JournalofPrimaryPrevention,6(1),Fall,1985
Children's U n d e r s t a n d i n g of Health and Illness Concepts: a P r e v e n t i v e Health P e r s p e c t i v e D A V I D G. A L T M A N a n d T R A C E Y A. R E V E N S O N
ABSTRACT: The present study examined beliefs about health and illness among a sample of 101 healthy children and young adolescents, from 8 to 14 years old. Respondents were administered a series of open- and closed-ended interview questions and were asked to draw a picture of a sick person. Various dimensions of health and illness were examined, including definition, concern, susceptibility, and locus of control. Several agelinked differences along these dimensions were found. Younger children were more concerned about their health and maintained a more external health locus of control, yet tended to rate their health more positively than older respondents. Younger children also tended to define illness from a more concrete, present-oriented, and symptom-specific, perspective. No effects of gender, self-reported illness experience, or family illness experience were found. Implications for the design of preventive health interventions and for future research are discussed.
In recent years, research interest in children's health knowledge, attit u d e s , a n d b e h a v i o r h a s g r o w n ( B i b a c e & W a l s h , 1979; B r u h n & P a r cel, 1982; D i e l m a n , Leech, B e c k e r , R o s e n s t o c k , H o r v a t h , & R a d i u s , 1980; K a l n i n s & Love, 1982; R o t h m a n & B y r n e , 1981). So too h a s a n i n t e r e s t i n p r i m a r y p r e v e n t i o n a n d p r e v e n t i v e h e a l t h care. A s forcef u l l y s t a t e d b y M a t a r a z z o (1983), there is m o u n t i n g evidence [from] w i t h i n the federal government, from private business and industry, from teachers and a d m i n i s t r a t o r s . . , and from the professions of medicine and psychology . . . t h a t p r i m a r y and secondary schools are excellent settings for promoting health and preventing illness and dysfunction in large n u m b e r s of our n a t i o n ' s curr e n t l y h e a l t h y c h i l d r e n . . . (p. 84) B r i d g i n g t h e s e two a r e a s is p a r t i c u l a r l y r e l e v a n t for p e d i a t r i c h e a l t h p s y c h o l o g i s t s , s i n c e c h i l d r e n ' s a t t i t u d e s a n d b e h a v i o r s a r e t h o u g h t to The order of the authors names is alphabetical. The authors thank Edward Siedman for his helpful comments on an earlier draft of the manuscript. David G. Altman is a postdoctoral fellow at the Stanford Center for Research in Disease Prevention. Tracey A. Revenson is an Assistant Professor of Psychology, Barnard College of Columbia University. Address all correspondence to David G. Altman, Stanford Heart Disease Prevention Program, Health Research and Policy Building, Stanford University, Stanford, California 94305. 53
©1985HumanSciencesPress
54
Journal of Primary Prevention
be more malleable than those of adults (Dielman et al., 1980) and because teaching healthy habits to children will likely lead to the acquisition and maintenance of healthy adult habits (Becker, Haefner, Kasl, Kirscht, Maiman, & Rosenstock, 1977). Before this can be achieved, a clearer understanding of how healthy children of different ages conceptualize health, illness, and health-related behavior is needed. Some researchers studying children's concepts of health and illness have adopted a cognitive-developmental perspective using Piagetian theory (Singer & Revenson, 1978) to explain how these concepts qualitatively and systematically change in tandem with cognitive developmental processes (cf. Bibace & Walsh, 1979; Campbell, 1975; Kister & Patterson, 1980; Nagy, 1951; Natapoff, 1982; Perrin & Gerrity, 1981). These studies have identified sequential stages in children's understanding of illness concepts and causality, and have suggested that illness experience interacts with age in the development of illness concepts (Campbell, 1975). For the most part, these studies have adopted a medical model orientation which treats health as the absence of illness and focuses almost exclusively on the development of illness concepts. Age differences in children's conceptions of health and illness have also been reported by researchers using a more social-psychological approach. Based on expectancy theory, this work focuses primarily on individual expectations and values of health as determinants of health behavior (cf. Becker et al., 1977; Dielman et al., 1980; Gochman & Saucier, 1982). For example, studies utilizing the Health Belief Model have proposed that beliefs about the likelihood, severity, and consequences of illness, as well as the costs and benefits of taking health actions, are related to actual health behaviors (e.g., Becker et al., 1977). Studies from both these approaches have focused primarily on beliefs about health-related actions that prevent disease (illness prevention) and not on those which promote health (health promotion). While these two domains overlap to a certain extent, they are conceptually different. Health promotion implies activities taken by healthy individuals with the intent of enhancing well-being. In contrast, illness prevention activities reflect actions taken by healthy individuals with the intent of avoiding illness. The distinction lies in the goals of the action. While health promotion ultimately can result in the avoidance of illness, its more immediate goal is the enhancement of well-being. In turn, while the goal of illness prevention behaviors is clearly the avoidance of illness, such actions may also result in increased well-being.
David G. Altman and Tracey A. Revenson
55
T h e r e still r e m a i n s a d e a r t h of k n o w l e d g e in t h i s a r e a a n d a b e t t e r u n d e r s t a n d i n g is n e e d e d before successful i n t e r v e n t i o n s c a n be developed ( B r u h n & Parcel, 1982; G o c h m a n , 1982). To t h i s end, t h e c u r r e n t s t u d y e x a m i n e s t h e r e l a t i o n s h i p of age, gender, a n d illness e x p e r i e n c e to h e a l t h a n d illness concepts a m o n g h e a l t h y , school-aged youth. Methods Procedures a n d S a m p l e The sample consisted of elementary and junior high school students (grades 3 - 8 ) from a California public school. Students were randomly selected from class rosters to participate in the study, with approximately equal numbers of male and female respondents selected from each grade level. Consent to participate in the study was obtained from parents one week before the interview and from students at the time of the interview. Twelve parents removed their children from the sample frame and eight students chose not to participate in the interview. Subjects were interviewed privately during school hours by trained graduate and undergraduate students. Interviews ranged in length from 15 to 45 minutes (mean of 24 minutes) and included both open- and closed-ended questions as well as a pictorial measure. One hundred and one respondents (51 boys, 50 girls) were interviewed, ranging in age from 8 to 14 years; 90% were white. While no data are available on socioeconomic status, the school population consisted of children from primarily middle- and upper-middle-class families. Measures The interview schedule covered three primary content areas: (1) health and illness concepts; (2) pictorial representation of an ill person, and (3) social relationships and health. Only analyses covering the first two areas will be reported in this paper. Health and illness concepts. Health and illness concepts were assessed with both closed- and open-ended questions. Eight closed-ended Likert-type items were used to measure specific health beliefs: how often health was thought about; difficulty in being healthy; perceived illness susceptibility; degree of worry about own health; internal health locus of control; external health locus of control (powerful others); external health locus of control (chance/luck); and self-rated health. Since these items were only modestly intercorrelated (average intercorrelation= .13), an exploratory principal factor analysis (oblique rotation) was performed to determine meaningful clusters of variables. Self-rated health was tapped by a standard single-item measure used in previous research (cf. Tessler & Mechanic, 1978) and thus was not included in the factor analysis. Using Kaiser's criterion (eigenvalue -> 1.00), four factors were retained, accounting for 71.1% of the total variance. Table 1 presents the
56
Journal of Primary Prevention
factor items and loadings. Scales for each of these factors were computed by unit-weighting and summing respondents' scores on those items which loaded above .40. The first scale, health concern, accounted for 47.2% of the common variance and was composed of three items: how often respondents thought about their health, how much respondents worried about their health, and how long respondents talked about health (duration of interview). There were a number of conceptual and empirical reasons for including interview duration in the factor analysis and health concern scale, even though it is often considered to be a
Table I Factor Analysls of Health Bellef Varlables: Factor 1
Factor 2
Health Concern
Susceptibillty to lllness
Items, Loadlngs end Communalltles F~ctor 3
Factor 4
External Health Locus of Control
internal Health Locus of Control
h2
Item
Worry about health
.71
.20
-.03
-.15
.58
Think about health
.66
.01
.14
.06
.49
Length of intervlew
.58
-.22
.01
.06
.39
.57
.19
.05
.34
.51
-.32
-.06
.38
I I I I I
Difficulty in being healthy
-.07
Likelihood of becoming sick
.08
Health locus of control: Powerful others
.13
.07
.70
.06
.55
Health locus of control: Chance, luck
.03
-.01
.44
-.15
.24
Health locus of control: Internal
.01
.04
-.05
I t .62 I
I _ _
NQ#e. ~= 101. Factor loadings are from a principal oblique rotation.
