Factors Affecting Children's Attitudes Toward Health Care and Responses to Stressful Medical Procedures 1

Transcription

1 Journal ofpediatric Psychology, Vol. 20, No. 3, 1995, pp Factors Affecting Children's Attitudes Toward Health Care and Responses to Stressful Medical Procedures 1 Pamela J. Bachanas Emory University School of Medicine Michael C. Roberts 2 University of Kansas Received November 24, 1993; accepted September 16, 1994 Assessed factors hypothesized to influence children's and mothers' attitudes toward health care phenomena and children's distress during a stressful medical procedure in a pediatric outpatient clinic. Children, ages 6-11 years, and their mothers attending a county health department for a well-child physical examination participated. Pearson correlation coefficients were calculated and hierarchical regression analyses were conducted. Results indicated that several factors, including age, health locus of control, and maternal health care attitudes were significant predictors and/or correlates of children's attitudes toward health care and their behavioral responses during an aversive procedure. Implications of these findings for health prevention and education efforts with children are discussed. KEY WORDS: children's distress; health care attitudes; children's perceptions; parental perceptions. It is estimated that each year 5,000,000 American children undergo medical procedures for diagnosis or treatment (Bush, Melamed, Sheras, & Greenbaum, 'This article is based on the doctoral dissertation of the first author under the direction of the second author at the University of Alabama. The authors thank the Tuscaloosa County Health Department, their patients and families, and members of the doctoral committee. 2 A1I correspondence should be sent to Michael C. Roberts, Clinical Child Psychology Program, Joseph R. Pearson Hall, University of Kansas, Lawrence, Kansas /95/060O-O261SO7.5O/ Plenum Publishing Corporation

2 262 Bachanas and Roberts 1986). As a result of the growing needs of these children, pediatric psychologists are currently involved in a wide range of activities in medical settings. These include working with children prior to and during their medical treatment or hospitalization to reduce or minimize anxiety and distress associated with treatment, consulting with children and parents to help ensure compliance with their medical regimen, and working in concert with teachers, nurses, physicians, and other health professionals to shape prohealth habits. These intervention and prevention efforts have become essential components of comprehensive health care for children. Children's perceptions of or attitudes toward specific aspects of health care have been hypothesized to play a significant role in determining the manner in which children approach and experience medical events (Gochman, 1985; Jay, 1988). Thus, obtaining a better understanding of children's health care attitudes and beliefs would have a significant impact on the efficacy of these various intervention and prevention efforts; however, few published studies have empirically investigated how children actually perceive medical procedures, personnel, and settings (Bush & Holmbeck, 1987). Rather, much of the literature has focused on more abstract concepts such as children's definitions of health and illness, beliefs regarding the causes of illness, and perceptions of vulnerability to illness (Roberts, 1993). Another shortcoming of this literature is that the vast majority of these studies have been conducted in nonmedical settings, limiting the generalizability of these findings to medical settings. Further, while many investigators have employed various intervention programs designed to modify children's health beliefs, few systematic attempts have been made to empirically determine what factors may influence children's attitudes toward health care (Gochman, 1988). Recognizing the paucity of empirical data on children's attitudes toward health care, Bush and Holmbeck (1987) developed an instrument aimed at measuring children's attitudes toward concrete health care entities (health care providers, procedures, and institutions). The Children's Health Care Attitudes Questionnaire (CHCAQ) taps attitudes toward eight targets (doctors, dentists, nurses, hospitals, medicine, shots, blood tests, and surgery) along three dimensions: like-dislike, ineffectiveness-effectiveness, and approach-avoidance. The CHCAQ also contains a pain scale asking children to rate the painfulness of 17 medical and nonmedical stimuli. They observed that children tend to have general levels of liking, approach, and attributed ineffectiveness with respect to health care entities, rather than having entity-specific attitudes (e.g., specific attitudes toward dentists and hospitals). Hackworth and McMahon (1991) demonstrated further support for the psychometric properties of the CHCAQ, reporting consistent estimates of reliability and validity for this scale and examining correlations with other variables. These investigators also extended the utility of this scale by modifying its

