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Parenting practices, stressors and parental concerns during COVID-19 in Pakistan

Background COVID-19 is a global crisis that has added fear, uncertainty, and stress to parents. Parents are going through several challenges related to school closure, financial insecurity and working remotely. These stressors are affecting the mental health of parents. Objectives This study aimed to observe major stressors along with the impact of COVID-19 on parental concerns and practices during lockdown. Participants Sample (N = 923) was selected through purposive sampling from parents attending Out Patients Departments of hospitals in three provincial capital cities of Pakistan having a high burden of COVID-19, i.e. Lahore, Karachi and Peshawar. Parents having at least one child younger than 18 years were included in the study. Methods A quantitative design was used using a COVID-19 Parenting Response Scale (α = 0.74). It was used as a self-administered tool for parents who knew how to read and write Urdu/English language, however it was conducted as a structured interview for those who could not read/write. Data was analyzed by applying descriptive statistics (frequency, mean, percentage), independent sample t-test and Pearson Product Moment Correlation. Results Findings of the current study showed several stressful factors for parents during COVID-19 pandemic, mainly financial burden, children's education, uncertainty of the situation, and many others. The study also suggests an association of parental concerns during COVID-19 with parenting practices. Conclusion COVID-19 pandemic presents a global crisis not only of the health of the people but also on family relations and mental well-being. Findings of this research indicate the need for targeted and accessible interventions for mental health of parents especially during these challenging circumstances so that they can cope with the challenges in an effective way and be able to take care of their children better.

study provides some insight into how the lives of children and parents have been affected due to this pandemic which is very critical to address at this time. As this crisis hampers daily life and functioning, it is also important to understand its consequences on family life particularly parents' mental well-being and parent child relationship in order to manage its negative short term and long-term effects.
The current research was designed to identify the lockdown related key parental stressors, assess parental concerns due to COVID-19 and understand the relationship between mental health and parenting practices. Based on these objectives, this study attempted to answer the following questions: 1. What factors have added stress to parents during COVID-19 lockdown in Pakistan? 2. What are the parental concerns during COVID-19 lockdown in Pakistan? 3. Is there any relationship between the stressors and parental concerns during . Is there any association between parental concerns and parenting practices during COVID-19?

Research design
The research design of the study was descriptive in nature and a quantitative approach was used through conducting a survey. Quantitative survey methods have been considered useful when researchers attempt to investigate attitudes and practices while sticking to the quantitative approach (Naeem et al., 2020).

Participants
Participants were recruited from parents visiting the pediatrics Out-Patient Department (OPD) of public and private hospitals in three provincial capitals of Pakistan i.e. Lahore, Karachi and Peshawar. These large cities had a high burden of COVID-19. These participants were visiting the out-patients for any reason including child's intercurrent illness, well baby visit or regular vaccination. All women and men, who were mother/father of at least one child under the age of 18 visiting the pediatric OPDs for any reason and who agreed to fill the questionnaire were included in the study through a purposive sampling technique. The sample size was 923. Initially, data was collected from 962 Participants (response rate = 96%) 39 participants were excluded due to incomplete/missing information. Sample characteristics have been shown in table A1.

Instrumentation and validation
A scale on parenting response during COVID-19 was developed by the researchers. The initial items pool was generated by reviewing available literature on parenting practices, parental concerns and stressors during COVID-19 lockdown. A focus group of parents was also conducted online to determine various stressors and parenting practices during COVID-19 lockdown. These items were presented to a team consisting of medical doctors, psychologists and research experts, and after consensus the items were finalized for each subscale of the instrument. The sub-scale of stressors included 14 statements while responses ranged from 1= "not at all stressful" to 4= "very much stressful". The subscale of parental concerns due to COVID-19 consisted of 13 items and responses were rated from not relevant = 1 to very much relevant = 4 (reverse scoring of item number 1, 9 and 12), higher score shows higher parental concerns. The sub-scale of parenting practices consisted of 9 items on the scale of 1 to 4 where 1 = always and 4 = never (reverse scoring on items 6 and 9), higher score shows practice of more positive parenting.
Reliability was calculated through Cronbach's Alpha and its value was α = 0.74 for the overall instrument whereas α =0.70 for parental concerns subscale, α =0.76 for parenting practices subscale and α =0.80 for subscale of stressors.

Data analysis
Descriptive statistics were calculated in the form of frequency, percentage, mean and standard deviation. t-test and ANOVA were applied to investigate the differences in the parental concerns scores of the different groups on the basis of demographic characteristics. Correlation was applied to see if there was any relationship among parental concerns, stressors, and parenting practices during COVID-19 lockdown.