I .39
I
factor analysis using
David G. Altman and Tracey A. Revenson
57
control variable. F i r s t , since the interview was open-ended and allowed child r e n to t a l k as much or as little as t h e y wanted, the a m o u n t of t i m e t h e y did in fact t a l k was a s s u m e d to reflect t h e i r concern about health. Second, age was inv e r s e l y r e l a t e d to all t h r e e scale v a r i a b l e s (r = - . 1 8 , p < .07; r = - . 2 1 , p < .04, r = - . 2 2 , p < .03, for thought, worry, and l e n g t h variables, respectively). Thus, the a m o u n t of t i m e t a l k i n g about h e a l t h was not a function of v e r b a l development. T a k e n together, these findings suggest t h a t l e n g t h of i n t e r v i e w is a m e a n i n g f u l reflection of h e a l t h concern and not a n artifact of differential comm u n i c a t i o n abilities b e t w e e n age groups. 1 The second scale, external health locus of control accounted for 21.4% of the variance. It included two items: belief in chance and belief in powerful others, as r e l a t e d to health. A n internal locus of control i t e m clearly emerged as a sepa r a t e factor and accounted for 12.1% of the variance. (All t h r e e items were modeled after those developed by Parcel and Meyers, 1978.) The final scale, accounting for 19.3% of the variance, was labeled susceptibility to illness. It also was composed of two items: difficulty in being h e a l t h y and t h e e s t i m a t e d chance t h a t the respondent would become ill in t h e n e x t year. I n t e r c o r r e l a t i o n s a m o n g these five dependent v a r i a b l e s (the four factors and self-rated h e a l t h status) revealed t h e m to be quite i n d e p e n d e n t (average interc o r r e l a t i o n = .12). Only two of the correlations were s t a t i s t i c a l l y significant: h e a l t h concern w i t h e x t e r n a l h e a l t h locus of control (r -- .27, p < .01) a n d w i t h self-rated h e a l t h s t a t u s (r = .22, p < .05). In a d d i t i o n to the closed-ended measures, t e n open-ended questions were included in the interview. These questions addressed b r o a d e r issues such as the i m p o r t a n c e of health, illness causation, h e a l t h - r e l a t e d behavior, and the likelihood of becoming ill. Responses for each question were content-analyzed a n d a 10% r a n d o m s a m p l e of responses was coded by two g r a d u a t e students to det e r m i n e i n t e r - r a t e r reliability. A v e r a g e exact a g r e e m e n t r e l i a b i l i t y was 87%. Pictorial representation of an ill person. Respondents also were a s k e d to "draw a picture of a sick person." No f u r t h e r directions were given and child r e n were given as much t i m e as t h e y w a n t e d to d r a w the picture. Discrete features of the d r a w i n g s were coded in a n effort to categorize and describe the cont e n t of t h e drawings. No a t t e m p t was m a d e to analyze the d r a w i n g s clinically a n d only those aspects of the d r a w i n g s which reflected children's definitions of h e a l t h and illness were analyzed. To obtain r e l i a b i l i t y of the coding scheme, 10% of t h e pictures were r a n d o m l y selected and t h e n i n d e p e n d e n t l y coded by the authors. Exact a g r e e m e n t r e l i a b i l i t y a v e r a g e d 96%. In order to control for possible age and i n d i v i d u a l differences in d r a w i n g ability, respondents also were a s k e d to describe t h e i r drawing. Illness experience. Since personal experience w i t h major or m i n o r illness 1. In addition, repeating the analyses presented in this paper using a two-item health concern scale (excluding duration) while controlling for duration of interview at the same time produced no changes either in the magnitude or significance of the effects.
Journal of Primary Prevention
58
may affect understanding of health concepts (Campbell, 1975; Weisenberg, Kegeles, & Lund, 1980), children's self-reports of health problems during the past year were elicited. Two variables were used to assess recent experience with illness, one for self and one for family. Response categories for three variables were: no illness, mild illness (e.g., colds), moderate illness (e.g., flu), or severe illness (e.g., surgery).
Results In this section, we will first examine the closed-ended measures for age differences in children's conceptions of health and illness. Open-ended and pictorial data then will be presented to illustrate age differences as well as to provide an overall perspective of how children view health and illness. Finally, the influence of gender and illness experience on conceptions of health and illness will be discussed.
Age Differences For these analyses, three age groups were used: 8-10, 11-12, and 1 3 - 1 4 years. As shown in Table 2, younger respondents were more
Table 2 Age Differences
In Health B e l i e f s Means for Aoe Grouos a
Health B e l l e f
E
df
~
8-10
11-12
13-14
Health concern
4.82
2,95
.01
2.94
2.72
2.40
-.28
Susceptibility to Illness
2.24
2,97
NS
2.31
2.15
2.50
.02
External health locus of control
9.30
2,98
.001
2.30
1.95
1.53
-.41
Internal health locus of control
.98
2,98
NS
3.34
3.35
3.38
.04
4.68
2,97
.01
4.03
3.89
3.48
-.30
Self-rated health
£
Note. Scale scores range from I to 4 except for self-rated health which ranges from I to 5. a ~'s for each age group (from youngest to oldest) are 35, 37, and 29.
David G. A l t m a n and Tracey A. Revenson
59
concerned about their health, had a more external health locus of control, and rated their current health more positively than older respondents. Both the pattern of means and Pearson correlations indicate linear relationships. A few notable age differences also emerged in the open-ended interview questions, presented in Table 3. In conceptualizing health and illness, older respondents tended to report nonspecific conditions, for example, defining health as the absence of illness or simply feeling good, or describing a sick person in terms of general symptom states. Regarding causes and prevention of illness, too, older and younger respondents shared somewhat different concerns. Younger children worried more about contracting childhood illnesses, such as chicken pox, while the oldest children (ages 13 to 14) were more concerned about major diseases and disabilities. Younger children more often mentioned behavioral actions, such as not eating right, as causes of illness, while older children focused on germs or disease, including contact with sick people. Younger respondents also were more likely to mention current feelings of ill health as signs they would get sick. Those children in good health at the time of the interview predicted they would be healthy the following year, whereas children who displayed symptoms expected to be ill the following year. Finally, younger children focused on specific symptoms as indications that they were ill, while older children were more apt to use the persistence of symptoms as a criterion.
