Lippincott Williams & Wilkins

A Children's Health Belief Model

Author(s): Patricia J. Bush and Ronald J. Iannotti
Source: Medical Care, Vol. 28, No. 1 (Jan., 1990), pp. 69-86
Published by: Lippincott Williams & Wilkins
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MEDICAL CARE
January 1990, Vol. 28, No. 1

A Children'sHealth Belief Model

PATRICIA J. BUSH, PHD, AND RONALD J. IANNOTTI,PHD

The classic Health Belief Model (HBM) was adapted to explain children's
expected medicine use for five common health problems. To evaluate this
Children's Health Belief Model (CHBM), 270 urban preadolescents, stratified
by socioeconomic status, grade level, and sex, and their primary caretakers (93%
mothers) were individually interviewed. Analyses were performed in two
steps. First, regression analysis evaluated the influence of the child's primary
caretaker on the child's expected medicine use. Individual differences in chil-
dren's motivations, perceived benefits and threats, and expectations to take
medicines were partially explained by caretakers' perceptions of these chil-
dren. Second, path analysis evaluated hypothesized causal relationships in the
CHBM, accounting for 63% of the adjusted variance in children's expected
medicine use. Two readiness factors, perceived severity of illness and per-
ceived benefit of taking medicines, had the highest path coefficients, with
illness concern and perceived vulnerability to illness accounting for a smaller,
but significant, portion of the variance. Cognitive/Affective variables, notably
children's health locus of control, contributed to indirect paths between demo-
graphic and readiness factors. The CHBM appears to be a promising model for
studying the development of children's health beliefs and expectations. Key
words: child development; drug utilization; health belief model; health behav-
ior, child; mothers. (Med Care 1990; 28:69-86)

Although adult health beliefs and atti-
tudes may be influenced by childhood expe-
riences with families, peers, and illness,1
children's understanding of health and ill-
ness has received sporadic attention.2-6 To
increase understanding of how children ac-
quire health beliefs, and to identify personal
and environmental factors that predispose
From the Laboratory for Children's Health Promo-
tion, Department of Community and Family Medicine,
Georgetown University School of Medicine, Washing-
ton, DC.
Supported by Grant DA-02686 from the National
Institute on Drug Abuse.
Address correspondence to: Patricia J. Bush, PHD,
Laboratory for Children's Health Promotion, Depart-
ment of Community and Family Medicine, George-
town University School of Medicine, Washington, D.C.
20007.
children to expect treatment for common
health problems, a Children's Health Belief
Model (CHBM) was hypothesized and eval-
uated. The Health Belief Model (HBM) has
utility for predicting adult health behav-
iors7-" but a model for children should re-
flect developmental theories. The CHBM
differs from the classic (adult) HBM primar-
ily in its recognition of these and in its rec-
ognition of the influence of the child's pri-
mary caretaker.
Medicine use was selected as the focus of
the study of the CHBM for several reasons:
medicine use is a frequent household activ-
ity for both adults and children,12 medicine
use is directly observable by children, the
family unit influences individual use,13
there is a large element of individual discre-
tion in medicine use, medicines are used for
69

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BUSH AND IANNOTTI
both prevention and treatment of illness,
medicine use has origins in both the formal
and the informal health care system, medi-
cines are the subject of advertising to which
children are exposed,14'5 and the age at
which children begin to take responsibility
for some aspects of medicine use was un-
known.
Background
As discussed by Becker and Maiman,7 the
original conception of the prevention-fo-
cused value-expectancy-based HBM formu-
lated by Rosenstock8 included the follow-
ing major "readiness to take action" ele-
ments: 1) the level of threat posed by the
health problem as determined by the indi-
vidual's perception of the problem's sever-
ity and perception of vulnerability to it; 2)
the individual's perception of benefit to be
derived from engaging in a behavior to re-
duce the threat, weighed against his or her
perception of barriers (psychologic, physi-
cal, social, economic) to performing the be-
havior, and 3) some type of external or in-
ternal trigger or cue to action. Demographic
and psychosocial factors were viewed as
modifying these relationships but were not
conceived as directly affecting preventive
health behavior.
Subsequent to its original formulation,
the HBM was explored for its applicability
to sick role behavior such as medicine use.9
Becker and his associates7'10'11'16 reformu-
lated the HBM for predicting compliance
with physician directives. The reformulated
version places greater emphasis on motiva-
tions, prior experience, and interpersonal
relationships.
One element in the classic HBM, per-
ceived vulnerability to illness, has been
evaluated extensively in children by Goch-
man,5'17-23 who found it to be a weak corre-
late of their dental health behaviors. Other
components of the HBM have received little
attention relative to children's health beliefs
and behaviors.
70
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MEDICALCARE
In addition to the HBM, three conceptual
systems have influenced research efforts re-
garding the health orientations of preado-
lescent children,24 with Social Learning
Theory (SLT)25predominant. Central to SLT
is the notion that behaviors are gradually
acquired and shaped as a result of positive
and negative consequences in the child's
social and physical environment. SLT is
used most frequently in intervention stud-
ies. A second conceptual system, Cognitive
Development Theory (CDT)26 has in-
fluenced studies of children's understand-
ing of illness-related processes.4'2728 CDT
emphasizes the role of developmental
changes in cognitive processes that influ-
ence children's understanding of social and
physical events. The third system, Behav-
ioral Intention Theory (BIT)29has received
the least attention, but is attractive for use
with children because it includes reference
group norms, emphasizes specific behaviors
as compared with abstractions and infer-
ences for which children often are not cog-
nitively prepared, and indicates that behav-
ioral intentions are the best available pre-
dictors of behaviors. The CHBM integrates
salient elements of SLT, CDT, and BIT into
the HBM to increase understanding of chil-
dren's illness behavior, expectations, and
intentions.24 The theories are not mutually
exclusive in that the same variable may be
consistent with more than one theory. The
relationship of specific variables in the hy-
pothesized CHBM to these theories has
been presented elsewhere.24 The CHBM is
consistent with Gochman,30 who has argued
for placing children's health behavior
within its personal and social context, a
context that recognizes the relationship of
children's health behavior to their personal
attributes, i.e., their beliefs, expectations,
motives, and other cognitive elements, and
recognizes that these personal attributes are
influenced by families, peers, and social
groups. This view of children's health be-
haviors supports the inclusion in a CHBM of
caretaker influences, and cognitive and af-
Vol. 28, No. 1 CHILDREN'S HEALTH BELIEFMODEL

