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Self-Concept and Health Locus of Control: Factors Related to Children's Adherence to Recommended Asthma Regimen

Posted on: Tuesday, 18 October 2005, 03:01 CDT

By Burkhart, Patricia Vernal; Rayens, Mary Kay

Purpose: To determine the relationships of adherence to daily peak expiratory flow rate (PEFR) monitoring, recommended for asthma self-management, with self-concept and health locus of control in a sample of 42 children, ages 7 through 11.

Design/Methods: Secondary analysis was conducted on data collected as part of our 5-week randomized, controlled asthma self- management clinical trial. During the study, the Piers-Harris Children's Self-Concept Scale (PHCSC) and Children's Health Locus of Control Scale (CHLOC) were administered at baseline (Week 1) and Week 5 for comparison, while adherence to electronically-measured peak flow monitor (PFM) was evaluated during Week 5.

Results: Adherence was positively correlated with higher self- concept (r^sub s^= .33, p = .03) and internal health locus of control (r^sub s^= .30, p = .05). Adherence to PFM and the intellectual and anxiety subscales of the PHCSC also were positively associated (r^sub s^= .38, p = .01, in both cases).

Conclusions: Children who have a positive self-concept, particularly in the areas of intellect and anxiety, are more adherent to their recommended asthma regimen. Similarly, those who perceive their ability to control their health more positively adhere better to daily PEFR monitoring. These results suggest that children's adherence interventions may need to include components aimed at enhancing self-concept and health locus of control.

Little is known about factors that may be related to children's adherence to recommended asthma self-management. Although many demographic and psychosocial variables have been explored in relationship to health behaviors of children with asthma, the findings have been equivocal. Two psychosocial attributes that may contribute to children's adoption of self-monitoring behaviors and the prediction of adherence to recommended asthma self-management are self-concept and health locus of control. These concepts are significant with regard to asthma self-management programs, especially those built on cognitive social learning theory (Bandura, 1997), in that they may influence the degree to which children will make an effort to learn to manage their asthma and perform the requisite behaviors.

The primary objective of the study was to examine the relationships of children's self-concept and health locus of control with adherence to recommended asthma self-management, specifically the practice of daily peak flow monitoring. Other objectives were to (a) ascertain whether adherence is related to demographic or baseline asthma characteristics and (b) determine whether self- concept and health locus of control change during the course of a 5- week randomized intervention study.

Background

Asthma is the most prevalent chronic disease in children, affecting approximately 6.1 million children under the age of 18 (Centers for Disease Control and Prevention [CDC], 2002). Although effective treatments have been shown to dramatically reduce asthma morbidity, they are only effective if patients regularly and consistently adhere to the prescribed regimen. Daily peak expiratory flow rate monitoring is recommended for individuals with moderate to severe persistent asthma as part of asthma self- management (National Asthma Education and Prevention Program [NAEPP], 1997; 2003).

Adherence is the extent to which a patient's behavior is consistent with the health care provider's recommendations (World Health Organization, 2003). Adherence to recommended treatment regimen in the pediatrie population for all conditions ranges from 43%-100%, with just half of children, on average, adhering to recommended treatment (Burkhart & Dunbar-Jacob, 2002). Although many factors have been investigated with both adults and children for their association with nonadherence to recommended treatment, none have consistently shown to be significant predictors.

Factors related to children's adherence to recommended treatment. Socioeconomic variables have not consistently been associated with adherence to recommended asthma self-management in children. Gender did not influence adherence (McQuaid, Kopel, Klein, & Fritz, 2003; Kovacs, Charron-Prochownik, & Obrosky, 1995; Tamaroff, Fester, Adesman, & Walco, 1992). However, non-adherence was associated with lower socioeconomic status for adults (Apter, Reisine, Affleck, Barrows, & Zuwallack, 1998) and for children (Bender et al., 2000; Charron-Prochownik, Becker, Brown, Liang, & Bennett, 1993; Miller- Johnson et al., 1994). Similarly, poorer treatment adherence in adults was associated with fewer than 12 years of formal education (Apter et al., 1998). Others found no relationship between adherence and socioeconomic status (Kovacs, Qoldston, Obrosky, & lyengar, 1992; Wysocki et al., 1996) or education level (Laiard, Chamberlain, & Spicer, 1994). Lack of adherence to asthma medication taking was related to minority status in a sample of 106 children with asthma and their parents (McQuaid et al., 2003). Conversely, there was no influence of race, family income, or gender on protocol adherence for 133 school-age children (Strunk et al., 2002). Some researchers report that older children are less adherent than their younger counterparts (Bender et al., 2000; McQuaid et al., 2003). Parents may withdraw responsibility for the child's disease management as the child ages, but the child may not assume the responsibility in a consistent manner.