General Thoughts About Health and Illness Along with examining age differences, it also is informative to study what health and illness issues are salient to children and preadolescents. In an attempt to assess the importance of health in a nondirective manner, the interview commenced with the question: "When you think about what is important in your life, what do you usually think about?" Even though some respondents knew the topic of the research, few (15%) mentioned health as a life concern. Only 9% (3) of the 8 - 1 0 years olds, 16% (6) of the 1 1 - 1 2 year olds, and 21% (6) of the 1 3 - 1 4 year olds mentioned health as a concern. The data in Table 3 (column 2, labeled Total Sample) also provide a broad picture of how healthy children and adolescents think about health and illness. Major concerns centered around diet (28%), bodily functions and anatomy (27%), being healthy (22%), exercise (20%), and getting sick (16%); thus, they think about aspects of good health, illness prevention, and illness behavior. Over half the respondents (51%)
Journal of Primary Prevention
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Table 3 Summary of Responses to Open-Ended Health Belief Questlons Question
TgTal Samole ~a
Deflnlne health: What does it mean to be healthy? (N=98) Feellng/belng In good physlcal or mental health Having gcx~d health habits Absence of illness
~
Ace Grouo (~)b 8-10
11-12
13-14
51
(52)
18
12
22**
30 25
(30) (25)
11 5
14 8
5 12 +
Describe a sick person (~=I01) c Unfocused ~ymptoms General symptoms Descriptions of emotions Specific symptoms Slckrole/patlent behavior Limitations on actlvity
82 80 58 42 37 34
(83) (81) (59) (42) (37) (34)
31 28 18 17 12 12
30 26 24 17 15 13
22 27 + 17 8 10 9
W~ot Illnesses do vou worrv about aettine? (~=I00) Viral/bacterlal infections Major disease or disability Childhood illnesses
64 26 20
(64) (26) (20)
23 6 10
20 7 9
21 13 I*
What causes 0eoDle to oet ~iqk? (~=I01) Behavioral actions Diseases or germs Contact with sick people
72 44 15
(73i (44) (15)
27 11 I
31 16 9
15" 17 + 5*
[What is the chance that you will get very sick this year?] How do you know? (~=I01) Because of past experiences Current feelings of ill health
33 32
(33) (32)
13 15
7 13
13 + 4+
47 25 20 13 8 6 5 4
(47) (25) (20) (13) (8) (6) (53 (4)
17 6 5 2 4 3 I 2
22 8 3 8 2 I I I
8* 11 12"* 3 2 2 3 I
28 27 22 20 16
(28) (26) (21) (19) (15)
11 13 5 6 I
12 7 6 8 7
6 10 + 5 7~
How do vou know when you are III? (~=I01) Specific symptom(s) General slckness state Symptoms persist Parents decide I don't know Role loss You just know Psychological factors
When you t h i n k about your health what do you u s u a l l y t h i n k about? (~=95) Diet B o d i l y f u n c t i o n s and anatomy Being healthy Exercise Getting sick and how I feel when sick
4
David G. Altman and Tracey A. Revenson
61
Table 3 (continued) Total Sample
Question
~
Age Greuo (~) 8-I0
II-12
13-14
What thlnQs can you do to stay healthy? (~:I01) Eat proper food Exercise Maintain good personal hygiene Sleep enough See a doctor
90 65 22 13 9
(91 (66) (22) (13) (9)
34 14 10 4 0
30 28 7 3 5
27 + 24** 5 6 4
Wh@n i~ it h~r¢@~t for you to be healthy? (~=I01) Food When you're sick Maintaining healthy behavior
36 18 14
(36) (18) (14)
15 I 6
13 7 2
8 I~** 6
a For some questions, percents add up to over 100% since respondents were allowed to give more than one response.
For those questions in which responses
could not be coded, the total percent is less than 100 percent. b Significant chi-square analyses for differences among age groups are noted at the end of each row. c Mean number of symptoms described was 5.78
± 1.9 for the total sample, and
no significant age differences were found. ** ~ < .01
* ~ < .05
+ ~ < .I0
defined health as feeling good or being in good physical or mental health and 30% defined it as maintaining good health habits. Only one quarter of the sample defined health as the absence of illness. Interestingly, almost three quarters of the respondents (72%) mentioned that their behavioral actions (for example, not eating correctly, not sleeping enough, not wearing warm clothes) contributed to their becoming ill. Contact with germs (44%) or with sick people (15%) also were seen as causal agents. Respondents were more concerned about contracting viral and bacterial infections (e.g., colds, flu, with 64% reporting this) than either with contracting major disease or disability (26%) or childhood illness such as chickenpox (20%). Behavioral factors such as eating nutritious food (90%) and exercising regularly (65%) were seen as pivotal to staying healthy. Similarly, over a third of the respondents (36%) mentioned dietary issues as contributing to difficulties in being healthy, for example, overeating or being tempted by unhealthy food. In characterizing a sick person, a majority of the respondents men-
62
Journal of Primary Prevention
tioned either unfocused (82%) and general symptoms (80%) as key features. Unfocused symptoms reflected nonspecific feeling states, such as feeling sick or bad; general symptoms involved reference to more focused feeling states, such as being weak, sweaty, or dizzy. However, when respondents were asked how they knew when they were sick, almost half (47%) reported the occurrence of specific symptoms (e.g., runny nose, sore throat) as important signs, although 25% mentioned the presence of a general sickness state (e.g., not feeling well).
Pictorial Data Table 4 presents the univariate frequency data on the pictorial variables. A broad range of drawings of ill people was obtained, some very detailed, others quite simple. For example, some drawings included m a n y different body parts while others focused simply on facial features. Almost half (45%) of the sick people were drawn in bed, with 5% in a hospital bed as indicated by IV tubes and other machinery. Interestingly, approximately one fifth (21%) of the figures in the drawings were clothed, suggesting that the illness depicted was not disabling. Slightly over one third (37%) of the individuals were unhappy, as indicated by frowns or tears. This finding was echoed in the verbal descriptions of the drawings: almost a third (28%) of the children described the sick person drawn as unhappy, and one fifth, (20%) as generally feeling "bad." Children described a wide variety of specific symptoms in their drawings, including red or runny eyes (28%), feeling tired or weak (23%), flushed cheeks or fever (17%), and cold symptoms (16%).
Gender differences No significant differences were found between sexes on any of the measures. In addition, there were no significant gender by age interactions.
The influence of illness experience Contrary to expectations, the degree to which respondents or their immediate family had experienced illness was unrelated to any of the study variables. Even when the two illness experience measures (self and family) were collapsed into no illness versus mild, moderate, or serious illness dichotomies, no significant findings emerged.
David G. Altman and Tracey A. Revenson
63
Table 4 Pictorial
and Verbal Characterl s t l c s o f Drawings o f A Sick Person Total
Feature o f Drawlne
Samnle (~=95) ~
~
Aae Grouo (~)b 8-10
11-12
13-14
Emotional expression NO d e t e c t i o n o f emotion Unhappy Happy
60 37 3
(57) (35) (3)
19 11 3
22 13 0
16 11 0
Person drawn In bed No Yes: r e g u l a r bed Yes: h o s p i t a l bed
55 40 5
(52) (38) (5)
15 15 3
21 13 I
16 10 1
Accessories (e.g.p thermometer) Not drawn Drawn
59 41
(56) (3g)
20 13
23 12
13 14
Emotional c o n t e n t No r e p o r t Unhappy Other Happy
66 28 3 2
(63) (27) (3) (2)
21 10 1 1
23 9 2 1
19 8 0 0
Presence o f I l l n e s s a NO I l l n e s s r e p o r t e d General ( f e e l s badly) Minor I l l n e s s Serious-acute Serlous-chronlc
56 20 7 15 6
(53) (20) (6) (14) (6)
15 7 2 8 2
20 6 3 5 3
18 7 1 1 I
28 23 16 10
(27) (22) (15) (g)
4 4 5 6
12 g 5 1
11" g 5 2
7 5 3 2
(7) (5) (3) (2)
2 2 3 I
3 1 0 1
~2 2 0 0
Verbal DescrlntIon of Drawlna
Symptoms mentloned c Red eyes, runny eyes T i r e d , weak, f a t i g u e Cold symptoms Skin: cheeks f l u s h e d , pale s k l n , spots Fever, c h i l l s , sweats Groanlngp c r y i n g Stomach problems Other
a Percents add up t o over 100~ since respondents were allowed t o g i v e more than one response. b Signlflcant
c h l - s q u a r e analyses f o r d i f f e r e n c e s
among age groups are noted
at t h e end o f each row. c Mean number of symptoms mentioned was .95 ~ .92 f o r t h e t o t a l signlficant
age d l f f e r e n c e s
* ~ < .05
were found.
