- Email: [email protected]
The lifestyle questionnaire for school-aged ■ children: A tool for primary care ■
The Lifestyle Questionnaire for School-aged 9 Children: A Tool for Primary Care 9 Carol A. VanAntwerp,
M S , R N , PNP, CS
The Lifestyle Questionnaire for School-Aged Children can be used by nurse practitioners in the primary care setting to enhance assessmentand focus health teaching. A survey of 75 school-aged children seen for well child examinations is highlighted, illustrating how nurse practitioners can use the Lifestyle Questionnaire to assesslifestyle patterns and promote healthy behaviors and habits. J PEDIATRICHEALTH CARE. (1 995). 9, 2 5 1 - 2 5 5 .
C h i l d r e n ' s lifestyles affect their adult health and their current well-being. Therefore it is critical to assess lifestyle patterns during health professionals' encounters with children. Nurse practitioners, with their tradition of providing primary care and focusing on prevention, are in a unique position to positively impact children's health. Prevention saves money, and intervention programs such as campaigns to increase the use of bicycle helmets have been effective. The Lifestyle Questionnaire for School-aged Children (LQ) is a tool nurse practitioners Can use to promote health and prevent injuries. 9 THE LIFESTYLE QUESTIONNAIRE FOR SCHOOL-AGE CHILDREN
The L Q was developed by two nurse educators at Bronson School of Nursing in ICalamazoo, Michigan, in 1988. Teachers at a local elementary school contacted staffmembers at Bronson Methodist Hospital for assistance in developing a screening tool for a health fair they were planning (VanAntwerp & Spaniolo, 1991). Bronson Methodist Hospital was known in the region for sponsoring yearly child health fairs that focused on health promotion and injury prevention. The content of the L Q was based on childhood mortality and morbidity statistics and on recommendations from such organizations as the American Academy of Pediatrics. The University of Wisconsin-Stevens Point Foundation (1978) Lifestyle Assessment Questionnaire for adults was also helpful in the development of the LQ. The L Q focuses on health promotion (11 items), injury prevention (14 items), and feelings (5 items) (Box 1). The original L Q has had minor revisions; the most significant change is the addition of a Likert-type response Carol A. VanAntwerp, MS, RN, PNP, CS, is a Pediatric Nurse Practitioner for
Rambling Road Pediatrics in Kalamazoo, Michigan. Reprint requests: Carol A. VanAntwerp, MS, RN, PNP, CS, Rambling Road Pediatrics, 2490 South 1 lth St., Kalamazoo, MI 49009. Copyright 9 1995 by the National Association of Pediatric Nurse Associates and Practitioners. 0891-5245/95/$5.00 + 0 25/1/63880 JOURNAL OF PEDIATRIC HEALTH CARE/November-December 1995
scale: "never," "sometimes," "usually," or "always." The L Q was developed for use with children and their parents. Initially, the LQ served two purposes. For the child and parent, it increased awareness of activities that promote health and prevent injury. For school staff members, it provided data so that the health education needs of the students could be identified. For nurse practitioners in primary care, the L Q provides pertinent information that directs anticipatory guidance and health teaching. The nurse practitioner can quickly scan the responses and identify areas that require education. For example, the child may report wearing a seat belt, but not a bicycle helmet. Thus counseling can focus on helmet use.
T h e nurse practitioner can quickly scan the responses and identify areas that require education. i
9 HEALTH A N D INJURY RISKS
Injuries cause almost 40% of the deaths among children 1 to 4 years of age and almost 70% of all deaths of children 5 to 14 years of age. Injuries lead to 20% of all hospitalizations among children (Center for Disease Control, 1990). Four hundred thousand children and adolescents are seen in emergency rooms each year as a result of bicycle-related injuries; 600 of these victims die. Head injury is the leading cause of hospital admission as the result of bicycle injuries and the number one contributor to death and severe morbidity (Brown, 1992). Yet bicycle helmets can reduce the risk of bicycle-related head injuries by 85% (Rivara et al., 1994). Residential injuries, responsible for 2,700 deaths of children through age 14 years in 1989 ( Jones, 1993), are an important cause of death and injury. House fires, suffocation and asphyxiation, falls, and poisoning are the most common causes of fatal injuries in the home (Jones, 1993). Christoffel (1994) reports that suicide and homi251
252
Journal of Pediatric Health Care Volume 9, Number 6
VanAntwerp
• BOX 1
Lifestyle Questionnaire for School-aged Children Please place check mark in the column to the right that describes how often you do the activity on the left. (see meaning of terms below)
Never
Sometimes
Usually
Always
1
2
3
4
ACTIVITIES THAT PROMOTE HEALTH
1. I sleep at least 8 hours every night. 2. I brush my teeth twice a day. 3. I visit the dentist every year. 4. I watch less than 2 hours of TV every day. 5. I exercise (running, biking, swimming, active sports) 1 hour every day. 6. I eat fruits every day. 7. I eat vegetables every day. 8. I limit my intake of salty snacks and high-sugar snacks. 9. I have a physical examination every 2 or 3 years. 10. I say "no" to smoking cigarettes. 11. I stay away from alcohol.
