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DEVELOPMENT OF AN INSTRUMENT TO ASSESS MATERNAL CHILDHOOD INJURY HEALTH BELIEFS AND SOCIAL INFLUENCE
KATHLEEN M. RUSSELL Ball State University, School of Nursing
Unintentional home related injuries are a major cause of morbidity and mortality among children under the age of five years. Injury incidence in homes for these children continues at high levels despite injury prevention education programs for their caregivers. This article reports the development of an instrument that assesses injury prevention health beliefs and social influence perceptions in mothers of young children. Based on the Health Belief Model, the tool is composed of six scales that measure injury susceptibility and seriousness, benefits and barriers of injury prevention, self efficacy of injury prevention performance, and social influence. Reliability measurements showed that all scales produced high Cronbach alphas (.83 to .98) and significant test-retest correlations (.30 to .62, p 5 .05). Criterion related validity was established ( - .36 to - .59, p 5 .05) for all scales except the seriousness scale. This instrument has utility for nursing investigations on the predictors of injury prevention behavior and for development of nursing interventions to prevent injuries in young children.
Each year thousands of children are involved in injuries that could have been prevented. Annual national estimates show that as a result of injury mishaps approximately 600,OOO children are hospitalized, almost 16 million are treated in emergency rooms, and more than 30,000 acquire permanent disability (Centers for Disease Control, 1990; Rodriquez, 1990). Furthermore, injuries are the leading contributor to deaths among children (Committee on Trauma Research, 1985; United States Department of Health and Human Services, 1986, 1990a, 1990b). An- nually, approximately 10,OOO deaths of children under age 15 are caused by injuries (Baker & Waller, 1989). Injury prevention in young children includes developing interventions that address factors that influence in- jury prevention actions in the caregivers of young children. The purpose of this article is to describe the development of an instrument that as-
The author thanks Dr. Victoria Champion at Indiana University School of Nursing for her review of this article. This project is part of a larger childhood injury prevention study, funded by the National Institutes of Health National Center for Nursing Research Predoctoral Fellowship NR06485.
Issues in Comprehensive Pediatric Nursing, 14:163-177, 1991 Copyright 0 1991 by Hemisphere Publishing Corporation 163
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sesses mothers’ beliefs about injury prevention in their young children and their perceptions of social pressures that influence whether or not they should engage in injury prevention behavior.
BACKGROUND OF INJURY PROBLEM IN YOUNG CHILDREN
Young children are especially vulnerable to unintentional injuries that occur in their residences. The home related injury fatality rate among children ages one to four is 8.7 deaths per 100,OOO population (Pollock, McGee, & Rodriquez, 1988). Because of the developmental stages and dependency needs of young children, active participation in preventing early childhood injuries is required on the part of their caregivers (Agran, 1987; Halperin, Bass, & Mehta, 1983). Environmental modifi- cations such as changes in product design, for example, fire retardant clothing, and mandated use of safety devices, for example, installation of smoke detectors in residences, have resulted in significant reductions in home related injuries for children (Barlow, Niemirska, Gandhi, & Leblanc, 1983; Gorman, Charney, Holtzman, & Roberts, 1985; Guyer et al., 1989). Some degree of active participation by the caregiver is required in most of these passive approaches (Micik & Miclette, 1985).
Injury prevention research shows that education-based interventions to increase parental knowledge have not significantly reduced the occur- rence of injuries in children (Baldwin, Fisher, & Simon, 1987; Min- chom, Newcombe, Sibert, & Bowley, 1984; Kelly, Stein, & McCarthy, 1987). Health education directed toward behavioral change with little or no attention to factors that influence behavior has minimal success in injury prevention (Pless, 1987). Identifying behavioral and psychosocial factors that influence whether or not caregivers engage in actions to prevent injuries is a critical component in early childhood injury preven- tion (Committee on Trauma Research, 1985; Garbarino, 1988; Pless, 1987; Scheidt, 1988).
