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Health Perceptions and Behaviors of School-Age Boys and Girls Mary Virginia Graham & Constance Rae Uphold Published online: 07 Jun 2010.
To cite this article: Mary Virginia Graham & Constance Rae Uphold (1992) Health Perceptions and Behaviors of School-Age Boys and Girls, Journal of Community Health Nursing, 9:2, 77-86, DOI: 10.1207/ s15327655jchn0902_2 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0902_2
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JOURNAL OF COMMUNITY HEALTH NURSING, 1992,9(2), 77-86 Copyright O 1992, Lawrence Erlbaum Associates, Inc.
Health Perceptions and Behaviors of School-Age Boys and Girls
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Mary Virginia Graham, ARNP, PhD, and Constance Rae Uphold, ARNP, PhD University of Florida
This study described and compared the health perceptions and behaviors of 83 schoolage boys and girls. An age-appropriate interview schedule was designed to collect data related to demographic characteristics, health perceptions, safety, life-style practices, nutrition, dental health, and care of minor injuries. Findings indicated that most boys and girls viewed themselves as healthy and managed their own care fairly well in the areas of seat belt use, exercise, and dental health. Nutrition was identified as an area of concern, with 10% of the children skipping breakfast, and over half eating snacks with empty calories. Generally, children were found to be knowledgeable in the management of simple injuries and how to respond in the event of an emergency. Boys and girls were similar in all areas of health perceptions and behaviors except for dental health, with boys reporting more regular visits to the dentist than did girls. Further research is needed to learn more about the process by which school-age children acquire positive health behaviors to assist nurses to design and implement intervention programs that appropriately address the needs of this age group.
A confluence of social and economic circumstances over the past several decades have led to a dramatic increase in the numbers of dual-career and single-parent families (U.S. Department of Health & Human Services [USDHHS], 1989). At the same time, child-care services have not kept pace with the increasing demand, and the availability of relatives to care for dependent children, once a common arrangement in America, is a declining option in today's mobile society. Although there are no data to determine exactly the number of children who regularly care for themselves, estimates for those younger than 13 years of age range from 2 million to 6 million (Richardson et al., 1989). Coupled with these demographic realities is the fact that school-age children are highly active in their play and are thus susceptible to cuts, abrasions, fractures, strains, and sprains (Whaley & Wong, 1989). More children in this age group die from accidents than from disease, and more than half of all injuries to children occur in or around the home (Gephart, Egan, & Hutchins, 1984). Because parents act as gatekeepers to both opportunities and barriers to engage Requests for reprints should be sent to Mary Virginia Graham, ARNP, PhD, Box 5-187, JHMHC, University of Florida, College of Nursing, Gainesville, FL 32610-0187.
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in various life-style practices, decreased parental supervision for many children has serious implications for the role of children in their own self-care and healthbehavior management. This is not necessarily an undesirable situation because children in this age group are cognitively and physically able to obtain independence in most areas of health behavior, especially as they approach adolescence. On the other hand, the more care children manage on their own, the more important it is that their health practices are sound. Self-care is a concept of taking care of one's health, including both activities to stay healthy and activities to heal oneself (Orem, 1985). Children who care for themselves during out of school hours need to be able to practice self-care. For example, they need to know how to handle emergency situations such as a serious injury and also how to manage simple injuries that commonly occur. In spite of the fact that many children manage their own health practices, little is known about health perceptions and behaviors of school-age boys and girls. Several factors may be responsible for this apparent gap in knowledge. First, the health status of children in this age group is generally better than in other age groups in childhood-infancy, preschool, and adolescence (USDHHS, 1989). This has contributed, perhaps, to a tendency by health-care providers to focus on those age groups in which needs are more evident. A second possible reason is the change in utilization patterns of health resources that occurs during these years. Although the infant and preschooler have more health promotion and disease prevention visits than acute illness visits, the reverse occurs for the school-age child (Gephart et al., 1984). School-age children then, are more likely to seek care only for specific illnesses, rather than for health maintenance purposes. Acute illness visits may not offer a conducive setting for assessment of health perceptions and behaviors and appropriate counseling by providers. Paradoxically, it is during the school-age years that life-style patterns are established and may persist into adulthood. The early development of practices such as regular patterns of exercise, healthy eating habits, good dental care, and strategies for managing stress is paramount for a healthy and vigorous childhood as well as for quality of life in later adult years (Pender, 1987). Because relatively little research related to school-age children has been conducted, gender differences in terms of health perceptions and behaviors are largely unknown. We do know that boys at this age are more likely than girls to sustain a minor or serious injury, presumably because boys are more physically active (Whaley & Wong, 1989). Whether or not boys are better able to care for minor injuries is unknown, however. We also know that girls are more likely than boys to be obese, and that this difference is particularly pronounced among Black and Hispanic children (USDHHS, 1989). Whether these differences are associated with different health practices related to dietary intake or to exercise practices has not been established. The purpose of this study was to describe and compare the health perceptions and behaviors of school-age boys and girls. School age is defined as 6 to 12 years of age. Over the past decade, much attention has been focused on youth cardiovascular
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health promotion, and a variety of intervention programs have been developed to reduce risks in this area (Stone, Perry, & Luepker, 1989; Walter, Hofman, Vaughn, & Wynder, 1988). At the same time, there has been little attention directed to the more basic issue of health perceptions and health behaviors among children. Because many children in this age group care for themselves, health behaviors, including the management of simple injuries, need to be assessed before implementing intervention programs. This study, then, was designed to learn more about health perceptions and behaviors of children as a beginning step to designing health promotion programs that appropriately address the needs of this age group.
