- Email: [email protected]
Evaluating health and safety knowledge of preschoolers: Assessing their early start to being health smart
ORIGINAL ARTICLE
PH C
ABSTRACT
Introduction: The purpose of this study was to establish the validity, reliability, and utilization of a revised and expanded Preschool Health and Safety Knowledge Assessment (PHASKA), an instrument evaluating health and safety knowledge of young children, on a diverse group of preschool children. Methods: This study included 308 children (133 boys and 175 girls) ranging in age from 28 to 80 months (M = 53.7 months). The PHASKA was administered to children at 6 preschools and 5 health fairs on an individual basis. Results: Scores on the PHASKA ranged from 1 to 49 (out of a possible 50 points), with a mean score of 37.25. Ninety-seven percent of the children older than age 3 years completed the assessment. No significant differences attributable to gender were found. However, significant age group differences were found [F (7, 300) = 31.09, P <.0001]. In general, items related to safety were learned first, followed by those related to hygiene, health promotion, and nutrition. Discussion: Preschoolers’ scores on the PHASKA showed significant improvement with age, supporting the assertion that preschoolers are ready and willing learners of health and safety knowledge. Children rapidly gain health and safety knowledge between 31⁄2 and 51⁄2 years of age and master much of this content by their sixth birthday. The PHASKA was shown to be appropriate for determining health and safety knowledge scores for preschoolaged children. J Pediatr Health Care. (2000). 14, 160-165.
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Evaluating Health and Safety Knowledge of Preschoolers: Assessing Their Early Start to Being Health Smart C a r y l E . M o b l e y, P h D, R N , C P N P, & Jo a n E va s h e v s k i , M S , R N
A
ccidental injury is the leading cause of death for children ages 1 to 14 years in the United States. In 1995, 5824 children in this age group died as a result of accidents, which represents 39% of deaths from all causes for these ages (Anderson, Kochanek, & Murphy, 1997). Sixteen million children require emergency medical care each year, of whom 600,000 require hospitalization and 30,000 sustain serious or permanent damage (Rodriguez, 1990). Another threat during childhood is the onset of poor health habits. Many preventable chronic illnesses seen in adults have their foundation in behaviors established during childhood. For example, two of the risk factors for heart disease—hypercholesterolemia and obesity—are prevalent by the preschool years (Williams et al., 1998). Williams et al. stated that one of the premises of the “Healthy Start” program is that teachers can have a strong influence over health behavior and antecedent risk factors by working with young children and their families. Those who provide health education need to have baseline knowledge about what young children are learning to develop appropriate programs. Wortel, De Geus, Kok, and Van Woerkum (1994) explored the child–environment interaction that can make a child at risk for injury. They postulated 3 types of strategies to prevent injury: adoption of safety measures, supervision of the child, and education of the child about safety measures. Adopting safety measures includes complying with strategies mandated through legislation that regulate safety practices (eg, use of seat belts and car seats) and using structural measures that do not require any actions by the child or parent (eg, use of fire-retardant cloth in children’s pajamas). Caryl E. Mobley is an Associate Professor at Texas Woman’s University, Dallas. Joan Evashevski is currently doing volunteer work with women’s support groups. Reprint requests: Caryl E. Mobley, PhD, RN, CPNP, Texas Woman’s University, 1810 Inwood Rd, Dallas, TX 75235. Copyright © 2000 by the National Association of Pediatric Nurse Associates & Practitioners. 0891-5245/2000/$12.00 + 0 25/1/103954 doi:10.1067/mph.2000.103954
July/August 2000
PH ORIGINAL ARTICLE C Although these types of measures are widely recognized as being the most effective strategies (Agran, Winn, & Anderson, 1997), many safety situations exist for which legislation and structural measures cannot be applied (Peterson & Saldana, 1996). As a result, education and supervision are also essential, especially for preschool-aged children. Certain characteristics of preschoolaged children make this an ideal time to teach them health and safety knowledge. Their curiosity and desire to master tasks enable them to readily absorb concrete information that is presented using visual, auditory, and motor strategies. Repetitive activities in which they are physically as well as cognitively involved facilitate learning (Sewell & Gaines, 1993). However, preschool children are not reliable decision makers about health and safety behaviors. Their cognitive processes have not developed to the point where they can understand complex cause-and-effect relationships, and their worlds are still very much ruled by fantasy (Athey, 1995). Their thinking is very concrete in that preschoolers think about what they can see and have proof of; they can only work with information that is available to them, not that with which they have had no experience (Fraiberg, 1959). They center, or concentrate, on one aspect of a situation and can only focus on a limited amount of information (Ginsburg & Opper, 1969). As a result, they remain vulnerable to injuries, and parents must continue to monitor their activities while they are learning. Strategies that have been used successfully to teach preschoolers about health and safety promotion involve primarily modification of behavior. Wurtele, Kast, Miller-Perrin, and Kondrick (1989) compared two types of educational programs in Head Start preschools. One program was a behavioral skills training program and taught the children a rule to follow when handling inappropriate touch. The other program was a “feelings” program and focused on the feelings a child has when touched inappropriately. Although both programs were effective in teaching knowledge and skills, children in the “feelings” program had difficulty differentiating between appropriate and inappropriate touch. “Healthy Start,” a comprehensive health education program for preschool-
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ers that focuses on decreasing children’s risk for cardiovascular disease, uses a behaviorally oriented curriculum and actively involves children through games, hands-on experiments, and skill rehearsal (D’Agostino, D’Andrea, Lieberman, Sprance, & Williams, 1999). Although school-aged children derive their knowledge of health and safety from many sources, including family, school, and community organizations, parental teaching and role modeling is the primary source of knowledge for preschool-aged children. Part of the young child’s socialization process involves a cyclical pattern in which parents strive to provide knowledge and guidance for their children to help prevent accidental injury. For this process to be effective, the child must be responsive to the parental attempts (Peterson & Stern, 1997). As children get older and more independent and show that they can apply the parents’ teaching, parents tend to allow them to make more decisions about their health care (Arneson & Triplett, 1990).
M
any preventable
chronic illnesses seen in adults have their foundation in behaviors established during childhood.