fective attributes that change with age and
experience such as knowledge and health
locus of control.
The Hypothesized CHBM
The hypothesized CHBM is depicted in
Figure 1. The specific variables included are
those that have been related to children's
health-related beliefs and behaviors. For re-
views, the reader may see Lewis and Lewis,1
Bush and Iannotti,24 and Mickalide.31 Most
of these variables were developed and eval-
uated in prior phases of the current
study.32-36A description of each variable is
in the Appendix.
Two hypotheses were posed: 1) CHBM
variables predict children's expectations to
take medicines and 2) Caretaker health be-
liefs and expectations increase the ability of
the CHBM to explain children's states of
readiness and expectations to take medi-
cines. The hypotheses were tested in two
steps.
Step 1. All of the variables in the hy-
pothesized CHBM (Fig. 1) except for the
caretaker variables were subjected to re-
gression analysis to predict children's ex-
pected medicine use. The regression analy-
sis was repeated with the addition of the
caretaker variables and the equations were
compared to see if the caretaker variables
increased the ability of the CHBM to predict
children's expected medicine use.
Step 2. Causal pathways were hypothe-
sized in the CHBM and the model was sub-
jected to path analysis and tested for good-
ness of fit against a fully recursive model.
Methods
Sample and Data Collection
The total sample consisted of 300 District
of Columbia school children in grades 3-7
and 270 of their primary caretakers (93%
mothers). A stratified sample was selected
on the basis of grade, sex, and socioeco-
nomic status (SES), the latter determined by

MODIFYINGFACTORS READINESSFACTORS BEHAVIORFACTORS

CoRnitive/Affective

Health Locus of Control

Self-Esteem
Health Risk-Taking Motivations
Med Knowledge
Med Autonomy Illness Concern

Perceived Illness Threat Expectd ed Use

Med

Perceived Vulnerability
Perceived Severity
i
Med Use
Environmental Perceived Benefit of
Medicines
Caretaker's:
Motivations Perceived Med Benefit
for Child Perceived Nonmed Benefit
Perceived Child's
Illness Threat
Perceived Benefit
of Medicines
Expected Child's
Med Use

FIG. 1. Hypothesized Children's Health Belief Model. SES, Socioeconomic status; med, medicine; MD, physi-
cian.