REVIEW OF LITERATURE
Most research related to health perceptions and behaviors among school-age children has focused on selected risky behaviors such as tobacco use-in this age group, usually the effects of second-hand smoke (O'Connor, Weiss, Tager, & Speizer, 1987), sedentary life-styles (Murphy, Alpert, Christman, & Willey, 1988), unhealthful eating practices (Zuckerman et al., 1989), and inconsistent seat belt use (Agran, Castillo, & Winn, 1990). There have been only a few reports of research related to overall health perceptions and behaviors. Cohen, Brownell, and Felix (1990) conducted a survey of school children, Grades 3 through 12, about their health habits and beliefs in the areas of smoking and dietary practices, attitudes about exercise, and parental involvement in health. They found that whereas girls reported healthier food habits than boys, boys tended to smoke less and exercise more, indicating substantial differences in health-related behaviors based on gender. Lewis and Lewis (1989) studied the illness behavior of participants in a child-initiated care system for over 12 years. Girls at all ages were more frequent health-care users than boys. Girls also had more vague symptoms and less favomble perceptions of their health status than boys. Terre, Drabman, and Meydrech (1990) studied predominantly poor, public school children, ages 11 through 18, enrolled in a rural school. Health behaviors were assessed in five areas: exercise, eating, smoking, alcohol use, and stress-related behaviors. There were a number of important developmental differences found, particularly in the areas of fast/junk food eating, smoking, and alcohol use. Unfortunately, no findings related to gender differences in these health behaviors were reported. By far the most interesting findings from the study were those that cast doubt on the notion of a globally healthy or risky "life-style." In all age groups, children were found to be at risk for some unhealthy habits, but not others. For example, adolescents who participated in regular exercise ranked high in terms of physical activity, but at the same time, ranked low in the area of nutrition, frequently consuming most of their calories in a fast food restaurant. Terre et al. (1990) concluded that an individual's risk status is not consistent across behaviors or across time and that health-care providers must keep in mind that amelioration
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of one unhealthy behavior, such as failure to use a seat belt, may not at all generalize to a second unhealthy behavior such as tobacco use. Although a number of studies have examined common illnesses and self-care among both adolescents and adults (Green, 1990; Frey & Denyes, 1989; Wilkinson, Darby, & Mant, 1987), no reports were found regarding self-care practices of children in the management of simple injuries. Frederick and White (1989) examined behavioral intentions related to safety and first aid among third grade students. Although this study did not measure actual self-care practices, it did measure behavioral intentions to act, and for that reason was included in this review. Intentions to act in four categories-stranger safety, fire safety, accident prevention, and first aid-were measured by use of behavioral intention indicators on a 25-item questionnaire. The researchers found that the children scored best on stranger safety items and poorest on first aid items, with the number of incorrect responses exceeding correct ones on all items related to first aid. Gender differences were not considered in this study, in spite of the fact that boys are injured and killed much more often than girls during the school-age years (USDHHS, 1989). To summarize, there have been few studies of overall health perceptions and behaviors among school-age boys and girls, and the study of gender differences has been largely ignored in this age group. Further, in spite of the fact that many children are responsible for some, if not most of their own care, and that accidents are the major cause of morbidity and mortality among 6 to 12 year olds, actual practices of managing minor injuries have not been the subject of any known study. METHOD Sample The sample consisted of 83 children between the ages of 6 and 12 who were attending two afterschool programs. The afterschool programs were nonprofit organizations which were designed for school-age children of all ethnic and socioeconomic groups who were in need of supervision at the end of their usual school day. The afterschool programs were located in a small southern city. Parental consent was obtained prior to the study and all children in attendance at the afterschool program on the scheduled days of data collection were included in the study. A total of 43 girls and 40 boys participated in the study. The mean age of the children was 8.5 years. The majority of children were White (n = 72, 87%). 7iventy-seven (32.5%) children lived in single-parent households. There were no statistically significant differences between girls and boys in terms of age, race, and type of household residence. Procedure
Trained interviewers collected the data. As suggested by Anatasi (1988), interviewers were encouraged to state questions in a nonthreatening manner and to rephrase
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items when needed. The face-to-face interview format allowed children the opportunity to ask questions and clarify unfamiliar words or terminology. In addition, the interviewers were able to establish rapport and adapt their questions to the developmental and cognitive level of each individual child.
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Measurement The interview schedule was developed after a thorough review of the literature. Frequently used tools such as the Health-Promoting Lifestyle Profile (Walker, Sechrist, & Pender, 1985) and the Health Protective Behavior Scale (Harris & Guten, 1979) were not used in this study for several reasons. First, the items in these instruments are more appropriate for use with adults than children. Instruments must be modified substantially to measure school-age children's unique characteristics. For example, children have different time perceptions, shorter attention spans, and tend to respond more affirmatively when asked questions than adults (Randall, 1991). Also, as Williams and his associates (Williams, Thomas, Young, Jozwiak, & Hector, 1991) noted, previous health-behavior tools were not designed for studying disadvantaged individuals, such as those who made up this study's sample. Second, the focus of this study was to describe specific health behaviors rather than to determine a child's overall level of engaging in a healthy life-style. Previous research has shown that most children do not have a globally healthy life-style; instead, their health habits are multidimensional (Terre et al., 1990). Thus, in this study there was no need for a composite score or aggregate measure of health behaviors. Based on these considerations, an age-appropriate interview schedule was designed for this study. The interview schedule contained 34 open-ended questions which were simple and direct. To avoid response-set problems, children were asked to describe their typical health behaviors in various situations. A review of previous health behaviors instruments and research enabled the generation of questions designed to explore the following seven areas: demographic characteristics, health status, safety, life-style practices, nutrition, dental health, and care of minor injuries. ?kro experts in children's health reviewed and modified items in the interview schedule prior to its use.