At a time when the health care system is under considerable review and attempts to contain health care costs are an economic priority, prevention of injuries and illness and the human and monetary costs that go with them takes on heightened importance. In the fields of health promotion and injury prevention, research that explores how we can best educate our very young to achieve a lifetime of optimal health is of utmost importance. Most research with this age group has involved development of educational programs (Arneson & Tripplett, 1990;
Sloan, 1990; Williams et al., 1998). However, little is known about the level of preschoolers’ health and safety knowledge. In one study on knowledge of health-related concepts, Maheady (1986) found that preschoolers are in the process of gaining this knowledge. However, measurement of such knowledge has focused on determining the health knowledge of the parent rather than assessing the knowledge of the child (Eichelberger, Gotschall, Feely, Harstad, & Bowman, 1990). To effectively evaluate health and safety education knowledge of young children, an instrument is needed that is appropriate to preschoolers’ cognitive and linguistic levels and that can hold their attention. In 1990, Mobley developed and began pilot testing a nonverbal method of assessing health and safety knowledge that met these criteria (Mobley, 1996). The instrument, called the Preschool Health Knowledge Assessment, was shown to be an effective measure. The study suggested that preschoolers are rapidly gaining this important knowledge. The study also pointed out ways to improve the instrument by adding more advanced content. Prior to the current study, this instrument was revised, expanded, and formatted for computerized reproduction and was renamed the Preschool Health and Safety Knowledge Assessment (PHASKA). The purpose of this study was to evaluate the validity, reliability, and utilization of a revised and expanded form of the instrument on a diverse group of preschool children.
METHOD Sample The subjects for this study included 308 children (133 boys and 175 girls) ranging in age from 28 to 80 months (M = 53.7 months). Including subjects younger and older than the usual age parameters for preschoolers allowed a clearer evaluation of whether this instrument was specific in applicability to this age group. Using a significance level of .05 and a calculated effect size of 0.835, the power for this sample size was greater than 99% (Cohen, 1977). Researchers used a convenience sampling and sought recruitment sites that offered an ethnically and socioeconomically diverse population. The sample was predominantly White (69%), with 16% Black and 10%
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ment experts reviewed the instrument to evaluate face and content validity, and the instrument was revised based on their input. Reliability was examined using the test/retest method. Fortythree (14%) of the children were retested within 2 hours of the first test. The test/retest correlation coefficient for the total score was r = 0.88, P < .001. Internal consistency was computed using Cronbach’s α. Coefficient α on the last 50 items was .51.
Procedure
FIGURE
Sample item from the Preschool Health and Safety Knowledge
Assessment.
Hispanic subjects. Annual family income varied, with 28% having incomes less than $20,000, 17% in the $20,00 to $39,999 range, 19% in the $40,000 to $59,999 range, and 36% at $60,000 or higher. A majority of the parents were well educated, with 75% of the fathers and 81% of the mothers having at least some college education. Before initiation of data collection, permission to conduct the research was obtained from the Human Subjects Review Committee at Texas Woman’s University. All data were identified using a numeric code to protect the confidentiality of the children and their families. Researchers recruited and assessed children at day care centers and health fairs. In both settings, they gave parents written explanations and consent forms. Preschoolers received a brief verbal explanation of the project and were asked to participate.
Instrumentation The PHASKA consists of 53 items. Each item is represented by a card showing pictures that depict various healthy/ unhealthy and safe/unsafe behaviors or situations that children encounter (Figure 1). The preschooler is asked to point to the picture that best represents a particular health or safety concept. The first 3 items in the instrument are designed to teach the child how to respond to the questions about the pictures. The other 50 items cover household, playground, bicycle, and motor vehicle safety and accident prevention
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(31 items), nutrition (6 items), general hygienic measures (5 items), and health recognition and promotion (8 items). The PHASKA is accompanied by a manual describing the procedure for administering the instrument, the verbal cues that accompany each item, and scoring sheets. The verbal cues are written in both English and Spanish. Each card contains 2 or 3 pictures. On most of the 3-picture cards, one picture is used to set up the situation and the other two pictures represent the choices. One card uses 3 pictures to give the child 3 choices. All pictures are black-andwhite line drawings with color added to highlight the focal behavior or situation. For example, card 33 shown in Figure 1 involves what a child should do if he or she finds a book of matches. The verbal cue that accompanies this card is: “This boy found some matches. What should he do to be safe—strike one to see if it lights, or give the matches to an adult?” Details of the child’s and adult’s facial features are left out to decrease association with any particular ethnic group. Color is used to highlight the book of matches and the fire. The researcher attempted to make the “wrong” alternative something that would appeal to preschoolers so that they would feel equally compelled to select that alternative if they did not know the correct answer. Of the cards that clearly depict the gender of the child, half show boys and half show girls. Acopy of the instrument can be obtained through the first author. A panel of 4 pediatric/child develop-
Four research assistants were trained to administer the PHASKA and achieved an interrater reliability rate of 90% or better with the principal investigator before administering the instrument to children. One of the research assistants was bilingual and administered the instrument to 4 children who spoke only Spanish.
T
o effectively evaluate health and safety
education knowledge of young children, an instrument is needed that is appropriate to preschoolers’ cognitive and linguistic levels and that can hold their attention. Parents were contacted through 6 preschools, 5 health fairs, and personal contacts through community groups. The preschool settings included two centers in predominantly white, middle-to-upper socioeconomic suburban areas, two in predominantly black and Hispanic lower socioeconomic urban areas, and two in a small city with a mixed ethnic population. The classroom teachers sent home consent forms and letters explaining the project. They sent a reminder note home 2 weeks
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PH ORIGINAL ARTICLE C later. Based on enrollment figures for the schools, return rates of consent forms ranged from 30% to 48% for the preschools. The highest return rate occurred in one of the predominantly white, middle-to-upper socioeconomic preschools in an area where a young girl had recently been abducted and murdered. One health fair was in a predominantly white, middle socioeconomic small city outside the metropolitan area, and four health fairs were in predominantly black lower to low-middle socioeconomic suburban areas. Researchers approached parents individually, gave them a brief explanation of the research, and asked them to read and sign the consent forms. More than 90% of those approached whose children fulfilled the study criteria agreed to participate. The PHASKAwas administered individually to the children in a quiet room or area of the preschool or health fair setting. The researcher met each child, gave a brief explanation of the project, and obtained assent. All agreed to participate, although several were reticent and agreed only after they saw other classmates return with smiles and stickers after completing the PHASKA.