71

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BUSH AND IANNOTTI
the average household income in the child's
elementary school census tract. A pilot
study35 had indicated that 97% of District
of Columbia elementary school children live
within a mile of their elementary schools.
The average age of the children was 10.7
years, and the range was 8.0 to 14.7 years.
The population is not representative of
the District of Columbia school population.
Fifty-six percent of the study children were
black, 33% were white, and 11% were His-
panic or "other." Ninety-three percent of
District of Columbia public school children
are black. Also, the average child in the
study came from a more affluent family
with a better educated primary caretaker
than the average District of Columbia pub-
lic-school child. The average primary care-
taker had 14.5 years of education; 14.3% of
the children lived in households in which
the family income was below $10,000;
23.8% in which the income was from
$10,000-20,000; 15.8% in which the in-
come was from $20,000-30,000; 21.9% in
which the income was from $30,000-
50,000, and 24.3% in which the income was
$50,000 or more.
Each student was interviewed privately at
his or her school by a trained interviewer of
the same race, the interview taking about
forty minutes. No earlier than two weeks
following the child's interview, the child's
primary caretaker (person named by the
child in response to a question, "Who takes
care of you when you're sick? You know,
who gives you medicine?") was interviewed
by telephone. Ten percent of the children's
primary caretakers could not be located,
were not reachable after ten attempts, or re-
fused to be interviewed. Children whose
mothers were interviewed did not differ sig-
nificantly in terms of age, sex, or SES char-
acteristics from those whose mothers were
not interviewed. The interviews included
questions about the health status and ex-
pected medicine use (Expected Med Use) of
the other as well as the self.
For Likert-type scale questions in the
72
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MEDICALCARE
child's instrument, an unlabeled graph with
six graduated bars was used, with choice
indicated by the child pointing to a corre-
sponding bar. In the telephone interviews,
the primary caretaker was asked to number
from one to six across a page, to write, for
example, "not at all likely" under the one,
and "very likely" under the six, and to re-
spond to questions by using the scale. The
interviewer asked as many test questions as
necessary, e.g., "How likely are you to ride
an elephant to school this year?," before
each use of the bar graph until certain that
the respondents understood how to use the
scales. Instruments are available from the
authors.
A 10% random sample of coded ques-
tionnaires stratified by the interviewers was
recoded; intercoder reliability over both in-
struments was 94.6% for items requiring
judgment or computation.
Hypothesized Causal Relationships
in the CHBM
Causal pathways, derived primarily from
previous studies, were hypothesized for
specific variables in the CHBM. In most
cases, the hypothesized paths represent
causal relationships from more general vari-
ables to health beliefs to illness-specific
readiness variables and expectations. For
clarity, the hypothesized paths are repre-
sented in Figure 1 by arrows between the
variable categories rather than between
each variable.
The Demographic variables were not hy-
pothesized to have direct effects on the
Readiness and Behavior variables, but to
have indirect effects only. The Cognitive/
Affective and Enabling variables were hy-
pothesized to have only indirect effects
through the Readiness variables. The Envi-
ronmental (caretaker) variables were hy-
pothesized to influence the Enabling, Readi-
ness, and Behavior variables. Specific causal
pathways were hypothesized among vari-
ables within the same category of variables
as well as among the categories.
Vol. 28, No. 1
Bush and Iannotti37 have reviewed the
use of path analysis in health behavior stud-
ies and specifically the assessment of direct
and indirect relationships associated with
use of medicines. Previous studies37-40have
predicted adult medicine use within a path
model of health behavior proposed by An-
dersen and Newman.41 To test the hypoth-
esized causal relationships in the CHBM,
regression analyses were performed in steps
to evaluate the indirect as well as the direct
determinants of the children's expectation
of treating common health problems with
medicines, and to explain the Readiness
variables hypothesized to have direct effects
on the dependent variable, Expected Med
Use. As shown in Table 1, none of the inde-
pendent variables exceeded Farrar and
Glauber's42 collinearity or multicollinearity
criterion, i.e., zero order or multiple correla-
tions that exceed 0.80; therefore, no inde-
pendent variables were excluded for this
reason.
Results
Relationship Between Expected Med Use
and Med Use
The rates of medicine use found in this
study are similar to those reported in pre-
vious studies for both adults and chil-
dren.12'13'37In this study, 33.0% of children
said they had taken one or more medicines
(including vitamins and minerals) in the two
days prior to interview, whereas 42.6% of
mothers said their child had done so. How-
ever, the children and their mothers were
describing medicine use for different days,
and as previously reported, most of the dif-
ference is accounted for by mothers' over-
estimating their children's vitamin con-
sumption.35 As for mothers responding for
themselves, 58.1% had taken one or more
medicines or vitamins in the two days prior
to interview.
Children or mothers who most expected
to take medicines for common health prob-
lems might be expected to be those who
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CHILDREN'S HEALTH BELIEFMODEL
take medicines most frequently. Although
no such relationship was found for either
children or mothers, this can be attributed to
the fact that the medicine use variable was
operationalized as use of any medicine or
vitamin in the two days before interview,
while Expected Med Use refers to medicines
for five specific health problems. Failure to
find a significant positive relationship be-
tween Expected Med Use and Med Use in
two days does not preclude a positive rela-
tionship between taking medicine for one of
the five common health problems when it
occurs and having a high expectation of
taking medicine for it. Also, the frequency
of medicine use over a longer time period
may have a stronger relationship to ex-
pected use than use in two days, the time
period chosen to increase the validity of the
self-reports. Expected Med Use has been
found relatively stable in this population
during middle to late childhood.43
Step 1. Predicting Expected Med Use
Without and With Caretaker Variables.
Table 1 shows the intercorrelations among
the variables. Standardized regression coef-
ficients, i.e., Beta weights (B), were calcu-
lated twice using the Reg procedure in
SAS.44Only variables based on information
obtained directly from the children were in-
cluded in the first equation; the second
equation included the caretaker variables.
The variables with significant standardized
coefficients are shown in Table 2. With the
caretaker variables in the regression, the
overall adjusted R2increased a small but sig-
nificant amount from 0.67 to 0.69 (F13256
= 2.88; P < 0.01) as indicated by the proce-
dure suggested by Goldberger.45
The relatively small contribution of the
set of caretaker variables to the explained
variance of Expected Med Use does not
argue for including them in the CHBM if the
purpose is only to predict children's expec-
tation of medicine use. The CHBM without
the caretaker variables is sufficient. The
caretaker variables remain of great interest,
however, to help explain the origin of the
73
 TABLE1. Intercorrelation Matrix of Variables in Hypothesized Children's Health

Variable
------- C1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Grade C1
SES C2 02
Sex C3 -01 -06
Health Locus of Control C4 21 49 -04
Self-Esteem C5 13 16 -08 29
Risk Illness C6 15 26 -04 28 00
Risk Injury C7 -02 27 -18 17 01 39
Med Knowledge Cs 32 41 -01 46 25 33 17
Med Autonomy C9 25 03 07 04 -17 26 21 12
MD Visits CIo -05 05 11 01 -01 01 -01 09 10
Illness Frequency C11 -12 00 04 06 -02 02 -05 08 12 12
Illness Concern C12 -15 -40 09 -43 -10 -30 -17 -24 -17 09 -03
Perceived Vulnerability C13 08 41 01 31 02 19 14 24 21 10 29 -11
Perceived Severity C14 -25 -44 -03 -48 -17 -33 -16 -30 -03 15 05 63 -21
Perceived Med Benefit C15 -10 -16 06 -16 -12 -11 01 -09 10 01 08 40 03 45
Preceived Nonmed
Benefit C16 01 19 05 23 10 10 12 27 08 00 12 01 20 -09 30
-19 -13 -07 -25 -13 -12 10 -15 06 00 03 53 06 67 66
Expected Med Use C17
Illness Concern for Child MCi -05 -36 -02 -25 -13 -20 -09 -22 -01 04 00 28 -12 29 03
Perceived Child's
Vulnerability MC2 -02 27 11 17 -04 12 00 20 05 16 23 -06 24 -06 01
Child's Illness Frequency MC3 -02 01 11 -08 09 02 01 03 04 06 13 18 06 08 09
Perceived Child's Need
for Care MC4 04 -10 11 -08 -01 -02 01 -06 00 08 -13 19 -09 09 -07
Expected Child's Med
Use MC5 -13 -18 07 -13 -16 -03 -01 -13 05 16 17 04 13 10 15
Mother Perceived Med
Benefit M1 03 -10 04 -05 -04 -12 00 -05 -07 -06 01 01 09 -02 04
Mother Perceived
Nonmed Benefit M2 -04 24 01 18 20 01 03 13 -13 00 -03 -01 17 -09 -20