PURPOSE OF THE STUDY
The purpose of the study was to develop an instrument that measures maternal perceptions of injury susceptibility and seriousness in their children, benefits and barriers of engaging in injury prevention mea- sures, self efficacy or ability to perform injury prevention measures, and social influence to perform injury prevention measures for their chil- dren. The injuries are unintentional injuries that occur most frequently in the home to toddlers and preschool-aged children. The instrument was designed to be used for further exploration of predictors of injury
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Childhood Injury Instrument Development I65
prevention behaviors that are amenable to nursing practice interven- tions.
THEORY TO GUIDE INSTRUMENT DEVELOPMENT
Instrument development was based on the Health Belief Model (Becker, 1974; Becker & Maiman, 1975; Rosenstock, 1966, 1974; Rosenstock, Strecher, & Becker, 1988) and the subjective norm construct from the Theory of Reasoned Action (Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975). Numerous health behavioral studies have found con- structs of both theories to be significant predictors of health behavior including behaviors for preventive health (Janz & Becker, 1984; Lier- man, Young, Kasprzyk, & Benoliel, 1990; O’Leary, 1985; Strecher, Devellis, Becker, & Rosenstock, 1986), maternal compliance (Becker, Maiman, Kirscht, Haefner, & Drachman, 1977; Kviz, Dawkins, & Er- vin, 1985) and parental injury prevention behaviors (Foss, 1985; Greaves, Glik, Kronenfeld, & Jackson, 1990; Peterson, Farmer, & Kashani , 1990).
According to the original Health Belief Model, the likelihood of an individual engaging in a specific health action to prevent a health prob- lem is a function of the individual’s beliefs about the susceptibility and seriousness of the health problem and the benefits and barriers of engag- ing in the health action. Susceptibility refers to the individual’s percep- tion of subjective risk of contracting the health problem. Seriousness refers to the individual’s perception about the severity that the condition may have on his or her life. Benefits are the individual’s beliefs in the positive consequences of engaging in a particular health action to reduce susceptibility to a serious health problem. Barriers are the perceived negative aspects of engaging in the health action. An individual is more likely to engage in a specific health action or behavior if the individual perceives greater susceptibility to and more seriousness of the health problem and believes more benefits than barriers exist for engaging in the health action. Health action is least likely to occur if the individual perceives little or no personal susceptibility to the health problem, be- lieves the problem not to be serious, and feels that more barriers than benefits exist in performing the health action.
A more recent construct that has been added to the Health Belief Model is self efficacy (Rosenstock, Strecher, & Becker, 1988). Self efficacy is the belief that one is capable of successfully performing the behavior needed to produce the desired outcome (Bandura, 1977). The individual is more likely to perform the health action of interest if the individual believes he or she will be successful in executing the be- havior.
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Subjective norm is the individual’s perception of social pressure that is placed on him or her to perform or not perform the behavior of interest (Ajzen & Fishbein, 1980). If the individual believes that specific persons or groups, termed referent others, think that the individual should perform the behavior and the individual is motivated to comply, then the individual’s subjective norm puts pressure on him or her to perform the behavior. If the individual believes that the referent others with whom the individual is motivated to comply do not want the behav- ior to be performed by that individual, then the behavior is not likely to be performed by the individual. The subjective norm construct is con- ceptually compatible with the Health Belief Model and is viewed as a refinement of the benefit or barrier constructs (Jam & Becker, 1984). Performance of socially approved behavior is perceived as a benefit, whereas performing socially disapproved behavior is a barrier.
METHOD
Description of Instrument
The instrument consists of six scales: susceptibility, seriousness, bene- fits, barriers, self efficacy, and social influence scales. A five-point Li- kert scale of agree/disagree was used in the construction of all scales except the social influence scale. Items are summed for each scale to produce a total scale score. A description of each scale will be pre- sented.