3 Attitudes and Distress 263 use to assess maternal health care attitudes. Thus, some research is beginning to measure children's health care attitudes. Children's health-related beliefs, expectations, and attitudes are frequently assumed to reflect the impact of family characteristics (Gochman, 1985, 1993). Although the family is presumed to be a major determinant of health beliefs, few empirical studies have systematically investigated the family's influence on children's health concepts (Bush & Iannotti, 1990) and many equivocal findings have been reported (Pen-in & Shapiro, 1985). Along this line, Hackworth and McMahon (1991) obtained initial support for a positive relationship between children's and mothers' health care attitudes, observing that mothers' attitudes significantly predicted children's attitudes on several of the attitudinal subscales. Also recognizing that the degree to which a child perceives him- or herself as capable of influencing his or her health may play a significant role in shaping health care attitudes, Hackworth and McMahon examined the relation between children's health locus of control and attitudes toward health care. They found that children who endorsed more of an internal health locus of control rated health care procedures, personnel, and settings as less effective and rated stimuli as less painful. These results offer initial support for a relation between children's attitudes toward health care and their health locus of control; however, no relationship was obtained between children's health locus of control and children's like dislike or approach-avoidance attitudes about medical phenomena. This consideration needs to be explored further to determine if these variables are related and acting in the health care setting. These initial studies of children's health care attitudes are limited in that both studies were conducted in nonmedical settings (i.e., at a science museum health fair and a private school setting). The ecological validity of this measure might be extended if assessed while a child was actually in a medical setting exposed to the situations presented. Additionally, these measurements of children's attitudes would be further validated if they were linked to a behavioral measure of the child's response to a medical procedure while in the medical setting. The present study was designed to further explore the relation between children's and mothers' attitudes toward health care and other factors such as health locus of control that may influence children's health care attitudes. The relationship between those factors and children's behavior exhibited during a stressful medical procedure was also investigated in ah outpatient pediatric clinic with children undergoing medical examinations. Several hypotheses were tested in this study. First, we predicted that children's and mothers' health care attitudes would be positively related such that children who reported liking the targets more, wanting to approach the targets more, and who viewed the targets as more effective would have mothers who

4 264 Bachanas and Roberts reported these same positive attitudes. Second, we predicted that children's health care attitudes and health locus of control would be significantly related and that children who endorse more of an external health locus of control would tend to hold more positive attitudes toward health care. We also predicted that children's attitudes toward health care would be related to their displayed distress during a painful medical procedure such that children who report wanting to approach the targets less, liking the targets less, and viewing the targets as less effective would exhibit more anxiety and distress than children who view health care procedures, personnel, and settings more positively. Last, we predicted that mothers' attitudes toward health care may be related to children's responses to medical events and that children with mothers who report more negative health care attitudes would tend to exhibit more distress during a procedure than children with mothers who report more positive health care attitudes. A hierarchical regression model was developed to assess these hypothesized relations between children's and mothers' health care attitudes and children's behavior during a stressful procedure in an integrative fashion. METHOD Subjects and Setting Ninety-five children (48 boys, 47 girls) between the ages of 6 and 11 (M = 8.2 years) who were undergoing outpatient annual well-child medical examinations and their mothers served as subjects. The subjects were recruited and assessed at the outpatient pediatric clinic of a local health department. The mothers who participated in this study ranged in age from years (M = 31). The mean education level of the mothers was partial high school completion and the mean socioeconomic status (SES) of this sample falls in the low range (Hollingshead, 1975). The majority of the subjects in this study represented the minority populations. Measures Child Self-Report. Children completed the Children's Health Care Attitudes Questionnaire (CHCAQ; Bush & Holmbeck, 1987). This measure consists of 24 questions tapping the attitudinal dimensions of like-dislike, ineffectivenesseffectiveness, and approach-avoidance toward eight targets: doctors, dentists, nurses, hospitals, medicine, shots, blood tests, and surgery (e.g., "How do you like doctors?, When people are sick and they have an operation, does it make them better?"). Pictures and graphic symbols are included at the top of each page