Note: Values >12 are significant at P < 0.05; C .. .n refers to data obtained from the child that refers to the self; MC .. .. refers to data ob
child; M ... refers to data obtained from the primary caretaker that refers to the self; Medicine is abbreviated as Med, and, Mother also rep
mothers.

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Vol. 28, No. 1 CHILDREN'S HEALTH BELIEFMODEL

TABLE2. Regressions of Expected Medicine Use on Modifying and Readiness

Variables Without and With Caretaker Variables

Standardized Coefficients (Beta)

Dependent Variable Without Caretaker With Caretaker

Independent Variable Variables Variables

Expected Med Use (C17)

Grade (C1)
SES (C2) 14a 21c
Sex (C3)
Health Locus of Control (C4)
Self-Esteem (C5)
Risk Illness (C6)
Risk Injury (C7) 13b 13b
Med Knowledge (C8)
Med Autonomy (C9)
MD Visits (C1o) -10b -11b
Illness Frequency (C1l)
Illness Concern (C12) 16b 21c
Perceived Vulnerability (C13) 126 10a
Perceived Severity (C14) 52c 54'
Perceived Med Benefit (C15) 39C 36c
Perceived Nonmed Benefit (C16)
Illness Concern for Child (MC1)
Perceived Child's Vulnerability (MC2) -10a
Child's Illness Frequency (MC3)
Perceived Child's Need for Care (MC4)
Expected Child's Med Use (MC5) 13b
Mother's Perceived Med Benefit (M1)
Mother's Perceived Nonmed Benefit (M2)

R2/Adjusted R2 69/67 72/69d

Note: C ... refers to data obtained from the child that refers to the self; MC1... refers to data obtained from the
primary caretaker that refers to the child; M ... n refers to data obtained from the primary caretaker that refers to the
self; medicine is abbreviated as med, and mother also represents the 7% of primary caretakers who were not
mothers.
P < 0.05.
bp< 0.01.
p < 0.0001.
d
The increase in variance explained with the caretaker variables included is significant at P < 0.01.

children's Readiness variables, i.e., to ex-
plain the importance of mothers' health be-
liefs in the development of their children's
health beliefs and expectations.
Step 2. Path Analysis to Test Hypothe-
sized Causal Relationships in the CHBM.
For the following discussion, refer to Figure
2, which, for the sake of clarity and in order
to restrict discussion to path coefficients that
were at least +.10, depicts only those paths
that were significant at the 0.02 level. A
table specifying the hypothesized paths and
the results of all the regressions forming the
path analysis is available from the authors.
The hypothesized CHBM was tested for
Goodness of Fit against a fully recursive
(just identified or all possible paths) model
using the method described by Pedhazur.46
Chi-square was 164.1 (df 142; P = 0.12),
indicating that the hypothesized CHBM fits
the data.
The results of the first regression to pre-
dict Expected Med Use (C17) in the path
analysis indicated that the hypothesized
predictor variables explained 63% of the
adjusted variance. Perceived Severity (C14)
and Perceived Med Benefit (C15) were the
strongest predictors with Perceived Med
75

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BUSH AND IANNOTTI MEDICAL CARE

Perceived Child's 16
Need for Care (MC4) .Illness Concern (C12)

Health Locus of 20
-SControl (C,) / / 36

y (C14)

46
-18 /
26
MD P eived /ed Expected Med
%k/ 2 ~ Visits (CIo) Benefi], (C15)- 39---- Use (C17)

\ \-'\ >( Perceived Nonmed /

~\\^ , Child's
/Y \Benefit
/
(C16)
/ /
/
Expected
Med Use( ( ) 17
'

1'3
19\ ,/9 Perceived Vulnerability (C13)

erceived Child's
Vulnerability 21
(MC2)
ruc19
In s /
e19Illness ss
Frequency (C/l)

FIG.2. Path diagram for Children's Health Belief Model. For clarity of presentation and to focus on major paths,
coefficients with P > 0.02 are not illustrated. C ...n refers to data obtained from the child that refers to the self,
MC .. .n refers to data obtained from the primary caretaker that refers to the child, M .. .n refers to data obtained
from the primary caretaker that refers to the self, Medicine is abbreviated as Med, and Mother also represents the
7% of primary caretakers who were not mothers.

