 |
Four or more | 173 | 38.2 | 0.85 | 0.7 | 1.0 | 0.010 | 0.008 | 225 | 49.7 | 0.89 | 0.8 | 1.0 | 0.016 | 0.430 |
Medical regionc | ||||||||||||||
Shozu | 127 | 41.4 | 1.00 | 156 | 50.8 | 1.00 | ||||||||
Okawa | 595 | 46.6 | 1.14 | 1.0 | 1.3 | 0.078 | 0.224 | 632 | 49.5 | 0.99 | 0.9 | 1.1 | 0.822 | 0.224 |
Takamatsu | 2700 | 41.6 | 1.03 | 0.9 | 1.2 | 0.640 | 0.054 | 3475 | 53.6 | 1.00 | 0.9 | 1.1 | 0.969 | 0.338 |
Chusan | 1839 | 42.3 | 1.05 | 0.9 | 1.2 | 0.532 | 0.120 | 2234 | 51.4 | 1.00 | 0.9 | 1.1 | 0.963 | 0.585 |
Mitoyo | 861 | 43.0 | 1.06 | 0.9 | 1.2 | 0.417 | 0.002 | 976 | 48.8 | 1.00 | 0.9 | 1.1 | 0.989 | 0.467 |
Demographic variable | n | PAPEMCS | ||
---|---|---|---|---|
Mean | SD | P-valued | ||
Family structure | <0.0024 | |||
Single mother | 369 | 2.56 | 0.66 | A |
NFFW | 4794 | 2.52 | 0.65 | A |
NFDI | 5632 | 2.49 | 0.67 | A |
LGFW | 940 | 2.44 | 0.68 | AB |
LGDI | 1763 | 2.40 | 0.68 | B |
SFG | 71 | 2.42 | 0.68 | AB |
SMG | 357 | 2.56 | 0.67 | A |
Number of children | <0.0083 | |||
One | 3026 | 2.57 | 0.66 | A |
Two | 7898 | 2.49 | 0.66 | B |
Three | 3061 | 2.45 | 0.68 | BC |
Four or more | 453 | 2.38 | 0.74 | C |
Medical region | <0.005 | |||
Shozu | 307 | 2.36 | 0.70 | B |
Okawa | 1276 | 2.56 | 0.62 | A |
Takamatsu | 6487 | 2.55 | 0.62 | A |
Chusan | 4349 | 2.44 | 0.70 | B |
Mitoyo | 2002 | 2.41 | 0.71 | B |
PAPEMCS: Parental anxiety about pediatric emergency medical care services; CRR: Common relative risk; CI: Confidence interval, BDT: Breslow-Day test, SD: Standard deviation, NFFW: Nuclear family, father working, NFDI: Nuclear family, double incomes, LGFW: Living together with grandparents, father working, LGDI: Living together with grandparents, double incomes, SFG: Single father living together with grandparents, SMG: Single mother living together with grandparents. aAdjustment for number of children and medical region. bAdjustment for family structure and medical region. cAdjustment for family structure and number of children. dThe p-value of the generalized linear model of each variable showed P < 0.0001. Different alphabets indicate a significant difference based on the significance level by the Wilcoxon rank sum test adjusted by the Bonferroni method.
