PARENTING STRESS AND QUALITY OF LIFE OF SPECIAL NEED CHIDREN'S PARENTS: A SCHOOL HEALTH SURVEY AMONG DISABLED CHILDREN IN BADEAN BONDOWOSO

The family with special need children experience children's dependency behavior. This situations related to parenting stress which affected parental quality of life. The objective of this study was to examine the correlation characteristic of parents and parenting stress and parental quality of life among special need children's parents. A cross sectional study design conducted among 52 parents with special need children in School of Disabled Children in Badean Bondowoso. A self-administered questionnaire including the Alabama Parenting Questionnaire and the World Health Organization Quality of Life-BREF Indonesian version were used to assess parenting stress; and parental quality of life, respectively. Pearson Product Moment and Spearman Rank was performed to answer the objective of this study. The results showed that, there were no correlation between parenting stress and parental quality of life of special need children's parents (p>0.05). However, length of disability correlated with parenting stress (r=0.339; p=0.014). Meanwhile; parent's gender (Z=-2.089; p=0.037), special need children's gender (Z=-2.102; p=0.036), and number of childrens (r=-0.297; p=0.033) were correlated with parental quality of life. This study concluded that characteristic of parents and children with special needs correlated with parental quality of life. Therefore, adaptive parenting environment should implement to reduce parenting stress.


INTRODUCTION
Indonesia's population is 237 million (BPS, 2012), where there are 2.45% of the people, including children, with disabilities (Ministry of Health, 2014). Children with disabilities have difficulties in meeting their needs, so they need the help of others to fulfill them; it can also be called children with special needs (Gomez & Gomez, 2013). Based on estimates of the United Nations (UN) in 2016, there are 10% of children with special needs from the total number of children in the world (Desiningrum, 2016). Children with special needs have dependency behavior to meet their needs (Bariroh, 2018). This dependency behavior can be a stressor for families, especially parents of children with special needs (Moawad, 2012). Parental stress experienced by parents can go along with the development of children with special needs (Smith & Grzywacz, 2014). The stress of care can cause changes in the quality of life in parents of children with special needs (Murray, et al., 2013). Prolonged care stress on parents of children with special needs is likely to be related to the quality of life of parents of children with special needs so that there will be disruption in the family and health problems in the parents of children with special needs. Desiningrum (2016) explains the UN estimate that at least 10% of children with special needs out of the total number of children in the world in 2016.
In the world, there are 1.25 billion children aged 5-14 years and 125 million children with special needs aged 5-14 years based on these estimates in 2016. Indonesia had 42.8 million people aged 5-14 years of school age in 2016. Based on these estimates, there were 4.2 million people with special needs for school-age 5-14 years in Indonesia in 2016 because of the absence of official data from the government regarding this matter. East Java was one of the five provinces, with the largest disability population in Indonesia in 2014 (Ministry of Health, 2014). Data from the Bondowoso Education Office in 2018 stated that there were 79 children with special needs in SDLBN Badean, Bondowoso Regency. The pres-ence of children is an encouraging thing in the family, but the presence of children with special needs in the family becomes a source of stress for the family (Moawad, 2012). Parenting stress experienced by the family, in this case, parents, can go along with the development of children with special needs (Smith & Grzywacz, 2014).
Parenting children with special needs are activities that cause high stress on parents of children with special needs (Moawad, 2012). Parenting a child with special needs can increase parental stress due to an increase in the health costs of children with special needs, time spent meeting the needs of children with special needs, physical care of children with special needs, and concerns about the future of children with special needs (Smith & Grzywacz, 2014 ). Prolonged parental stress can cause serious health problems and has the potential to increase the risk of low health status in parents of children with special needs (Smith & Grzywacz, 2014). Parenting stress that occurs in parents of children with special needs can cause changes in the quality of life in parents of children with special needs and disorders in the family (Murray, et al., 2013). Nurses as the primary implementers in promoting and preventive steps need to carry out the need to study the stress of care that can occur in parents of children with special needs in Bondowoso District, especially in SDLBN Badean Bondowoso Regency. Kholifah et al. (2016) explained that nurses could carry out tasks to the family if they have good relations with the family. Based on this, it is necessary to research the relationship of the stress of caregiving with quality of life in parents with children with special needs in SDLBN Badean Bondowoso Regency.