Benefit having an indirect effect through
Perceived Severity (C14)and Illness Concern
(C12)(Fig. 3). Although the simple correla-
tion coefficient between Illness Concern
and Expected Med Use (C17)is 0.53 (Table
1), much of this relationship is indirect or
noncausal; the standardized regression co-
efficient is only 0.11. However, Illness Con-
cern exerts a relatively large indirect effect
through Perceived Severity. Other variables
exerting significant effects on Expected Med
Use (C17) are Perceived Vulnerability (C13)
with a positive effect and Perceived Child's
Vulnerability (MC2) with a negative effect.
Significant amounts of variance were ex-
plained in each of the four significant Readi-
ness variables. The adjusted variance ex-
plained in Illness Concern (C12)was 0.38 by
seven variables that had significant direct
paths. A more external Health Locus of
Control and less willingness to Risk Illness
were associated with expressing more con-
76
cer about illness. Also, children expressing
more concern about illness were more likely
to have mothers who indicated their chil-
dren were ill more often than other children,
mothers who indicated they were more
likely to take their children to a physician,
and mothers who expressed more concern
about their children's illness.
Caretaker variables were of less value in
explaining the other Readiness variables.
Twenty-one percent of the adjusted vari-
ance in Perceived Vulnerability (C13) was
explained by three significant variables of
which none was a caretaker variable. Al-
though 52% of the adjusted variance in
Perceived Severity (C14) was explained by
six variables, only one, Illness Concern for
Child (MC1), was a caretaker variable. Per-
ceived Med Benefit (C15)is one of the most
important Readiness variables in the
CHBM, but only 14% of the adjusted vari-
ance was explained in this variable and only

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Vol. 28, No. 1 CHILDREN'S HEALTH BELIEFMODEL

r Illness Concern (C12)

/ -28 ^-28_
~'
Health Locus of 36
(C4) _
XFontrol
-24
-24 ~ Perceived 11
46 Severity (C14)
-18 26 46
SES (C2) Perceived Med Expected Med
Benefit (C15) 39 )o Use (C17)
35
26
22 Perceived Nonmed
Benefit (C16)
17

-10
Perceived Child's
Vulnerability (MC2)

FIG.3. Path Diagram for Strongest Predictors of Children's Expected Medicine Use. Predictors are variables with a
net effect of at least +0.10. C .. .n refers to data obtained from the child that refers to the self, MC .. .n refers to data
obtained from the primary caretaker that refers to the child, M ...n refers to data obtained from the primary
caretaker that refers to the self, Medicine is abbreviated as Med, and Mother also represents the 7% of primary
caretakers who were not mothers.

two variables, Health Locus of Control (C4)
and Perceived Nonmed Benefit (C16),were
significant predictors. Children with more
internal Health Locus of Control perceived
themselves to be ill more often than other
children, to be less likely to see a physician
for the common health problems, and to re-
ceive less benefit from treating the common
health problems with medicines. Children
who perceived the most benefit from medi-
cines perceived they were more likely to see
a physician for the common health prob-
lems and to receive benefit from nonmedi-
cine treatments such as food, drink, or rest.
Perceived Nonmed Benefit was itself pre-
dicted by Med Knowledge (C8), suggesting
that children who know the most about
medicines have the greatest faith in non-
medicine treatments.
Most Important Paths to Expected Med Use
The most important pathways to Ex-
pected Med Use in the CHBM, all with a net
effect of least +0.10, are shown in Figure 3.
Perceived Severity (probability of seeing a
physician for common health problems) ap-
pears to be the most important variable for
both its strong positive direct effect and
contribution in indirect pathways, but Per-
ceived Med Benefit is also important. Per-
ceived Med Benefit is involved in many in-
direct paths and has a strong positive direct
effect.
Health Locus of Control exerted direct ef-
fects on all four of the significant Readiness
variables and was involved in six indirect
paths. The path coefficients indicate that
children who were most internal on Health
Locus of Control most expected to experi-
ence common health problems but were less
concerned, perceived less severity, and per-
ceived medicines to be less beneficial. These
children tended to be higher SES, to be
older, to have higher self-esteem, and to
have more knowledge about medicines.
SES had positive and negative indirect
effects, mostly through Health Locus of
Control. SES (C2) exerted an indirect effect
on Expected Med Use (C17) along seven
paths, six of which were via Health Locus of
Control, that, when multiplied along the
paths and summed, resulted in a net indirect
77