RESULTS Total scores on the instrument were computed by summing the number of correct answers. The first 3 items in the PHASKA were not used in total score calculations because their primary purpose was to teach the child how to use the instrument. Out of 50 possible points, scores ranged from 1 to 49, with a mean score of 37.25. A t test computed using gender as the independent variable found no significant differences (t = -0.38, P = .70). Therefore, gender was not used as a variable in further statistical analyses. Only two individual items showed gender differences: girls had greater knowledge about what body parts were considered “private” than did boys (item 37, P < .01) and girls were better able to select a nutritious meal than were boys (item 39, P < .01). The sample was then divided into 8 age groups, each in 6-month increments from age 21⁄2 to 6 years. Ninetyseven percent of the children older than 3 years of age completed the PHASKA, whereas only 37.5% of those younger than 3 years of age who were tested completed it. A one-way analysis of
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variance was performed to analyze age group differences in total test scores. Significant age group differences were found [F (7, 300) = 31.09, P <.0001] (see Table 1). Based on the results of Scheffé procedures, scores for 21⁄2-year-olds were significantly different from scores for all other age groups; scores for 3year-olds, 31⁄2-year-olds, and 4-yearolds were also significantly different from those for all older age groups. The percentage of correct answers for each age group by item were calculated. Table 2 summarizes these findings and shows the earliest age group in which 75% and 90% of the children gave the correct answer. At the 75% correct level, children were considered to be in the process of mastering the content. Children in age groups in which 90.0% or more gave correct answers were considered to have mastered the content.
C
hildren were rapidly
gaining health and safety knowledge between 31⁄2 and 51⁄2 years of age and had mastered much of this content by their sixth birthday.
DISCUSSION Results of this study support Maheady’s (1986) assertion that preschoolers are ready and willing learners of health and safety knowledge. Preschoolers’ scores on the PHASKA showed significant improvement with age. Children were rapidly gaining health and safety knowledge between 31⁄2 and 51⁄2 years of age and had mastered much of this content by their sixth birthday. Items related to safety, as a group, were learned first, followed by items related to hygiene, health promotion, and nutrition. Sixtyfive percent of the items in the safety category were learned by 5 years of age.
TABLE 1 Total score means and ranges by age groups and Scheffé test results Group
Age (y)
Sample size
Mean score
Range
1 2 3 4 5 6 7 8
21⁄2 3 31⁄2 4 41⁄2 5 51⁄2 6
8 34 57 54 56 47 36 16
15.75 28.41 32.23 35.50 39.14 42.04 44.36 43.44
1-30 3-47 18-48 15-47 23-48 28-49 29-49 21-49
Age group mean scores were significantly different at a P <.0001 value. Results of Scheffé tests: Group 1 was significantly different from all other groups; Group 2 was significantly different from Groups 4, 5, 6, 7, and 8; Group 3 was significantly different from Groups 5, 6, 7, and 8; and Group 4 was significantly different from Groups 6, 7, and 8.
The patterns of scores were of particular interest. By chance, 50% of the children in all age groups would be expected to get the correct answer when given two choices. However, the younger age groups performed well below 50% on many of the cards. This finding suggests that the “wrong” alternative was compelling enough to encourage the majority of younger age groups to give the incorrect answer. It also suggests that the vast majority of children in the older age groups who gave the correct answer have the prerequisite knowledge as expected. The methodology used in the PHASKA was shown to be appropriate for ascertaining health and safety knowledge scores for children in the preschool age group. Preschoolers from 3 years of age and up were capable of completing the PHASKA. The instrument utilized both verbal and visual cues to help focus the children’s attention on the salient content being tested. In addition, having the children point to their answers involved them behaviorally as well as cognitively in the task, as Sewell and Gaines (1993) suggested. Researchers administering the instrument observed that the preschoolers were very social and inquisitive, just as Athey (1995) proposed. The children appeared to enjoy the one-onone contact with the researchers, and none who participated in the retest procedure showed any hesitancy to complete the instrument a second time.
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TABLE 2 Age groups at which 75% and 90% of children gave correct answers on items Age groups (in years) PHASKA items
75%
90%
Safety 6 Wearing seatbelt 8 Sitting vs standing on swing 11 Playing ball in street vs driveway 12 Walking on fence vs jumping on sidewalk 13 Playing with outlet vs pretending to cook 14 Playing with fan vs reading book 17 Crossing street alone vs with mother 22 Holding handlebars when riding bike 23 Crossing street on green vs red light 26 Swimming alone vs with friend 29 Riding bike on side vs middle of road 30 Riding in cab vs back of truck 33 Lighting match vs giving matches to adult 34 Touching pot on stove 35 Taking candy from a stranger 36 Sitting in seat belt in car 37 Identifying private parts of body 38 Petting a strange dog 40 Getting in car with stranger 41 Handing scissors to friend 42 Running vs walking around pool 44 Wearing helmet vs cap when riding bike 45 Answering door when home alone 46 Running for help vs stop-drop-roll 47 Playing with space heater vs toy 48 Confiding in friend vs trusted adult 49 Playing with ball vs poison 50 Stopping bleeding vs getting help 51 Playing with pills vs leaving untouched 52 Answering phone when home alone 53 Handling gun
3.0 3.5 4.0 4.0 3.5 3.5 3.5 3.0 6.0 3.5 5.0 4.5 4.0 3.5 4.5 3.5 N/A 4.5 4.0 5.5 4.0 4.0 4.5 5.5 3.5 4.0 3.5 4.0 4.0 N/A 4.5
5.0 4.5 5.5 5.0 5.0 5.0 4.5 4.5 N/A 6.0 N/A 5.5 4.5 4.0 5.0 4.5 N/A N/A 5.0 N/A 5.0 5.0 N/A N/A 4.5 4.5 4.5 4.5 4.5 N/A 5.0
Nutrition 4 Soda vs milk 7 Eating food vs dog food 9 Chocolate bar vs raisins 16 Sandwich and apple vs cupcake and chips 21 Apple vs piece of cake 39 Chicken dinner vs pizza dinner
4.0 4.5 5.0 5.0 5.5 5.5
5.5 5.0 N/A N/A 6.0 N/A
Hygiene 15 Brushing teeth after meal vs playing 18 Bathing vs going to bed dirty 27 Washing hands vs playing after using toilet 28 Sneezing into handkerchief vs hand 32 Brushing teeth after snack
4.5 3.5 4.5 4.0 4.5
N/A 4.0 5.0 5.5 5.5
Health Promotion 5 Point to child who feels sick 10 Staying up late vs sleeping 19 Wearing proper clothes on a cool day 20 Good posture when sitting 24 Watching TV vs exercising 25 Eating vs not eating meal 31 Standing upright vs holding abdomen 43 Adults smoking vs not smoking
3.0 5.5 4.5 5.0 6.0 3.0 3.5 3.5
4.5 N/A 5.5 N/A N/A 3.5 4.5 5.0
N/A indicates that none of the age groups achieved the appropriate percentage correct.