RESULTS
The children were first asked to describe their health in their own words. Approximately 90% of both the girls (n = 38) and boys (n = 36) described themselves as in good health. Similarly, the majority of both girls (n = 37, 86%) and boys (n = 38, 95%) did not have any chronic illnesses, such as asthma, nor did they take regular medication for health problems. As seen in Table 1, 100% of the children reported that they participated in three or more different types of exercise daily. The children were asked to list what they had eaten over the preceding 24 hr. Ten percent of the children had not eaten break-
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Graham and Uphold TABLE 1 Selected Health Behaviors of Children by Gender
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Item Life-style practices Always wear seat belts Three different types of exercise daily Nutrition Eat breakfast Eats empty calorie snacks Fast food dinner Dental Care Dental visits twice a year or more
28 43
65 100
23 40
57 100
51 83
61 100
38 27
88 63
37 21
93 53
75 48
90 58
6
14
8
20
14
16
24
56
31
77
55
66d
fast. The majority of the children (58%) had eaten snacks with empty calories. Approximately 16% of the children had eaten fast food dinners. There were no statistically significant differences between boys and girls in exercise and nutrition. However, boys visited dentists more frequently than girls. Seventy percent of the boys compared to 56070 of the girls made dental visits twice a year or more. Safety issues were also investigated. Sixty-one percent of the children always wore seat belts when riding in a car. Three girls reported never wearing their seat belts whereas none of the boys reported total nonuse of seat belts. The majority (85%) of children responded appropriately in choosing what action to take in case of an emergency such as a fire. Twenty-one (25%) children were left at home alone once a week or more. Over half (54%) of the children had been locked out of their house at some point. There were no statistically significant differences between boys and girls in frequency of being at home alone and being locked out of their houses. An almost equal percentage of boys and girls knew what to do in an emergency. Findings concerning care of minor injuries revealed that the majority of children knew how to care for a cut (see Table 2). A little over half of the children responded correctly concerning the care of burns, whereas only 34% of the children knew the first aid treatment of bruises. There were no gender differences on questions concerning care of minor injuries. TABLE 2 Correct Responses to Questions on Care of Minor Injuries by Gender -
--
Girlsa
Cuts Bruises Burns
Boysb
TotaP
n
%
n
Yo
n
%
33 13 24
76 31 55
27 15 20
67 37 50
60 28 44
72 28 53
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DISCUSSION
The children's perceptions of their health status were favorable. Their perceptions were consistent with their accounts that very few of the sample had a chronic illness or needed to take medication on a regular basis. As has been discussed, the schoolage period is a time of relatively good physical health, with injuries being the leading cause of morbidity and mortability in this age group (Guyer & Ellers, 1990). Both girls and boys viewed their health similarly. This finding appears to conflict with Lewis and Lewis's (1989) study of self-initiated school health care which found that girls perceived themselves as having more illness symptoms and visited the health clinic more frequently than boys. In the Lewis and Lewis study, however, 15% of the children accounted for more than half of all health clinic visits. Further, the majority of the 15% of the children who visited the clinic most often were girls. Lewis and Lewis concluded that children with chronic complaints unrelated to a physical cause need to be identified early in an effort to assist them to deal with the true cause of their distress. Thus, girls in their study who perceived themselves as less healthy than boys and who made frequent clinic visits may not be typical of school age children in general. Further study is needed to identify differences between girls and boys in terms of how they view their health. Although only a few children reported never wearing seat belts, it is still of concern that 39% of all the children in this study were not frequent seat belt wearers. This is especially significant in view of the fact that there is a mandatory seat belt use law in the state in which the study was conducted. Motor vehicle-related injuries are the leading cause of childhood injury death in the U.S. (Guyer & Ellers, 1990). Presently, there are still 17 states without mandatory belt use laws (USDHHS, 1990). These states need to enact laws, enforcement needs to be consistent, and perhaps most importantly, the public must accept this enforcement. Regarding nutritional intake, it was disappointing to find that most children were eating empty calorie snacks. According to a report issued by the staff of the Division of Maternal and Child Health (Gephart et al., 1984), fewer children today are undernourished, but nutritional problems continue to exist, nonetheless. Nutritional problems today are more likely to reflect overconsumption and imbalances in substances such as sugar, fat, and salt in the average diet. For example, more than half of the children in this study did not list fruits or vegetables in their dietary recall of snacks. Although the media has highlighted the importance of low fat and low cholesterol foods in one's diet, it appears that children and their families are still consuming potentially harmful snack foods. Interestingly, 16% of the children had eaten dinner the preceding night at a fast food restaurant. With the growing number of single parent and dual-career families, it is likely that more children will be receiving much of their nutrition from fast food restaurants. Fast food chains have made a great deal of progress in recent years in improving the nutritional quality of their meals and consumers need to continue to demand that healthier foods are offered in such restaurants.