Procedure
The current study was conducted during the first peak of COVID-19 in Pakistan. Initial permission was granted by the ethical review board of King Edward Medical University Lahore and Agha Khan University Hospital Karachi. Permissions for data collection were then taken from Pediatric departments Mayo Hospital Lahore, Fauji Foundation Hospital Lahore, Govt. Women and Children Molvi Ameer Shah Memorial Hospital Peshawar and Dow University Hospital Karachi. Each hospital presented a focal person for correspondence with the research team. A team of data collectors from each hospital was trained for data collection through Zoom meetings. These teams consisted of doctors, nurses, and medical students from each hospital. Sample was selected through purposive sampling, inclusion criteria for the study were to include those visitors in the pediatric out-patient departments of the hospitals who were parents of at least one child and who were willing to take part in the study. Self-reported questionnaire was administered to the participants who were able to read and comprehend English/Urdu language, the data collection team conducted structured interviews for those who were not able to read. Average time of questionnaire completion was 15 min. After the completion of the survey from each city, data were entered, compiled, cleaned, and then analyzed by using SPSS version 21.0.

Results
Among 923 participants 318 (34.45%) were male and 605 (65.55%) were female. The average age of participants was 34 years (M = 34.19; SD = 8.03). 96.7% were married, 2.1% were widowed and 1.2% of the participants were divorced. Monthly household income of less than 20,000 PKR was reported by 24.2% of the participants, 37.2% reported 20,000 PKR to 40,000 PKR, 17.9% reported that they belonged to a monthly income group of 40,000 to 60,000 PKR. (USD 130, 260 and 390 per month respectively) whereas 20.7% reported monthly income above 60,000 PKR. Considering that in Pakistan middle income families can be loosely defined as a household having a household income of 50,000 PKR (USD 325 per month) (Adil, 2017), our sample primarily belonged to low or low middle-income group. Majority of the participants (64.7%) experienced loss in income due to COVID-19 (Table A1). In majority of the cases (71.2%) mothers have the primary responsibilities of taking care of the child. More than half of the participants (57.75%) reported that in their households, mothers help the children in their studies whereas 29.7% reported that fathers help the children in study (Table A2).

Stressors during COVID-19 lockdown
Uncertainty about the situation of COVID-19 was reported as a stressful indicator by the highest percentage of the respondents (83.8%). Continued updates on the media on COVID-19 situation and economic burden came out as the second highest reported stressful indicators (reported by 81.2% of the respondents). A large majority (79.9%) also reported being stuck indoors a stressful indicator, 79% considered unavailability of the desired products due to lockdown while 75% considered inability to go out and socialize stressful, during lockdown.
Other stressful indicators during COVID-19 lockdown reported by majority of the respondents include constant supervision of the children (74.6%), studies of children (74.4%), and lack of recreational activities (72.2%), see Table 1. Table 2 presents frequency and percentage of the respondents regarding parental concerns during COVID-19 outbreak. Results indicate that many parents find relevance with the statements like "I fear, if my child remained behind in his studies", "I feel, if we will not be able to get access to basic needs items in coming days", "I sometimes feel trapped in the current circumstances of lockdown", "I don't have any hope that our lives will ever become normal as they were before lockdown situation", "I feel sad thinking that I cannot go out like I used to go before".