After adjustment for the other demo-graphic variables, only one child showed significantly higher risks of the four factors versus three groups of two or more children. In 8 pediatric emergency institutions that 9,445 participants had used in the most recent past, almost all participants used the pediatric emergency institution in the secondary medical region in which they lived (
Because the PAPEMCS, the risk factors, and non-urgent usage of pediatric emergency institutions were different among pediatric emergency institutions, a
Variable (Item) | n | Okawa medical region Okawa night emergency children’s clinic | Takamatsu medical region | |||||||
---|---|---|---|---|---|---|---|---|---|---|
Takamatsu night emergency children’s clinic | One group of hospitals on rotational duty | Kagawa university hospital | ||||||||
n Mean | % SD | n Mean | % SD | n Mean | % SD | n Mean | % SD | |||
Family structurea n = 9090 | ||||||||||
NFFW | 2822 | 115 | 23.2 | 538 | 36.8 | 244 | 37.1 | 166 | 33.6 | |
NFDI | 3831 | 222 | 44.8 | 634 | 43.4 | 271 | 41.3 | 209 | 42.3 | |
LGFW | 639 | 49 | 9.9 | 74 | 5.0 | 36 | 5.5 | 33 | 6.7 | |
LGDI | 1245 | 79 | 15.9 | 121 | 8.3 | 67 | 10.2 | 64 | 13.0 | |
Single mother | 272 | 13 | 2.6 | 52 | 3.6 | 22 | 3.4 | 12 | 2.4 | |
SFG | 49 | 3 | 0.6 | 10 | 0.7 | 2 | 0.3 | 0 | 0.0 | |
SMG | 232 | 15 | 3.0 | 32 | 2.2 | 15 | 2.3 | 10 | 2.0 | |
Number of childrenb n = 9418 | ||||||||||
One | 1948 | 90 | 17.6 | 374 | 24.7 | 151 | 22.2 | 124 | 24.4 | |
Two | 5130 | 299 | 58.4 | 822 | 54.3 | 356 | 52.4 | 263 | 51.7 | |
Three | 2025 | 107 | 20.9 | 283 | 18.7 | 152 | 22.4 | 108 | 21.2 | |
Four or more | 315 | 16 | 3.1 | 36 | 2.4 | 21 | 3.1 | 14 | 2.8 | |
ABCD | D | ABCD | BCD | |||||||
Medical regiona n = 9445 | ||||||||||
Okawa | 871 | 486 | 94.2 | 11 | 0.7 | 33 | 4.9 | 151 | 29.4 | |
Takamatsu | 4161 | 29 | 5.6 | 1469 | 96.9 | 599 | 88.1 | 353 | 68.7 | |
Chusan | 2880 | 1 | 0.2 | 31 | 2.0 | 39 | 5.7 | 6 | 1.2 | |
Mitoyo | 1409 | 0 | 0.0 | 3 | 0.2 | 8 | 1.2 | 2 | 0.4 | |
Syozu | 124 | 0 | 0.0 | 2 | 0.1 | 1 | 0.2 | 2 | 0.4 | |
Medical examination and treatmenta n = 8620 | ||||||||||
A medical examination | 1634 | 106 | 22.2 | 297 | 21.5 | 137 | 23.0 | 67 | 13.8 | |
Internal medicine, suppository etc. | 4566 | 314 | 65.7 | 917 | 66.4 | 217 | 36.4 | 216 | 44.4 | |
Infusion, inhalation etc. | 1369 | 58 | 12.1 | 167 | 12.1 | 100 | 16.8 | 103 | 21.2 | |
Hospitatization | 1051 | 0 | 0.0 | 0 | 0.0 | 143 | 24.0 | 100 | 20.6 | |
PAPEMCSb | ||||||||||
Parental anxiety about quality of pediatric emergency medical care services | 2.74 | 0.8 | 2.79 | 0.8 | 2.90 | 0.8 | 2.78 | 0.9 | ||
B | B | A | AB | |||||||
Parental anxiety about pediatric emergency medical care service system | 2.87 | 0.9 | 2.73 | 0.8 | 2.82 | 0.8 | 2.65 | 0.9 | ||
A | BC | AB | C | |||||||
Parental anxiety about public support | 2.23 | 0.7 | 2.12 | 0.7 | 2.18 | 0.7 | 2.23 | 0.8 | ||
A | A | A | A | |||||||
Parental anxiety about private support | 1.92 | 1.0 | 2.08 | 1.0 | 2.07 | 1.0 | 2.10 | 1.1 | ||
BC | A | ABC | ABC | |||||||
Scale | 2.55 | 0.7 | 2.55 | 0.6 | 2.63 | 0.6 | 2.54 | 0.7 | ||
