Children's Views of Health: A Developmental Study

JANET NIELSON NATAPOFF, RN, EDD

Abstract: Two hundred and sixty-four first, fourth, and seventh grade children were asked to define health, state what it felt like to be healthy and not healthy, and to give criteria they would use to judge another person's health status. A chi square analysis was done to compare differences for age, sex, intelligence, and socioeconomic status. Results indicated that children saw health as a positive attribute which enabled them to participate in desired activities, that a person was healthy if he could do what he wanted to do, and that health and illness were two different

concepts rather than on a continuum as is often cited in the literature. Mental health was not considered as part of being healthy except by a few of the oldest children. There were both qualitative and quantitative changes with age which were consistent with theories of concept development. It is recommended that future studies be conducted with both adults and health workers. (There is some evidence that consumers and health professionals do not have the same ideas about health.) (Am. J. Public Health 68:995-1000, 1978)

Public health workers are concerned with health yet much of their literature is concerned with illness. The concept of health has not been fully explored and, in fact, it is not clear what health means to consumers or to health professionals. This study explored how one group of consumers-children--defined the word health. It attempted to determine ideas which contributed to a concept of health and examined how these change as children develop. Children are a part of their culture and reflect its values and concepts. In cultures throughout the world an individual or a collective of individuals within each culture determines when an individual is healthy. In our culture, health professionals-writing as spokespersons for society-have attempted to define health in a variety of ways. These definitions can be classified along a continuum ranging from negative (the absence of symptoms) to positive (optimal functioning) to utopian (complete physical and social wellbeing). 1- 7 Despite the variety of these statements, there is almost universal agreement that adequate definitions of health do not exist. The literature reveals three major reasons for this difficulty. One reason advanced by some is that the attributes of health and wellness have not been determined, thus making definitions of these attributes impossible.2 4 8 A second reason is that health is a culturally determined concept. As such, a universal definition cannot be obtained beAddress reprint requests to Dr. Janet N. Natapoff, Associate Professor, City College of the City University of New York, School of Nursing, New York, NY 10031. This paper, submitted to the Journal July 25, 1977, was revised and accepted for publication April 26, 1978.
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cause cultures vary and therefore the concept varies from society to society.9 A third reason is that health is a value or concept derived partly from the individual's cognitions and ideas.10' 11 Such a multidimensional concept is difficult to measure. If one accepts the idea that society determines when an individual is healthy, however, then it should be possible to explore how members of a given society view health.

Method
The study was conducted in three elementary and one junior high school in a medium-sized town in central New Jersey. Permission letters were sent to parents of first, fourth, and seventh grade children enrolled in the lcoal school system.* All children whose parents granted consent were interviewed. The final sample consisted of 91 first graders, 89 fourth graders, and 84 seventh graders from a suburban community (See Table 1). They represented blue collar, white collar, and professional families (as defined by the United States Department of Labor) although the population was skewed toward the blue collar occupations. Many of the families work in small, local manufacturing plants; a few commute to nearby cities. There were no formal health education classes in any of the elementary schools, although teachers did include some health instruction with content varying from class to class. The seventh graders had attend-

*Forty-nine per cent of the parents signed consent forms.

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CHILDREN'S VIEWS OF HEALTH

TABLE 1-Sex, Age, Intelligence Quotient (10), and Socioeconomic Status (SES) by Grade in School for Sample Population
Characteristic
First Grade Fourth Grade Seventh Grade

Number Female Male Mean Age S.D. Range

91 34 57 6.58 years 5.9 months 5.50 years to 7.58 years

Mean IQ* S.D. Range Socioeconomic Status % Professional % White Collar % Blue Collar % Unknown
Information not available for first grade

89 42 47 9.58 years 5.5 months 8.33 years to 10.33 years 112 13.8 83-148 10 26 54 10

84 38 46 12.66 years 5.7 months 11.42 years to 13.66 years 107 12.1 83-120 8 8 69 15