METHODS
This research was used descriptive correlational study with cross sectional design. The population used is all parents of children with special needs in SDLBN Badean, Bondowoso Regency totaling 79 people. The sampling technique in this study uses a non-probability sampling technique with a convenience sampling approach. 27 respondents could not find so they could not participate in this study. The sample has determined by researchers and is willing to follow the research of 52 parents of children with special needs. The inclusion criteria of this study were parents of children with special needs in SDLBN Badean, Bondowoso Regency. While the exclusion criteria are parents of children with special needs in SDLBN Badean, Bondowoso Regency, who refuse to participate in this study. This research conduct in January 2019 at SDLBN Badean, Bondowoso Regency.
The data collection use convenience sampling techniques. Researchers researched by visiting the parents of children with special needs SDLBN Badean Bondowoso Regency at the time agreed with the parents.
The researcher explains the aims and objectives of the research. After that asks the willingness of the respondents to participate in the study, gives an informed consent signed by the respondent if the respondent agrees to participate in research activities, informs the respondents how to fill in the questionnaire, and tells the time needed in filling out the questionnaire, at which time which use about 30 minutes per visit. The data that has obtained is collected and processed using data analysis.
The data collection procedure is a questionnaire related to the characteristics of respondents containing the characteristics of parents/guardians parents. There are sex, age, education, marital status, health conditions, occupation, parent/guardian relationship with the child, number of family members, number of children, and number of children with disabilities. The characteristics of the child, namely the child's name, age of the child, the sex of the child, the type of limitation of the child, the length of time the child has a disability, the use of assistive devices in children, and the range of study of the child in school. Alabama Parenting Questionnaire questionnaire by Frick (1991) in Maguin, et al., (2016), was used to determine subjective stress reactions in parenting which contained 42 statement items with a Likert scale providing 5 scales with a minimum value of 0 and a maximum value of 210 with a content validity index (CVI) of 0.81. The Alabama Parenting Questionnaire questionnaire has five dimensions, namely parental involvement, positive parenting, inadequate monitoring/supervision, inconsistent discipline, and corporate punishment. This questionnaire carried out back in the Indonesian version on the expert panel of seven nurses in the community and fam-ily, as well as child nursing with a CVI value between 0.8-0.9 and a total Cronbach's alfa value of 0.56, which carried out on 52 parent respondents. The Indonesian version of The World Health Organization Quality of Life-BREF Questionnaire by Skevington, et al., (2004). was used to measure the quality of life of parents which contained physiological, psychological, social, and environmental dimensions of care provided to children with special needs which includes 26 questions with Likert scale holding 5 scales with a minimum value of 0 and a maximum value of 130 with a value of r = 0.60.
This research conduct on an ethics test at the Faculty of Dentistry, University of Jember, with No. 201/UN25.8/KEPK/DL/2018. The researcher then obtained administrative approval from the National Unity and Politics Agency and the Bondowoso Health Office and SDLBN Badean Bondowoso Regency.
Categorical data are presented in a frequency distribution using percentage values. They usually have distributed numeric data present in the mean and standard deviation -numerically distributed numerical data current in median and percentile val-ues25-percentiles75. Pearson Product Moment Test and Spearman Rank are data analysis used to determine the correlation of domains and sub-domains of each variable between parental stress and the quality of life of parents with children with special needs. The Mann-Whitney and Kruskal-Wallis test used to identify the correlation between the characteristics of respondents with both variables (both parenting stress and quality of life of parents). The significance level use p <0.05. Data analysis performed using the SPSS 20 software application.