sample and no
Journal of Primary Prevention
64
Discussion
The current findings provide important information on how healthy children and young adolescents conceptualize health. Unlike some other studies, this research included concepts of health promotion as well as illness prevention. Health was not a particularly important life concern for this sample, although it was a frequent topic of thought. This does not appear to be an idiosyncrasy of the sample, as similarly low levels of concern about health matters were found in a randomly selected community sample of children (Dielman et al., 1980). It does, however, have implications for the interpretation of the findings and their applications in health education. The dimensions of children's health beliefs found through an exploratory factor analysis resemble those of Dielman et al. (1980), although the Dielman study used a much larger item pool. Concern about health was not related to illness susceptibility, confirming Dielman's suggestion that they are independent components of the Health Belief Model. It is possible that the failure of previous studies to demonstrate a clear link between susceptibility (or health threat) and health behaviors (Kegeles, 1980; Kegeles & Lund, 1982) may be due to the fact that health c o n c e r n is a more salient motivational factor of health behavior. By treating concern and susceptibility as distinct constructs as well as examining their reciprocal and interactive influences in future research, a better understanding of the factors affecting preventive health behaviors may be obtained. Several interesting age differences were found in the study. First, younger respondents were more concerned about their health than older respondents, a finding congruent with the results of Dielman et al. (1980). Second, younger respondents tended to attribute control over their health more to external factors, such as chance and powerful other people, than older respondents. It is not clear whether this is the result of developmental differences in causal attributions (e.g., Kister & Patterson, 1980) or to the fact that older children do indeed have somewhat more personal control over their health. While it is likely that younger children may be more concerned about health as a result of their feelings of low personal control or of their inability to understand concepts of personal versus external causation fully, we found the correlation between health concern and locus of control to remain strong and positive even with the effects of age partialled out. Therefore, while it appears logical that attributions of control to external factors would increase concern over health matters, the causal mechanisms underlying this relationship remain to be determined.
David G. Altman and Tracey A. Revenson
65
Third, older and younger respondents tended to define health and illness in somewhat different manners. Younger children emphasized specific health states, such as symptoms, in their definitions, particularly childhood illness symptoms close to their own experience. They also tended to focus on their own past illness experiences and healthrelated actions to a greater extent than older children. Older children, in contrast, stressed more general and abstract feeling states and particular illnesses; they also relied more heavily on temporal components of illness, such as the persistence of symptoms or the possibility of reccurrence. Overall, as age increased, so did a growing recognition of illness more as an abstract syndrome of symptoms and feelings with a definite time perspective and less as isolated symptoms. This corroborates the work of developmental psychologists in this and other content areas, which suggest that younger children are more egocentric and concrete in their phenomenological experiences (Campbell, 1975; F u r m a n & Bierman, 1983). While some studies have suggested that the mechanisms which cause illness are not understood until the eighth grade at the earliest (Perrin & Gerrity, 1981), our respondents appeared to understand these relationships. There also is evidence that they understood cause and effect relationships between their behavioral actions and subsequent health outcomes. Additional research examining these causal links is crucial, as it is possible that healthy children do not see the need for preventive health behavior when they are in good health. Given the fact that younger respondents relied somewhat more heavily on personal experience in their definitions of health and rated their health more positively than older respondents, it was expected that this age difference would result from differences in illness experience across age groups. No evidence for this proposition was found. It is possible that the absence of such effects in this sample is due to the insensitivity or unreliability of the self-report illness experience measure. For example, we know from the question on health worries that younger respondents worried more often about common childhood illn e s s e s - i l l n e s s e s probably closer in time to their personal experience. Also, younger children based their predictions of future illness susceptibility on how they currently felt. In contrast, older respondents were more concerned with serious illness and functional disabilities, most likely reflecting their understanding of the severity of these illnesses or the likelihood of their contact with chronically ill persons. The pictorial data also reflect the potential influence of illness experience; according to the children's descriptions, most of the figures in the draw-
66
Journal of Primary Prevention
ings were suffering from minor childhood illnesses, such as colds or sore throats. Furthermore, three of the five children who drew the ill person in a hospital bed had been exposed to a serious illness during the preceding year. It is likely that more sensitive measures of illness experience, such as reports from family members or examination of medical records, will reveal more clearly the age-linked relationship between illness experience and the development of health and illness concepts. The age differences in perceived health status might also indicate that perceptions of health status, rather than actual or medically defined health status, vary with age. If true, the limitations of self-rated health measures with children should be acknowledged and age-specific distinctions taken into account. In contrast to findings reported in other studies (Bibace & Walsh, 1979; Campbell, 1975), psychological and social dimensions of health were infrequently mentioned. This finding was quite unexpected, particularly since the school's health curriculum incorporated a biopsychosocial perspective (Engel, 1977); such concepts may be more sophisticated than grade school children can understand. In light of this and the other age-linked differences noted above, it might be useful to focus on cognitive level rather than content area in designing and evaluating school health education programs. Charting the developmental progression of health and illness concepts and their relationship to health behavior is necessary for the development of successful prevention programs. Research should incorporate longitudinal designs to assess the development of health beliefs and attitudes, directing attention to familial and societal influences on their development. Comparisons among healthy, acutely ill, and chronically ill children of different ages may help untangle the effects of age and illness experience. Before jumping on the prevention bandwagon, researchers and i~ractitioners alike are well advised to invest more time studying how children and adolescents conceptualize health and illness. In the absence of this knowledge, preventive interventions are likely to fail, as evidenced by the early smoking education programs which emphasized the long-term dangers of smoking (e.g., Thompson, 1978). If we accept the slogan of our medical colleagues, "dictim premum notion," our professional obligation to design interventions and health education programs on the basis of research knowledge and primary prevention concepts is clear and convincing.