11 13 62 14

ed a six-week health course which focused on drugs and smoking just prior to the study. After extensive piloting, an interview format was developed. Three main questions and several subquestions were used. These included: 1) What does the world health mean?; 2) How do you feel when you are healthy?; How can you tell when a family member is healthy?; and 3) Can you be part healthy and part not healthy at the same time? Probes seeking more information, explanation, or examples were used as necessary. Because each child presented a unique situation, the probes varied slightly but each question was included in the same order for each child. The interview averaged 20-30 minutes. During the pilot phase, 29 categories based on the three major question areas were developed from a content analysis.* Independent coders then scored each response with 87 per cent agreement. Responses were scored only once and all responses were used. After final categories were established, ten children from each class were interviewed; a follow-up interview three weeks later was conducted by a second person. Coded responses between the first and second interview showed 94 per cent agreement. The data were analyzed by determining the total number of statements corresponding to each category. Percentages were used to rank these responses, first for the total sample then by age groups. Values of chi square were calculated from the data to determine the statistical significance using a cross tabulation procedure to compare age, sex, intelligence, and socioeconomic status. A probability level of < 0.05 was considered significant. Because some categories were mentioned in response to several questions, the data analysis
*Seven categories with low frequency responses were not included in this report.
996

was further refined by combining these categories. The combined results were treated by further chi square analysis. Finally, the-results were reviewed for indication of developmental progression or change.

Results
The first section of this report will present the subject's ideas about health for all classes as a group; the second section will look at age differences between classes.
Ideas Contributing to a Concept of Health Table 2 shows answers to the first two questions: "What does the word health mean?" and "What does it feel like to be healthy?" The third column represents combined cate-

TABLE 2-Percentage of Total Sample Stating Category to "What Does the Word Health Mean?" and "How Do You Feel When You Are Healthy?"
Category
% Question 1 (N = 264)
-

% Question 2 (N = 264)

% Combined*

FeelGood Do Wanted Things Not Sick Food Exercise Clean Happy Strong Body Good Condition Good Checkups

18 31 42 29 26
-

67 53 29 6 5 21
24

13 18 7

15
-

67 61 48 44 31 27 24 23
-

*Each child given credit for stating category once

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NATAPOFF
TABLE 3-Percentage of Total Sample Stating Category to "How Do You Feel When You Are Not Healthy?"
Category

Percentage (N = 264)