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Generalizability of the results is limited because of several factors related to sampling. One limitation was the use of convenience sampling. Another was that all subjects lived within a single large metropolitan area. Researchers tried to obtain a diverse sample, but situational and demographic characteristics of the population being sampled led to a higher than desired representation of children from white middle and upper socioeconomic families. Therefore, further research is needed to determine the generalizability of this instrument to a diverse population. Reliability of the PHASKA, based on test/retest data, was high. Internal consistency, as measured by Cronbach’s α, was lower. This finding was not surprising because of the wide variation in ages and developmental levels of children represented in the sample and because of the variety of health and safety knowledge areas being tested. The reliability and validity of this instrument should continue to be studied on larger and more diverse groups of preschoolers. Further research also needs to be done, using the PHASKA, on the relationship between the level of health and safety knowledge in young children and the occurrence of injury accidents. The interaction between health and safety knowledge and health and accident risk factors is another important field of inquiry. This type of data is not currently available. At a time when evidence-based health care is becoming the standard, determining the links between education and health and safety outcomes is very important. Parents, teachers, and health care providers cannot assume that preschool children will use the knowledge demonstrated on the PHASKA, or any other knowledge-based instrument, in a given situation and therefore cannot feel safe in decreasing their monitoring of young children’s activities. Also, the learning capabilities of preschool children limit the inferences that can be made about their utilization of knowledge. It is well known that preschool-age children concentrate on a particular aspect of a situation rather than see a situation from various perspectives (Ginsburg & Opper, 1969) and that they are very limited in their ability to transfer knowledge from one situation to another. By the schoolage years, children are less centered and show the ability to apply and transfer
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PH ORIGINAL ARTICLE C knowledge already gained to an everincreasing variety of situations. Because preschoolers in this study demonstrated their ability to learn health and safety information, knowledge gained during this period serves as a foundation for application of knowledge as children become more cognitively mature. Therefore, pediatric nurse practitioners and other health educators who work with preschoolers need to take every available opportunity to teach the children and their parents about health and safety. Opportunities for pediatric nurses and nurse practitioners to teach and reinforce health and safety knowledge arise when doing anticipatory guidance as part of health maintenance visits and when managing care related to acute injuries and health problems. As active members of the community, these nurses can provide information through various modalities such as parent education classes, health fairs, and parish nursing. Health and safety education must become a pervasive theme of health care, particularly for preschoolers and their families. Laying the foundation for such knowledge early in life will hopefully help prevent childhood accidents and help the child
Mobley & Evashevski
establish behavior patterns that will lead to a long and healthy life.
REFERENCES Agran, P., Winn, D., & Anderson, C. (1997). Child occupant protection in motor vehicles. Pediatrics in Review, 18, 413-423. Anderson, R. N., Kochanek, K. D., & Murphy, S. L. (1997). Report of final mortality statistics, 1995. Monthly Vital Statistics Report, 45(11)(Suppl. 2). Hyattsville, MD: National Center for Health Statistics. Arneson, S. W., & Triplett, J. L. (1990). Riding with Bucklebear: An automobile safety program for preschoolers. Journal of Pediatric Nursing, 5, 115122. Athey, A. M. (1995). Pediatric injury control: Strategies for the nurse practitioner. Nurse Practitioner Forum, 6, 167-172. Cohen, J. (1977). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum Associates. D’Agostino, C., D’Andrea, T., Lieberman, L. Sprance, L., & Williams, C. L. (1999). Healthy Start: A new comprehensive preschool health education program. Journal of Health Education, 30, 9-12. Eichelberger, M. R., Gotschall, C. S., Feely, H. B., Harstad, P., & Bowman, L. M. (1990). Parental attitudes and knowledge of child safety. American Journal of Diseases of Children, 144, 714-720. Fraiberg, S. H. (1959). The magic years: Understanding and handling the problems of early childhood. New York: Charles Scribner. Ginsburg, H., & Opper, S. (1969). Piaget’s theory of intellectual development: An introduction. Englewood Cliffs, NJ: Prentice-Hall.
Maheady, D. C. (1986). Health concepts of preschool children. Pediatric Nursing, 12, 195-197. Mobley, C. E. (1996). Assessment of health knowledge in preschoolers. Children’s Health Care, 25, 11-18. Peterson, L., & Saldana, L. (1996). Accelerating children’s risk for injury: Mothers’ decisions regarding common safety rules. Journal of Behavioral Medicine, 19, 317-331. Peterson, L., & Stern, B. L. (1997). Family processes and child risk for injury. Behavior Research and Therapy, 35, 179-190. Rodriguez, J. G. (1990). Childhood injuries in the United States: A priority issue. American Journal of Diseases of Children, 144, 625-626. Sewell, K. H., & Gaines, S. K. (1993). A developmental approach to childhood safety education. Pediatric Nursing, 19, 464-466. Sloan, K. A. (1990). The Safety Seal Injury Prevention Program: A response to the epidemic of injury and death in children. Journal of Emergency Nursing, 16, 83-89. Williams, C. L., Squillace, M. M., Bollella, M. C., Brotanek, J., Campanaro, L., D’Agostino, C., Pfau, J., Sprance, L., Strobino, B. A., Spark, A., & Boccio, L. (1998). Healthy Start: A comprehensive health education program for preschool children. Preventive Medicine, 27, 216-223. Wortel, E., De Geus, G. H., Kok, G., & Van Woerkum, C. (1994). Injury control in pre-school children: A review of parental safety measures and the behavioral determinants. Health Education Research, 9, 201-213. Wurtele, S. K., Kast, L. C., Miller-Perrin, C. L., & Kondrick, P. A. (1989). Comparison of programs for teaching personal safety skills to preschoolers. Journal of Counseling and Clinical Psychology, 57, 505-511.