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Surprisingly, there were no differences between boys and girls in nutritional practices which contrasts with previous findings that girls tend to have more healthy overall eating patterns which includes making more healthful food choices and having more healthful food preferences than boys (Perry, Griffin, & Murray, 1985). Similarly, in Cohen et al.'s (1990) study, girls were found to have better food habits and to eat less empty calorie snacks than boys. Failure to find a difference in this study may be related to measurement error. Frank (1991) observed that dietary recall relies on a child's memory and ability to think abstractly, thus eating behavior is very difficult to measure. Differences between boys and girls were found in the area of dental health, however. Sixty-six percent of all of the children visited the dentist twice a year or more which is recommended for dental health. Interestingly, boys tended to visit more frequently than girls. The reason for this statistical difference is unclear. Perhaps boys had more dental problems than girls. However, as Randall (1991) noted, it is sometimes problematic to ask children to list how frequently they visit health professionals or how often they perform certain behaviors. Children are present-oriented and have difficulty responding to questions related to events in the past. In this study only a minority of children were left at home alone frequently. This is not consistent with recent national statistics which estimate numbers of children caring for themselves during out of school hours to be as high as 6 million (Moore, Strickland, Melcher, & Walker, 1988). It must be remembered, however, that this sample was selected from a group of children attending afterschool programs. Thus, it is likely that parents of these children were concerned about their children's safety during after-school hours. All children should be taught self-care behaviors including care of minor injuries as part of their movement toward self-reliance. Interestingly, a substantial number of children had been locked out of the house on one or more occasions. Health providers and educators need to alert parents to the dangers of this situation and need to help families develop contingency plans for these circumstances. Positively, most children responded appropriately to what to do in case of an emergency. Apparently, the schools and the media are successfully conveying the message of appropriate action in emergency situations. For both boys and girls, knowledge of correct care of minor injuries was fairly good in the areas of appropriate care for cuts and burns, but rather poor in the area of caring for bruises. These findings are very dissimilar to those in Frederick and White's (1989) study of safety and first aid behavioral intentions of third grade students. Frederick and White found that percentages of incorrect responses exceeded correct responses for all items related to first aid. Appropriate care of simple injuries can prevent complications such as infection, and even alleviate pain in the case of treating simple burns with cold water and applying ice packs to bruises. Further, the ability to do these tasks competently leads to mastery of the developmental task of industry. Erikson (1963) identified the school-age years as a very decisive stage for ego growth, a period of time in which the child applies himself or herself to learning the useful skills and tools of society.
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SUMMARY In summary, this study suggests that many boys and girls view themselves as healthy and manage their own care fairly well in the areas of seat belt use, exercise, and dental health. Nutrition is an area that needs improvement and children also need additional instruction in the management of simple injuries. Safety issues such as dealing with the situation of being locked out of the house also is an area where interventions may be needed. Except for frequency of dental visits, there were no differences between boys and girls. This is consistent with several studies (Dielman, Leech, Becker, Rosenstock, & Horvath, 1982), and contrasts with others that found gender differences in health behaviors (Cohen et al., 1990). Further research is needed to determine health perceptions and behaviors of schoohage children. Gender differences should also be explored to clarify similarities and dissimilarities in terms of health behaviors, with the aim of designing intervention programs that appropriately address the needs of these children. School-age children spend much of their time learning about their social world and developing skills that enable them to view themselves as competent members of society. Health teaching is particularly relevant during this period of childhood when important health habits are being formed which may persist throughout life. Community health nurses (CHNs) together with school nurses design many of the educational programs and provide most of the health teaching for children in this age group. Nurses, working with children and their parents, can promote the development of positive health behaviors in a number of ways. Parents may need to be encouraged to remember that school-age children respond very well to subtle reinforcements such as praise or special attention, and that these types of reinforcements can be much more effective and appropriate than more concrete rewards such as new toys or special foods. Moreover, shaping behaviors of school-age children is enhanced by the fact that this age group responds best to intrinsic rewards, for example, pride in themselves for their accomplishments. Opportunities for health teaching must be utilized by CHNs and school health nurses throughout childhood in order to optimize adoption of good health habits among the school-age child.
REFERENCES Agran, P., Castillo, D., & Winn, D. (1990). Childhood motor vehicle occupant injuries. American Journal of Diseases of Children, 144, 653-662. Anastasi, A. (1988). Psychological testing. New York: MacMillan. Cohen, R. Y., Brownell, K. D., & Felii, M. R. (1990). Age and sex differences in health habits and beliefs of school children. Health Psychology, 9, 208-244. Dielman, T. E., Leech, S., Becker, M. H., Rosenstock, I. M., & Horvath, W. J. (1982). Parental and child health beliefs and behaviors. Health Education Quarterly, 9, 156-173. Erikson, E. H. (1963). Childhood and society. New York: Norton. Frank, G. C. (1991). Taking a bite out of eating behavior: Food records and food recalls of children. Journal of School Health, 61(5), 198-200. Frederick, R. A., & White, D. M. (1989). Safety and first aid behavioral intentions of supervised and unsupervised third grade students. Journal of School Health, 59(4), 146-149.
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Frey, M. A., & Denyes, M. J. (1989). Health and illness self-care in adolescents with IDDM: A test of Orem's theory. Advances in Nursing Science, 12(1), 67-75. Gephart, J., Egan, M. C., & Hutchins, 0. L. (1984). Perspectives on health of school-age children: Expectations for the future. Journal of School Health, 54(1), 11-17. Green, K. E. (1990). Common illnesses and self-care. Journal of Community Health, 15(5), 329-338. Guyer, B., & Ellers, B. (1990). Childhood injuries in the United States. American Journal of Diseases of Children, 144, 649-652. Harris, D., & Guten, S. (1979). Health protective behavior: An explanatory study. Journal of Health and Social Behavior, 20, 17-29. Lewis, L. E., & Lewis, M. A. (1989). Educational outcomes and illness behaviors of participants in a child-initiated care system: A 12-year follow-up study. Pediatrics, 84(5), 845-850. Moore, E. R., Strickland, R. R., Melcher, M. J., & Walker, J. A. (1988). Protecting our children through kid safe. Pediatric Nursing, 14(1), 32-36. Murphy, J. K., Alpert, B. S., Christman, J. V., & Willey, E. S. (1988). Physical fitness in children: A survey method based on parental report. American Journal of Public Health, 78, 708-7 10. O'Connor, G. T., Weiss, S. T., Tager, I. B., & Speizer, F. E. (1987). The effect of passive smoking on pulmonary function and non-specific bronchial responsiveness in a population-based sample for children and young adults. American Review of Respiratory Diseases, 135, 800-804. Orem, D. E. (1985). Nursing: Concepts of practice. New York: McGraw-Hill. Pender, N. J. (1987). Health promotion in nursingpmctice. Norwalk, CT Appleton & Lange. Perry, C. L., Griffin, G., & Murray, D. M. (1985). Assessing needs for youth health promotion. Preventive Medicine, 14, 379-393. Randall, E. (1991). Measuring food use in school-age children. Journal of School Health, 61(5), 201203.