Susceptibility scale
The susceptibility scale, composed of 11 items, measures maternal per- ceptions of the likelihood of their child being injured by burns, falls, poisoning, suffocation, laceration, and firearms. The scale was adapted from a susceptibility subscale of the Injury Threat Scale developed by Glik, Kronenfeld, and Jackson (1990). The injuries were further speci- fied by etiology (bums from hot water; bums from a house fire; burns from hot food or liquids).
Seriousness scale
The seriousness scale contains the same injury items as the susceptibility scale. The scale, which consists of 11 items, measures mothers’ percep- tions of whether or not injuries from burns, falls, poisoning, suffoca- tion, laceration, and firearms would be serious in their child. This scale was adapted from Glik, Kronenfeld, and Jackson’s (1990) severity sub- scale of their Injury Threat Scale.
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Childhood Injury Instrument Development 167
Benefits scale
The benefits scale measures maternal perceptions of the positive attri- butes of performing general injury prevention measures for their chil- dren. Items for these scales were developed from adaptations of Cham- pion’s Benefits Scale (1991), responses from a convenience sample of four mothers with young children, and similar demographic characteris- tics as the study population and literature review on maternal health care behaviors for their children. The benefits scale initially consisted of 10 items that included feeling good about oneself, receiving praise from others, avoiding worry, saving money and time, and preventing suffer- ing in the child.
Barriers scale
The barriers scale measures maternal perceptions of the obstacles of engaging in measures that prevent injuries in their children. Similar to the development of the benefits scale, the barriers scale was adapted from Champion’s Barriers Scale ( 199 l ) , input from the convenience sample of four mothers, and literature review. The barriers scale was originally composed of 16 items that measured difficulty remembering to perform the injury prevention measures; lack of time and money; lack of injury prevention knowledge; lack of access to injury prevention knowledge; and deterrents in the family (too many children), the mother (fatigue), and the environment (confusion in home, cluttered home).
Self eflcacy scale
The self efficacy scale consists of 13 items that listed injury prevention measures specific for burns, falls, poisoning, suffocation, laceration, and firearms. Mothers are asked to rate their ability to perform these injury prevention measures in their child. The injury prevention mea- sures were identified from literature review and adapted from injury prevention education materials developed by Bass, Mehta, Ostrovsky, and Halperin ( 1985).
Social influence scale
The social inl-luence scale consists of two subscales: normative belief and motivation subscales. The subscales were developed according to scale construction procedures established by Ajzen and Fishbein (1980).
The normative belief subscale assesses mothers’ beliefs about specific individuals who approve or disapprove of them performing injury pre- vention behavior for their child. Seven individuals were identified by the convenience sample of four mothers and included partner/spouse/ boyfriend, close relative, close friends, nurse or doctor, social worker
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or caseworker, minister/preacher/priest , and church mother (an older woman in the church who is an informal leader and advisor). The nor- mative belief subscale was constructed with a five-point Likert scale of approve/disapprove responses.
The motivation subscale assesses the degree of motivation mothers have in complying with what the seven individuals think the subject should do about injury prevention for her child. The subscale uses Li- kert scale responses ranging from “not at all” to “very much.’’ The total scale score for the social influence scale is obtained by summing the products of corresponding items from each subscale.
Item Content Validation
Content validity for the scales was judged by a panel of six clinical and research experts with backgrounds in childhood injury prevention and health belief model research. Items were reviewed for their relevancy on a five-point Likert scale of “not at all relevant” to “extremely rele- vant.” Items were retained that reached 100% interrater agreement for items judged to be moderately to extremely relevant. Only minor changes in the wording of retained items that were recommended by the reviewers’ comments were made.
lnstmment Administration
Data were collected on 50 randomly selected mothers with children ages one through three years old residing in public housing. This population was chosen because young children from low income families have higher death rates of home related injury and higher rates of repeated injury in their residence (National Committee for Injury Prevention and Control, 1989). Public housing units were chosen for the purpose of controlling for type of dwelling and maintenance schedules. All units were structurally identical and were maintained on the same mainte- nance and smoke detector safety schedules. Mothers were female care- givers who had the primary responsibility for the care, health, and safety of the child. Informed consent was obtained from all subjects. Written permission was obtained from at least one parent of all uneman- cipated minors who were subjects for this study.