5 Attitudes and Distress 265 to aid the child in conceptualizing each possible response. Scores on each subscale (Like-Dislike, Approach-Avoidance, and Ineffectiveness-Effectiveness) range from 8-40, with higher subscale scores indicating liking the targets more, wanting to approach the targets more, and viewing the targets as less effective, respectively. Respondents are also asked to rate 17 medical and nonmedical stimuli in terms of painfulness. Pain thermometers are used to aid the child in responding to these items. Pain subscale scores range from 17-85, with higher scores indicating that subjects rate the stimuli as more painful. Bush and Holmbeck (1987) reported Cronbach's alpha coefficients of.63 to.76 and testretest reliability coefficients (2-week interval) of.70 to.76 for the attitudinal scales. Cronbach's alpha and test-retest reliability coefficients ranged from.57 to.75 and.69 to.84, respectively, on subscales of the Pain scale. Construct validity was also reported for the CHCAQ. Similar reliability estimates for the CHCAQ were reported by Hackworth and McMahon (1991). The Children's Health Locus of Control Scale (CHLC; Parcel & Meyer, 1978) was completed by all child subjects. This scale consists of 20 items designed to assess children's locus of control pertaining to aspects of health and illness (e.g., "Good health comes from being lucky"). Scores range from 20-40, with higher scores indicating more of an internal health locus of control. Parcel and Meyer (1978) reported overall Kuder-Richardson coefficients of.72 to.75 for this scale. O'Brien, Bush, and Parcel (1989) reported test-retest reliability coefficients over a 4-year period of.65 to.72 for the CHLC. In addition, Parcel and Meyer (1978) reported a Spearman r of.50 (p <.01) between the CHLC and the Nowicki-Strickland Children's Locus of Control Scale (Nowicki & Strickland, 1973). Maternal Self-Report. Mothers completed a questionnaire which requested demographic information on themselves and their children. This assessment required occupation/job description, educational level, marital status, and income level for both mother and any other person in the home sharing household finances in order to calculate an estimate of SES using the Hollingshead Four- Factor Index of Social Status (Hollingshead, 1975). Demographic information on the child, such as date of birth, sex, grade in school, and special education placement was also obtained. A modified version of the CHCAQ was completed by the mothers. The Health Care Attitudes Questionnaire (HCAQ; Hackworth & McMahon, 1991) contains the same items as the CHCAQ; however, minor changes in instructions have been made and the pictures and graphic symbols from the attitudinal scales have been excluded. Mothers were asked to report their own attitudes toward the targets. The subscales of this measure are scored the same as the subscales of the CHCAQ. Hackworth and McMahon (1991) obtained Cronbach's alpha coefficients ranging from.63 to.86 for the HCAQ, thus demonstrating acceptable reliability. Observational Measures of Child's Behavior. Children were observed undergoing a finger-prick blood test given by the nurse. Upon completion of the