Richardson, J. L., Dwyer, K., McGuigan, K., Hansen, W. B., Dent, C., Johnson, C. A., Sussman, S. Y., Brannon, B., & Flay, B. (1989). Substance use among eighth-grade students who take care of themselves after school. Pediatrics, 84(3), 556-566. Stone, E. J., Perry, C. L., & Luepker, R. V. (1989). Synthesis of cardiovascular behavioral research for youth health promotion. Health Education Quarterly, 16(2), 155-169. Terre, L., Drabman, R. S., & Meydrech, E. F. (1990). Relationships among children's health-related behaviors: A multivariate developmental perspective. Preventive Medicine, 19, 134-146. U.S. Department of Health and Human Services. (1989). Child Health USA '89. Washington, DC: U .S. Government Printing Office. U.S. Department of Health and Human Services. (1990). Healthy people 2000: National health promotion and disease prevention objectives. Washington, DC: U.S. Government Printing Office. Walker, S. N., Sechrist, K., & Pender, N. J. (1985). The health promoting lifestyle profile: Development and psychometric evaluation. Nursing Research, 34(6), 328-335. Walter, H. J., Hofman, A., Vaughn, R. D., & Wynder, E. L. (1988). Modification of risk factors for coronary heart disease: Five year results of a school-based intervention trial. New England Journal of Medicine, 318, 1093-1 100. Whaley, L. F., & Wong, D. L. (1989). Essentials of pediatric nursing. St. Louis: Mosby. Wilkinson, I. F., Darby, D. N., & Mant, A. (1987). Self-care and self-medication: An evaluation of individuals health care decisions. Medical Care, 25, 965-978. Williams, R. L., Thomas, S. P., Young, D. O., Jozwiak, J. J., &Hector, M. A. (1991). Development of health habits scale. Research in Nursing and Health, 14, 145-1 53. Zuckerman, A. E., Olevsky-Peleg, E., Bush, P. J., Horowitz, C., Davidson, F. R., Brown, D. G., & Walter, H. J. (1989). Cardiovascular risk factors among black school children: Comparisons among four know your body studies. Preventive Medicine, 18, 113-132.
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Health Perceptions and Behaviors of School-Age Boys and Girls Mary Virginia Graham & Constance Rae Uphold Published online: 07 Jun 2010.
To cite this article: Mary Virginia Graham & Constance Rae Uphold (1992) Health Perceptions and Behaviors of School-Age Boys and Girls, Journal of Community Health Nursing, 9:2, 77-86, DOI: 10.1207/ s15327655jchn0902_2 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0902_2
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JOURNAL OF COMMUNITY HEALTH NURSING, 1992,9(2), 77-86 Copyright O 1992, Lawrence Erlbaum Associates, Inc.
Health Perceptions and Behaviors of School-Age Boys and Girls
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Mary Virginia Graham, ARNP, PhD, and Constance Rae Uphold, ARNP, PhD University of Florida
This study described and compared the health perceptions and behaviors of 83 schoolage boys and girls. An age-appropriate interview schedule was designed to collect data related to demographic characteristics, health perceptions, safety, life-style practices, nutrition, dental health, and care of minor injuries. Findings indicated that most boys and girls viewed themselves as healthy and managed their own care fairly well in the areas of seat belt use, exercise, and dental health. Nutrition was identified as an area of concern, with 10% of the children skipping breakfast, and over half eating snacks with empty calories. Generally, children were found to be knowledgeable in the management of simple injuries and how to respond in the event of an emergency. Boys and girls were similar in all areas of health perceptions and behaviors except for dental health, with boys reporting more regular visits to the dentist than did girls. Further research is needed to learn more about the process by which school-age children acquire positive health behaviors to assist nurses to design and implement intervention programs that appropriately address the needs of this age group.
A confluence of social and economic circumstances over the past several decades have led to a dramatic increase in the numbers of dual-career and single-parent families (U.S. Department of Health & Human Services [USDHHS], 1989). At the same time, child-care services have not kept pace with the increasing demand, and the availability of relatives to care for dependent children, once a common arrangement in America, is a declining option in today's mobile society. Although there are no data to determine exactly the number of children who regularly care for themselves, estimates for those younger than 13 years of age range from 2 million to 6 million (Richardson et al., 1989). Coupled with these demographic realities is the fact that school-age children are highly active in their play and are thus susceptible to cuts, abrasions, fractures, strains, and sprains (Whaley & Wong, 1989). More children in this age group die from accidents than from disease, and more than half of all injuries to children occur in or around the home (Gephart, Egan, & Hutchins, 1984). Because parents act as gatekeepers to both opportunities and barriers to engage Requests for reprints should be sent to Mary Virginia Graham, ARNP, PhD, Box 5-187, JHMHC, University of Florida, College of Nursing, Gainesville, FL 32610-0187.