Sick
Not Able to Do Moods Weak Not Good No Food Dirty

49 40 30 14 13 4 4

gories; i.e. a child was given credit for an item if he mentioned it for either question or both. For example, being able to "do wanted things" like playing, going places, and participating in other desirable activities were mentioned by 18 per cent of the subjects in response to the first question while 53 per cent made reference to this category in response to the second question. Sixty-seven per cent of the 264 children included being able to do wanted things either in connection with the word health itself, feeling healthy, or both. As the table illustrates, feeling good, being able to do wanted things, not being sick, and eating food (being able to eat regular foods) were the most frequently mentioned categories in response to the first two questions for the sample as a whole. Cleanliness, or being clean (< .025), and having a strong body (< .010) were the only two categories showing statistical significance for sex as determined by chi square analysis. More girls mentioned the category clean than boys while the reverse was true for "strong body." More than one-quarter of the children who mentioned being clean saw cleanliness as the whole aspect of health and the only feeling associated with being healthy; when asked what it felt like to be not healthy, they responded with "dirty." "Feeling good' was the single category in which differences for socioeconomic status became statistically significant with children from working class families choosing this category more frequently than did other groups. Since a concept is understood only when instances and non-instances can be stated, the children were asked what it felt like to be not healthy. Table 3 presents the responses to this question. "Being sick," described by various symptoms or specific diseases like chicken pox, was the most frequent answer. Not being able to do the things they wanted to do was frequently seen as an aspect of not being healthy. The subjects also described various negative feeling states, defined here as "moods," including feeling sad, happy, horrible, awful, and "yukky". The children were also asked how they could tell if a family member was healthy or not healthy. They listed many clues they would use to determine a person's health. The majority (84 percent) relied on perceptual data defined as information that could be detected using any of the five senses, such as: "I can see him working," "he smiles a lot," "she can do housework," and "she has pink cheeks." Others (28 per cent) gave evidence of analytical thinking beyond the
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mere observation of overt behavior (non-perceptual), such as: "It depends upon the person." or "I can tell without having to think about it." During the past part of the interview, all the children were asked if they thought it was possible to be "part healthy and part not healthy" at the same time. More than one-half of the sample (61 per cent) felt that it was possible, giving many illustrations. "It's like when you have a cut and it doesn't hurt or when you have something but can still play," said one six-year-old. Finally, evidence that mental health was considered as part of general health was determined by reviewing each interview in its totality. The child was given credit for including this if he gave evidence that he considered thinking, emotions, or feelings as influencing one's physical state or if general mental well-being was considered healthy. Only 16 per cent of the total group mentioned any ideas that could be classified as including mental health in their views of health.
The Influence of Age The question asked and average length of interview were the same for each age group; the probes used were similar. There were, however, differences in both quantity and quality between each age/class group. For example, there was an increase in the total number of categories mentioned with advancing age as well as changes in frequency for each category. An average of five categories were included by the first graders, eight by the fourth graders, and nine by the seventh graders. The comments became more complex, thoughtful, and increasingly longer with age. The first graders tended to give long lists of items with little hesitation. The seventh graders expressed doubts, thought before they spoke, or questioned whether they could, indeed, define health. Many of them said, "it is a hard word." Answers to the first and second questions were similar and the same significant differences emerged when these categories were combined or when treated alone. Table 4 outlines data for the first two questions-the definitions of health and how it feels to be healthy-in rank order using the collapsed (combined first and second questions) categories. Six categories showed signficant differences between ages using a confidence level of < 0.05. Three became significant for age when the children were asked what it felt like to be not healthy, as shown in Table 5. Four additional categories were highly significant for age (p = 0.001.). Answers to "How can you tell when a family member is healthy?" showed a strong developmental trend. Only 20 per cent of the first graders used analytical thinking beyond reliance on perceptual data to determine someone's health, while 50 per cent of the twelve-year-olds did so. A concomitant reliance on outward, observed behavior decreased with age. When the children were asked whether it was possible to be part healthy and part not healthy at the same time, only 25 per cent of the six-yearolds answered "yes," as compared to the same response from 74 per cent of the nine-year-olds and 84 per cent of the twelve-year-olds. This question, when posed to the first graders, often produced a puzzled look followed by a definite "no, it is not possible." The fourth graders were less
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CHILDREN'S VIEWS OF HEALTH

TABLE 4-Chi Square Analysis of Age Differences by Category with Two Degrees of Freedom-Health and Healthy
% of Each Age

Category
Feel Good Do Wanted Things Not Sick Food Exercise Clean Happy Strong Body

Total % (N = 264)

6 yrs. (N = 91)

9 yrs. (N = 89)

12 yrs.
(N
=

84)

Good Condition Check-ups

67 61 48 44 31 27 24 23 18 7

55 51 22 53 24 25 26 29 2 5

72 54 57 51 36 28 33 24 24 8

75 80 64 29 33 27 13 17 30 7

0.01 0.0001 0.0001 0.0004 0.07 0.90 0.01 0.17 0.0001 0.63

emphatic, many asking for examples before answering, while the seventh graders were again more definite, this time answering "yes" unhesitantly. Mental health was considered a part of health by 32 per cent of the seventh graders but by only 2 per cent of the first and 15 per cent of the fourth graders. These four categories were all abstract ideas showing a decreasing use of concrete thinking with a growing ability to consider ideas like mental health, inner feelings and ability to consider parts and wholes simultaneously. It was impossible to analyze statistically many of the ideas expressed by the children because of the abstract, philosophical nature of their comments but a general feeling did begin to emerge. It became clear, as alluded to by one-third of the nine-year-olds and one-half of the twelve-year-olds, that being healthy and being sick were two different things. As one twelve-year-old said, "I can't exactly say, but I think health is like having a good body and being active. If you have a cold, you get over it quickly. Sick is like having something a long time. You can't do anything." Another said, 'sick is like having a virus ... unhealthy is no exercise, malnutrition, being fat...." There seemed to be a time factor in many of these answers, thus health is perceived as long-term and sickness as short-term.