The majority of the mothers were single parents (go%), African- Americans (96 %), who were full-time homemakers and not employed outside the home (88%). Their age range was 17 to 36 years ( M = 23). Seventy-one percent of the mothers had not completed high school.
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Childhood Injury Instrument Developtnerit 169
Reliability and Validity Testing
Internal consistency with Cronbach’s coefficient alpha and test-retest were used to determine the reliability of the scales. Criterion-related validity was assessed by correlation between the scales and injury pre- vention behavior in the mothers.
Data for reliability testing were collected by administering a struc- tured interview of the scales to the mothers. The interviews were admin- istered twice in the subjects’ homes. The time interval between the two administrations was two to three weeks.
Maternal injury prevention behavior was measured for the testing of concurrent criterion-related validity. Observations of potential safety hazards in the mothers’ homes were conducted on the second visit using Greaves’s Home Safety Hazards Observation tool (1990). This scale contained 24 categories with a total of 62 items of potential home haz- ards that could not be readily changed, for example, steep stairway, or were under the control of the mother, for example, cluttered stairway. The potential hazards were those that contributed to injury in young children. Internal consistency for this tool was .79. Each category was dichotomously scored for the absence or presence of any item listed under each category. Because specificity between beliefs and behavior is required for predictive ability (Ajzen & Timko, 1986), only injury cate- gories that were potential hazards for falls, burns, suffocation, poison- ing, laceration, and firearms and under the control of the mother were correlated with the injury health beliefs and social influence scales. The higher the score the more potential hazards were found in the home. Upon completion of the observations, the investigator informed the sub- jects of the hazards and provided them with information about how to correct them.
RESULTS
Reliability measures showed that all scales produced high Cronbach’s alphas (range of .83 to .98) and significant test-retest correlations (p I .05) as indicated in Table 1.
No modifications were needed in the susceptibility, seriousness or self efficacy scales for improved reliability. One item was deleted from the benefits scale due to a high intercorrelation (.79) with another item of similar content. The deletion resulted in a nine-item benefits scale. In- tercorrelations were high for four items with four corresponding items of similar content for the barriers scale (range of .70 to .90). These items were deleted, with the revised barriers scale consisting of 12 items.
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'hble 1. Mean, Standard Deviation, and Reliabilities for Scales
Corrected item-total
Scale M SD alpha retest with scale Item Item Cronbach Test- correlation
Susceptibility 3.6 .34 .95 .47**
My child is likely to be injured by: 1. falls from stairs. 2. bums from hot water. 3. burns from a house tire. 4. bums from stove or oven. 5. burns from hot foods or liquids. 6. electric shock. 7. poisoning. 8. getting a cord or string tightened around his or her
9. smothering. 10. gashes and cuts from knives and other sharp objects. 11. gunshot wound.
neck.
Seriousness 4.1 .39 .88 .43**
(Insert injury) would be serious in my child. 1. Falls from stairs. 2. Burns from hot water. 3. Burns from a house fire. 4. Burns from stove or oven. 5. Burns from hot foods or liquids. 6. Electric shock. 7. Poisoning. 8. Getting a cord or string tightened around his or her
9. Smothering. 10. Gashes and cuts from knives and other sharp objects. 11. Gunshot wound.
neck .
Benefits 4.1 .47 .83 .32*
I . When I do things to prevent injuries to my child, I feel
2. My family will praise me if I do things to prevent injuries
3. My friends will praise me if I do things to prevent injuries
good about myself.
to my child.
to my child.