Family characteristics related to adherence. Adherence is associated with family characteristics. Children living in two- parent families were more adherent to dialysis treatment regimens (Brownbridge & Fielding, 1994). Family conflict was associated with poor self-management in childhood diabetes (Mauser, et al. 1990) and in juvenile arthritis (Chaney & Peterson, 1989). Poor family communications, decision making, and problem-solving abilities may reduce adherence, resulting in increased asthma episodes (Schobinger, Florin, Zimmer, Lindemann, & Winter, 1992; Wamboldt, Wamboldt, Qavin, Roesler, & Brugman, 1995). Children's medication nonadherence was correlated with lower levels of asthma knowledge and family dysfunction (Milgrom, Rand, & Ackerson, 1998). Therefore, it is possible that for certain families, the structure, style, and dynamics of their interactions may contribute to poor adherence to recommended treatment for their children with chronic illnesses.

Relationship of self-concept to adherence to treatment. Self- concept is a composite view of oneself formed through direct experience with and the evaluations of significant others (Bandura, 1997). The terms self-concept and self-esteem have been used interchangeably in the literature. Research on the relationship between adherence to recommended treatment and self-concept is inconclusive. In a study of 260 school-age children, self-concept predicted health perception which, in turn, predicted health behavior (Ferrand & Cox, 1993). Higher selfesteem was related to greater treatment adherence among 50 children, ages 9-17 years, who had cystic fibrosis (Ricker, Delamater, & Hsu, 1998). For 21 adolescent children with diabetes, stronger self-concept was associated with better metabolic control (Burroughs, Pontious, & Santiago, 1993). Lower treatment adherence was associated with higher self-ratings of anxiety and depression for 60 children and adolescents in end stage renal failure who were undergoing dialysis (Brownbridge & Fielding, 1994). Conversely, self-concept was not related to the performance of health promotion or self-care behaviors for children with asthma (Kieckhefer, 1987). In conclusion, better self-concept is not consistently related to treatment adherence, and there are few studies of the relationship between self-concept and adherence to treatment for children with chronic conditions.

Health locus of control and adherence to treatment. Health locus of control refers to the perception that a health outcome will be largely determined by the individual's own actions (internal health locus of control) or by outside forces (external health locus of control) beyond the individual's control (Rotter, 1954). There are few current studies of the relationship between health locus of control and adherence to recommended treatment regimen in chronic illness, and the findings of these studies are inconsistent. Adolescents with cancer who were adherent to medication did not differ on health locus of control compared with those who were nonadherent (Tamaroff et al., 1992). Conversely, when the effect of age was controlled, children and adolescents with diabetes (N = 61) who had a higher internal health locus of control were more adherent to treatment (i.e., diet, metabolic monitoring, and insulin adjustment) over a 4- year study compared with those with an external health locus of control (Jacobson et al., 1990). The relationships of children's adherence to daily peak expiratory flow rate (PEFR) monitoring and their scores on the Piers-Harris Children's Self-Concept Scale (PHCSC) and the Parcel Health Locus of Control Scale (CHLOC) were assessed. In addition, an evaluation of the relationships between adherence and demographic or baseline asthma characteristics was examined. Changes in children's self- concept and health locus of \control scores over a 5-week period were assessed.

Methods

Design. Secondary analysis of existing data from a larger study was conducted to examine the relationships of adherence with self- concept and health locus of control. The children were participating in a 5-week randomized, controlled trial evaluating the effectiveness of an asthma selfmanagement program on adherence to daily PEFR monitoring, recommended as part of asthma self- management (Burkhart, Dunbar-Jacob, Fireman, & Rohay, 2002; Burkhart, Dunbar-Jacob, & Rohay, 2001; Burkhart & Ward, 2003).

Sample. A sample of 42 children, ages 7 through 11 years, who had persistent asthma was recruited primarily from pdiatrie practices in West Virginia. Inclusion criteria were: persistent asthma, diagnosed at least 6 months prior to the study, English speaking, and the presence of a parent or guardian who was willing and able to participate with the child. Exclusion criteria were the following: children being treated for other chronic conditions in addition to asthma, no telephone access, participating siblings, or self-report of current adherence to daily peak flow monitoring (PFM). There was no attrition over the course of the 5-week study.