Intelligence, a variable which might affect children's ideas, did not influence the results. Intelligence quotients, obtained from school records, were available for the fourth and seventh graders. Socioeconomic status, with the exception of cleanliness and strength, also did not influence the results. Age proved to be the one significant variable.

Discussion
The literature suggests that current definitions of health range from a negative view as an absence of symptoms to the positive view of complete mental and physical well-being. Only a few investigators have actually asked respondents to define health, however, and most of these studies involved adults from a variety of socioeconomic backgrounds. Baumann found that clinic patients defined health as being able to perform necessary daily activities.'2 More recent studies involving health and the healthy state support these findings.13' 14 Others have looked at socioeconomic status as a determinant of how one perceives health. Pratt, for example, found that low income women saw health as a quality which enabled them to meet minimum daily requirements.'5 The

TABLE 5-Analysis of Age Differences by Category With Two Degrees of Freedom-Not Healthy
% of Each Age

Category

Total % (N = 264)

6 yrs. (N = 91)

9 yrs. (N = 89)

12 yrs. (N = 84)

Sick Not Able To Do Moods Weak Not Good Dirty No Food

49 40 23 14 13 4 4

36 25 12 14 14 3 2

60 42 17 18 17 7 6

52 55 41 11 8 1 4

0.005 0.0003 0.0002 0.38 0.26 0.16 0.50

998

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NATAPOFF

salience of health, perceptions of vulnerability to health problems, and locus of control were related elements in a study by Gochman, one of the few investigators to work directly with children. But, he did not determine how children define the word health nor what images the concept elicited.16, 17 One large study, based on a sample of 5,000 children, did explore development of a concept of health. Children from kindergarten through grade 12 responded to the question: "What is good health?" These results were reported in a book designed for the lay public and, unfortunately, details of the study methodology and the original data are missing. The remaining information suggests that ideas about health show a clear developmental trend from specific, concrete concern for health practices to future-oriented interests in optimum development and societal problems.18 Various methods were used to obtain information, however, with no attempt to hold methodology constant for each grade. Finally, a few studies have explored indirectly the health variable with children.'9-21 Several of these show clear-cut age differences in the ideas about healing, bodies, and illness. Others, investigating similar ideas about sickness and health, found that while beliefs of parents and children were similar, the specific parent-child set was not. These results suggest that ideas about health are determined by the general society rather than specifically passed from parent to child. The children who participated in the present study appear to have defined health in a positive way. They saw feeling good and being able to participate in desired activities as the most important components of health. It enabled them to do the things they really wanted to do, such as playing with friends, running, playing active sports, and participating in other activities. They did not mention necessary activities like school work or household duties as Baumann and others reported in their work with adults.12' 13, 15 It appears that children see health as a state enabling them to perform desired activities while adults view health as enabling them to perform minimal daily activities. When it came to determining the health of someone else, the children listed many observations that served as clues. Someone would be considered healthy if they had rosy cheeks, a good body, clear eyes, and nice skin. In addition, they had to be active, happy, and perform daily chores as well as pleasurable activities. Here, too, a positive view of health that allows for optimal functioning was seen more often than reported in the literature. The data indicated differences between age groups in both content and philosophy. The first graders (six years old) saw health as a series of specific health practices (e.g., eating meats and vegetables, getting exercise and keeping clean). It enabled them to play with friends, to go outside, and to be with the family. It was not possible to be part healthy and part not healthy at the same time. Someone was either healthy or not healthy. Abstract qualities were not conceptualized by these young children either in reference to themselves or to others. The idea of mental health, for instance, was simply not considered as an aspect of health. The fourth graders (nine years) were less concerned
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with specific health practices and more concerned with total body states such as being in good shape and feeling good. At the same time they felt it was possible to be part healthy and part not healthy, showing an ability to shift from the whole to the part. They, like the six-year-olds, used perceptual clues to determine another person's health status. They were concemed with the performance of daily activities which required physical fitness. They showed little future orientation and did not see mental health as a part of general physical well-being. The twelve-year-olds, in increasing numbers, also saw health as feeling good and being able to participate in desired activities while not being sick, but, they showed evidence of abstract thinking not present in the younger groups. Mental health, an abstract idea, became a concern of 32 per cent of these children. Perceptual data was not sufficient enough to judge someone else's health; analysis of clues was needed. For many of them, health was perceived as long-term-involving the body, mind, and, in some cases, the environment-while sickness was a transient, superimposed state. The results of this study indicate that children view health more positively than most definitions proposed by health professionals. Rather than seeing health as the absence of symptoms or the ability to perform minimally, they see health as feeling good and being able to participate in desired activities. Children as young as six years have ideas about health, can talk about health matters and express these ideas quite positively. Preventive health programs and health education, whether for groups or individuals, should use children's ideas as a framework. This study and others like it can help establish that framework. Ideas about health, as expressed by these children, mature with age. Abstract qualities like mental health and the ability to consider part-whole relationships enter into the concept as the child approaches adolescence. These findings demonstrate that the concept of health changes over time as do other concepts frmm the social and physical world.2529 Theories of concept development, then, have relevance for health education. It would seem that maturation has at least as much influence on childrens' ideas about health as any other variable. Finally, it is hoped that further studies will be conducted, not only with children, but also with adults and health professionals. The relevance of the findings of this study and similar studies for health education and health care need to be explored. Health programs will be successful when consumers and professionals view health in a similar way and together plan programs based on these views.

