Two Promising Measures of Health Education Program Outcomes and Asthmatic Children

Kathy E. Green Case Kolff

Two measures of health education program outcomes were administered to a group of 50 asthmatic children: the Child’s Health Locus of Control Scale and the Piers-Harris Children’s Self Concept Scale. Interest centered on the reliabilities and discriminant validity of these instruments. Results showed high alpha reliabilities f o r both scales and a low, positive intercorrelation. Mean health locus of control and selfconcept scores for this group were comparable to those of healthy children. These findings may be useful in designing and evaluating health education programs for children with asthma.

Introduction

Health education programs often have the goal of in- creasing participants’ responsibility for self-care. Short of measuring actual long-term behaviors, self-care assessment is frought with problems. A health locus of control scale (HLC) may serve as a useful, immediately available, intermediate outcome measure. An adult HLC scale has been shown to have validity as a con- currently available measure by a number of researchers.’** The assumption underlying HLC validation studies is that an educational problem pro- ducing a self-concept or self-perception change will result in a corresponding behavioral change. The inter- mediate measure, HLC, could then be used with confidence as a substitute for the behavioral change measure not yet available.

Multidimensional models for assessing health-related behaviors include variables such as HLC, self-concept, self-esteem, knowledge, abilities, ethnicity, cognitive

This work was supported in part by the Robert Wood Johnson Clinical Scholars Program. The views herein are those of the authors but not necessarily those of the R WJ Foundation.

style and attitude. A clear understanding of the relation- ships among these variables has not yet been established, nor have valid, reliable instruments been shown to exist for some of the major variables. Until good instruments are available and until the inter- relationship of variables is clarified, evaluation of multidimensional models and the underlying assumptions will be circumspect. This paper examines the reliability of a HLC scale for children’ and its relationship with a self-concept measure. Reliability will be herein defined as an index of the consistency of measurement - that is, how consistent HLC or self- concept scores are from one measurement to another. Health locus of Control and Self -Concept Scales

The concept of internal versus external control of reinforcement, developed from social learning t h e ~ r y , ~ . ~ has stimulated extensive study.”’ Strickland’ identified the relationship between locus of control and physical health as an important emergent direction of locus of control research and cited 11 studies in which locus of control was found to be a significant predictor of health

332 THE JOURNAL OF SCHOOL HEALTH AUGUST 1980

Figure I Parcel-Meyer Children’s Health Locus of Control Scale My Views About Health and Illness (Children’s Form)

We would like to learn about different ways children look at their health. Here are some statements about health or illness (sickness). Some of them you will think are true and so you will circle the YES. Some you will think are nor true so you will circle the NO. Even i f it is very hard to decide, be sure to circle YES or NO for every Ftatement. Never circle both YES and NO for one statement. There are no right or wrong answers. Be sure to an4wer the way you really feel and not the way other people might feel.

PRACTICE:

NOW Item-Total Correlation

.26 -.04

. I 7 .52 .33 .2 I

.36

.6 1

.42

.5 I -.@I .58 .30

. I 3

.33

.I6

.4 1

.I4

.22

.23

C = Chance, I =

Children can get sick.

I f you think this is true, circle YES. I f you th ink this is not true, circle NO.

DO THE REST OF THE STATEMENTS THE SAME WAY YOU PRACTICED

Statement

1 . 2.

3. 4. 5 . 6.

7 .

8.

9. 10. 1 1 . 12. 13.

14.

15.

16. 17.

18.

19.

20.

Good health comes from being lucky. (C) There is nothing I can do to keep from getting sick. ( I ) Bad luck makes people get sick. (C) I can only do what the doctor tells me to do. (P) Getting sick just happens. (C) People who never get sick are just plain lucky. (C) I t is my mother’s job to keep me from getting sick. (P) Only a doctor or a nurse keeps people from getting sick. (P) I can make very few choices about my health. ( I ) Accidents just happen. (C) I can do many things to fight illness. (I) Only the dentist can take care of my teeth. (P) The only way I can stay healthy is to do what other people tell me to do. (P) I always go to the nurse right away if 1 get hur t at school. (P) It is the teacher’s job to keep me from having accidents at school. (P) I can make many choices about my health. ( I ) I f I feel sick I have to wait for other people to tell me what to do. (P) Whenever I feel sick I go to see the school nurse right away. (P) There is nothing I can do to have healthy teeth. ( I ) I can do many things to prevent accidents. ( I )

Internality, P = Powerful Others

YES YES

YES YES YES YES

YES

YES

YES YES YES YES YES

YES

YES

YES YES

YES

YES

YES

NO NO

NO NO NO NO

NO

NO

NO NO NO NO NO

NO

NO

NO NO

NO

NO

NO

AUGUST 1980 THE JOURNAL OF SCHOOL HEALTH 333

behavior. Instances of nonsignificant findings relating locus of control and health behavior have been attributed to the use of a generalized scale rather than one specific to health. Rotter8(ps9) suggested using specific measures “if one’s interest is in a limited area and particularly if one is seeking some practical application where every increment in prediction is important.” Adult HLC scales have been developed which prove to be more effective predictors of target health behaviors than general locus of control scores. ’ As Wallston et all suggest, investigators assessing children’s HLC beliefs are advised to use a scale constructed for children. An HLC scale appropriate for children developed by Parcel and Meyer’ has shown high internal consistency and an ability to discriminate between age and socioeconomic groups. Parcel and Meyer suggest further studies to determine its relation- ship with other measures, how consistently or reliably this instrument measures HLC and if it is a reasonable intermediate measure of change of health-related behaviors.