David G. Altman and Tracey A. Revenson
67
References Becker, M.N., Haefner, D.P., Kasl, S.V., Kirscht, J . P , Maiman, L.A., & Rosenstock, I.M. (1977). Selected psychosocial models and correlates of individual health-related behaviors. Medical Care, 5 (suppl.), 27-45. Bibace, R., & Walsh, M.E. (1979). Developmental stages in children's conceptions of illness. In G.C. Stone, F. Cohen, & N.E. Adler (Eds.), Health psychology. San Francisco: Jossey-Bass. Bruhn, J.G., & Parcel, G.S. (1982). Current knowledge about the health behavior of young children: A conference summary. Health Education Quarterly, 9(2 & 3), 142/238-166/262. Campbell, J.D. (1975). Illness is a point of view: The development of children's concepts of illness. Child Development, 46, 92-100. Dielman, T.E., Leech, S.L., Becker, M.H., Rosenstock, I.M., Horvath, W.J., & Radius, S.M. (1980). Dimensions of children's health beliefs. Health Education Quarterly, 7, 219-238. Engel, G.L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129-136. Furman, W., & Bierman, K.L. (1983). Developmental changes in young children's conceptions of friendship. Child Development, 54, 549-556. Gochman, D.S. (1982). Labels, systems and motives: Some perspectives for future research programs. Health Education Quarterly, 9(2 & 3), 167/263-174/270. Gochman, D.S., & Saucier, J.R. (1982). Perceived vulnerability in children and adolescents. Health Education Quarterly, 9(2 & 3), 46/142-59/155. Kalnins, I., & Love, R. (1982), Children's concepts of health and illness--and implications for health education: An overview. Health Education Quarterly, 9(2 & 3), 8/104-19/115. Kegeles, S.S. (1980). The health belief model and personal health behavior. Social Science and Medicine, 14C, 227-229. Kegeles, S.S., & Lund, A.K. (1982). Adolescents' health beliefs and acceptance of a novel preventive dental activity: Replication and extension. Health Education Quarterly, 9(2 & 3), 96/192-112/208. Kister, M.C. & Patterson, C.J. (1980). Children's conceptions of the causes of illness: Understanding of contagion and use of immanent justice. Child Development, 51, 839-846. Matarazzo, J.D. (1983). Education and training in health psychology: Boulder or bolder? Health Psychology, 2(1), 73-114. Nagy, J.H. (1951). Children's ideas of the origin of illness. Health Education Journal, 9, 6-12. Natapoff, J.N. (1982). A developmental analysis of children's ideas of health. Health Education Quarterly, 9(2 & 3), 34/130-45/141. Parcel, G.S., & Meyer, M.P. (1978). Development of an instrument to measure children's health locus of control. Health Education Monograph, 6(2), 149-159. Perrin, E.C. & Gerrity, P.S. (1981). There's a demon in your belly: Children's understanding of illness. Pediatrics, 67(6), 841-849. Rothman, A.I. & Byrne, N. (1981). Health education for children and adolescents. Review of Educational Research, 51 (1), 85-100. Singer, D.G. & Revenson, T.A. (1978). A Piaget primer: How a child thinks. New York: International Universities Press. Tessler, R. & Mechanic, D. (1978). Psychological distress and perceived health status. Journal of Health and Social Behavior, 19, 254-262. Thompson, E.L. (1978). Smoking education programs 1960-1976. American Journal of Public Health, 68, 250-257. Weisenberg, M., Kegeles, S.S., & Lund, A.K. (1980). Children's health beliefs and acceptance of a dental preventive activity. Journal of Health and Social Behavior, 21, 59-74.
Children's U n d e r s t a n d i n g of Health and Illness Concepts: a P r e v e n t i v e Health P e r s p e c t i v e D A V I D G. A L T M A N a n d T R A C E Y A. R E V E N S O N
ABSTRACT: The present study examined beliefs about health and illness among a sample of 101 healthy children and young adolescents, from 8 to 14 years old. Respondents were administered a series of open- and closed-ended interview questions and were asked to draw a picture of a sick person. Various dimensions of health and illness were examined, including definition, concern, susceptibility, and locus of control. Several agelinked differences along these dimensions were found. Younger children were more concerned about their health and maintained a more external health locus of control, yet tended to rate their health more positively than older respondents. Younger children also tended to define illness from a more concrete, present-oriented, and symptom-specific, perspective. No effects of gender, self-reported illness experience, or family illness experience were found. Implications for the design of preventive health interventions and for future research are discussed.
In recent years, research interest in children's health knowledge, attit u d e s , a n d b e h a v i o r h a s g r o w n ( B i b a c e & W a l s h , 1979; B r u h n & P a r cel, 1982; D i e l m a n , Leech, B e c k e r , R o s e n s t o c k , H o r v a t h , & R a d i u s , 1980; K a l n i n s & Love, 1982; R o t h m a n & B y r n e , 1981). So too h a s a n i n t e r e s t i n p r i m a r y p r e v e n t i o n a n d p r e v e n t i v e h e a l t h care. A s forcef u l l y s t a t e d b y M a t a r a z z o (1983), there is m o u n t i n g evidence [from] w i t h i n the federal government, from private business and industry, from teachers and a d m i n i s t r a t o r s . . , and from the professions of medicine and psychology . . . t h a t p r i m a r y and secondary schools are excellent settings for promoting health and preventing illness and dysfunction in large n u m b e r s of our n a t i o n ' s curr e n t l y h e a l t h y c h i l d r e n . . . (p. 84) B r i d g i n g t h e s e two a r e a s is p a r t i c u l a r l y r e l e v a n t for p e d i a t r i c h e a l t h p s y c h o l o g i s t s , s i n c e c h i l d r e n ' s a t t i t u d e s a n d b e h a v i o r s a r e t h o u g h t to The order of the authors names is alphabetical. The authors thank Edward Siedman for his helpful comments on an earlier draft of the manuscript. David G. Altman is a postdoctoral fellow at the Stanford Center for Research in Disease Prevention. Tracey A. Revenson is an Assistant Professor of Psychology, Barnard College of Columbia University. Address all correspondence to David G. Altman, Stanford Heart Disease Prevention Program, Health Research and Policy Building, Stanford University, Stanford, California 94305. 53
©1985HumanSciencesPress
54
Journal of Primary Prevention
be more malleable than those of adults (Dielman et al., 1980) and because teaching healthy habits to children will likely lead to the acquisition and maintenance of healthy adult habits (Becker, Haefner, Kasl, Kirscht, Maiman, & Rosenstock, 1977). Before this can be achieved, a clearer understanding of how healthy children of different ages conceptualize health, illness, and health-related behavior is needed. Some researchers studying children's concepts of health and illness have adopted a cognitive-developmental perspective using Piagetian theory (Singer & Revenson, 1978) to explain how these concepts qualitatively and systematically change in tandem with cognitive developmental processes (cf. Bibace & Walsh, 1979; Campbell, 1975; Kister & Patterson, 1980; Nagy, 1951; Natapoff, 1982; Perrin & Gerrity, 1981). These studies have identified sequential stages in children's understanding of illness concepts and causality, and have suggested that illness experience interacts with age in the development of illness concepts (Campbell, 1975). For the most part, these studies have adopted a medical model orientation which treats health as the absence of illness and focuses almost exclusively on the development of illness concepts. Age differences in children's conceptions of health and illness have also been reported by researchers using a more social-psychological approach. Based on expectancy theory, this work focuses primarily on individual expectations and values of health as determinants of health behavior (cf. Becker et al., 1977; Dielman et al., 1980; Gochman & Saucier, 1982). For example, studies utilizing the Health Belief Model have proposed that beliefs about the likelihood, severity, and consequences of illness, as well as the costs and benefits of taking health actions, are related to actual health behaviors (e.g., Becker et al., 1977). Studies from both these approaches have focused primarily on beliefs about health-related actions that prevent disease (illness prevention) and not on those which promote health (health promotion). While these two domains overlap to a certain extent, they are conceptually different. Health promotion implies activities taken by healthy individuals with the intent of enhancing well-being. In contrast, illness prevention activities reflect actions taken by healthy individuals with the intent of avoiding illness. The distinction lies in the goals of the action. While health promotion ultimately can result in the avoidance of illness, its more immediate goal is the enhancement of well-being. In turn, while the goal of illness prevention behaviors is clearly the avoidance of illness, such actions may also result in increased well-being.