The mean age of the school-age children was 9.6 years (SD = 1.6). The sample was predominantly male; Caucasian; and from two-parent, middle income families (see Table 1). The low rate of minority children reflected the rural area (3.3% minority) of West Virginia where the study was conducted. The mean number of years since the child was diagnosed with asthma was 4.7 years (SD = 2.8). Most of the children had no hospitalizations for asthma and reported monthly, rather than weekly or daily, asthma symptoms. More than half of the parents reported that their child's asthma was in good or very good control.

Table 1. Sociodemographic and Asthma Characteristics of the Sample (N = 42)

Measures. Adherence to PEFR monitoring. Adherence to recommended daily PEFR monitoring was assessed during Week 5 of the study. Adherence was scored as the percent of days the child used the electronic peak flow monitor at least once, with scores ranging from 0% to 100%. PEFR monitoring was measured using the PeakLog (Medtrac Technologies, Lakewood, Colorado). The PeakLog is a hand-held computer that records the date, time, and PEFR value. It provides an objective measure of PEFR, meeting the American Thoracic Society (1995) standards for PEFR and the NAEPP (1997; 2003) recommendations for measuring portable peak flow accuracy.

Self-concept. The PHCSC scale examines the self-attitudes for children ages 8 to 18 years (Piers, 1984). The pencil-and-paper questionnaire assesses six aspects of a child's self-concept that include: behavior, intellectual and school status, physical appearance and attributes, anxiety, popularity, and happiness and satisfaction. It consists of 80 short sentences for which the child answers yes or no. Each positive response is scored with one point and each negative response with O points. Children indicating high scores on the intellectual and school status subscale answered positively (i.e., "yes") to statements such as: (a) When 1 grow up 1 will be an important person; (b) I have good ideas; and (c) I am smart. Similarly, children scoring high on the anxiety subscale answered "no" to statements such as: (a) 1 get worried when we have tests in school; (b) I give up easily; and (c) 1 worry a lot.

Approximately half of the 80 statements indicate high self- concept and half are low self-concept. High scores indicate a better self-concept. The scale has been found to have acceptable levels of test-retest reliability (r= .80) and convergent validity (r= .61) with other self-concept instruments. The reading difficulty of the scale is approximately third grade level. Since the reading levels of children vary, it is recommended that the items are read aloud to the child. Responses are easily scored using a scoring key. An overall assessment of self-concept is reflected in a total raw score, percentile score, and an overall stanine score. Scores for each of the six subscales also can be calculated. Cronbach's alpha for the PHCSC was .89 in this sample.

Health locus of control. The CHLOC scale is a measure of the extent to which children believe their own healthdirected behaviors will lead to positive health outcomes (Parcel & Meyer, 1978). External health locus of control is the belief that outside forces, over which the individual has no control, determine what happens to the individual's health outcomes. Internal health locus of control is the belief that control over health events resides with the individual.

The scale consists of 20 statements about factors influencing health to which the child can either agree or disagree (in a yes or no response format). It was developed for children 7 years of age and older. The 20 items are summed to obtain a total scale score. Three factors, calculated as subscores, can be assessed: internal control; general beliefs about the degree that health and illness are determined by luck or chance; and beliefs about the degree to which powerful others (e.g., physicians, nurses, and parents) determine health and illness outcomes.

The CHLOC is the first scale specifically designed to measure health locus of control in children. It was developed, based on social learning theory, to operationalize the concept of health motivation (i.e., the degree to which the individual is ready to engage in health behaviors). An internal health locus of control may be necessary for children to assume responsibility for certain types of health behaviors (Parcel & Meyer, 1978).

Responses are scored based on an internal or external direction (i.e., children's belief that they have control over their health outcomes or they do not). Higher scores (31 to 40) indicate internal health locus of control, and lower scores (O to 20) indicate external health locus of control. Higher internal locus of control was reflected in the children's "yes" answer to questions such as: (a) I can do many things to fight illness; (b) 1 can make many choices about my health; and (c) 1 can do many things to prevent accidents.

In prior research with children, the instrument demonstrated acceptable levels of test-retest reliability (r = .62 to .80), internal consistency (r = .75), as well as construct and discriminant validity (O'Brien, Bush, & Parcel, 1989). Cronbach's alpha for the CHLOC was .80 in this sample.