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in various life-style practices, decreased parental supervision for many children has serious implications for the role of children in their own self-care and healthbehavior management. This is not necessarily an undesirable situation because children in this age group are cognitively and physically able to obtain independence in most areas of health behavior, especially as they approach adolescence. On the other hand, the more care children manage on their own, the more important it is that their health practices are sound. Self-care is a concept of taking care of one's health, including both activities to stay healthy and activities to heal oneself (Orem, 1985). Children who care for themselves during out of school hours need to be able to practice self-care. For example, they need to know how to handle emergency situations such as a serious injury and also how to manage simple injuries that commonly occur. In spite of the fact that many children manage their own health practices, little is known about health perceptions and behaviors of school-age boys and girls. Several factors may be responsible for this apparent gap in knowledge. First, the health status of children in this age group is generally better than in other age groups in childhood-infancy, preschool, and adolescence (USDHHS, 1989). This has contributed, perhaps, to a tendency by health-care providers to focus on those age groups in which needs are more evident. A second possible reason is the change in utilization patterns of health resources that occurs during these years. Although the infant and preschooler have more health promotion and disease prevention visits than acute illness visits, the reverse occurs for the school-age child (Gephart et al., 1984). School-age children then, are more likely to seek care only for specific illnesses, rather than for health maintenance purposes. Acute illness visits may not offer a conducive setting for assessment of health perceptions and behaviors and appropriate counseling by providers. Paradoxically, it is during the school-age years that life-style patterns are established and may persist into adulthood. The early development of practices such as regular patterns of exercise, healthy eating habits, good dental care, and strategies for managing stress is paramount for a healthy and vigorous childhood as well as for quality of life in later adult years (Pender, 1987). Because relatively little research related to school-age children has been conducted, gender differences in terms of health perceptions and behaviors are largely unknown. We do know that boys at this age are more likely than girls to sustain a minor or serious injury, presumably because boys are more physically active (Whaley & Wong, 1989). Whether or not boys are better able to care for minor injuries is unknown, however. We also know that girls are more likely than boys to be obese, and that this difference is particularly pronounced among Black and Hispanic children (USDHHS, 1989). Whether these differences are associated with different health practices related to dietary intake or to exercise practices has not been established. The purpose of this study was to describe and compare the health perceptions and behaviors of school-age boys and girls. School age is defined as 6 to 12 years of age. Over the past decade, much attention has been focused on youth cardiovascular
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health promotion, and a variety of intervention programs have been developed to reduce risks in this area (Stone, Perry, & Luepker, 1989; Walter, Hofman, Vaughn, & Wynder, 1988). At the same time, there has been little attention directed to the more basic issue of health perceptions and health behaviors among children. Because many children in this age group care for themselves, health behaviors, including the management of simple injuries, need to be assessed before implementing intervention programs. This study, then, was designed to learn more about health perceptions and behaviors of children as a beginning step to designing health promotion programs that appropriately address the needs of this age group.
REVIEW OF LITERATURE
Most research related to health perceptions and behaviors among school-age children has focused on selected risky behaviors such as tobacco use-in this age group, usually the effects of second-hand smoke (O'Connor, Weiss, Tager, & Speizer, 1987), sedentary life-styles (Murphy, Alpert, Christman, & Willey, 1988), unhealthful eating practices (Zuckerman et al., 1989), and inconsistent seat belt use (Agran, Castillo, & Winn, 1990). There have been only a few reports of research related to overall health perceptions and behaviors. Cohen, Brownell, and Felix (1990) conducted a survey of school children, Grades 3 through 12, about their health habits and beliefs in the areas of smoking and dietary practices, attitudes about exercise, and parental involvement in health. They found that whereas girls reported healthier food habits than boys, boys tended to smoke less and exercise more, indicating substantial differences in health-related behaviors based on gender. Lewis and Lewis (1989) studied the illness behavior of participants in a child-initiated care system for over 12 years. Girls at all ages were more frequent health-care users than boys. Girls also had more vague symptoms and less favomble perceptions of their health status than boys. Terre, Drabman, and Meydrech (1990) studied predominantly poor, public school children, ages 11 through 18, enrolled in a rural school. Health behaviors were assessed in five areas: exercise, eating, smoking, alcohol use, and stress-related behaviors. There were a number of important developmental differences found, particularly in the areas of fast/junk food eating, smoking, and alcohol use. Unfortunately, no findings related to gender differences in these health behaviors were reported. By far the most interesting findings from the study were those that cast doubt on the notion of a globally healthy or risky "life-style." In all age groups, children were found to be at risk for some unhealthy habits, but not others. For example, adolescents who participated in regular exercise ranked high in terms of physical activity, but at the same time, ranked low in the area of nutrition, frequently consuming most of their calories in a fast food restaurant. Terre et al. (1990) concluded that an individual's risk status is not consistent across behaviors or across time and that health-care providers must keep in mind that amelioration
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of one unhealthy behavior, such as failure to use a seat belt, may not at all generalize to a second unhealthy behavior such as tobacco use. Although a number of studies have examined common illnesses and self-care among both adolescents and adults (Green, 1990; Frey & Denyes, 1989; Wilkinson, Darby, & Mant, 1987), no reports were found regarding self-care practices of children in the management of simple injuries. Frederick and White (1989) examined behavioral intentions related to safety and first aid among third grade students. Although this study did not measure actual self-care practices, it did measure behavioral intentions to act, and for that reason was included in this review. Intentions to act in four categories-stranger safety, fire safety, accident prevention, and first aid-were measured by use of behavioral intention indicators on a 25-item questionnaire. The researchers found that the children scored best on stranger safety items and poorest on first aid items, with the number of incorrect responses exceeding correct ones on all items related to first aid. Gender differences were not considered in this study, in spite of the fact that boys are injured and killed much more often than girls during the school-age years (USDHHS, 1989). To summarize, there have been few studies of overall health perceptions and behaviors among school-age boys and girls, and the study of gender differences has been largely ignored in this age group. Further, in spite of the fact that many children are responsible for some, if not most of their own care, and that accidents are the major cause of morbidity and mortality among 6 to 12 year olds, actual practices of managing minor injuries have not been the subject of any known study. METHOD Sample The sample consisted of 83 children between the ages of 6 and 12 who were attending two afterschool programs. The afterschool programs were nonprofit organizations which were designed for school-age children of all ethnic and socioeconomic groups who were in need of supervision at the end of their usual school day. The afterschool programs were located in a small southern city. Parental consent was obtained prior to the study and all children in attendance at the afterschool program on the scheduled days of data collection were included in the study. A total of 43 girls and 40 boys participated in the study. The mean age of the children was 8.5 years. The majority of children were White (n = 72, 87%). 7iventy-seven (32.5%) children lived in single-parent households. There were no statistically significant differences between girls and boys in terms of age, race, and type of household residence. Procedure
Trained interviewers collected the data. As suggested by Anatasi (1988), interviewers were encouraged to state questions in a nonthreatening manner and to rephrase
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items when needed. The face-to-face interview format allowed children the opportunity to ask questions and clarify unfamiliar words or terminology. In addition, the interviewers were able to establish rapport and adapt their questions to the developmental and cognitive level of each individual child.