AB | AB | A | AB | |||||||
Variable (Item) | Chusan medical region Kagawa national children’s hospital | Mitoyo medical region Mitoyo night emergency children’s clinic | Kagawa prefecture | ||||||
---|---|---|---|---|---|---|---|---|---|
Family doctor | Holiday on duty doctor | ||||||||
n Mean | % SD | n Mean | % SD | n Mean | % SD | n Mean | % SD | ||
Family structurea n = 9090 | |||||||||
NFFW | 688 | 27.0 | 134 | 23.8 | 382 | 30.5 | 555 | 34.4 | |
NFDI | 1062 | 41.6 | 209 | 37.1 | 512 | 40.8 | 712 | 44.2 | |
LGFW | 211 | 8.3 | 57 | 10.1 | 92 | 7.3 | 87 | 5.4 | |
LGDI | 447 | 17.5 | 132 | 23.5 | 166 | 13.2 | 169 | 10.5 | |
Single mother | 68 | 2.7 | 11 | 2.0 | 48 | 3.8 | 46 | 2.9 | |
SFG | 15 | 0.6 | 2 | 0.4 | 14 | 1.1 | 3 | 0.2 | |
SMG | 62 | 2.4 | 18 | 3.2 | 40 | 3.2 | 40 | 2.5 | |
Number of childrenb n = 9418 | |||||||||
One | 484 | 18.2 | 113 | 19.4 | 252 | 19.3 | 360 | 21.9 | |
Two | 1431 | 53.7 | 316 | 54.1 | 711 | 54.4 | 932 | 56.7 | |
Three | 647 | 24.3 | 135 | 23.1 | 282 | 21.6 | 311 | 18.9 | |
Four or more | 105 | 3.9 | 20 | 3.4 | 62 | 4.7 | 41 | 2.5 | |
A | ABC | AB | CD | ||||||
Medical regiona n = 9445 | |||||||||
Okawa | 9 | 0.3 | 0 | 0.0 | 87 | 6.7 | 94 | 5.7 | |
Takamatsu | 78 | 2.9 | 6 | 1.0 | 502 | 38.4 | 1125 | 68.3 | |
Chusan | 2025 | 75.7 | 6 | 1.0 | 431 | 33.0 | 341 | 20.7 | |
Mitoyo | 562 | 21.0 | 575 | 98.0 | 201 | 15.4 | 58 | 3.5 | |
Syozu | 2 | 0.1 | 0 | 0.0 | 87 | 6.7 | 30 | 1.8 | |
Medical examination and treatmenta n = 8620 | |||||||||
A medical examination | 499 | 20.5 | 96 | 19.2 | 154 | 12.4 | 278 | 18.5 | |
Internal medicine, suppository etc. | 1043 | 42.8 | 280 | 55.9 | 604 | 48.8 | 975 | 64.9 | |
Infusion, inhalation etc. | 321 | 13.2 | 125 | 25.0 | 320 | 25.8 | 175 | 11.7 | |
Hospitatization | 573 | 23.5 | 0 | 0.0 | 161 | 13.0 | 74 | 4.9 | |
PAPEMCSb | |||||||||
Parental anxiety about quality of pediatric emergency medical care services | 2.59 | 1.0 | 2.52 | 1.0 | 2.72 | 0.9 | 2.80 | 0.8 | |
C | C | B | AB | ||||||
Parental anxiety about pediatric emergency medical care service system | 2.38 | 1.0 | 2.40 | 1.0 | 2.64 | 0.9 | 2.69 | 0.8 | |
D | D | C | C | ||||||
Parental anxiety about public support | 2.20 | 0.8 | 2.19 | 0.8 | 2.19 | 0.8 | 2.16 | 0.7 | |
A | A | A | A | ||||||
Parental anxiety about private support | 1.97 | 1.0 | 1.96 | 1.0 | 2.03 | 1.0 | 2.06 | 1.0 | |
C | ABC | ABC | AB | ||||||
Scale | 2.37 | 0.7 | 2.34 | 0.7 | 2.50 | 0.7 | 2.54 | 0.6 | |
C | C | B | AB |
N: Number, SD: Standard deviation, NFFW: Nuclear family, father working, NFDI: Nuclear family, double incomes, LGFW: Living together with grandparents, father working, LGDI: Living together with grandparents, double incomes, SFG: Single father living together with grandparents, SMG: Single mother living together with grandparents, PAPEMCS: Parental anxiety about pediatric emergency medical care service. aChi square test P < 0.0001, bSteel-Dwass test (Tukey-Kramer test) Difference in alphabet indicates a significant difference among 8 emergency institutions (P < 0.05).
multiple correspondence analysis was employed to examine these relationships more precisely.