.69
.86
.86
.73
.76
.83
.88
.80
.85
.57
.36
.55
.71
.54
.52
.68
.71
.77
.78
.78
.31
.28
.22
.48
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Childhood Injury Instrument Development I 71
Table 1. Mean, Standard Deviation, and Reliabilities for Scales (Continued)
Corrected item-total
Item Item Cronbach Test- correlation Scale M SD alpha retest with scale
Benefits (con?.):
4. When I do things to prevent injuries to my child, I don’t
5. If I do things to prevent injuries to my child, he or she will
6. If I do things to prevent injuries to my child, I will save
7. People who are important to me will praise me if I do
8. Doing things to prevent injury to my child now will save
9. If I prevent injuries to my child, suffering to my child can
worry as much about him or her being injured.
be less likely to have an injury.
.53
.55
money on medical bills. .70
things to prevent injuries to my child. .46
time later. .67
be prevented. .54
Barriers 2.6 .24 .98 .52**
1 . It is hard to remember to do things that would prevent
2. I don’t have enough money to do things that would prevent
3. Doing things to prevent injuries to my child would take too
4. I do not know enough about how to prevent injury to my
5. I usually am too tired to do things that would prevent
6. Trying to prevent an injury to my child is too hard. 7. My child will not do what I say that will keep him or her
from getting injured. 8. I do not know how to contact people in the housing
authority who will repair the safety hazards in my home. 9. There is too much confusion in my house to do things to
prevent injuries to my child.
injuries to my child.
injuries to my child.
injuries to my child.
much time.
child.
injury to my child.
10. My house is too messy for me to do things to prevent
.79
.81
.88
.85
.96
.88
.67
.79
.78
.84
(Table continues on next page)
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Table 1. Mean, Standard Deviation, and Reliabilities for Scales (Continued)
Corrected item-total
Scale M SD alpha retest with scale Item Item Cronbach Test- correlation
Barriers (cont.):
11. It is difficult for me to get information on how to prevent
12. There are too many children to take care of for me to injuries to my child. .83
prevent injuries to my child. .85
Self efficacy 4.0 .32 .86 .30*
I have the ability to . . . 1. 2. 3.
4. 5 . 6. 7.
8. 9.
10.
11.
12. 13.
keep plastic wrappers out of reach of my child. obtain the poison control number. keep medicine and household products in a locked cabinet. keep knives and sharp objects out of reach of my child. have safety caps on all medicine bottles. have safety plugs on unused electrical outlets. keep matches and cigarette lighters out of reach of my child. keep guns and air rifles in a locked cabinet. have Ipecac in the house. keep handle of pots and pans when on the stove out of the reach of my child. keep electrical appliances and cords out of reach of my child. install a toddler safety gate. install cabinet locks.
Social influence 20.0 1.7 .90 .62**
1. Partner/boyfriend/husband. 2. Close relative. 3. Close friends. 4. Nurse or doctor. 5. Social worker or case worker. 6. Minister, preacher, or priest.
.I3
.62
.59
.62
.74
.38
.52
.47
.38
.61
.63
.53
.57
.78
.77
.67
.71
.76
.68 ~
* p = -05 **p - .01
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Childhood Injury Instrument Development 173
The social influence scale produced a high intercorrelation (.98) be- tween minister and church mother. The scale was revised by deleting church mother from the normative beliefs and motivation to comply subscales. The revised social influence scale consisted of six items on each subscale.
Concurrent validity analysis showed that all scales except seriousness were significantly correlated @ I .05) with maternal injury prevention behavior as shown in Table 2.
Inconsistent with the theoretical framework, the barriers scale was negatively rather than positively correlated with the number of hazards observed in the homes of the subjects.
DISCUSSION
In this study, internal consistency, test-retest reliability, and criterion- related validity were used in a newly developed instrument for measur- ing maternal beliefs about injury prevention in their young children and perceptions of individuals who influence their performance of injury prevention measures for their children. Revisions of the instrument were made based on content validity and reliability analysis. The revisions resulted in a reliable instrument.