Pediatric Pearl Removal of Cerumen Two or three drops of docusate sodium (Colace) inserted into an ear canal filled with cerumen dissolves the obstructive wax, allowing easy removal with a cerumen scoop or irrigation. Catherine Burns, PhD, RN, CPNP Portland, Oregon
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PH C
ABSTRACT
Introduction: The purpose of this study was to establish the validity, reliability, and utilization of a revised and expanded Preschool Health and Safety Knowledge Assessment (PHASKA), an instrument evaluating health and safety knowledge of young children, on a diverse group of preschool children. Methods: This study included 308 children (133 boys and 175 girls) ranging in age from 28 to 80 months (M = 53.7 months). The PHASKA was administered to children at 6 preschools and 5 health fairs on an individual basis. Results: Scores on the PHASKA ranged from 1 to 49 (out of a possible 50 points), with a mean score of 37.25. Ninety-seven percent of the children older than age 3 years completed the assessment. No significant differences attributable to gender were found. However, significant age group differences were found [F (7, 300) = 31.09, P <.0001]. In general, items related to safety were learned first, followed by those related to hygiene, health promotion, and nutrition. Discussion: Preschoolers’ scores on the PHASKA showed significant improvement with age, supporting the assertion that preschoolers are ready and willing learners of health and safety knowledge. Children rapidly gain health and safety knowledge between 31⁄2 and 51⁄2 years of age and master much of this content by their sixth birthday. The PHASKA was shown to be appropriate for determining health and safety knowledge scores for preschoolaged children. J Pediatr Health Care. (2000). 14, 160-165.
160
Evaluating Health and Safety Knowledge of Preschoolers: Assessing Their Early Start to Being Health Smart C a r y l E . M o b l e y, P h D, R N , C P N P, & Jo a n E va s h e v s k i , M S , R N
A
ccidental injury is the leading cause of death for children ages 1 to 14 years in the United States. In 1995, 5824 children in this age group died as a result of accidents, which represents 39% of deaths from all causes for these ages (Anderson, Kochanek, & Murphy, 1997). Sixteen million children require emergency medical care each year, of whom 600,000 require hospitalization and 30,000 sustain serious or permanent damage (Rodriguez, 1990). Another threat during childhood is the onset of poor health habits. Many preventable chronic illnesses seen in adults have their foundation in behaviors established during childhood. For example, two of the risk factors for heart disease—hypercholesterolemia and obesity—are prevalent by the preschool years (Williams et al., 1998). Williams et al. stated that one of the premises of the “Healthy Start” program is that teachers can have a strong influence over health behavior and antecedent risk factors by working with young children and their families. Those who provide health education need to have baseline knowledge about what young children are learning to develop appropriate programs. Wortel, De Geus, Kok, and Van Woerkum (1994) explored the child–environment interaction that can make a child at risk for injury. They postulated 3 types of strategies to prevent injury: adoption of safety measures, supervision of the child, and education of the child about safety measures. Adopting safety measures includes complying with strategies mandated through legislation that regulate safety practices (eg, use of seat belts and car seats) and using structural measures that do not require any actions by the child or parent (eg, use of fire-retardant cloth in children’s pajamas). Caryl E. Mobley is an Associate Professor at Texas Woman’s University, Dallas. Joan Evashevski is currently doing volunteer work with women’s support groups. Reprint requests: Caryl E. Mobley, PhD, RN, CPNP, Texas Woman’s University, 1810 Inwood Rd, Dallas, TX 75235. Copyright © 2000 by the National Association of Pediatric Nurse Associates & Practitioners. 0891-5245/2000/$12.00 + 0 25/1/103954 doi:10.1067/mph.2000.103954
July/August 2000
PH ORIGINAL ARTICLE C Although these types of measures are widely recognized as being the most effective strategies (Agran, Winn, & Anderson, 1997), many safety situations exist for which legislation and structural measures cannot be applied (Peterson & Saldana, 1996). As a result, education and supervision are also essential, especially for preschool-aged children. Certain characteristics of preschoolaged children make this an ideal time to teach them health and safety knowledge. Their curiosity and desire to master tasks enable them to readily absorb concrete information that is presented using visual, auditory, and motor strategies. Repetitive activities in which they are physically as well as cognitively involved facilitate learning (Sewell & Gaines, 1993). However, preschool children are not reliable decision makers about health and safety behaviors. Their cognitive processes have not developed to the point where they can understand complex cause-and-effect relationships, and their worlds are still very much ruled by fantasy (Athey, 1995). Their thinking is very concrete in that preschoolers think about what they can see and have proof of; they can only work with information that is available to them, not that with which they have had no experience (Fraiberg, 1959). They center, or concentrate, on one aspect of a situation and can only focus on a limited amount of information (Ginsburg & Opper, 1969). As a result, they remain vulnerable to injuries, and parents must continue to monitor their activities while they are learning. Strategies that have been used successfully to teach preschoolers about health and safety promotion involve primarily modification of behavior. Wurtele, Kast, Miller-Perrin, and Kondrick (1989) compared two types of educational programs in Head Start preschools. One program was a behavioral skills training program and taught the children a rule to follow when handling inappropriate touch. The other program was a “feelings” program and focused on the feelings a child has when touched inappropriately. Although both programs were effective in teaching knowledge and skills, children in the “feelings” program had difficulty differentiating between appropriate and inappropriate touch. “Healthy Start,” a comprehensive health education program for preschool-
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ers that focuses on decreasing children’s risk for cardiovascular disease, uses a behaviorally oriented curriculum and actively involves children through games, hands-on experiments, and skill rehearsal (D’Agostino, D’Andrea, Lieberman, Sprance, & Williams, 1999). Although school-aged children derive their knowledge of health and safety from many sources, including family, school, and community organizations, parental teaching and role modeling is the primary source of knowledge for preschool-aged children. Part of the young child’s socialization process involves a cyclical pattern in which parents strive to provide knowledge and guidance for their children to help prevent accidental injury. For this process to be effective, the child must be responsive to the parental attempts (Peterson & Stern, 1997). As children get older and more independent and show that they can apply the parents’ teaching, parents tend to allow them to make more decisions about their health care (Arneson & Triplett, 1990).
M
any preventable
chronic illnesses seen in adults have their foundation in behaviors established during childhood.