All of the higher score groups of the PAPEMCS were close in distance to a demo-graphic cluster including nuclear family, single parent and few children, the treatment for slight disease, and 3 pediatric emergency medical institutions in Takamatsu (
In addition, although generalized linear models and multiple comparison using Wilcoxon rank-sum tests were not adjusted by two other variables, the differences in PAPEMCS scores among parental vulnerabilities and PEMCS systems were similar to the results examined by multiple correspondence analysis.
The purpose of the present study was to develop a scale of parental anxiety about PEMCS and provide evidence of initial reliability, validity, generalizability and usefulness for this new scale. The strengths of this study are that the fairly large sample allowed us to develop a psychometrically robust scale, and the participants possessed high representativeness that fulfilled the research requirements: multifarious family structure, various PEMCS systems, and diverse geographical features.
EFA and CFA implemented for odd and even number groups, respectively, provided one general construct and four factors as evidence of the validity of the scale structure.
The first factor, “anxiety about quality of PEMCS”, constituted anxiety about two characteristics of pediatric emergency institutions (resources and family-centered care) that are important concerns of parents with sick children. The second factor, “anxiety about PEMCS system”, was comprised of anxiety about accessibility to pediatric emergency institutions. The fourth factor, “anxiety about private support”, was comprised of anxiety about a shortage of private support. These three factors demonstrate content validity, because they are consistent with the parental anxieties about PED usage in previous studies, or correspond with the reasons of parents visiting a PED for a child with a non-urgent condition [
The third factor, “anxiety about public support,” was constituted of not only pre-hospital care (telephone consultation, information on website) but also post-hospital care (Kagawa Emergency Support Network). The factor represents
parental anxiety not only about pediatric emergency institutions but also all care services for sick children. In addition, the emergency support network service for the sick child care increased from 47 municipalities in 2009 to 142 municipalities in 2013 [
Hence, the PAPEMCS demonstrated content validity in that the four factors were comprehensively constituted from parental anxiety about PEMCS.
Excellent evidence was demonstrated about the internal homogeneity and reliability of the PAPEMCS. All reliability estimates (the polychoric ordinal alpha coefficients and item-rest correlations), the item discrimination (good-poor analysis), fit indices for CFA (goodness-of-fit index, adjusted goodness-of-fit index, Bentler-Bonett normed fit index, root mean square residual, and standardized root mean square residual), the convergent validity (indicator reliabilities, composite reliabilities, and average variance extracteds), and the discriminant validity (Fornell-Lacker criterion) fulfilled the acceptability thresholds.
The generalizability of the PAPEMCS was revealed from evidence of Tucker’s congruence coefficients, congruence tests, and strict factor invariance across 16 demographic groups that showed substantial heterogeneity. Because strict factorial invariance reveals that differences in scale scores reflect true differences on the construct being measured, the present findings provided convincing evidence that the PAPEMCS enables comparing parental anxiety about PEMCS among various contexts, such as parental vulnerabilities and PEMCS systems.
The PAPEMCS offered some useful findings for PEMCS. First of all, parents who are known as non-urgent PED users, single parent and parents with a few number of children, showed higher anxiety of PEMCS. Using multiple correspondence analysis, the study demonstrated the new finding that the mutual close relationship was among higher groups of the PAPEMCS, the risk factors of non-urgent users of PEMCS (single parent, nuclear family and parents with a few number of children), and non-urgent users whose child received a medical examination or an internal medicine at pediatric emergency institution. The other finding was the mutual close relationship among lower groups of the PAPEMCS, family living together with grandparents, parents with three children or more, and users whose child received treatment by infusion or hospitalization at pediatric emergency institutions. These results suggest the possibility that the shortage of private support to parents or the shortage of the parents’ child rearing experience, caused higher parental anxiety about PEMCS and resulted in non-urgent usage of pediatric emergency institutions.