Concurrent validity was established for the susceptibility, benefits, self efficacy, and social influence scales. Subjects who perceived higher susceptibility of injuries in their child, more benefits in preventing inju- ries, and more ability in carrying out prevention measures had fewer injury hazards observed in their homes than subjects with perceptions of lower susceptibility, benefits, and self efficacy. The subjects with fewer injury hazards also perceived that more referent others approved of
Table 2. Correlational Analysis of Scales with Injury Prevention Behavior
Scale Pearson correlation coefficient
Susceptibility Seriousness Barriers Benefits Self efficacy Social influence
- .36* - .21 - .59** - .34* - .45** - .49**
* p - .05 **p - .01
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174 K. M. Russell
them engaging in injury prevention measures for their children and were more willing to comply with the referents than mothers with fewer referents and less motivation to comply with them.
The seriousness scale was not significantly correlated with the crite- rion maternal injury prevention behavior. This scale measured the sub- jects’ rating of the amount of agreement with whether or not certain injuries would be serious in their child. The scale consisted of injuries that could have potential life-threatening consequences for young chil- dren and subsequently all of the injuries would be serious. Little vari- ability was found in the subjects’ seriousness beliefs, with most subjects (82% to 95%) agreeing or strongly agreeing that each injury would be serious in their child. A recommendation is made that the scale be re- vised to measure the subjects’ perceptions of the degree of seriousness of the injuries in their child rather than their agreement or disagreement about whether each injury would be serious.
Although the barriers scale was significantly correlated with injury prevention behavior, the relationship was in the opposite direction as postulated by the Health Belief Model. Mothers who perceived in- creased barriers to engaging in injury prevention measures for their child had fewer potential injury hazards in their homes than more haz- ards. Mothers may have significantly underreported the barriers due to effects of social desirability. Fear of appearing to be an unconcerned mother, being potentially scrutinized for their parenting practices, and jeopardizing public assistance benefits may have contributed to their responses. These same fears are not associated with the other scales due to the nonthreatening nature of the item statements. Although all respon- dents were informed of the confidential nature of the study, other mea- sures to minimize the effects of social desirability may be needed when refining this tool with similar populations.
Measurement of maternal injury prevention behavior with the Home Safety Observations Tool was limited to the presence or absence of po- tential safety hazards in the home. Frequency and severity of the hazards were not measured.
Implications for Nursing
Refinement of the instrument through research efforts is warranted. In addition to integrating the recommendations for the seriousness and bar- riers scales, investigators can expand the number of items to include other injuries that occur to young children in other settings beyond the immediate home environment. The instrument should be tested with an increased sample size and with other socioeconomic populations. With a
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Childhood Injury Instrument Development I 75
larger sample size validity analysis can be extended by performing fac- tor analysis for construct validity.
Due to the paucity of behavioral research on childhood injury preven- tion, investigations are needed to identify predictors of injury prevention behaviors and to explore nursing interventions that effectively decrease injuries among young children. This instrument can be adapted for use in these and other related injury investigations.
SUMMARY
The problem of early childhood injuries and lack of a caregiver behav- ioral assessment tool led to the development of an instrument that as- sesses the health beliefs and social influences of mothers in preventing injuries in their child. Further development of the instrument is recom- mended to include refinement of the seriousness scale, minimize social desirability of the barriers scale, and expand the type of childhood inju- ries to incorporate those that commonly occur to young children outside the home. This instrument can be used in health behavior research to increase nursing knowledge about predictors of injury prevention behav- ior of primary caregivers of young children. This new knowledge will provide the basis for the development of effective nursing interventions in childhood injury prevention.
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Baker, S. P., & Waller, A. E. (1989). Childhood injury: State-by-state mortality facts. Baltimore, MD: The Johns Hopkins Injury Prevention Center.
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