Pennebaker9 and Tolor et allo have suggested that high self-concept correlates with the perception of a high level of internal control and have found some tentative support for this suggestion.

. HLC Self-Concept

n (070 internal) (# of items) I

Methodology

The two instruments used in this study were the Parcel-Meyer Children’s Health Locus of Control Scale and the Piers-Harris Children’s Self-concept S ~ a l e . ~ J l Both instruments are self-report measures requiring yes- no responses. Though usually scored only as a total, the HLC scale can be divided to yield three subscale scores (chance, powerful others and internality). (See Figure 1 .) These subscales follow a scale division suggested by Wallston et all for an adult HLC scale. The present authors were interested in whether the children’s scale could be use- fully subscaled in the same manner.

The Piers-Harris yields six subscale scores and a total score. The six subscales are behavior, intellectual and school status, physical appearance and attributes, anxiety, popularity and happiness and satisfaction. Sample items include: “ I am easy to get along with,” “I wish I were different.” Items on all scales were coded so that high scores reflected high internality or high self- concept. For example, a high score on the anxiety sub- scale of the Piers-Harris presumably reflects low anxiety.

Fifty asthmatic children from grades two through

334 THE JOURNAL OF SCHOOL HEALTH

seven (mean =4.9, SD = 1.3) participated in the study. All were contacted as part of the Asthma Self-Manage- ment Program, an educational program sponsored by the Washington Lung Association. Ages ranged from 8 to 13 (mean= 11.1, SD= 1.15); 38 were boys, 12 were girls. The children came from predominantly middle- class families. All children had moderate to severe asthma and required daily medication to control their symptoms. Instruments were administered to all children in the same order as part of a battery of questionnaires. The instructions for each scale were read aloud to the children.

Sex M F

Grade 2 3 4 5 6 7

Range

Mean (SD) Mode

Median

38 12

2 7

12 12 1 1 5

67.1 68.0

65.0 56.4 59.2 66.3 80.8 73.2

2 1 - 1 00%

67.265 ( 1 8.1 57)

70

69.812

62.7 58.9

66.0 60.4 56. I 63.7 64 .5 65.6

13-77

61.816 ( 12.380)

66

65.580 I

Results

A breakdown of total scores on both instruments by sex and grade is presented in Table 1. HLC scores are the percent of items answered in an internal direction; self-concept scores are the number of items responded to in a positive direction. No item was omitted by more than two children; and omitted items never constituted more than 3% of a child’s responses, so modal values were substituted for missing responses. It was judged that this procedure would not seriously alter the results.

A one-way analysis of variance showed significant differences (p < -05) in HLC score between grades; trend analysis showed no significant deviations from linearity (Table 2), indicating an increase in internal HLC in higher grades.

AUGUST 1980

TABLE 2 Analysis of Variance of HLC by Grade

ss df MS F P

Between Grades 3823.38 5 764.68 2.69 < .05 Within Grades 11939.46 42 284.27

Linear 2724.05 1 2724.05 9.58 < .01 Deviations from 1099.33 4 274.83 .97 NS

Linearity

The correlation matrix between the test instruments and their subscales, including number of items in each subscale, is presented in Table 3 with Cronbach's o< reliability coefficients in the diagonal. Cronbach's a is an index indicating how internally consistent the scale is - that is, to what extent items reliably measure a single construct. Although no exact standards of minimum values for reliability coefficients are available, a reliability above .65 would be desirable for an experimental instrument; and a reliability approaching .9 or above would be desirable in an instrument used in aiding decision making for individuals.

Item statements and item-total correlations for the HLC scale are included.

Discussion Alpha reliabilities for the Piers-Harris Self-concept

Scale are consistent with previous reports and indicate a very high total scale reliability (.93) with fairly high reliabilities for each subscale. Separate interpretation of subscale scores may lead to some misinterpretation of the internal structure of the overall concept.