6 266 Bachanas and Roberts observed procedure, the investigator or research assistant completed a behavior rating scale that measured specific child distress behaviors displayed during the blood test. This scale was developed by the authors as an adaptation of the behavioral codes of several published behavioral observation scales (e.g., OSBD: Elliott, Jay, & Woody, 1987; CAMPIS: Blount et al., 1989) that have demonstrated acceptable reliability and validity. This rating scale used here consists of the same 11 operationally defined behaviors indicative of anxiety or pain in children (e.g., crying, verbal resistance, nervous behavior) used on the OSBD and CAMPIS scales. Each behavior was rated on a Likert-type scale from 1 to 10, indicating the degree to which the child displayed the behavior during the medical procedure. Scores range from 11 to 110 with higher scores indicating more observed distress. Behavior rating scales have been shown to correlate highly with observational measures and are much more economical and efficient to use (Blount et al., 1989; Jay, 1988). Eighty percent of the observations were completed by research assistants who were not knowledgeable of the hypotheses of the study. They were trained by the first author to use the behavior rating scale. Training consisted of an explanation of the behavioral descriptors and agreement on operational definitions provided on the OSBD. The experimenter and each research assistant then observed five or more finger-prick procedures and independently rated the child's displayed behavior. Training continued until an agreement of at least 85% was achieved between the experimenter and the research assistants. Interrater reliability between the experimenter and research assistants during the training was calculated to be.89 using the kappa coefficient. Procedure Subjects were approached in the clinic's general waiting area immediately after checking in for their scheduled appointments. The purpose and requirements of the study were explained to the subjects, and their participation was requested. No potential subjects declined participation in the study; however, three potential subjects could not be included as the adult accompanying the child was not the child's parent or primary caregiver. Two subjects had to be dropped from the data analysis due to incomplete data sets. Subjects were offered a small incentive (free lunch coupons at McDonald's) for their participation. Subjects were then taken into a large conference room to be interviewed and to complete the assessments. Mothers and children were placed at opposite ends of the room to encourage independent responding on the measures. After obtaining informed consent (and assent from the child), the experimenter or research assistant administered the assessment battery to the mother and offered assistance with completing the questionnaires. The questionnaires were read aloud to each child participant and their responses were recorded. The order of presentation of the ques-

7 Attitudes and Distress 267 tionnaires was counterbalanced for both mothers and children. Completion of the assessment phase took approximately 20 minutes. Immediately upon completing the assessment battery, the child was called into the laboratory of the clinic, where a nurse performed the following set of procedures: height and weight check, vision and hearing screen, temperature, and a finger-prick blood test. Each participant received the same medical protocol. The child was observed by the experimenter or research assistant during the blood-test procedure. Immediately following the child's blood test, the experimenter or research assistant completed the behavior rating scale indicating the distress behaviors the child displayed during the procedure. The experimenter or research assistants did not know the children's scores on the questionnaires when the behavioral observations were made. The child was then seen by a nurse practitioner for a well-child physical examination. RESULTS Overview of Data Analyses Means and standard deviations of all measures are presented in Table I. It is significant to note that the CHCAQ and HCAQ means obtained in this study are similar to and consistent with the means obtained in earlier studies conducted in nonmedical settings (e.g., Hackworth & McMahon, 1991). A series of Pearson correlation coefficients was calculated to provide an initial assessment of the hypothesized relation between children's health care attitudes and children's sex, Measure" Table I. Means and Standard Deviations of Measures Age CHCAQ Approach-Avoidance Like-Dislike Ineffectiveness-Effectiveness Health locus of control HCAQ Approach-Avoidance Like-Dislike Ineffectiveness-Effectiveness Children's distress scores M SD Range "CHCAQ = Children's Health Care Attitudes Questionnaire; HCAQ = Health Care Attitudes Questionnaire; Health locus of control = Children's Health Locus of Control scale.

8 268 Bachanas and Roberts Table II. Intercorrelation Matrix of Children's Health Care Attitudes and Independent Measures (n = 95) Measure CHCAQ-lneffectiveness 2. CHCAQ-Like 3. CHCAQ-Approach 4. Sex 5. Age 6. Health locus of control 7. HCAQ-Ineffectiveness 8. HCAQ-Like 9. HCAQ-Approach -.32' -.28'.42' ' -.24' * -.27' ' '.33' * "CHCAQ-lneffectiveness = CHCAQ Ineffectiveness-Effectiveness Scale; CHCAQ-Like = CHCAQ Like-Dislike Scale; CHCAQ-Approach = CHCAQ Approach-Avoidance Scale; Health locus of control = Children's Health Locus of Control Scale; HCAQ-Ineffectiveness = HCAQ Ineffectiveness-Effectiveness Scale; HCAQ-Like = HCAQ Like-Dislike Scale; HCAQ-Approach = HCAQ Approach-Avoidance Scale. b p <.05 c p <.01. age, health locus of control, and maternal health care attitudes (Table II). Sex was not found to significantly relate to any variables of interest; therefore, it was not included in the final analyses. However, children's health care attitudes (Like-Dislike and Approach-Avoidance scores) were found to significantly correlate with children's age, health locus of control, and mother's health care attitudes of Like-Dislike in the predicted directions. A series of hierarchical regression analyses were then conducted in which the predictor variables were added in a theoretically determined sequence. Specifically, intrinsic variables (e.g., sex, age) were entered first, followed by extrinsic variables (e.g., maternal health care attitudes). Independent regression equations were analyzed for the three attitudinal scales of children's health care attitudes (Like-Dislike, Approach-Avoidance, and Ineffectiveness-Effectiveness). The strategies for testing statistical significance described by Cohen and Cohen (1983) were utilized to examine variance accounted for in each regression equation. In addition, the Bonferroni corrected alpha level (p <.0175; Hays, 1981) was used to determine the statistical significance of the three regression equations assessing children's health care attitudes, as the three subscales of the CHCAQ were significantly related to each other (see Table II). Multicolinearity was assessed for all predictor variables, and inspection of the tolerance values indicated that this was not problematic in this sample. Similar analyses were conducted to assess the relations of these predictor variables to children's distress behaviors.