At a time when the health care system is under considerable review and attempts to contain health care costs are an economic priority, prevention of injuries and illness and the human and monetary costs that go with them takes on heightened importance. In the fields of health promotion and injury prevention, research that explores how we can best educate our very young to achieve a lifetime of optimal health is of utmost importance. Most research with this age group has involved development of educational programs (Arneson & Tripplett, 1990;
Sloan, 1990; Williams et al., 1998). However, little is known about the level of preschoolers’ health and safety knowledge. In one study on knowledge of health-related concepts, Maheady (1986) found that preschoolers are in the process of gaining this knowledge. However, measurement of such knowledge has focused on determining the health knowledge of the parent rather than assessing the knowledge of the child (Eichelberger, Gotschall, Feely, Harstad, & Bowman, 1990). To effectively evaluate health and safety education knowledge of young children, an instrument is needed that is appropriate to preschoolers’ cognitive and linguistic levels and that can hold their attention. In 1990, Mobley developed and began pilot testing a nonverbal method of assessing health and safety knowledge that met these criteria (Mobley, 1996). The instrument, called the Preschool Health Knowledge Assessment, was shown to be an effective measure. The study suggested that preschoolers are rapidly gaining this important knowledge. The study also pointed out ways to improve the instrument by adding more advanced content. Prior to the current study, this instrument was revised, expanded, and formatted for computerized reproduction and was renamed the Preschool Health and Safety Knowledge Assessment (PHASKA). The purpose of this study was to evaluate the validity, reliability, and utilization of a revised and expanded form of the instrument on a diverse group of preschool children.
METHOD Sample The subjects for this study included 308 children (133 boys and 175 girls) ranging in age from 28 to 80 months (M = 53.7 months). Including subjects younger and older than the usual age parameters for preschoolers allowed a clearer evaluation of whether this instrument was specific in applicability to this age group. Using a significance level of .05 and a calculated effect size of 0.835, the power for this sample size was greater than 99% (Cohen, 1977). Researchers used a convenience sampling and sought recruitment sites that offered an ethnically and socioeconomically diverse population. The sample was predominantly White (69%), with 16% Black and 10%
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ment experts reviewed the instrument to evaluate face and content validity, and the instrument was revised based on their input. Reliability was examined using the test/retest method. Fortythree (14%) of the children were retested within 2 hours of the first test. The test/retest correlation coefficient for the total score was r = 0.88, P < .001. Internal consistency was computed using Cronbach’s α. Coefficient α on the last 50 items was .51.
Procedure
FIGURE
Sample item from the Preschool Health and Safety Knowledge
Assessment.
Hispanic subjects. Annual family income varied, with 28% having incomes less than $20,000, 17% in the $20,00 to $39,999 range, 19% in the $40,000 to $59,999 range, and 36% at $60,000 or higher. A majority of the parents were well educated, with 75% of the fathers and 81% of the mothers having at least some college education. Before initiation of data collection, permission to conduct the research was obtained from the Human Subjects Review Committee at Texas Woman’s University. All data were identified using a numeric code to protect the confidentiality of the children and their families. Researchers recruited and assessed children at day care centers and health fairs. In both settings, they gave parents written explanations and consent forms. Preschoolers received a brief verbal explanation of the project and were asked to participate.
Instrumentation The PHASKA consists of 53 items. Each item is represented by a card showing pictures that depict various healthy/ unhealthy and safe/unsafe behaviors or situations that children encounter (Figure 1). The preschooler is asked to point to the picture that best represents a particular health or safety concept. The first 3 items in the instrument are designed to teach the child how to respond to the questions about the pictures. The other 50 items cover household, playground, bicycle, and motor vehicle safety and accident prevention
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(31 items), nutrition (6 items), general hygienic measures (5 items), and health recognition and promotion (8 items). The PHASKA is accompanied by a manual describing the procedure for administering the instrument, the verbal cues that accompany each item, and scoring sheets. The verbal cues are written in both English and Spanish. Each card contains 2 or 3 pictures. On most of the 3-picture cards, one picture is used to set up the situation and the other two pictures represent the choices. One card uses 3 pictures to give the child 3 choices. All pictures are black-andwhite line drawings with color added to highlight the focal behavior or situation. For example, card 33 shown in Figure 1 involves what a child should do if he or she finds a book of matches. The verbal cue that accompanies this card is: “This boy found some matches. What should he do to be safe—strike one to see if it lights, or give the matches to an adult?” Details of the child’s and adult’s facial features are left out to decrease association with any particular ethnic group. Color is used to highlight the book of matches and the fire. The researcher attempted to make the “wrong” alternative something that would appeal to preschoolers so that they would feel equally compelled to select that alternative if they did not know the correct answer. Of the cards that clearly depict the gender of the child, half show boys and half show girls. Acopy of the instrument can be obtained through the first author. A panel of 4 pediatric/child develop-
Four research assistants were trained to administer the PHASKA and achieved an interrater reliability rate of 90% or better with the principal investigator before administering the instrument to children. One of the research assistants was bilingual and administered the instrument to 4 children who spoke only Spanish.
T
o effectively evaluate health and safety
education knowledge of young children, an instrument is needed that is appropriate to preschoolers’ cognitive and linguistic levels and that can hold their attention. Parents were contacted through 6 preschools, 5 health fairs, and personal contacts through community groups. The preschool settings included two centers in predominantly white, middle-to-upper socioeconomic suburban areas, two in predominantly black and Hispanic lower socioeconomic urban areas, and two in a small city with a mixed ethnic population. The classroom teachers sent home consent forms and letters explaining the project. They sent a reminder note home 2 weeks
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PH ORIGINAL ARTICLE C later. Based on enrollment figures for the schools, return rates of consent forms ranged from 30% to 48% for the preschools. The highest return rate occurred in one of the predominantly white, middle-to-upper socioeconomic preschools in an area where a young girl had recently been abducted and murdered. One health fair was in a predominantly white, middle socioeconomic small city outside the metropolitan area, and four health fairs were in predominantly black lower to low-middle socioeconomic suburban areas. Researchers approached parents individually, gave them a brief explanation of the research, and asked them to read and sign the consent forms. More than 90% of those approached whose children fulfilled the study criteria agreed to participate. The PHASKAwas administered individually to the children in a quiet room or area of the preschool or health fair setting. The researcher met each child, gave a brief explanation of the project, and obtained assent. All agreed to participate, although several were reticent and agreed only after they saw other classmates return with smiles and stickers after completing the PHASKA.