Differences in the mean scores of parental concerns based on sample characteristics (gender, income loss during COVID-19, family system, household income and age of the index child)
Table 3 presents differences in the mean scores of parental concerns during COVID-19 based on their gender, income loss during COVID-19 and family system. Mean values are shown for male (n = 318) and female (n = 605) participants as well as the results of ttests (equal variance assumed) comparing the parameter estimates between the two groups. Results show a statistically significant difference in the parental concerns of males and females t (921) = − 2.045, p = .041, d = 0.138. Mean scores are higher in the female participants (M = 2.32, SD = 0.44) than male participants (M = 2.26, SD = 0.43) whereas higher scores reflect higher parental concerns. It reflects that the females reported higher parental concerns during COVID-19 than males.
Results show a statistically significant difference in the parental concerns during COVID-19 of the participants who suffered from loss of income during COVID-19 and those who didn't face any loss in income t(921) = 4.823, p = 000, d = 0.349. Results indicate higher mean scores (M = 2.36, SD = 0.44) for the participants who faced loss in income during COVID-19 lockdown than those who didn't face any loss in the income (M = 2.21, SD = 0.42), whereas higher scores indicate higher parental concerns during COVID-19. It shows that participants who faced loss in income reported higher parental concerns during COVID-19 than those who had not faced loss in income (Table 3).
Results show a statistically significant difference in the parental concerns scores of the two groups living in joint (n = 552) and nuclear family systems (n = 371), t (921) = 2.017, p = 044, d = 0.136. Findings reflecting that the participants living in a joint family system reported higher parental concerns during COVID-19 than those living in a nuclear family system (Table 3). Table 4 shows mean, standard deviation and the result of ANOVA to compare the parental concerns of different groups. Participants in the low-income group reflected higher parental concerns compared to those with relatively higher income. Mean scores are highest in the group where household income was less than 20,000PKR (about 129 USD) and lowest for the group where income was greater than 60,000 PKR (387USD) whereas higher the mean scores, higher the parental concerns. Value of F (3, 880) = 3.68, p = .012 is significant at α = 0.05. It shows there is a difference in the parental concerns scores of these groups. Post-Hoc test further shows that there is a significant difference between the mean scores of two groups having household income of less than 20,000 PKR and those  having income of more than 60,000PKR with p = .021. Mean scores are higher for group having less than 20,000 PKR household income (M = 30.66, SD = 5.16) than the group having household income of more than 60,000 PKR (M = 28.91, SD = 6.51), whereas high mean scores in the parameter reflect higher parental concerns during COVID-19. Table 4 shows that parental concerns were higher where the age of the index child is between 5 and 8 years and lowest in the group where age of the index child is below 5 years. Value of F (3, 919) =3.06, p = .027 is significant at α = 0.05. Post-Hoc test further shows that there is a significant difference between the mean scores of two groups who reported age of the index child below 5 years and 5-8 years with p = .041. Mean scores are higher for group who have index child between 5 and 8 years of age (M = 30.69, SD = 6.06) than the group where age of the index child is below 5 years (M = 29.35, SD = 5.61) whereas high mean scores in the parameter reflect higher parental concerns. Table 5 indicates parenting practices during COVID-19 lockdown. Parents reported positive as well as negative parenting practices during lockdown. Among the positive practices, 85.1% and 80.6% of the participants reported that they did various learning and fun activities respectively with their children. Among negative practices 76.9% reported that they get easily irritated when their children did not listen to them, 67.5% reported that their children did not listen to them unless they were being shouted at whereas 63.9% reported that they slapped their children if they misbehaved. More than half of the participants (59.3%) reported that it took so much yelling and cursing to make their children sit and do any work whereas 56.1% reported that without hitting/slapping it was impossible to make their children obey (Responses for always, mostly and sometimes have been combined here to indicate overall occurrence of a behavior, please see Table 5 for details).

Parenting practices and parental concerns during COVID-19
Pearson product moment correlation was used to investigate the relationship of parenting practices and parental concerns during COVID-19 lockdown. Findings indicate that parenting practices and parental concerns were significantly negatively correlated, r(921)  = − 0.29, p = .000, where higher scores in parenting practices represent positive practices and higher scores in parental concerns indicate higher parental concerns as per the scoring of respective parameters. Negative correlation between these two variables show that parents with higher parenting concerns reported negative parenting practices.