Demographic and baseline asthma characteristics. Demographic data were collected that included: the child's age, grade level, family income, family structure, and parents' education. Similarly, children's baseline asthma characteristics, including asthma severity, number of years with asthma, number of hospitalizations, asthma symptom frequency, and the parent's report of the child's symptom control and overall health were recorded.

Procedure

Prior to recruitment, the study was approved by the Medical Institutional Review Board at the university of Pittsburgh. Recruitment brochures announcing the study were placed in offices of pediatricians in a metropolitan area of northern West Virginia. Parents of children with persistent asthma contacted the researchers to indicate their interest in having their children participate. Parents gave written consent and children gave verbal assent to participate. Children were included if they met the inclusion criteria, their parents gave written consent for their children to participate, and the children gave their assent.

The self-concept and health locus of control instruments were administered at two different time intervals, 4 weeks apart, to the children participating in a 5-week asthma self-management intervention study. These times were at the initial face-to-face session (Week 1) and during the final intervention session (Week 5). The intervention and control groups did not differ on adherence during Week 5 (Burkhart et al., 2002); as a result, these groups were combined for the purpose of this analysis.

The measures were administered to the children with the researcher asking each of the questions out loud and recording the responses. Parents were asked not to comment, as the questions were directed to the children. Children were told that the questions would be asked, not as a test, but to see how children felt about some things related to themselves and their health. To discourage the parents from answering for the child, each child was told that these questions were for children only and not for adults. Each item on the scales was read aloud to the child twice. The child was instructed to answer "yes" or "no" to every question, even if sometimes it was hard to decide on the answer.

During the Week 1 session, the participants received asthma education based on the NAEPP (1997; 2003) treatment guidelines. Behavioral rehearsal of PFM was included. At the end of the session, children were asked to monitor their morning and evening PEFR at home over a 5-week period using an electronic peak flow meter that displayed and internally recorded the date, time, and peak flow number. The children were asked to report the peak flow numbers, displayed on the electronic monitor, in their asthma diary.

During Week 5 session, asthma education was once again reviewed for both groups, and peak flow monitoring adherence was collected. The CHLOC and the PHCSC were administered using the same format as the Week 1 session.

Data Analysis

The data were analyzed using SAS for Windows, version 8.2 (SAS Institute, 1999-2001); p values ≤. .05 were deemed significant throughout. Given the non-normal distribution of the adherence data with an inability to transform the data and the ordinal level of the scale items, non-parametric statistics were used for the analyses.

The association between the scores on each of the scales and adherence to daily peak flow monitoring was exami\ned using Spearman's rank correlation. To limit the number of tests of association, only the Week 1 psychosocial measures were correlated with adherence during Week 5.

The relationships of adherence with demographic and baseline asthma variables were determined using Spearman's rank correlation, the Mann-Whitney U test, or Kruskal-Wallis test. The change in self- concept and locus of control from Week 1 to Week 5 was assessed using the Wilcoxon signed-ranks test for matched pairs; this test was indicated due to the non-normal distribution of the change scores for PHCSC and CHLOC scales.

Group adherence data from an earlier pilot project, with children not included in the present study, revealed adherence rates of 63% and 36% for the intervention and control groups, respectively. Based on this difference and an alpha level of .05, power analysis determined that 40 subjects (n = 20 per group) would be needed to achieve 80% power for a one-sided Mann-Whitney U test.

Results

Adherence during Week 5 was positively correlated with the total scores for both self-concept (r^sub s^ = .33, p = .03) and health locus of control (r^sub s^ = .30, p = .05) at Week 1. Adherence to daily monitoring during week five and the intellectual and anxiety subscales of the PHCSC measured during the first interview also were positively associated (r^sub s^ = .38, p = .01, in both cases). The higher the baseline levels of self-concept and internal health locus of control, the higher the degree of adherence to daily PFM at Week 5. For most of the self-concept and locus of control subscales, there was a significant increase from Week 1 to 5; the only exceptions were for PHCSC happiness/satisfaction and CHLOC internal control and health-related luck/chance (see Table 2).

Adherence to daily PFM was not related to the child's age or education, family income, family structure, or parents' education. Similarly, children's baseline asthma characteristics, such as asthma severity, number of years with asthma, or number of hospitalizations, symptom frequency, parent report of child's symptom control, and overall health were not related to adherence.