The reliability estimate of the HLC scale (.72) is consistent with Parcel and Meyer's report' of o< = .81

TABLE 3 Scale Reliabilities and Subscale Correlations

# of' items I 2 3 4 5 6 7 8 9 10 I I

Parcel-Meyer HLC I , total scale

2 . L11311ce

3 powerf'ul others

4. internality

Piers-liarrir Self- C'oncept Scale 5 . icital scale

h . Iiehavior

7. intellectual k school status

X . physical appear- ance & attributes

9. iinxiety

10. pcipularity

I I . happine\, & \at islaction

2 0

5

9

6

80

17

14

9

10

10

X

72'

71 43

87 51

75 56

34 27

35 23

32 30

13 05

20 15

33 17

14 20

71

53 13

22 32 93

30 22 72

22 34 77

07 17 79

12 17 70

20 44 72

00 19 69

78

33 82

48 67 70

35 47 45 69

36 58 53 47 57

68 39 62 31 39 75 ~ ~~

*l)rciinalc ha\e been omitted; o< internal conqistency reliabilitier appear i n the diagonal.

AUGUST 1980 THE JOURNAL OF SCHOOL HEALTH 335

(with 168 subjects). Low subscale reliabilities and moderately high subscale intercorrelations indicate that constructing subscales may not be useful when working with this scale for children.’

As previous work with generalized locus of control suggests, the trend analysis showed that internality in children increased with grade.

The relatively low, positive correlation of HLC with self-concept is also consistent with reported results and suggests discriminant validity for the two measures: the scales appear to be measuring distinctly different constructs.

I t is of interest to note that the mean HLC score (67.27) for our sample of children with asthma is approximately the same as the mean score (67.20) reported by Parcel and Meyer for a sample of 98 healthy, predominantly middle-class elementary school children in Texas. Also, the mean self-concept score (61.82) for this sample is slightly higher than the scores (47.99 to 60.40) reported by Piers and Harris for urban and suburban Pennsylvania and New York samples. These results suggest that it should not be assumed that children who are chronically ill have lower self-concepts or see themselves as having less control over their health than other groups.

Summary

In summary, both the Piers-Harris and the Parcel- Meyer HLC Scales were shown to be reliable instruments for our sample of children with asthma. Both the HLC and self-concept scales were shown to be consistent measures and may be employed in evaluating achievement of affective educational goals. The low intercorrelation between the two measures supports their continued use as indices of distinct constructs. The HLC measure may be used in assessing educational program impact on children’s perceptions that they can assume responsibility for part of their health and are not necessarily dependent upon other people. The self- concept scale may be used to evaluate the child’s level of self esteem.

Changes in health behaviors as well as changes in self- perceptions are often primary goals of health education. The impact of changes in internality and self-concept on subsequent behaviors is a crucial direction for future research.

Both instruments used in this study may be used as reliable measures of the affective impact of health education programs. Confirmation of their value to the educator as intermediate measures of behavioral change is dependent upon the results of future studies detailing how well these instruments predict criteria of interest and long-range studies of stability in HLC and self- concept.

REFERENCES

I . Wallston B, Wallston K , Kaplan G, et al: Development and validation of the health locus of control (HLC) scale. J Consult Clin

2. Strickland B: Locus of control: where have we been and where are we going? Paper presented at the meeting of the American Psychological Association, Montreal, 1973.

3. Parcel G, Meyer M: Toward an intermediate outcome evaluation instrument for health education. Paper presented at the American School Health Association annual meeting, New Orleans, 1976.

4. Rotter JB: Social Learning and Clinical Psychology. Englewood Cliffs, Prentice-Hall, 1954.

5. Rotter J , Chance J , Phares E (eds): Applications of a Social Learning Theory of Personality. New York, Holt, Rinehart & Winston, 1972.

6. Throop M, Thornhill A, Youngman M: A computerized and categorized bibliograpy on locus of control. Psychol Rep 36505-506. 1975.

7 . Lefcourt H: Internal versus external control of reinforcement: a review. Psychol Bull 65:206-220, 1966.

8. Rotter J: Some problems and misconceptions related to the construct of internal versus external control of reinforcement. J Consult Clin Psychol 43:56-67, 1975.

9. Pennebaker D: Conceptual and empirical clarification of two measures of self esteem. Unpublished Master’s Thesis, University of Washington, 1977.

10. Tolor A, Tolor B, Blumin S: Self-concept and locus of control i n primary grade children identified a5 requiring special educational programming. Psychol Rep 40:43-49, 1977.

I I . Piers E, Harris D: The Piers-Harris Children S Self-Concept Scale. Nashville, Counselor Recordings and Tests, 1969.

Psycho1 44~580-585, 1976.

Bl B L I O C R A P H Y

Shavelson R, Hubner J , Stanton G: Self-concept: validation of construct interpretations. Rev Educ Res 46:407-441, 1976.

Kathy E. Green, MEd, PhC (Corresponding author) Department of Educational Psychology, 312 Miller Hall, DQ-12, University of Washington, Seattle, WA 98195. Case Kolff , MD, MPH, Sea-Mar Community Health Center, Seattle, WA.

336 THE JOURNAL OF SCHOOL HEALTH AUGUST 1980