9 Attitudes and Distress. 269 Children's Health Care Attitudes Approach-Avoidance Scale. The overall R 2 when all variables hypothesized as significantly contributing to children's health care attitudes were considered was significant, accounting for 19.4% of the variance (Table III). The hierarchical analysis allowed for testing of the specified hypotheses for each predictor variable. For the first step, significant variance was accounted for by age (P =.23, p <.05), with younger children rating health care personnel, procedures, and settings as more approachable than older children. A significant increment in the variance accounted for in children's Approach-Avoidance scores was also obtained when mother's health care attitudes, Like-Dislike scores, were considered (P =.28, p <.01). Children who rated the targets as more approachable had mothers who reported liking the targets more. Although children's health locus of control was significantly correlated with the CHCAQ Approach-Avoidance Scale (r =.27, p <.01), it was not a significant predictor when other variables were controlled for in the equation, P = -.16; r(89) = -1.55, ns. Like-Dislike Scale. The overall R 2 when all variables hypothesized as significantly contributing to children's health care attitudes were considered was nonsignificant using the Bonferroni corrected alpha level of p <.0175 (Hays, 1981), F(5, 89) = 2.45, p <.03. Although these variables accounted for a significant portion of the variance (12%), the overall significance level does not meet the Bonferroni criteria. As depicted in Table II, a significant correlation between age and Like-Dislike scores was obtained, indicating that younger children reported liking health care personnel, procedures, and settings more than older children. Children's health locus of control scores were significantly correlated with the CHCAQ Like-Dislike Scale, suggesting that children who endorse more of an external locus of control report liking the targets more than Table III. Hierarchical Multiple Regression Analysis on Children's Health Care Attitudes: Approach-Avoidance Scale Step Independent variable 0 R z /? 2 -change F-change fc f Child's age Health locus of control HCAQ-Approach HCAQ-Like HCAQ-Ineffectiveness ' * "Health locus of control = Children's Health Locus of Control Scale; HCAQ-Approach = Approach-Avoidance Scale; HCAQ-Like = HCAQ Like-Dislike Scale; HCAQ-Ineffectiveness = HCAQ Ineffectiveness-Effectiveness Scale. b F for entire model = 4.29, p <.001. c p <.05.