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BUSH AND IANNOTTI
effect of only -0.12. The path through
Health Locus of Control (C4) accounted for
most of the net negative indirect effect of
SES on Expected Med Use. High SES chil-
dren perceived more vulnerability to health
problems that in turn was positively asso-
ciated with expecting medicines, but low
SES children scored higher on those vari-
ables that were positively correlated with
Expected Med Use such as Perceived Sever-
ity, Illness Concern, and Perceived Benefit
of Medicines.
Discussion
The utility of elements of the classic adult
HBM to explain preadolescent children's
expectations of taking medicines to treat
common health problems in the hypothe-
sized CHBM is supported. The CHBM ex-
plained 63% of the adjusted variance in
children's expectations to take medicines for
common health problems. The success of
this model can be seen when it is compared
with other path applications in health be-
havior research; a recent review indicates
that the range of variance explained varied
from 3-49%.37 Many of the hypothesized
causal relationships in the CHBM were
supported and proved a satisfactory fit to
the data.
Classic HBM predictors in the CHBM
were perceived severity of illness (a measure
of perceived threat), and perceived benefit
of taking medicines for common health
problems, both of which had strong positive
path coefficients to Expected Med Use. The
strong positive relationship between Per-
ceived Severity and Expected Med Use may
indicate a general propensity toward taking
action for common health problems. The
five health problems (colds, fever, upset
stomach, nervousness, trouble sleeping)
that were selected as the focus of the vari-
ables are more likely to be self-treated than
treated by either physician visits or pre-
scribed medicines, and consistently, the
78
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MEDICALCARE
children were much more likely to name
over-the-counter remedies than prescrip-
tion medicines as expected treatments for
these problems.35 These problems were se-
lected because, although medicines are
taken for all of them, the problems vary in
the probability that a medicine will be taken
for them. Because many parents and chil-
dren report that children have an active role
in the acquisition and use of medicines,35
the beliefs and expectations with regard to
these common problems could have a direct
association with children's current and fu-
ture medicine use.
Two variables derived from the HBM that
had significant although weaker paths than
Perceived Severity and Perceived Med Ben-
efit were 1) Illness Concern, which was pos-
itively related to Expected Med Use; and 2)
another classic perceived threat variable,
Perceived Vulnerability, which also was
positively related.
The second hypothesis was also con-
firmed. Caretaker variables contributed sig-
nificantly (but not strongly) to the variance
explained in children's expectations of tak-
ing medicines for common health problems,
and caretaker variables helped explain the
origin of the children's states of readiness
and expectations to take medicines. Al-
though the caretaker variables accounted
for significant amounts of explained vari-
ance in Expected Med Use and Illness Con-
cern, and most simple correlations between
comparable variables were significant for
mothers and their children, the involvement
of caretaker variables in indirect paths was
small. Because they both have indirect ef-
fects through several of the Readiness vari-
ables and one has a direct effect on Expected
Med Use, one can cautiously conclude that
mother's Perceived Child's Vulnerability
and Illness Concern for Child are the most
important caretaker variables in the CHBM.
These relationships suggest that medicines
for common health problems are expected
by children who most expect to have com-
mon health problems, but that mothers who
Vol. 28, No. 1
expect their children to have common
health problems are least likely to treat these
health problems with medicines. It appears
that mothers use medicines as a substitute
for physician visits for common health
problems rather than having expectations
for treatment with both physician visits and
medicines.
Even when their children are young,
mothers daily provide them with many
health messages or indicate concern for
their health.47 Mothers differ not only in the
frequency with which they present these
messages, but also in the context, e.g., they
may emphasize the child's responsibility for
health behavior or their own responsibility.
The path analysis suggests such interactions
affect the child's beliefs and attitudes re-
garding health behaviors but have little di-
rect effect on their expected health actions.
These results are consistent with previous
research47-50'59suggesting that, while paren-
tal beliefs may be internalized by their chil-
dren, the children show considerable au-
tonomy in formulating specific health ac-
tions.
Value of Conceptual Systems to the CHBM
The conceptualization of the CHBM was
developed primarily from the HBM but in-
corporates conceptual systems that may in-
crease understanding of children's health-
related beliefs and behaviors. In this study,
BIT supported the focus on Expected Med
Use as the best available predictor of behav-
ior, the focus on specific illnesses rather
than illness in general, and, consistent with
SLT, the importance of reference group
norms such as the mother's beliefs and be-
haviors.
CDT suggests that children's conceptions
of time, probability, and the future change
with age.26 As such, CDT may explain why
Perceived Vulnerability has not proved to
be a strong correlate of children's preventive
health behavior,23'51and why, in this study,
Perceived Severity and Perceived Med Ben-
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CHILDREN'S HEALTH BELIEFMODEL
efit were both much stronger predictors of
Expected Med Use than Perceived Vulnera-
bility. Perceived Vulnerability is based on
questions about the perception of the proba-
bility that the child will have the five health
problems in the coming year, estimations
that many preadolescent children may not
be cognitively prepared to make. In this
study, which used face-to-face interviews
and unlimited use of preliminary test ques-
tions, great care was taken to ensure that
each child understood what was meant by
the questions that had the format, "How
likely are you to have . .. this year?" How-
ever, the subsequent questions that inquired
into attitudes and behaviors after the child
has the health problem refer to concrete
events that most of the children have expe-
rienced, e.g., "If you had a cold, how likely
would you be to take something special for
it?" For concrete events, CDT suggests that
most preadolescent children are capable of
making inferences by drawing upon past ex-
periences: the children have or have not
taken medicines for a cold, they have or
have not seen a doctor for a cold, etc. The
illness is specific and the beliefs and behav-
iors are specifically related to the event. In
contrast, in studies of preventive health care
(e.g., Gochman20), children have been asked
not only to estimate the probability that
they will develop a health problem, e.g.,
teeth cavities, but to estimate the probability
that the problem can be prevented by a
health behavior, e.g., tooth brushing. Al-
though children certainly know whether
they brush their teeth, there are many rea-