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Measurement The interview schedule was developed after a thorough review of the literature. Frequently used tools such as the Health-Promoting Lifestyle Profile (Walker, Sechrist, & Pender, 1985) and the Health Protective Behavior Scale (Harris & Guten, 1979) were not used in this study for several reasons. First, the items in these instruments are more appropriate for use with adults than children. Instruments must be modified substantially to measure school-age children's unique characteristics. For example, children have different time perceptions, shorter attention spans, and tend to respond more affirmatively when asked questions than adults (Randall, 1991). Also, as Williams and his associates (Williams, Thomas, Young, Jozwiak, & Hector, 1991) noted, previous health-behavior tools were not designed for studying disadvantaged individuals, such as those who made up this study's sample. Second, the focus of this study was to describe specific health behaviors rather than to determine a child's overall level of engaging in a healthy life-style. Previous research has shown that most children do not have a globally healthy life-style; instead, their health habits are multidimensional (Terre et al., 1990). Thus, in this study there was no need for a composite score or aggregate measure of health behaviors. Based on these considerations, an age-appropriate interview schedule was designed for this study. The interview schedule contained 34 open-ended questions which were simple and direct. To avoid response-set problems, children were asked to describe their typical health behaviors in various situations. A review of previous health behaviors instruments and research enabled the generation of questions designed to explore the following seven areas: demographic characteristics, health status, safety, life-style practices, nutrition, dental health, and care of minor injuries. ?kro experts in children's health reviewed and modified items in the interview schedule prior to its use.
RESULTS
The children were first asked to describe their health in their own words. Approximately 90% of both the girls (n = 38) and boys (n = 36) described themselves as in good health. Similarly, the majority of both girls (n = 37, 86%) and boys (n = 38, 95%) did not have any chronic illnesses, such as asthma, nor did they take regular medication for health problems. As seen in Table 1, 100% of the children reported that they participated in three or more different types of exercise daily. The children were asked to list what they had eaten over the preceding 24 hr. Ten percent of the children had not eaten break-
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Graham and Uphold TABLE 1 Selected Health Behaviors of Children by Gender
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Item Life-style practices Always wear seat belts Three different types of exercise daily Nutrition Eat breakfast Eats empty calorie snacks Fast food dinner Dental Care Dental visits twice a year or more
28 43
65 100
23 40
57 100
51 83
61 100
38 27
88 63
37 21
93 53
75 48
90 58
6
14
8
20
14
16
24
56
31
77
55
66d
fast. The majority of the children (58%) had eaten snacks with empty calories. Approximately 16% of the children had eaten fast food dinners. There were no statistically significant differences between boys and girls in exercise and nutrition. However, boys visited dentists more frequently than girls. Seventy percent of the boys compared to 56070 of the girls made dental visits twice a year or more. Safety issues were also investigated. Sixty-one percent of the children always wore seat belts when riding in a car. Three girls reported never wearing their seat belts whereas none of the boys reported total nonuse of seat belts. The majority (85%) of children responded appropriately in choosing what action to take in case of an emergency such as a fire. Twenty-one (25%) children were left at home alone once a week or more. Over half (54%) of the children had been locked out of their house at some point. There were no statistically significant differences between boys and girls in frequency of being at home alone and being locked out of their houses. An almost equal percentage of boys and girls knew what to do in an emergency. Findings concerning care of minor injuries revealed that the majority of children knew how to care for a cut (see Table 2). A little over half of the children responded correctly concerning the care of burns, whereas only 34% of the children knew the first aid treatment of bruises. There were no gender differences on questions concerning care of minor injuries. TABLE 2 Correct Responses to Questions on Care of Minor Injuries by Gender -
--
Girlsa
Cuts Bruises Burns
Boysb
TotaP
n
%
n
Yo
n
%
33 13 24
76 31 55
27 15 20
67 37 50
60 28 44
72 28 53
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DISCUSSION
The children's perceptions of their health status were favorable. Their perceptions were consistent with their accounts that very few of the sample had a chronic illness or needed to take medication on a regular basis. As has been discussed, the schoolage period is a time of relatively good physical health, with injuries being the leading cause of morbidity and mortability in this age group (Guyer & Ellers, 1990). Both girls and boys viewed their health similarly. This finding appears to conflict with Lewis and Lewis's (1989) study of self-initiated school health care which found that girls perceived themselves as having more illness symptoms and visited the health clinic more frequently than boys. In the Lewis and Lewis study, however, 15% of the children accounted for more than half of all health clinic visits. Further, the majority of the 15% of the children who visited the clinic most often were girls. Lewis and Lewis concluded that children with chronic complaints unrelated to a physical cause need to be identified early in an effort to assist them to deal with the true cause of their distress. Thus, girls in their study who perceived themselves as less healthy than boys and who made frequent clinic visits may not be typical of school age children in general. Further study is needed to identify differences between girls and boys in terms of how they view their health. Although only a few children reported never wearing seat belts, it is still of concern that 39% of all the children in this study were not frequent seat belt wearers. This is especially significant in view of the fact that there is a mandatory seat belt use law in the state in which the study was conducted. Motor vehicle-related injuries are the leading cause of childhood injury death in the U.S. (Guyer & Ellers, 1990). Presently, there are still 17 states without mandatory belt use laws (USDHHS, 1990). These states need to enact laws, enforcement needs to be consistent, and perhaps most importantly, the public must accept this enforcement. Regarding nutritional intake, it was disappointing to find that most children were eating empty calorie snacks. According to a report issued by the staff of the Division of Maternal and Child Health (Gephart et al., 1984), fewer children today are undernourished, but nutritional problems continue to exist, nonetheless. Nutritional problems today are more likely to reflect overconsumption and imbalances in substances such as sugar, fat, and salt in the average diet. For example, more than half of the children in this study did not list fruits or vegetables in their dietary recall of snacks. Although the media has highlighted the importance of low fat and low cholesterol foods in one's diet, it appears that children and their families are still consuming potentially harmful snack foods. Interestingly, 16% of the children had eaten dinner the preceding night at a fast food restaurant. With the growing number of single parent and dual-career families, it is likely that more children will be receiving much of their nutrition from fast food restaurants. Fast food chains have made a great deal of progress in recent years in improving the nutritional quality of their meals and consumers need to continue to demand that healthier foods are offered in such restaurants.