Limitations of the study include a small sample size (N=42) and the potential for bias in the children's responses due to their parents' presence in the room. Although the parents were asked not to comment and were distracted by filling out a demographic form while the children answered the items on the scales, there may have been a social desirability factor influencing the children's answers. Children may have felt they needed to answer in a way that would be acceptable to the parent, rather than responding honestly. This may have biased the responses given by children.

Discussion

Children's self-concept and health locus of control made some contribution to their adherence to a recommended daily asthma regimen. This suggests that greater perceived academic achievement and capability and low anxiety may be associated with adherence. Similarly, children with a higher internal health locus of control may be more adherent than those with more external health locus of control. These findings may be clinically significant in identifying children with low self-concept and external locus of control who may be less adherent to recommended asthma treatment regimen than their peers with higher self-concept and internal health locus of control. Identification of children who may be less adherent can assist health care providers in developing strategies to promote adherence in these children to improve asthma outcomes.

An interesting finding was that the scores for both the CHLOC and the PHCSC increased over the course of the 5-week self-management study. This was consistent with another study that reported increasing scores on the PHCSC for 123 children participating in an intensive asthma self-management program (Creer et al., 1988). Conversely, some studies found no significant difference in scores on the PHCSC pre- to post-asthma self-management intervention (Rubin et al, 1986; Weiss & Hermalin, 1987). The CHLOC moved toward internal health locus of control from baseline to completion of a comprehensive asthma self-management program for both the intervention and control children in this study and in other asthma self-management studies (Creer et al., 1988; Taggart, Zuckerman, Lucas, Acty-Lindsey, & Bellanti, 1987). Although the magnitude of difference in the PHCSC and CHLOC between Weeks 1 and 5 is relatively small, these increases may be clinically significant because of the link between these attributes and adherence.

Table 2. Comparisons of Self-concept and Health Locus of Control at Weeks 1 and 5 (N = 42)

Implications for Nursing Practice and Future Research

The results of this study indicate that children with higher self- concept and internal locus of control were more adherent to daily PFM recommended as part of asthma selfmanagement. Perhaps this reflects the concept of self-efficacy identified by Bandura (1997) as the perception that one can successfully execute behavior required to produce the required outcome. Research begun by Schlosser and Havermans (1992) on the development of a child asthma self-efficacy scale warrants further investigation. Self-efficacy in children with asthma may be clinically significant if, in future studies, it is found to affect children's adherence to treatment. Interventions designed to build self-efficacy may need to be incorporated into self-management programs. Given the paucity of studies examining the constructs of locus of control, self-concept, and self-efficacy, randomized, controlled studies with larger sample sizes are needed to evaluate their effects on adherence to recommended treatment for asthma and other chronic conditions, such as diabetes.

This is particularly important for children with chronic conditions whose control of symptoms and prevention of significant exacerbations are contingent upon long-term adherence to a recommended treatment regimen. Identification of markers of nonadherence, such as poor self-concept or external health locus of control, may facilitate more efficient targeting of effective behavioral interventions, resulting in better adherence and symptom control and, ultimately, improved health outcomes.

The Practice Applications of Research section presents reports of research that are clinically focused and discuss the nursing application of the findings, If you are interested in author guidelines and/or assistance, contact Janice S, Hayes, PhD, RN; section Editor; Pediatrie Nursing: East Holly Avenue Box 56; Pitman, NJ 08071 -0056; (856) 256-2300 or FAX (856) 256-2345.

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Patricia Vernal Burkhart, PhD, RN, is Associate Professor, College of Nursing, university of Kentucky, Lexington, KY.

Mary Kay Rayens, PhD, is Associate Professor, Colleges of Nursing, Medicine, and Public Health, University of Kentucky, Lexington, KY.

Acknowledgments: This study was funded by a grant from the Nursing Research Program, Clinical Applications Research, GlaxoSmithKline Inc., #N(JR-017, awarded to Dr. Burkhart. The authors gratefully acknowledge the constructive criticism of the manuscript by Dr. Lynne Hall, Professor and Assistant Dean for Research and the PhD Program, College of Nursing, University of Kentucky.

Note: The results of the study were presented as a paper presentation in July 2004 at the 15th International Nursing Research Congress of Sigma Theta Tau International in Dublin, Ireland.

Copyright Anthony J. Jannetti, Inc. Sep/Oct 2005

Source: Pediatric Nursing

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