10 270 Bachanas and Roberts children who endorse more of an internal locus of control. Mother's ratings on the Like-Dislike Scale and children's Like-Dislike scores were significantly correlated, indicating that children who reported liking the targets more had mothers who also reported liking the targets more. Ineffectiveness Effectiveness Scale. The overall R 2 when all variables hypothesized as contributing to children's health care attitudes were considered was nonsignificant, F(5, 89) = 0.41, p >.80. Furthermore, as shown in Table II, none of the hypothesized variables were found to significantly correlate with children's ratings of the effectiveness of health care personnel, procedures, and settings. Children's Distress Behaviors Similar analyses were conducted for children's distress scores (Table IV). The overall R 2 when all variables hypothesized as contributing to children's distress scores were considered was significant, F(8, 62) = 3.94, p <.001, accounting for 34.7% of the variance. Significant variance was accounted for by age (P =.24, p <.05), with younger children displaying more distress than older children during a stressful medical procedure. A significant increment in the variance was obtained when children's health care attitudes Approach- Avoidance scores were added to the equation O = -.42, p <.001). Children who displayed higher levels of distress reported more avoidant attitudes and rated the targets as less approachable than children displaying lower levels of Step Table IV. Hierarchical Multiple Regression Analysis on Children's Distress Scores: Total Distress Scores Independent variable" Child's age CHCAQ-Approach CHCAQ-Like CHCAQ-Ineffectiveness Health locus of control HCAQ-Approach HCAQ-Like HCAQ-Ineffective R K 2 -change f-change* 4.04< " < C ' P "CHCAQ-Approach = CHCAQ Approach-Avoidance Scale; CHCAQ-Like = CHCAQ Like-Dislike Scale; CHCAQ-Ineffectiveness = CHCAQ Ineffectiveness-Effectiveness Scale; Health locus of control = Children's Health Locus of Control Scale; HCAQ-Approach = HCAQ Approach-Avoidance Scale; HCAQ-Like = HCAQ Like-Dislike Scale; HCAQ-Ineffectiveness = HCAQ Ineffectiveness- Effectiveness Scale.»F for entire model = 3.94, p <.001. c p <.05. <>p <.01.

11 Attitudes and Distress 271 distress. The addition of children's health care attitudes Ineffectiveness- Effectiveness scores also resulted in a significant increment in the variance (P =.24, p <.05), revealing that children who displayed higher levels of distress tended to rate the targets as less effective than children displaying lower levels of distress. Finally, significant increments in the variance were obtained when mother's health care attitudes, both Approach-Avoidance and Ineffectiveness scores, were considered (3 =.22, p <.05; J =.22, p <.05; respectively). Children who exhibited higher levels of distress had mothers who rated the targets as less approachable and less effective than children who exhibited lower levels of distress. DISCUSSION Our results indicate that several factors significantly relate to children's attitudes toward health care and behavioral responses to a stressful medical procedure. Further, these variables account for more variance in children's attitudes and behavior than any variable independently, supporting the assessment of these variables in an integrated fashion. Significant relations were obtained between children's and parents' attitudes toward health care. Support was also obtained for a relation between children's health care attitudes and their behavior displayed during a medical procedure. The current findings suggest that those factors related to children's health care attitudes differ from one CHCAQ attitudinal scale to another. No one factor consistently correlated with all three subscales. This finding is consistent with Hackworth and McMahon's (1991) results and supports the approach of making a distinction between these attitudes or constructs. Several factors were shown to make unique contributions to predicting children's health care attitudes and/or to have significant relations with the CHCAQ scales. Younger children rated health care personnel, procedures, and settings as more approachable and reported liking them more than older children. This finding is not consistent with the earlier studies that found that older children tended to report liking the targets more and wanting to approach the targets more (Bush & Holmbeck, 1987; Hackworth & McMahon, 1991). The restricted age range of the participants in this study (e.g., 6-11 years), relative to the earlier two studies, may be responsible for this incongruent finding. For example, Bush and Holmbeck (1987) assessed children ranging from 6-19 years of age and reported "complex, nonlinear age trends" (p. 440). Further, they had a smaller sample with fewer young children making direct comparisons between samples difficult. Consequently, additional research is needed to clarify specific age trends in the health care attitudes of grade school-aged children. Furthermore, children with more of an external locus of control tended to