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Surprisingly, there were no differences between boys and girls in nutritional practices which contrasts with previous findings that girls tend to have more healthy overall eating patterns which includes making more healthful food choices and having more healthful food preferences than boys (Perry, Griffin, & Murray, 1985). Similarly, in Cohen et al.'s (1990) study, girls were found to have better food habits and to eat less empty calorie snacks than boys. Failure to find a difference in this study may be related to measurement error. Frank (1991) observed that dietary recall relies on a child's memory and ability to think abstractly, thus eating behavior is very difficult to measure. Differences between boys and girls were found in the area of dental health, however. Sixty-six percent of all of the children visited the dentist twice a year or more which is recommended for dental health. Interestingly, boys tended to visit more frequently than girls. The reason for this statistical difference is unclear. Perhaps boys had more dental problems than girls. However, as Randall (1991) noted, it is sometimes problematic to ask children to list how frequently they visit health professionals or how often they perform certain behaviors. Children are present-oriented and have difficulty responding to questions related to events in the past. In this study only a minority of children were left at home alone frequently. This is not consistent with recent national statistics which estimate numbers of children caring for themselves during out of school hours to be as high as 6 million (Moore, Strickland, Melcher, & Walker, 1988). It must be remembered, however, that this sample was selected from a group of children attending afterschool programs. Thus, it is likely that parents of these children were concerned about their children's safety during after-school hours. All children should be taught self-care behaviors including care of minor injuries as part of their movement toward self-reliance. Interestingly, a substantial number of children had been locked out of the house on one or more occasions. Health providers and educators need to alert parents to the dangers of this situation and need to help families develop contingency plans for these circumstances. Positively, most children responded appropriately to what to do in case of an emergency. Apparently, the schools and the media are successfully conveying the message of appropriate action in emergency situations. For both boys and girls, knowledge of correct care of minor injuries was fairly good in the areas of appropriate care for cuts and burns, but rather poor in the area of caring for bruises. These findings are very dissimilar to those in Frederick and White's (1989) study of safety and first aid behavioral intentions of third grade students. Frederick and White found that percentages of incorrect responses exceeded correct responses for all items related to first aid. Appropriate care of simple injuries can prevent complications such as infection, and even alleviate pain in the case of treating simple burns with cold water and applying ice packs to bruises. Further, the ability to do these tasks competently leads to mastery of the developmental task of industry. Erikson (1963) identified the school-age years as a very decisive stage for ego growth, a period of time in which the child applies himself or herself to learning the useful skills and tools of society.
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SUMMARY In summary, this study suggests that many boys and girls view themselves as healthy and manage their own care fairly well in the areas of seat belt use, exercise, and dental health. Nutrition is an area that needs improvement and children also need additional instruction in the management of simple injuries. Safety issues such as dealing with the situation of being locked out of the house also is an area where interventions may be needed. Except for frequency of dental visits, there were no differences between boys and girls. This is consistent with several studies (Dielman, Leech, Becker, Rosenstock, & Horvath, 1982), and contrasts with others that found gender differences in health behaviors (Cohen et al., 1990). Further research is needed to determine health perceptions and behaviors of schoohage children. Gender differences should also be explored to clarify similarities and dissimilarities in terms of health behaviors, with the aim of designing intervention programs that appropriately address the needs of these children. School-age children spend much of their time learning about their social world and developing skills that enable them to view themselves as competent members of society. Health teaching is particularly relevant during this period of childhood when important health habits are being formed which may persist throughout life. Community health nurses (CHNs) together with school nurses design many of the educational programs and provide most of the health teaching for children in this age group. Nurses, working with children and their parents, can promote the development of positive health behaviors in a number of ways. Parents may need to be encouraged to remember that school-age children respond very well to subtle reinforcements such as praise or special attention, and that these types of reinforcements can be much more effective and appropriate than more concrete rewards such as new toys or special foods. Moreover, shaping behaviors of school-age children is enhanced by the fact that this age group responds best to intrinsic rewards, for example, pride in themselves for their accomplishments. Opportunities for health teaching must be utilized by CHNs and school health nurses throughout childhood in order to optimize adoption of good health habits among the school-age child.
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