sons why they may do so other than to pre-
vent cavities. Thus, the relationship be-
tween behavior and perception of threat is
likely to be more difficult for preadolescent
children to make for preventive behavior
than for illness behavior such as medicine
use. This difficulty may account for the
weak relationships usually found between
children's perceptions of vulnerability
and health behavior in past applications of
the HBM.
79
BUSH AND IANNOTTI
SLT, more than BIT or CDT, guided the
addition of Cognitive/Affective and care-
taker variables to a classic HBM to form the
CHBM. SLT emphasizes the influence of the
child's environment. Central to SLT is oper-
ant conditioning, the notion that behaviors
are gradually acquired and shaped as the
result of the positive and negative conse-
quences of those behaviors. Thus, the envi-
ronment in which the behavior occurs is
important as the source of cues, rewards,
punishments, and observational learning,
especially from the child's primary care-
taker. Observational learning, the direct ob-
servation of the behaviors and conse-
quences of behaviors of others in the child's
environment, may be the strongest influ-
ence on the child's behaviors and behav-
ioral expectations. Recent representations of
SLT recognize that the child is capable of
imagining or anticipating the attitudes of
significant others such as parents or peers,
and of placing a value on behavior or its
consequences. As discussed by Parcel and
Baranowski,52 SLT expanded operant con-
ditioning to include the interaction between
cognitive representations of the environ-
ment and the actual environment as an in-
fluence on behavioral factors. In SLT, envi-
ronment shapes the child, but Cognitive/
Affective elements or internal readiness
states such as locus of control play a modi-
fying role. In adult representations of the
HBM, it has not been thought necessary or
practical to seek out the origins of beliefs or
readiness states. For children, the possibility
of intervention exists, and it is important to
understand how they learn and develop
their health-related beliefs.
In this study, consistent with SLT, both
the mother's beliefs and the child's internal
states (health locus of control and risking
illness) were related to readiness to take
medicines. Previously, Gochman19 found
that health locus of control was positively
(more internally) related to perceived vul-
nerability in children for whom health was
salient. Although children with more inter-
80
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MEDICALCARE
nal health locus of control perceived they
were vulnerable to the common health
problems used as the focus in this study,
they also were less concerned about the
health problems when they occurred, and
they perceived the problems to be less se-
vere, i.e., they were less likely to say they
would see a doctor for the health problems.
Health Locus of Control itself is strongly in-
fluenced by SES and by development, with
higher SES and older children scoring more
internally.
SES in the CHBM
Historically, SES has had a prominent
place in both etiologic and intervention re-
search. Its importance does not lie in finding
intercorrelations among the indicators of
SES, e.g., family income, mother's years of
education, and living with two parents, but
in those variables that help explain what it is
about SES that leads to differences in
health-related behavior. In the CHBM, SES
was hypothesized to have no direct effect
on health behavior or behavioral expecta-
tions, but only indirect effects via its rela-
tionships with attitudes and health beliefs.
SES had significant indirect effects along
many paths. This study suggests that health
locus of control may be one of those ex-
plaining or integrating variables by virtue of
its relationships with SES, perceived vulner-
ability, illness concern, perceived benefit of
medicines, and perceived severity of illness.
Although lower SES children perceived
themselves and were perceived by their
mothers to be relatively sicker, higher SES
children perceived themselves and were
perceived by their mothers to be signifi-
cantly more vulnerable, i.e., higher SES
children were more likely to have health
problems in the coming year than lower SES
children. However, higher SES respondents
were significantly less threatened by this
expectation. Higher SES mothers and chil-
dren said they would be significantly less
worried if the children had these problems,
Vol. 28, No. 1
and they perceived the problems would be
less severe if the children had them. Health
locus of control was positively (more inter-
nally) related to SES and negatively to per-
ceived severity and illness concern. These
relationships suggest that feelings of control
facilitate high SES children's willingness to
take risks and to expect to have common
health problems. Health problems may not
be threatening to high SES children or their
mothers because they feel more confident
about the outcomes and their abilities to
deal with adverse outcomes should they
occur.
Implications
The results of this study suggest that the
CHBM has utility for predicting children's
expectations of treatment for common
health problems. There is recent evidence
that the readiness and cognitive/affective
elements of the CHBM are relatively stable
during childhood.43 This suggests the need
for early identification and longitudinal in-
vestigation of the determinants of changes
in these factors. Also, further studies are
needed to determine whether the model is
applicable to other expected illness behav-
iors of children, whether the model general-
izes to injury or other health problems,
whether Expected Med Use predicts actual
use in childhood or in later years, whether
caretaker influences are more strongly re-
lated to actual behavior than to behavioral
intentions, whether other environmental in-
fluences such as peers' beliefs and behaviors
affect children's expected illness behaviors,
and whether other variables or their repre-
sentations have utility in the CHBM. Factors
that are known to influence compliance,
real or perceived side effects, and unpleas-
antness of medicine taste or formulation54
also may influence children's Expected Med
Use. One of these, children's experience of
bad tasting medicines and pain of inocula-
tions, was previously explored and no rela-
tionship to children's Expected Med Use or
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CHILDREN'S HEALTH BELIEFMODEL
to readiness to take medicines was found.36
Also, other measures of health knowledge,
self-esteem, or children's developmental
level may be more successful than the ones
used here.53 BIT supports the notion of un-
derstanding expectations as the path to un-
derstanding behaviors, relationships that
are borne out in abusable substance re-
search.55'56However, a prospective study is
needed to test this theory in the CHBM. Re-
liable methods are needed to measure the
actual medicines taken by children in re-
sponse to their common health problems so
that the CHBM can be evaluated relative to
its utility for predicting and improving chil-
dren's medicine use.
Acknowledgments
The authors gratefully acknowledge the helpful
comments of Drs. Guy Parcel, Gail Cafferata, and Jer-
emy Finn on an earlier draft, and the assistance of
Frances R. Davidson, PHD, and Susan Schneider,
MPH, with data collection.
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BUSH AND IANNOTTI MEDICALCARE