12 272 Bachanas and Roberts rate health care personnel, procedures, and settings as more approachable and reported liking the targets more. Previous studies have shown that children's health locus of control scores highly correlate with age, and that scores tend to become more internal in older children (O'Brien et al., 1989; Parcel & Meyer, 1978). Findings from the current study also support a strong correlation between children's health locus of control scores and age (r =.38). Based on the obtained results, adding children's health locus of control scores to the equations after the effects of age had been partialed out diminished the independent relation between health locus of control and ratings of approachability and liking the targets. Further research needs to clarify these types of age trends in the relation between children's health locus of control and children's health care attitudes. As hypothesized, mothers' health care attitudes were shown to be significant predictors of children's health care attitudes. Specifically, children who reported liking health care personnel, procedures, and settings more also had mothers who reported liking these targets more. In addition, children who viewed the targets as more approachable had mothers who reported liking the targets more. These findings are consistent with earlier studies that assessed relations between mothers' and children's health concepts (Bush & Iannotti, 1988) and lend support to the notion that children may incorporate parental attitudes with regard to health care. These findings have significant implications for health prevention and education efforts. Specifically, interventions to enhance children's views of and utilization of health care services should also include a parent education component which attempts to enhance parents' attitudes toward health care and to encourage parents to model more positive attitudes toward health care for their children. Support was also obtained for assessing factors related to children's distress behaviors displayed during a stressful medical procedure in an integrative fashion, as the set of variables was shown to account for significantly more variance than any independent factor. A single variable or screening measure is likely to be inadequate for predicting distress. Consistent with previous research, younger children displayed more distress during a painful medical procedure than older children. It has been suggested that the heightened distress displayed by younger children may be related to their immature cognitive processes and to the meaning they attribute to the painful experience (e.g., punishment for misdeeds, etc.; Jay, 1988). Children who displayed higher levels of distress rated health care personnel, procedures, and settings as less approachable and less effective than children displaying lower levels of distress. This finding is significant because we have been unable to ascertain other studies documenting that children's attitudes toward health care actually predict their behavioral response during a medical procedure. Previous studies have assessed the relation between children's health cognitions and the likelihood that they will engage in health-related behaviors, but not children's behavioral responses to medical events.

13 Attitudes and Distress 273 The lack of studies relating children's attitudes and behavior may be due to theoretical restrictiveness and/or differences in experimental emphases. We might speculate that those developing behavioral measures (by observation) eschew attitude measures (whether by interview or pencil-and-paper questionnaires) and vice versa. Furthermore, the foci of the studies of children's attitudes reviewed by Roberts (1993) and those of distress behaviors (e.g., Blount et al., 1989) have been fundamentally different. Consequently, attempts at relating attitudes and behavior in children have been limited. Such research appears necessary for an integrated understanding of children's thinking and behaving. In addition to age and children's attitudes, mothers' health care attitudes were also found to relate significantly to children's exhibited distress. Children who displayed higher levels of distress had mothers who rated health care personnel, procedures, and settings as less approachable and less effective than children who displayed lower levels of distress. Thus, children who are more distressed during a medical procedure have mothers who hold more negative attitudes toward health care. Further research needs to examine this relation in order to devise more efficacious intervention and preventive approaches. The results obtained from the present study have significant implications for both prevention and educational efforts in child health psychology. Perhaps the most important implication from the current findings is that parents should be involved in efforts to educate children with respect to wellness, illness prevention, and early intervention. These findings strongly suggest that mothers' attitudes toward health care are significantly related to children's views of health care. Therefore, a parallel parent-education component which attempts to enhance parents' attitudes toward health care and encourages parents to model more positive attitudes toward health care for their children should be incorporated into children's interventions. Results from this study also suggest that children with more negative attitudes toward health care are more likely to display higher levels of distress during medical treatment. These findings offer support for prevention and education efforts aimed at enhancing children's views of health care and suggest that interventions that lead children to hold more positive attitudes toward health care may also have a positive impact on children's ability to cope with aversive medical procedures. Together with the finding that children who had more difficulty coping with a stressful procedure tended to have mothers who held more negative attitudes toward health care, these results offer support for including a parent-training component in the intervention efforts aimed at reducing children's anxiety and distress and increasing their ability to cope with aversive events. Parents who feel more positively toward health care and who feel more competent in their ability to help their children cope will likely have a more positive impact on their children's behavior during a painful procedure. Although the findings from the current study have important clinical impli-