Discussion
COVID-19 can seriously affect the child and his/her family life. UNESCO reports 1.6 billion children out of school or childcare centers, leaving them deprived of group activities and sports (UNESCO, 2021). Parents and caregivers are struggling due to increased pressure of childcare responsibilities, uncertain situations and financial insecurity during the pandemic (Cluver et al., 2020;Kalil et al., 2020). Current study highlights various stressors affecting parents in Pakistan, a low middle-income country, along with the mental health of parents and how mental health is affecting parenting practices during COVID-19.
Uncertainty on the situation about COVID-19 was a major stressor for the parents. Continued updates from the media, economic burden, being stuck indoors, unavailability of the desired products due to lockdown and inability to go out and socialize were also reported major stressors by majority of the parents. Constant supervision of the children, studies of children and lack of recreational activities were the other factors increasing the stress in the parents. Hiraoka and Tomoda (2020) also reported an increased level of stress in the parents during COVID-19, their findings reflect that parenting stress was increased after the school closures than before the school closures.
Several researchers have reported increased levels of stress and mental health issues among parents during COVID-19, however intensity of the stressors has been different in each household which results in variable consequences (Evans et al., 2020;Janssen et al., 2020). Findings of the current study indicate that majority of the participants expressed concerns on how this pandemic will affect their child's education, fear of unavailability of basic needs, feeling of being trapped and not going out and wondering if lives would ever normalize again. Evans et al. (2020) also reported similar concerns by parents, such as children missing out on their education and absence of co-curricular and recreational activities for children.
Current study also indicates an association between relevance with the stressors during COVID-19 and parental concerns. It suggests that parents who perceive an increased level of stress due to COVID-19 lockdown reflect higher parental concerns. Janssen et al. (2020); Hiraoka and Tomoda (2020);Cluver et al. (2020) also strengthened the current findings through their studies and reported that higher stressors for the parents lead to their poor mental health and increased parental concerns. Janssen et al. (2020) reported uncertainty during the quarantine duration of the COVID-19 pandemic as a significant indicator to elevate the stress level of the parents.
The current study points out an important risk factor that increases the vulnerability of parents to higher parental concerns during COVID-19 pandemic. Results of this study reveal higher parental concerns for those who suffered from loss in income during COVID-19, furthermore, the current study also reveals differences in the scores of parental concerns among different family income subsets, indicating higher concerns in low-income families than those from low-middle income groups. Previous studies have also highlighted the relationship of financial difficulties and stress of the caregivers (Fuller-Thomson & Minkler, 2005;Kiely et al., 2015). Similar findings were reported by Kalil et al., 2020, indicating higher stress levels in parents with income loss. They also reported that it is the financial difficulty that caused stress in the parents instead of job loss, parents who lost their jobs but did not face financial difficulties were reported spending more quality time with their children. Xu et al. (2020) also reported an association between caregiver stress and material hardship. Tiwari et al. (2020) reported that consequences of COVID-19 lockdown were equally stressful for the mothers of joint and nuclear families however their coping strategies were different in both systems, however, findings of the current study indicate higher concerns of parents living in joint families than those in the nuclear family system. This dimension needs further exploration by future research.
Staying at home may have provided family members some extra time to spend with each other but it also came with increased burden of chores and responsibilities for the parents, especially the mothers (Russell et al., 2020). The findings of the current study reflected that in majority of the families, mothers were mainly responsible for taking care of children and helping them in their studies. This highlights another significant finding of the current study that mothers reported higher mean scores for parental concerns during COVID-19 than the fathers. Del Boca et al. (2020) shares similar empirical findings in their study, reflecting that COVID-19 resulted in increased childcare and household responsibilities in women as compared to their partners. Moreover, maintaining work-life balance proved to be more difficult for women than men, especially when their partners continued to work outside the home during COVID-19.
Parents reported that COVID-19 pandemic has adverse effects on their relationship with their children (Evans et al., 2020). Although the findings of the current study indicate a combination of positive and negative parenting practices during lockdown, parents with higher concerns during COVID-19 lockdown reported more negative parenting practices. These findings are consistent with research showing that environmental stressors and challenging events are associated with negative parenting practices (Conger et al., 2010) and with the findings of Borre and Kliewer (2014) who reported that parents suffering from stress and mental health issues find difficulties in parenting.

Conclusion and implications
COVID-19 pandemic presents a global crisis not only related to the health of people but also on family relations and mental wellbeing. Most of the studies have been conducted in the upper-and middle-income countries, and very few from lower and low-middle income group countries. Parenting issues in every country have been different and peculiar to its own culture  and we are presenting the challenges faced by low-and middle-income parents from Pakistan, which has otherwise tackled the problem of COVID-19 relatively well. The current study was an attempt to identify stressors faced by parents and parental concerns during this pandemic. As parental well-being greatly affects the quality of the parent-child relationships (Borre & Kliewer, 2014), this study also highlighted the association between parental concerns and parenting practices during COVID-19. Findings of the current study show several stressful factors for parents during COVID-19 pandemic, these primarily include financial burdens, education of children and uncertainty of the situation among many others. Study suggests an association between parental concerns and relevance with the stressors, indicating that higher the relevance with the stressors, higher the parental concerns. Findings show certain risk factors that make individuals/families more vulnerable to increased concerns during COVID-19. These risk factors include gender as mother showed increased concerns than fathers, socio-economic status as low-income group reflected higher parental concerns than with the high-income group and income loss during COVID-19 as participants from families that suffered from income loss during this pandemic presented higher concerns as compared to those who have not suffered from income loss. This study also highlights the association between parental concerns and parenting practices, indicating higher concerns lead to negative parenting practices. Findings of this research indicate the need for targeted and accessible interventions for mental wellbeing of the parents especially during these challenging circumstances so that parents can cope with the challenges in an effective way.

Strengths and limitations
Data for the current study was collected in 2 months, June 2020 to July 2020 during the first peak of COVID-19 pandemic in Pakistan. It presents information from a larger sample size through in-person survey which might add value to the findings of the study as in the lockdown period there were not many options for in-person data collection. Hence, data were collected only from hospital outpatient departments which can be a limitation, but researchers included hospitals from both public and private sectors so that data can be collected from the participants with diverse backgrounds.

Grant support and financial disclosures
Partial support from Pakistan Pediatric Association Research Division.

Declaration of competing interest
No potential source of conflict of interest of any author.