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and Illness, pp. 165-187. By E. Gartly Jaco. Glencoe, IL: The Free Press, 1958. Dunn H: High Level Wellness. Arlington, VA: Beatty, 1961. Constitution of the World Health Organization. Chronicle of the World Health Organization. I Prologue, 1947. Shontz F: The Psychological Aspects of Physical Illness and Disability. New York: Macmillan, 112-126, 1975. Wilson R: The Sociology of Health. New York: Random House, 1970. Polgar S: Health Action in Cross-Cultural Perspective. In Handbook of Medical Sociology, pp. 397419. By Howard E. Freeman, Sol Levine, and Leo G. Reeder. Englewood Cliffs, NJ: Prentice-Hall, 1963. Hepner, JD and Hepner DM: The Health Care Strategy Game: A challenge for Reorganization and Management. St. Louis: C. V. Mosby, 1973. Baumann B: Diversities in conceptions of health and physical fitness. Journal of Health and Human Behavior 2:3946, 1961. Twaddle AC: Health decisions and sick role variations: An exploration. Journal of Health and Social Behavior 10:92-100, 1969. Palmore E and Luikart C: Health and social factors related to life satisfaction. Journal of Health and Social Behavior 13:6880, 1972. Pratt L: The relationship of socioeconomic status to health. Am J Public Health 61:281-291, 1971. Gochman D: The organizing role of motivation in health beliefs and intentions. Journal of Health and Social Behavior 13:285293, 1972. Gochman D: Some correlates of children's health beliefs and

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Inventory of Programs and Expenditures of State and Territorial Health Agencies-Fiscal Year 1976
The first publication based upon the Fiscal Year 1976 data collection of the National Public Health Program Reporting System (NPHPRS) of the Association of State and Territorial Health Officials (ASTHO) is now available. This report, called "Inventory of Programs and Expenditures of State and Territorial Health Agencies-Fiscal Year 1976," includes complete listings of the programs and program expenditures of each state health agency and provides a national summary of overall expenditures and major sources of funds for public health programs. The NPHPRS provides comprehensive and uniform data, on a national basis, concerning public health programs of State and Territorial Health Agencies. Central project costs have been supported by a contract with the Public Health Service, Department of Health, Education, and Welfare, while State and Territorial Health Agencies have contributed staff liaison, reporting services, and consultation on a voluntary, cooperative basis. Copies of the Inventory and the Comprehensive Report may be obtained by writing to: Ronald E. Whorton, Project Director ASTHO/NPHPRS 1555 Connecticut Avenue, N.W. Washington, DC 20036 A second report is in preparation covering services, expenditures, funding sources, programs, and responsibilities of state and territorial health agencies.

1000

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