Regarding the reason that 3 pediatric medical institutions in Takamatsu were related to the higher group of the PAPEMCS and 2 pediatric medical institutions in Chusan and Mitoyo were related to the lower group of the PAPEMCS; this may be due to the difference in family structures among the 5 medical regions [
Also, for parents living in a region providing the pediatric emergency night clinic the anxiety regarding PEMCS or usage of a pediatric emergency institution may be influenced by the pediatric emergency system of a neighboring region. Although the PEMCS system of Mitoyo is the same as that of Okawa, parents in Mitoyo can use a pediatric hospital that is available at the primary level of PEMCS 24 hours a day in Chusan, which is a neighboring region. Due to this, parents in Mitoyo were not very anxious about PEMCS and were at a lower rate of non-urgent users. In Okawa, parents did not use the secondary pediatric emergency hospital rotated every day and instead used Kagawa University hospital (tertiary) in Takamatsu. By using the PAPEMCS, this research suggests, at a minimum, the importance of being able to consult an emergency night hospital for sick children at the secondary level of PEMCS. The results suggest that parental anxieties regarding PEMCS are influenced by their vulnerability, and the convenience of a high quality of PEMCS. The PAPEMCS explained the mechanisms by which multifarious risks cause non-urgent use of pediatric emergency institutions, and which were not explained up to the present.
By expansion of the pediatric medical regions in 2014, the regions were reorganized with 231 regions having a pediatric emergency medical core hospital or a pediatric emergency center, and 69 regions not having a hospital (center) [
This study has several limitations regarding the development of the PAPEMCS. First, the findings of this study were limited to the participants and PEMCS systems that we investigated. For example, this study were not able to examine if the U. S. type of pediatric emergency medical system helps vulnerable family to decrease their anxiety of PEMCS or their non-urgent usage of PEMCS. Second, most participants were limited to parents with a child who goes to a kindergarten or day-care center. There is a possibility that it is inappropriate to generalize the findings to parents with an infant. Third, the participants were parents in only one prefecture, which has a temperate climate and is a small region. In addition, the results could not reveal parental anxiety about PEMCS for those residing in Naoshima (only one clinic) due to the small sample size. For confirming the generalizability of the PAPEMCS, it is important to examine parents with an infant and parents living under every geographical condition: big cities, depopulated areas, and doctor-less villages.
Lastly, the study did not examine the effects of public support, such as a telephone triage against non-urgent usage in PEMCS. It is possible to examine such effects in more detail by analyzing the PAPEMCS, in addition to intervention variables, risk factors such as a single parent, and non-urgent PEMCS usage.
The fact that all of the calculated measures for assessing reliability, validity and generalizability reached the recommended limit values demonstrated the reliability, validity and generalizability of the PAPEMCS. The fact that there was a close relationship among the PAPEMCS, individual factors and the PEMCS system has established the usefulness of the PAPEMCS. The PAPEMCS is useful to quantify the contents and extent of parental anxiety about PEMCS, and to clarify the mechanisms of non-urgent PEMCS usage.
We are very grateful to all those who participated in this study. This study was funded by Grants-in-Aid for scientific research expenses of the Japan Society for the Promotion of Science (20659352).
The authors have no conflicting interest in this study.
Sobue, I., Tanimoto, K. and Itoh, S. (2017) A Scale of Parental Anxiety about Pediatric Emergency Medical Care Services of Japan: Development, Reliability, Validity, Generalizability and Usefulness. Health, 9, 1427-1458. https://doi.org/10.4236/health.2017.910105
The Kagawa Emergency Support Network is a contract system in which parents ask trained volunteers to take care of their ill children. A VIF value of more than five (item number, VIF; 15/16, 7.66; 23/24, 6.33; 25/26, 5.02; 29/30, 5.33; 30/31, 5.75) and four items (15, 24, 25, and 30) were omitted from the polychoric correlation matrix in order to exclude multicollinearity. N: Number.