RESULTS
52 parents/guardians of children with special needs of productive age dominated by women (76.9%), namely mothers of children with special needs (65.4%) who work as housewives (48.1%) with the highest level of education at junior / senior high school level (42.3%) and married (88.5%). The majority of parents/guardians of children with special needs did not experience illness during the study (96.2%) and had a family member of between 3-4 people, where there were 2 children and 1 child with a disability. Children with special needs age between 9 years and 12 years, where there were 21 (40.4%) girls and 31 (59.6%) boys. The most disability experienced is mentally disabled (44.2%) since the age of 0-4 years. The duration of the study of children with special needs in school has a period of 4-4.75 hours. There are 5 (9.6%) children who use assistive devices.

Parenting Stress Children with Special Needs
Based on table 2 above, it can see that participants experience parental stress in terms of parental involvement, positive parenting, inadequate monitoring/supervision, and corporate punishment (p <0.05).

Quality of Life of Parents of Children with Special Needs
Based on table 3 above, it can see that the quality of life of parents with children with special needs is significant in physical health, psychological,

Relationship between Parenting Stress with Quality of Life of Parents of Children with Special Needs
Based on table 4 the results show that there is no relationship between the domain and sub-domains of parental stress and the quality of life of parents of children with special needs in SDLBN Badean, Bondowoso Regency (p> 0.05).

Relationship of Characteristics of Respondents with Parenting Stress Parents of Children with Special Needs
Based on table 5 the results show that there is a correlation between the disability time experienced by children with special needs and parental stress experienced by parents of children with special needs (r = 0.339; p-value = 0.014).

Relationship of Respondent Characteristics with Quality of Life of Parents of Children with Special Needs
Based on table 6 the results show that there is a correlation between the sex of parents (Z = -2.089; p-value = 0.037), the sex of children with spe-cial needs (Z = -2.102; p-value = 0.036), and the number of children (r = -0.297; p-value = 0.033) with the quality of life of parents of children with special needs.