RESULTS Total scores on the instrument were computed by summing the number of correct answers. The first 3 items in the PHASKA were not used in total score calculations because their primary purpose was to teach the child how to use the instrument. Out of 50 possible points, scores ranged from 1 to 49, with a mean score of 37.25. A t test computed using gender as the independent variable found no significant differences (t = -0.38, P = .70). Therefore, gender was not used as a variable in further statistical analyses. Only two individual items showed gender differences: girls had greater knowledge about what body parts were considered “private” than did boys (item 37, P < .01) and girls were better able to select a nutritious meal than were boys (item 39, P < .01). The sample was then divided into 8 age groups, each in 6-month increments from age 21⁄2 to 6 years. Ninetyseven percent of the children older than 3 years of age completed the PHASKA, whereas only 37.5% of those younger than 3 years of age who were tested completed it. A one-way analysis of
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variance was performed to analyze age group differences in total test scores. Significant age group differences were found [F (7, 300) = 31.09, P <.0001] (see Table 1). Based on the results of Scheffé procedures, scores for 21⁄2-year-olds were significantly different from scores for all other age groups; scores for 3year-olds, 31⁄2-year-olds, and 4-yearolds were also significantly different from those for all older age groups. The percentage of correct answers for each age group by item were calculated. Table 2 summarizes these findings and shows the earliest age group in which 75% and 90% of the children gave the correct answer. At the 75% correct level, children were considered to be in the process of mastering the content. Children in age groups in which 90.0% or more gave correct answers were considered to have mastered the content.
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hildren were rapidly
gaining health and safety knowledge between 31⁄2 and 51⁄2 years of age and had mastered much of this content by their sixth birthday.
DISCUSSION Results of this study support Maheady’s (1986) assertion that preschoolers are ready and willing learners of health and safety knowledge. Preschoolers’ scores on the PHASKA showed significant improvement with age. Children were rapidly gaining health and safety knowledge between 31⁄2 and 51⁄2 years of age and had mastered much of this content by their sixth birthday. Items related to safety, as a group, were learned first, followed by items related to hygiene, health promotion, and nutrition. Sixtyfive percent of the items in the safety category were learned by 5 years of age.
TABLE 1 Total score means and ranges by age groups and Scheffé test results Group
Age (y)
Sample size
Mean score
Range
1 2 3 4 5 6 7 8
21⁄2 3 31⁄2 4 41⁄2 5 51⁄2 6
8 34 57 54 56 47 36 16
15.75 28.41 32.23 35.50 39.14 42.04 44.36 43.44
1-30 3-47 18-48 15-47 23-48 28-49 29-49 21-49
Age group mean scores were significantly different at a P <.0001 value. Results of Scheffé tests: Group 1 was significantly different from all other groups; Group 2 was significantly different from Groups 4, 5, 6, 7, and 8; Group 3 was significantly different from Groups 5, 6, 7, and 8; and Group 4 was significantly different from Groups 6, 7, and 8.
The patterns of scores were of particular interest. By chance, 50% of the children in all age groups would be expected to get the correct answer when given two choices. However, the younger age groups performed well below 50% on many of the cards. This finding suggests that the “wrong” alternative was compelling enough to encourage the majority of younger age groups to give the incorrect answer. It also suggests that the vast majority of children in the older age groups who gave the correct answer have the prerequisite knowledge as expected. The methodology used in the PHASKA was shown to be appropriate for ascertaining health and safety knowledge scores for children in the preschool age group. Preschoolers from 3 years of age and up were capable of completing the PHASKA. The instrument utilized both verbal and visual cues to help focus the children’s attention on the salient content being tested. In addition, having the children point to their answers involved them behaviorally as well as cognitively in the task, as Sewell and Gaines (1993) suggested. Researchers administering the instrument observed that the preschoolers were very social and inquisitive, just as Athey (1995) proposed. The children appeared to enjoy the one-onone contact with the researchers, and none who participated in the retest procedure showed any hesitancy to complete the instrument a second time.
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TABLE 2 Age groups at which 75% and 90% of children gave correct answers on items Age groups (in years) PHASKA items
75%
90%
Safety 6 Wearing seatbelt 8 Sitting vs standing on swing 11 Playing ball in street vs driveway 12 Walking on fence vs jumping on sidewalk 13 Playing with outlet vs pretending to cook 14 Playing with fan vs reading book 17 Crossing street alone vs with mother 22 Holding handlebars when riding bike 23 Crossing street on green vs red light 26 Swimming alone vs with friend 29 Riding bike on side vs middle of road 30 Riding in cab vs back of truck 33 Lighting match vs giving matches to adult 34 Touching pot on stove 35 Taking candy from a stranger 36 Sitting in seat belt in car 37 Identifying private parts of body 38 Petting a strange dog 40 Getting in car with stranger 41 Handing scissors to friend 42 Running vs walking around pool 44 Wearing helmet vs cap when riding bike 45 Answering door when home alone 46 Running for help vs stop-drop-roll 47 Playing with space heater vs toy 48 Confiding in friend vs trusted adult 49 Playing with ball vs poison 50 Stopping bleeding vs getting help 51 Playing with pills vs leaving untouched 52 Answering phone when home alone 53 Handling gun
3.0 3.5 4.0 4.0 3.5 3.5 3.5 3.0 6.0 3.5 5.0 4.5 4.0 3.5 4.5 3.5 N/A 4.5 4.0 5.5 4.0 4.0 4.5 5.5 3.5 4.0 3.5 4.0 4.0 N/A 4.5
5.0 4.5 5.5 5.0 5.0 5.0 4.5 4.5 N/A 6.0 N/A 5.5 4.5 4.0 5.0 4.5 N/A N/A 5.0 N/A 5.0 5.0 N/A N/A 4.5 4.5 4.5 4.5 4.5 N/A 5.0
Nutrition 4 Soda vs milk 7 Eating food vs dog food 9 Chocolate bar vs raisins 16 Sandwich and apple vs cupcake and chips 21 Apple vs piece of cake 39 Chicken dinner vs pizza dinner
4.0 4.5 5.0 5.0 5.5 5.5
5.5 5.0 N/A N/A 6.0 N/A
Hygiene 15 Brushing teeth after meal vs playing 18 Bathing vs going to bed dirty 27 Washing hands vs playing after using toilet 28 Sneezing into handkerchief vs hand 32 Brushing teeth after snack
4.5 3.5 4.5 4.0 4.5
N/A 4.0 5.0 5.5 5.5
Health Promotion 5 Point to child who feels sick 10 Staying up late vs sleeping 19 Wearing proper clothes on a cool day 20 Good posture when sitting 24 Watching TV vs exercising 25 Eating vs not eating meal 31 Standing upright vs holding abdomen 43 Adults smoking vs not smoking
3.0 5.5 4.5 5.0 6.0 3.0 3.5 3.5
4.5 N/A 5.5 N/A N/A 3.5 4.5 5.0
N/A indicates that none of the age groups achieved the appropriate percentage correct.