David G. Altman and Tracey A. Revenson
55
T h e r e still r e m a i n s a d e a r t h of k n o w l e d g e in t h i s a r e a a n d a b e t t e r u n d e r s t a n d i n g is n e e d e d before successful i n t e r v e n t i o n s c a n be developed ( B r u h n & Parcel, 1982; G o c h m a n , 1982). To t h i s end, t h e c u r r e n t s t u d y e x a m i n e s t h e r e l a t i o n s h i p of age, gender, a n d illness e x p e r i e n c e to h e a l t h a n d illness concepts a m o n g h e a l t h y , school-aged youth. Methods Procedures a n d S a m p l e The sample consisted of elementary and junior high school students (grades 3 - 8 ) from a California public school. Students were randomly selected from class rosters to participate in the study, with approximately equal numbers of male and female respondents selected from each grade level. Consent to participate in the study was obtained from parents one week before the interview and from students at the time of the interview. Twelve parents removed their children from the sample frame and eight students chose not to participate in the interview. Subjects were interviewed privately during school hours by trained graduate and undergraduate students. Interviews ranged in length from 15 to 45 minutes (mean of 24 minutes) and included both open- and closed-ended questions as well as a pictorial measure. One hundred and one respondents (51 boys, 50 girls) were interviewed, ranging in age from 8 to 14 years; 90% were white. While no data are available on socioeconomic status, the school population consisted of children from primarily middle- and upper-middle-class families. Measures The interview schedule covered three primary content areas: (1) health and illness concepts; (2) pictorial representation of an ill person, and (3) social relationships and health. Only analyses covering the first two areas will be reported in this paper. Health and illness concepts. Health and illness concepts were assessed with both closed- and open-ended questions. Eight closed-ended Likert-type items were used to measure specific health beliefs: how often health was thought about; difficulty in being healthy; perceived illness susceptibility; degree of worry about own health; internal health locus of control; external health locus of control (powerful others); external health locus of control (chance/luck); and self-rated health. Since these items were only modestly intercorrelated (average intercorrelation= .13), an exploratory principal factor analysis (oblique rotation) was performed to determine meaningful clusters of variables. Self-rated health was tapped by a standard single-item measure used in previous research (cf. Tessler & Mechanic, 1978) and thus was not included in the factor analysis. Using Kaiser's criterion (eigenvalue -> 1.00), four factors were retained, accounting for 71.1% of the total variance. Table 1 presents the
56
Journal of Primary Prevention
factor items and loadings. Scales for each of these factors were computed by unit-weighting and summing respondents' scores on those items which loaded above .40. The first scale, health concern, accounted for 47.2% of the common variance and was composed of three items: how often respondents thought about their health, how much respondents worried about their health, and how long respondents talked about health (duration of interview). There were a number of conceptual and empirical reasons for including interview duration in the factor analysis and health concern scale, even though it is often considered to be a
Table I Factor Analysls of Health Bellef Varlables: Factor 1
Factor 2
Health Concern
Susceptibillty to lllness
Items, Loadlngs end Communalltles F~ctor 3
Factor 4
External Health Locus of Control
internal Health Locus of Control
h2
Item
Worry about health
.71
.20
-.03
-.15
.58
Think about health
.66
.01
.14
.06
.49
Length of intervlew
.58
-.22
.01
.06
.39
.57
.19
.05
.34
.51
-.32
-.06
.38
I I I I I
Difficulty in being healthy
-.07
Likelihood of becoming sick
.08
Health locus of control: Powerful others
.13
.07
.70
.06
.55
Health locus of control: Chance, luck
.03
-.01
.44
-.15
.24
Health locus of control: Internal
.01
.04
-.05
I t .62 I
I _ _
NQ#e. ~= 101. Factor loadings are from a principal oblique rotation.
I .39
I
factor analysis using
David G. Altman and Tracey A. Revenson
57
control variable. F i r s t , since the interview was open-ended and allowed child r e n to t a l k as much or as little as t h e y wanted, the a m o u n t of t i m e t h e y did in fact t a l k was a s s u m e d to reflect t h e i r concern about health. Second, age was inv e r s e l y r e l a t e d to all t h r e e scale v a r i a b l e s (r = - . 1 8 , p < .07; r = - . 2 1 , p < .04, r = - . 2 2 , p < .03, for thought, worry, and l e n g t h variables, respectively). Thus, the a m o u n t of t i m e t a l k i n g about h e a l t h was not a function of v e r b a l development. T a k e n together, these findings suggest t h a t l e n g t h of i n t e r v i e w is a m e a n i n g f u l reflection of h e a l t h concern and not a n artifact of differential comm u n i c a t i o n abilities b e t w e e n age groups. 1 The second scale, external health locus of control accounted for 21.4% of the variance. It included two items: belief in chance and belief in powerful others, as r e l a t e d to health. A n internal locus of control i t e m clearly emerged as a sepa r a t e factor and accounted for 12.1% of the variance. (All t h r e e items were modeled after those developed by Parcel and Meyers, 1978.) The final scale, accounting for 19.3% of the variance, was labeled susceptibility to illness. It also was composed of two items: difficulty in being h e a l t h y and t h e e s t i m a t e d chance t h a t the respondent would become ill in t h e n e x t year. I n t e r c o r r e l a t i o n s a m o n g these five dependent v a r i a b l e s (the four factors and self-rated h e a l t h status) revealed t h e m to be quite i n d e p e n d e n t (average interc o r r e l a t i o n = .12). Only two of the correlations were s t a t i s t i c a l l y significant: h e a l t h concern w i t h e x t e r n a l h e a l t h locus of control (r -- .27, p < .01) a n d w i t h self-rated h e a l t h s t a t u s (r = .22, p < .05). In a d d i t i o n to the closed-ended measures, t e n open-ended questions were included in the interview. These questions addressed b r o a d e r issues such as the i m p o r t a n c e of health, illness causation, h e a l t h - r e l a t e d behavior, and the likelihood of becoming ill. Responses for each question were content-analyzed a n d a 10% r a n d o m s a m p l e of responses was coded by two g r a d u a t e students to det e r m i n e i n t e r - r a t e r reliability. A v e r a g e exact a g r e e m e n t r e l i a b i l i t y was 87%. Pictorial representation of an ill person. Respondents also were a s k e d to "draw a picture of a sick person." No f u r t h e r directions were given and child r e n were given as much t i m e as t h e y w a n t e d to d r a w the picture. Discrete features of the d r a w i n g s were coded in a n effort to categorize and describe the cont e n t of t h e drawings. No a t t e m p t was m a d e to analyze the d r a w i n g s clinically a n d only those aspects of the d r a w i n g s which reflected children's definitions of h e a l t h and illness were analyzed. To obtain r e l i a b i l i t y of the coding scheme, 10% of t h e pictures were r a n d o m l y selected and t h e n i n d e p e n d e n t l y coded by the authors. Exact a g r e e m e n t r e l i a b i l i t y a v e r a g e d 96%. In order to control for possible age and i n d i v i d u a l differences in d r a w i n g ability, respondents also were a s k e d to describe t h e i r drawing. Illness experience. Since personal experience w i t h major or m i n o r illness 1. In addition, repeating the analyses presented in this paper using a two-item health concern scale (excluding duration) while controlling for duration of interview at the same time produced no changes either in the magnitude or significance of the effects.
Journal of Primary Prevention
58
may affect understanding of health concepts (Campbell, 1975; Weisenberg, Kegeles, & Lund, 1980), children's self-reports of health problems during the past year were elicited. Two variables were used to assess recent experience with illness, one for self and one for family. Response categories for three variables were: no illness, mild illness (e.g., colds), moderate illness (e.g., flu), or severe illness (e.g., surgery).
Results In this section, we will first examine the closed-ended measures for age differences in children's conceptions of health and illness. Open-ended and pictorial data then will be presented to illustrate age differences as well as to provide an overall perspective of how children view health and illness. Finally, the influence of gender and illness experience on conceptions of health and illness will be discussed.
Age Differences For these analyses, three age groups were used: 8-10, 11-12, and 1 3 - 1 4 years. As shown in Table 2, younger respondents were more
Table 2 Age Differences
In Health B e l i e f s Means for Aoe Grouos a
Health B e l l e f
E
df
~
8-10
11-12
13-14
Health concern
4.82
2,95
.01
2.94
2.72
2.40
-.28
Susceptibility to Illness
2.24
2,97
NS
2.31
2.15
2.50
.02
External health locus of control
9.30
2,98
.001
2.30
1.95
1.53
-.41
Internal health locus of control
.98
2,98
NS
3.34
3.35
3.38
.04
4.68
2,97
.01
4.03
3.89
3.48
-.30
Self-rated health
£
Note. Scale scores range from I to 4 except for self-rated health which ranges from I to 5. a ~'s for each age group (from youngest to oldest) are 35, 37, and 29.