DISCUSSION
The results showed that parenting stress was not related to the quality of life of parents of children with special needs. However, a relationship found between the duration of disability and the stress of caring for parents of children with special needs and the relationship between differences in the sex of parents, sex of children, and the number of children owned by the quality of life of parents of children with special needs in SDLBN Badean Bondowoso Regency. The following will discuss the relationship between several variables in this study. Parents of children with special needs in SDLBN Badean Bondowoso Regency do not experience the stress of caregiving. These results are different from Ljubeši?'s research in UNICEF (2014)  The coping pattern will cause parents' cognitive perceptions of children's behavior and needs. This study is supported by Prakoso (2018), who explains that parents need first to understand the inappropriate behavior of children and give sufficient attention to children so that the practice can change. Parent coping patterns can determine the understanding of parents against mistakes made by children. Parents of children with special needs in SDLBN Badean Bondowoso Regency experience a meaningful quality of life in physical health, psychological, and social relationships. These results have differences with Kvarme et al., (2016), where there are 27 immigrant parents with children with special needs who experience reduced quality of life. This study was explained by Gomez & Gomez (2013) that physical health is related to the health conditions of parents when caring for children with special needs. Psychological ranges from emotions to cognitive processes were caring for children with special needs can interfere with the mental health of parents of children with special needs. Social relationships are related to the social life of parents of children with special needs who can be disturbed by the lack of support when caring for children with special needs. Cognitive processes can influence parents' perceptions of their quality of life while caring for children with special needs. No relationship found between the characteristic of the age of parents, the gender of parents, the level of parental education, parental marital status, familial health status, type of parental occupation, parent-child relationship, number of family members, number of children, number of children with disabilities. Also characteristic of age child, sex of a child, type of disability of a child, aids used by a child, and length of time child in school with the stress of caring for parents of children with special needs. The duration of disability experienced by children with special needs is related to parental stress experienced by parents of children with special needs. The results of the study are different from Bariroh (2013), who found that parents who have children with special needs have a low level of supervision. The difference caused by the focus of study leading to the motivation of children with special needs to learn. These results are supported by Smith & Grzywacz (2014), explaining that parenting stress that occurs in parents of children with special needs can be higher if parents of children with special needs cannot meet and care for children with special needs. Therefore, parents of children with special needs need to provide adequate supervision to their children by helping, accompanying, and directing their children. No relationship found between characteristic of parental age, parental level of education, familial, marital status, parental health status, type of parental occupation, parent-child relationship, number of family members, number of children with disabilities, age of child, type of child disability, prolonged disability of children, tools used by children, and length of study of children in school with the quality of life of parents of children with special needs.
The gender of parents has a relationship with the quality of life of parents of children with special needs. This study is in line with research Kazmi, et al. (2014), which explains that the sex of parents influences the quality of life of parents of children with special needs. Mothers of children with special needs experience depression and lower quality of life than fathers of children with special needs. This problem is caused by stress and depression suffered by parents with special needs. Because they have to meet all the needs of children with special needs, these results are different from the study of Gomez & Gomez (2013), which explains that there is no relationship between the sex of parents with the quality of life of parents of children with special needs. This study can happen to caregivers of children with special needs other than parents and supported by activities between parents and children with special needs so that parents get more social support from these activities. Parents need to give more free time to accompany, supervise, and direct children with special needs in activities. The results found that the number of children is related to the quality of life of parents of children with special needs.
These results are different from Gomez & Gomez (2013), which explains that indicators of education level, income, financial condition, and duration of therapy that cause changes in the quality of life of parents of children with special needs. Parenting more than one child has an impact on the physical and psychological health of parents. Susanto et al. (2019) explain that parenting is related to breastfeeding to stimulate child growth for five years. The year is a golden year for children to get individual abilities, thoughts, language, conversation, and social behavior. Children with special needs can cause dependence on parents to meet their needs. This condition can affect the quality of life of parents of children with special needs. Appropriate management of care from the beginning needs to be done by parents of children with special needs so that changes in quality of life do not occur. The sex of children with special needs is related to the quality of life of parents of children with special needs. This study is different from Gomez & Gomez (2013), which explains that the sex of children with special needs is not related to the quality of life of parents of children with special needs. Gender differences in children with special needs lead to differences in parents' coping patterns when caring for children with special needs. This study can overcome by the concept of adaptive parenting (Prakoso, 2018), which states that educating or caring for children is done by parents according to the uniqueness of each child.
Effective communication can also help to parent parents to children. Effective communication between parents to children, between parents and children to parents can improve understanding between parents and children. Planning the number of children from an early age can also help reduce the risk of decreasing the quality of life of parents. This study cannot reveal a causal relationship regarding parenting stress and the quality of life of parents of children with special needs. Multivariate cross-sectional can be used in further research to find the relationship between the two variables. Test-retest needs to done again related to measuring instruments The Alabama Parenting Questionnaire and The WHOQoL BREF Indonesian version on multicultural and children with special needs so that the measuring tool is applicable for parents of children with special needs.

CONCLUSIONS
The results of this study indicate that parenting stress is not related to the quality of life of parents of children with special needs in SDLBN Badean, Bondowoso Regency. However, long disabilities are associated with parental stress. Meanwhile, the sex of parents, sex of a child, and some children owned are related to the quality of life of the parents of children with special needs in SDLBN Badean, Bondowoso Regency. Therefore, early detection of parental stress experienced by parents of children with special needs to done. Family nurses can conduct stress assessment of care from old age to parents of children with special needs so that families can form an adaptive care environment for children with special needs. Providing regular counseling every year to parents of children with special needs can be done by nurses. Then, providing appro-priate coping patterns and social support is expected to help parents avoid the stress of caregiving and achieve optimal quality of life.