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Generalizability of the results is limited because of several factors related to sampling. One limitation was the use of convenience sampling. Another was that all subjects lived within a single large metropolitan area. Researchers tried to obtain a diverse sample, but situational and demographic characteristics of the population being sampled led to a higher than desired representation of children from white middle and upper socioeconomic families. Therefore, further research is needed to determine the generalizability of this instrument to a diverse population. Reliability of the PHASKA, based on test/retest data, was high. Internal consistency, as measured by Cronbach’s α, was lower. This finding was not surprising because of the wide variation in ages and developmental levels of children represented in the sample and because of the variety of health and safety knowledge areas being tested. The reliability and validity of this instrument should continue to be studied on larger and more diverse groups of preschoolers. Further research also needs to be done, using the PHASKA, on the relationship between the level of health and safety knowledge in young children and the occurrence of injury accidents. The interaction between health and safety knowledge and health and accident risk factors is another important field of inquiry. This type of data is not currently available. At a time when evidence-based health care is becoming the standard, determining the links between education and health and safety outcomes is very important. Parents, teachers, and health care providers cannot assume that preschool children will use the knowledge demonstrated on the PHASKA, or any other knowledge-based instrument, in a given situation and therefore cannot feel safe in decreasing their monitoring of young children’s activities. Also, the learning capabilities of preschool children limit the inferences that can be made about their utilization of knowledge. It is well known that preschool-age children concentrate on a particular aspect of a situation rather than see a situation from various perspectives (Ginsburg & Opper, 1969) and that they are very limited in their ability to transfer knowledge from one situation to another. By the schoolage years, children are less centered and show the ability to apply and transfer
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PH ORIGINAL ARTICLE C knowledge already gained to an everincreasing variety of situations. Because preschoolers in this study demonstrated their ability to learn health and safety information, knowledge gained during this period serves as a foundation for application of knowledge as children become more cognitively mature. Therefore, pediatric nurse practitioners and other health educators who work with preschoolers need to take every available opportunity to teach the children and their parents about health and safety. Opportunities for pediatric nurses and nurse practitioners to teach and reinforce health and safety knowledge arise when doing anticipatory guidance as part of health maintenance visits and when managing care related to acute injuries and health problems. As active members of the community, these nurses can provide information through various modalities such as parent education classes, health fairs, and parish nursing. Health and safety education must become a pervasive theme of health care, particularly for preschoolers and their families. Laying the foundation for such knowledge early in life will hopefully help prevent childhood accidents and help the child
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establish behavior patterns that will lead to a long and healthy life.
REFERENCES Agran, P., Winn, D., & Anderson, C. (1997). Child occupant protection in motor vehicles. Pediatrics in Review, 18, 413-423. Anderson, R. N., Kochanek, K. D., & Murphy, S. L. (1997). Report of final mortality statistics, 1995. Monthly Vital Statistics Report, 45(11)(Suppl. 2). Hyattsville, MD: National Center for Health Statistics. Arneson, S. W., & Triplett, J. L. (1990). Riding with Bucklebear: An automobile safety program for preschoolers. Journal of Pediatric Nursing, 5, 115122. Athey, A. M. (1995). Pediatric injury control: Strategies for the nurse practitioner. Nurse Practitioner Forum, 6, 167-172. Cohen, J. (1977). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum Associates. D’Agostino, C., D’Andrea, T., Lieberman, L. Sprance, L., & Williams, C. L. (1999). Healthy Start: A new comprehensive preschool health education program. Journal of Health Education, 30, 9-12. Eichelberger, M. R., Gotschall, C. S., Feely, H. B., Harstad, P., & Bowman, L. M. (1990). Parental attitudes and knowledge of child safety. American Journal of Diseases of Children, 144, 714-720. Fraiberg, S. H. (1959). The magic years: Understanding and handling the problems of early childhood. New York: Charles Scribner. Ginsburg, H., & Opper, S. (1969). Piaget’s theory of intellectual development: An introduction. Englewood Cliffs, NJ: Prentice-Hall.
Maheady, D. C. (1986). Health concepts of preschool children. Pediatric Nursing, 12, 195-197. Mobley, C. E. (1996). Assessment of health knowledge in preschoolers. Children’s Health Care, 25, 11-18. Peterson, L., & Saldana, L. (1996). Accelerating children’s risk for injury: Mothers’ decisions regarding common safety rules. Journal of Behavioral Medicine, 19, 317-331. Peterson, L., & Stern, B. L. (1997). Family processes and child risk for injury. Behavior Research and Therapy, 35, 179-190. Rodriguez, J. G. (1990). Childhood injuries in the United States: A priority issue. American Journal of Diseases of Children, 144, 625-626. Sewell, K. H., & Gaines, S. K. (1993). A developmental approach to childhood safety education. Pediatric Nursing, 19, 464-466. Sloan, K. A. (1990). The Safety Seal Injury Prevention Program: A response to the epidemic of injury and death in children. Journal of Emergency Nursing, 16, 83-89. Williams, C. L., Squillace, M. M., Bollella, M. C., Brotanek, J., Campanaro, L., D’Agostino, C., Pfau, J., Sprance, L., Strobino, B. A., Spark, A., & Boccio, L. (1998). Healthy Start: A comprehensive health education program for preschool children. Preventive Medicine, 27, 216-223. Wortel, E., De Geus, G. H., Kok, G., & Van Woerkum, C. (1994). Injury control in pre-school children: A review of parental safety measures and the behavioral determinants. Health Education Research, 9, 201-213. Wurtele, S. K., Kast, L. C., Miller-Perrin, C. L., & Kondrick, P. A. (1989). Comparison of programs for teaching personal safety skills to preschoolers. Journal of Counseling and Clinical Psychology, 57, 505-511.
Pediatric Pearl Removal of Cerumen Two or three drops of docusate sodium (Colace) inserted into an ear canal filled with cerumen dissolves the obstructive wax, allowing easy removal with a cerumen scoop or irrigation. Catherine Burns, PhD, RN, CPNP Portland, Oregon
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