David G. A l t m a n and Tracey A. Revenson
59
concerned about their health, had a more external health locus of control, and rated their current health more positively than older respondents. Both the pattern of means and Pearson correlations indicate linear relationships. A few notable age differences also emerged in the open-ended interview questions, presented in Table 3. In conceptualizing health and illness, older respondents tended to report nonspecific conditions, for example, defining health as the absence of illness or simply feeling good, or describing a sick person in terms of general symptom states. Regarding causes and prevention of illness, too, older and younger respondents shared somewhat different concerns. Younger children worried more about contracting childhood illnesses, such as chicken pox, while the oldest children (ages 13 to 14) were more concerned about major diseases and disabilities. Younger children more often mentioned behavioral actions, such as not eating right, as causes of illness, while older children focused on germs or disease, including contact with sick people. Younger respondents also were more likely to mention current feelings of ill health as signs they would get sick. Those children in good health at the time of the interview predicted they would be healthy the following year, whereas children who displayed symptoms expected to be ill the following year. Finally, younger children focused on specific symptoms as indications that they were ill, while older children were more apt to use the persistence of symptoms as a criterion.
General Thoughts About Health and Illness Along with examining age differences, it also is informative to study what health and illness issues are salient to children and preadolescents. In an attempt to assess the importance of health in a nondirective manner, the interview commenced with the question: "When you think about what is important in your life, what do you usually think about?" Even though some respondents knew the topic of the research, few (15%) mentioned health as a life concern. Only 9% (3) of the 8 - 1 0 years olds, 16% (6) of the 1 1 - 1 2 year olds, and 21% (6) of the 1 3 - 1 4 year olds mentioned health as a concern. The data in Table 3 (column 2, labeled Total Sample) also provide a broad picture of how healthy children and adolescents think about health and illness. Major concerns centered around diet (28%), bodily functions and anatomy (27%), being healthy (22%), exercise (20%), and getting sick (16%); thus, they think about aspects of good health, illness prevention, and illness behavior. Over half the respondents (51%)
Journal of Primary Prevention
60
Table 3 Summary of Responses to Open-Ended Health Belief Questlons Question
TgTal Samole ~a
Deflnlne health: What does it mean to be healthy? (N=98) Feellng/belng In good physlcal or mental health Having gcx~d health habits Absence of illness
~
Ace Grouo (~)b 8-10
11-12
13-14
51
(52)
18
12
22**
30 25
(30) (25)
11 5
14 8
5 12 +
Describe a sick person (~=I01) c Unfocused ~ymptoms General symptoms Descriptions of emotions Specific symptoms Slckrole/patlent behavior Limitations on actlvity
82 80 58 42 37 34
(83) (81) (59) (42) (37) (34)
31 28 18 17 12 12
30 26 24 17 15 13
22 27 + 17 8 10 9
W~ot Illnesses do vou worrv about aettine? (~=I00) Viral/bacterlal infections Major disease or disability Childhood illnesses
64 26 20
(64) (26) (20)
23 6 10
20 7 9
21 13 I*
What causes 0eoDle to oet ~iqk? (~=I01) Behavioral actions Diseases or germs Contact with sick people
72 44 15
(73i (44) (15)
27 11 I
31 16 9
15" 17 + 5*
[What is the chance that you will get very sick this year?] How do you know? (~=I01) Because of past experiences Current feelings of ill health
33 32
(33) (32)
13 15
7 13
13 + 4+
47 25 20 13 8 6 5 4
(47) (25) (20) (13) (8) (6) (53 (4)
17 6 5 2 4 3 I 2
22 8 3 8 2 I I I
8* 11 12"* 3 2 2 3 I
28 27 22 20 16
(28) (26) (21) (19) (15)
11 13 5 6 I
12 7 6 8 7
6 10 + 5 7~
How do vou know when you are III? (~=I01) Specific symptom(s) General slckness state Symptoms persist Parents decide I don't know Role loss You just know Psychological factors
When you t h i n k about your health what do you u s u a l l y t h i n k about? (~=95) Diet B o d i l y f u n c t i o n s and anatomy Being healthy Exercise Getting sick and how I feel when sick
4
David G. Altman and Tracey A. Revenson
61
Table 3 (continued) Total Sample
Question
~
Age Greuo (~) 8-I0
II-12
13-14
What thlnQs can you do to stay healthy? (~:I01) Eat proper food Exercise Maintain good personal hygiene Sleep enough See a doctor
90 65 22 13 9
(91 (66) (22) (13) (9)
34 14 10 4 0
30 28 7 3 5
27 + 24** 5 6 4
Wh@n i~ it h~r¢@~t for you to be healthy? (~=I01) Food When you're sick Maintaining healthy behavior
36 18 14
(36) (18) (14)
15 I 6
13 7 2
8 I~** 6
a For some questions, percents add up to over 100% since respondents were allowed to give more than one response.
For those questions in which responses
could not be coded, the total percent is less than 100 percent. b Significant chi-square analyses for differences among age groups are noted at the end of each row. c Mean number of symptoms described was 5.78
± 1.9 for the total sample, and
no significant age differences were found. ** ~ < .01
* ~ < .05
+ ~ < .I0
defined health as feeling good or being in good physical or mental health and 30% defined it as maintaining good health habits. Only one quarter of the sample defined health as the absence of illness. Interestingly, almost three quarters of the respondents (72%) mentioned that their behavioral actions (for example, not eating correctly, not sleeping enough, not wearing warm clothes) contributed to their becoming ill. Contact with germs (44%) or with sick people (15%) also were seen as causal agents. Respondents were more concerned about contracting viral and bacterial infections (e.g., colds, flu, with 64% reporting this) than either with contracting major disease or disability (26%) or childhood illness such as chickenpox (20%). Behavioral factors such as eating nutritious food (90%) and exercising regularly (65%) were seen as pivotal to staying healthy. Similarly, over a third of the respondents (36%) mentioned dietary issues as contributing to difficulties in being healthy, for example, overeating or being tempted by unhealthy food. In characterizing a sick person, a majority of the respondents men-
62
Journal of Primary Prevention
tioned either unfocused (82%) and general symptoms (80%) as key features. Unfocused symptoms reflected nonspecific feeling states, such as feeling sick or bad; general symptoms involved reference to more focused feeling states, such as being weak, sweaty, or dizzy. However, when respondents were asked how they knew when they were sick, almost half (47%) reported the occurrence of specific symptoms (e.g., runny nose, sore throat) as important signs, although 25% mentioned the presence of a general sickness state (e.g., not feeling well).
Pictorial Data Table 4 presents the univariate frequency data on the pictorial variables. A broad range of drawings of ill people was obtained, some very detailed, others quite simple. For example, some drawings included m a n y different body parts while others focused simply on facial features. Almost half (45%) of the sick people were drawn in bed, with 5% in a hospital bed as indicated by IV tubes and other machinery. Interestingly, approximately one fifth (21%) of the figures in the drawings were clothed, suggesting that the illness depicted was not disabling. Slightly over one third (37%) of the individuals were unhappy, as indicated by frowns or tears. This finding was echoed in the verbal descriptions of the drawings: almost a third (28%) of the children described the sick person drawn as unhappy, and one fifth, (20%) as generally feeling "bad." Children described a wide variety of specific symptoms in their drawings, including red or runny eyes (28%), feeling tired or weak (23%), flushed cheeks or fever (17%), and cold symptoms (16%).
Gender differences No significant differences were found between sexes on any of the measures. In addition, there were no significant gender by age interactions.
The influence of illness experience Contrary to expectations, the degree to which respondents or their immediate family had experienced illness was unrelated to any of the study variables. Even when the two illness experience measures (self and family) were collapsed into no illness versus mild, moderate, or serious illness dichotomies, no significant findings emerged.