Appendix. Indices and Operational Definitions for Analysis.

Because information was obtained from both the child and the child's
primary caretaker, variable notation is as follows: Cl...n refers to data
obtained from the child that refers to the self; MCi...n refers to data
obtained from the primary caretaker that refers to the child; Mi...n refers
to data obtained from the primary caretaker that refers to the self; medicine
is abbreviated as Med, and Mother also represents the 7% of primary
caretakers who were not mothers.
(C1) Grade: 3-7.
(C2) SES: Weighted composite factor created from years of education of
the child's primary caretaker (0.30), average family income in school
census tract (0.38), race (0.28), and parental status (0.27); eigenvalue 2.6.
(C3) Sex: male 0, female 1.
(C4) Health Locus of Control: 10-item Y/N index adapted from Parcel
and Meyer57 (range, 3-10 represents external to internal control; mean,
7.68 ? 1.96 SD; Kuder-Richardson-20 0.69).
(C5) Self-Esteem: 10-item Rosenberg Self-Esteem Scale58 each item
scaled 1 (Strongly Disagree) to 6 (Strongly Agree) (range, 20-60 low to
high self-esteem; mean, 46.99 ? 7.89 SD).
(C6, C7) Health Risk Taking (C6, Risk Illness; C7, Risk Injury):Five items
adapted from Campbell and Carney59:how likely the child was to drink
out of a family member's glass, eat something that had fallen on the floor,
drink from a friend's bottle of pop or lick a friend's ice cream cone, put on
warmer clothes when it gets cold outside, and play in a way that might
result in injury. Also, the child was shown a picture of a wall of increasing
height with a stick figure on it representing the child and asked to indicate
from which of seven possible locations he or she would jump if he or she
were the figure on the wall. The wall varied in height from ground level to
the same height as the stick figure. Factor analyses indicated that two
factors were present, one consisting of the first five questions was labelled
Risk Illness, and the other Risk Injury. Higher scores indicate greater will-
ingness to take risks. Risk Illness items standardized prior to summing
(Risk Illness range -3.29 to 10.76, ? 2.85 SD; Kuder-Richardson-20
= 0.61; Risk Injury range, 0-7; mean, 3.42 + 2.38 SD).
(C8) Med Knowledge: 10 items in the following areas: the relationship of
medicine efficacy to dose size, taste, place purchased, recommendation of
physician, and prescription versus over-the-counter status; definition of
prescription; and the ability of medicines to come in different colors and to
both help and harm (range, 0-10; mean, 4.76 + 2.17 SD; Kuder-Richard-
son-20 = 0.75).35
(C9) Med Autonomy: 12-item scale developed to measure children's
perceptions of independence in medicine use35'59(range, 1-12; mean, 4.64
+ 2.59 SD; Kuder-Richardson-20 = 0.73).
(Clo) MD Visits: Estimate of number of times he/she visited a physician
in the previous year (range, 0-30; mean, 3.38 + 3.85 SD).

84

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Vol. 28, No. 1 CHILDREN'SHEALTHBELIEFMODEL

(C11)Illness Frequency: Perceived illness frequency compared with other

boys/girls the child's age (less often = 1, about the same = 2, more often
= 3; mean, 1.71 + 0.72 SD).
(C12) Illness Concern: Sum of responses to 5 questions about how wor-
ried the child would be if he/she had a cold, fever, upset stomach, ner-
vousness, or trouble sleeping (range, 5-30; mean, 15.04 ? 6.71 SD, Cron-
bach's Alpha = 0.80).
(C13) Perceived Vulnerability: summed responses to 5 questions mea-
sured on the 6-point scale, "How likely are you to have (a cold, fever, upset
stomach, nervousness, trouble sleeping) this year?" (range, 5-30; mean,
18.04 ? 6.30 SD; Cronbach's Alpha = 0.64).
(C14) Perceived Severity: the sum of the child's responses to 5 questions
measured on the 6-point scale, "If you had (cold, fever, upset stomach,
nervousness, trouble sleeping), how likely would you be to see a doctor?"
(range, 5-30; mean, 14.43 + 6.73 SD; Cronbach's Alpha = 0.83).
(C15) Perceived Med Benefit: represented by the sum of the child's re-
sponses to five questions measured on the 6-point scale, "If you had (a
cold, fever, upset stomach, nervousness, trouble sleeping) and took medi-
cine for it, how likely is it to help you feel better?" Scored zero for children
who said they would never take a medicine for the condition (range, 0-30;
mean, 13.82 + 6.58 SD, Cronbach's Alpha = 0.62).
(Ci6) Perceived Nonmed Benefit: as in the preceding variable, but asked
relative to taking "something other than medicine" (range, 0-30; mean,
10.61 + 7.58 SD; Cronbach's Alpha = 0.63).
(C17) Expected Med Use: represented by the sum of the child's responses
to five questions, "If you had (a cold, fever, upset stomach, nervousness,
trouble sleeping), how likely are you to take something special for it?"
(range, 5-30; mean, 14.35 ? 5.46 SD; Cronbach's Alpha = 0.67). Each of
the five questions was immediately followed by "What would you take?"
and in some cases, nonmedicine treatments were mentioned. However, the
correlation between a scale that was restricted to medicine-only responses
was 0.98 with the Expected Med Use index described above.
(MCi) Illness Concern for Child: same as C12 above but referring to child
(range, 5-30; mean, 15.71 + 6.07 SD; Cronbach's Alpha = 0.80).
(MC2) Perceived Child's Vulnerability: same as C13above but referring
to child (range, 5-28; mean, 14.48 ? 4.98; Cronbach's Alpha = 0.68).
(MC3) Child's Illness Frequency: response to "compared to other (boys/
girls) your child's age, would you say your child is sick 1 = less often, 2
= about the same, or 3 = more often? (range, 1-3; mean, 1.48 ? 0.61 SD).
(MC4) Perceived Child's Need for Care: represented by the amount of
agreement with two statements as measured on the 6-point scale, "If I wait
long enough, my child will get over any illness," and (reversed prior to
summing) "When my child is sick, I want her/him to go to the doctor right
away rather than wait a day or two." (range, 2-12; mean, 6.10 ? 2.63 SD).
(MCs) Mother's Expected Child's Med Use: same as C17but with mother
responding relative to her child (range, 5-30; mean, 13.93 ? 4.42 SD;
Cronbach's Alpha = 0.82).

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BUSH AND IANNOTTI MEDICAL
CARE

(M1) Mother's Perceived Med Benefit: same as C15 but with mother
responding relative to herself (range, 0-30; mean, 13.71 + 5.97; Cron-
bach's Alpha = 0.66).
(M2) Mother's Perceived Nonmed Benefit: same as C16but with mother
responding relative to herself (range, 0-30; mean, 14.01 ? 7.64; Cron-
bach's Alpha = 0.79).

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