14 274 Bachanas and Roberts cations, there are several limitations to this study. First, the amount of variance accounted for in the health care attitudes scales was relatively small, as was the magnitude of the correlation coefficients, indicating that a large portion of the variability in these ratings remains unaccounted for. Some factors influencing children's health care attitudes remain unidentified but are operating in the health care setting. Second, the sample used in this study was somewhat restricted in age and SES making it less representative of a normal sample and making direct comparisons with earlier samples more difficult. However, this type of sample does represent an important segment of children utilizing health services and in need of further study. Future research needs to be directed at better understanding the processes by which children adopt parental health beliefs, behaviors, and health care attitudes so that these processes can be eventually targeted directly in prevention and education efforts. In addition, further research should investigate the processes by which mothers influence their child's behavior so that intervention efforts aimed at reducing distress and increasing their compliance with medical treatment can be made more effective. REFERENCES Blount, R. L., Corbin, S. M., Sturges, J. W., Wolfe, V., Prater, J. M., & James, L. D. (1989). The relationship between adults' behavior and child coping and distress during BMA/LP procedures: A sequential analysis. Behavior Therapy, 20, Bush, J. P., & Holmbeck, G. N. (1987). Children's attitudes about health care: Initial development of a questionnaire. Journal ofpediatric Psychology, 12, Bush, J. P., Melamed, B. G., Sheras, P. L., & Greenbaum, P. E. (1986). Mother-child patterns of coping with anticipatory medical stress. Health Psychology, 5, Bush, P. J., & Iannotti, R. J. (1988). Origins and stability of children's health beliefs relative to medicine use. Social Science and Medicine, 27, Cohen, J., & Cohen, P. (1983). Applied multiple regression! correlation analysis for the behavioral sciences. Hillsdale, NJ: Erlbaum. Elliott, C. H., Jay, S. M., & Woody, P. (1987). An observational scale for measuring children's behavioral distress during painful medical procedures. Journal of Pediatric Psychology, 12, Gochman, D. S. (1985). Family determinants of children's concepts of health and illness. In D. C. Turk & R. D. Kerns (Eds.), Health, illness, and families: A life-span perspective (pp ). New York: Wiley. Gochman, D. S. (1988). Assessing children's health concepts. In P. Karoly (Ed.), Handbook of child health assessment (pp ). New York: Wiley. Gochman, D. S. (1992). Health cognitions in families. In T. J. Akamatsu, M. A. P. Stephens, S. E. Hobfall, & J. H. Crowther (Eds.), Family health psychology (pp ). Washington, DC: Hemisphere. Hack worth, S. R., & McMahon, R. J. (1991). Factors mediating children's health care attitudes. Journal of Pediatric Psychology, 16, Hays, W. L. (1981). Statistics (3rd ed.). New York: Holt, Rinehart & Winston. Hollingshead, A. B. (1975). Four-factor index of social status. New Haven, CT: Yale University Department of Sociology.

15 Attitudes and Distress 275 Jay, S. M. (1988). Invasive medical procedures: Psychological intervention and assessment. In D. K. Routh (Ed.), Handbook of pediatric psychology (pp ). New York: Guilford. Nowicki.S., & Strickland, B. R. (1973). A locus of control scale for children. Jounwl of Consulting and Clinical Psychology, 40, O'Brien, R. W., Bush, P. J., & Parcel, G. S. (1989). Stability in a measure of children's health locus of control. Journal of School Health, 59, Parcel, G. S., & Meyer, M. P. (1978). Development of an instrument to measure children's health locus of control. Health Education Monographs, 6, Perrin, E. C, & Shapiro, E. (1985). Health locus of control beliefs of healthy children, children with a chronic physical illness, and their mothers. Journal of Pediatrics, 107, Roberts, M. C. (1993). Children's perceptions and understanding of pediatrics. In M. C. Roberts, G. P. Koocher, D. K. Routh, & D. J. Willis (Eds.), Readings in pediatric psychology (pp ). New York: Plenum Press.