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Table 4 Pictorial
and Verbal Characterl s t l c s o f Drawings o f A Sick Person Total
Feature o f Drawlne
Samnle (~=95) ~
~
Aae Grouo (~)b 8-10
11-12
13-14
Emotional expression NO d e t e c t i o n o f emotion Unhappy Happy
60 37 3
(57) (35) (3)
19 11 3
22 13 0
16 11 0
Person drawn In bed No Yes: r e g u l a r bed Yes: h o s p i t a l bed
55 40 5
(52) (38) (5)
15 15 3
21 13 I
16 10 1
Accessories (e.g.p thermometer) Not drawn Drawn
59 41
(56) (3g)
20 13
23 12
13 14
Emotional c o n t e n t No r e p o r t Unhappy Other Happy
66 28 3 2
(63) (27) (3) (2)
21 10 1 1
23 9 2 1
19 8 0 0
Presence o f I l l n e s s a NO I l l n e s s r e p o r t e d General ( f e e l s badly) Minor I l l n e s s Serious-acute Serlous-chronlc
56 20 7 15 6
(53) (20) (6) (14) (6)
15 7 2 8 2
20 6 3 5 3
18 7 1 1 I
28 23 16 10
(27) (22) (15) (g)
4 4 5 6
12 g 5 1
11" g 5 2
7 5 3 2
(7) (5) (3) (2)
2 2 3 I
3 1 0 1
~2 2 0 0
Verbal DescrlntIon of Drawlna
Symptoms mentloned c Red eyes, runny eyes T i r e d , weak, f a t i g u e Cold symptoms Skin: cheeks f l u s h e d , pale s k l n , spots Fever, c h i l l s , sweats Groanlngp c r y i n g Stomach problems Other
a Percents add up t o over 100~ since respondents were allowed t o g i v e more than one response. b Signlflcant
c h l - s q u a r e analyses f o r d i f f e r e n c e s
among age groups are noted
at t h e end o f each row. c Mean number of symptoms mentioned was .95 ~ .92 f o r t h e t o t a l signlficant
age d l f f e r e n c e s
* ~ < .05
were found.
sample and no
Journal of Primary Prevention
64
Discussion
The current findings provide important information on how healthy children and young adolescents conceptualize health. Unlike some other studies, this research included concepts of health promotion as well as illness prevention. Health was not a particularly important life concern for this sample, although it was a frequent topic of thought. This does not appear to be an idiosyncrasy of the sample, as similarly low levels of concern about health matters were found in a randomly selected community sample of children (Dielman et al., 1980). It does, however, have implications for the interpretation of the findings and their applications in health education. The dimensions of children's health beliefs found through an exploratory factor analysis resemble those of Dielman et al. (1980), although the Dielman study used a much larger item pool. Concern about health was not related to illness susceptibility, confirming Dielman's suggestion that they are independent components of the Health Belief Model. It is possible that the failure of previous studies to demonstrate a clear link between susceptibility (or health threat) and health behaviors (Kegeles, 1980; Kegeles & Lund, 1982) may be due to the fact that health c o n c e r n is a more salient motivational factor of health behavior. By treating concern and susceptibility as distinct constructs as well as examining their reciprocal and interactive influences in future research, a better understanding of the factors affecting preventive health behaviors may be obtained. Several interesting age differences were found in the study. First, younger respondents were more concerned about their health than older respondents, a finding congruent with the results of Dielman et al. (1980). Second, younger respondents tended to attribute control over their health more to external factors, such as chance and powerful other people, than older respondents. It is not clear whether this is the result of developmental differences in causal attributions (e.g., Kister & Patterson, 1980) or to the fact that older children do indeed have somewhat more personal control over their health. While it is likely that younger children may be more concerned about health as a result of their feelings of low personal control or of their inability to understand concepts of personal versus external causation fully, we found the correlation between health concern and locus of control to remain strong and positive even with the effects of age partialled out. Therefore, while it appears logical that attributions of control to external factors would increase concern over health matters, the causal mechanisms underlying this relationship remain to be determined.
David G. Altman and Tracey A. Revenson
65
Third, older and younger respondents tended to define health and illness in somewhat different manners. Younger children emphasized specific health states, such as symptoms, in their definitions, particularly childhood illness symptoms close to their own experience. They also tended to focus on their own past illness experiences and healthrelated actions to a greater extent than older children. Older children, in contrast, stressed more general and abstract feeling states and particular illnesses; they also relied more heavily on temporal components of illness, such as the persistence of symptoms or the possibility of reccurrence. Overall, as age increased, so did a growing recognition of illness more as an abstract syndrome of symptoms and feelings with a definite time perspective and less as isolated symptoms. This corroborates the work of developmental psychologists in this and other content areas, which suggest that younger children are more egocentric and concrete in their phenomenological experiences (Campbell, 1975; F u r m a n & Bierman, 1983). While some studies have suggested that the mechanisms which cause illness are not understood until the eighth grade at the earliest (Perrin & Gerrity, 1981), our respondents appeared to understand these relationships. There also is evidence that they understood cause and effect relationships between their behavioral actions and subsequent health outcomes. Additional research examining these causal links is crucial, as it is possible that healthy children do not see the need for preventive health behavior when they are in good health. Given the fact that younger respondents relied somewhat more heavily on personal experience in their definitions of health and rated their health more positively than older respondents, it was expected that this age difference would result from differences in illness experience across age groups. No evidence for this proposition was found. It is possible that the absence of such effects in this sample is due to the insensitivity or unreliability of the self-report illness experience measure. For example, we know from the question on health worries that younger respondents worried more often about common childhood illn e s s e s - i l l n e s s e s probably closer in time to their personal experience. Also, younger children based their predictions of future illness susceptibility on how they currently felt. In contrast, older respondents were more concerned with serious illness and functional disabilities, most likely reflecting their understanding of the severity of these illnesses or the likelihood of their contact with chronically ill persons. The pictorial data also reflect the potential influence of illness experience; according to the children's descriptions, most of the figures in the draw-
66
Journal of Primary Prevention
ings were suffering from minor childhood illnesses, such as colds or sore throats. Furthermore, three of the five children who drew the ill person in a hospital bed had been exposed to a serious illness during the preceding year. It is likely that more sensitive measures of illness experience, such as reports from family members or examination of medical records, will reveal more clearly the age-linked relationship between illness experience and the development of health and illness concepts. The age differences in perceived health status might also indicate that perceptions of health status, rather than actual or medically defined health status, vary with age. If true, the limitations of self-rated health measures with children should be acknowledged and age-specific distinctions taken into account. In contrast to findings reported in other studies (Bibace & Walsh, 1979; Campbell, 1975), psychological and social dimensions of health were infrequently mentioned. This finding was quite unexpected, particularly since the school's health curriculum incorporated a biopsychosocial perspective (Engel, 1977); such concepts may be more sophisticated than grade school children can understand. In light of this and the other age-linked differences noted above, it might be useful to focus on cognitive level rather than content area in designing and evaluating school health education programs. Charting the developmental progression of health and illness concepts and their relationship to health behavior is necessary for the development of successful prevention programs. Research should incorporate longitudinal designs to assess the development of health beliefs and attitudes, directing attention to familial and societal influences on their development. Comparisons among healthy, acutely ill, and chronically ill children of different ages may help untangle the effects of age and illness experience. Before jumping on the prevention bandwagon, researchers and i~ractitioners alike are well advised to invest more time studying how children and adolescents conceptualize health and illness. In the absence of this knowledge, preventive interventions are likely to fail, as evidenced by the early smoking education programs which emphasized the long-term dangers of smoking (e.g., Thompson, 1978). If we accept the slogan of our medical colleagues, "dictim premum notion," our professional obligation to design interventions and health education programs on the basis of research knowledge and primary prevention concepts is clear and convincing.
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