5% 1% 1%
4% 35% 70/o 39%
23% 36% 6% 39%
73% 24% 86% 21%
1% 1% 5% 3%
15o/0 15O/o 190/0 35% 10%
36% 25% 36% 42% 22% 1%
49o/0 59% 44o/0 18O/o 65% 90o/0 1000/0
3% 3%
12% 18% 30% 13% 10% 6% 8% 3% 1% 21%
lO/o 5% 1%
3% 12%
88O/o 81% 63% 87% 33% 86% 86% 97% 96% 76% 1000/0 98% 72% 83%
17% 22% 40% 19% 15%
62% 780/o 36% 720/o 81%
INJURY PREVENTION
12. I wear a seat belt in an automobile. 13. I look both ways when crossing streets. 14. I follow bike safety rules. 15. I stay away from lighters or matches. 16. I wear a helmet when I go on bike trips. 171 swim with a buddy. 18. I wear a life jacket when I ride in a boat. 19. I take medicine only with my parent's permission. 20. I stay away from real guns. 21. I tell my parents where I am going. 22. I say "no" to drugs. 23. Our home has a smoke detector that works. 24. Our home has a fire extinguisher. 25. If there is a fire, I know a safe way out of my house.
1% 1%
6%
43% 1% 2%
14% 5% 4%
1% 20% 4%
FEELINGS
21%
26. I think it is okay to cry. 27. I enjoy my family. 28. It is easy for me to fall asleep at night. 29. My appetite is good. 30. I like myself just the way I am.
3% 1%
21% 8O/o 4%
*Copyrighted by Anna Mae Spaniolo and Carol VanAntwerp, 1988; Bronson School of Nursing, Kalamazoo, MI. Revised 1993 Never: Not ever done. Your a g e : Sometimes: Occasionally, as I feel the need, I do this. Usually: Most of the time, but not always, I do this. Always: With rare exceptions, I do this all the time.
cide cause about 22% o f the deaths in the childhood and adolescent years and 35% o f all injury deaths. African American male teens are especially vulnerable to death caused by the use of firearms. In the United States, 14 children and adolescents die in gun-related homicides, suicides, and accidents each day (Center to
Your grade:
Your sex: M
F
Prevent Handgun Violence, I994). The common belief is that keeping a gun in the home will protect family members and property from crime. Unfortunately, research suggests that keeping a gun in the home may have unexpected dangerous consequences for families. Eighty-eight percent o f children who are hurt or killed
Journal of Pediatric Health Care November-December 1995
VanAntwerp 253
•
BOX 2
RESOURCES
American Academy of Pediatrics, Division of Publications, 141 Northwest Point Blvd., P.O. 927, Elk Grove, IL 60009-0927 Growing Up Healthy--Fat, Cholesterol and More Alcohol: Your Child and Drugs A Guide to Children's Dental Health Tobacco Use: A Message to Parents and Teens Bicycle TIPP Economy Pack Growing Up Drug Free: A Parents Guide to Prevention Free booklet on how to talk with children about drugs. Telephone (800)-624-0100 National Federation of Parents for a Drug - Free Youth. P.O. Box 3878 St. Louis, MO 63122 Provides information on starting parent peer groups. TIPP Information: Sandoz Pharmaceuticals Corporation Bicycle Safety Dept. 59 Rte. 10, Bldg. 701, 3rd. Floor East Hanover, NJ 07936-1951 Telephone (800)-765-TIPP 10 Tips To Health Eating for Kids International Food Information Council 1100 Connecticut Ave., N.W. Suite 430 Washington, DC 20036 STOP Program and Straight Talk About Risks: A Pre K - 12 Curriculum for Preventing Gun Violence. Center to Prevent Handgun Violence National Headquarters 1225 Eye Street, N.W. Room 1150 Washington, DC 20005 Telephone (202)289-7319 Fax (202)408-1851
in accidental shootings are shot in their own homes or in the homes o f friends or relatives (Center to Prevent Handgun Violence, 1994). The American Heart Association Fact Sheet (1993) estimates that nine million children under the age o f 5 years live with at least one smoker and that every day 3,000 young people begin smoking. Most teen smokers are addicted to nicotine. Those teens who become addicted to tobacco increase their risk for smoke-related illnesses and premature death. The Surgeon General's report on preventing tobacco use among young people warns that nearly all first use o f tobacco occurs by age 18 years (Elders, Perry, Eriksen, & Giovino, 1994). Tobacco is often the first drug used by young people who later use illicit drugs and engage in other risktaking behaviors. The report concludes that adolescence is a critical time o f life to prevent tobacco use and its consequences because the years from 10 to 18 are
when initiation, regular use, and dependence begin (Elders et al., 1994). It is clear from this brief review that American children are at risk for injury and that tobacco use and second-hand smoke are problems for millions. To find support for the benefits o f a healthy lifestyle, it is helpful to look at the work o f Dr. Lester Breslow, physician and professor emeritus at the University of California at Los Angeles. H e has conducted a 30-year research project o f people who are leading long, healthy lives. He has identified seven lifestyle habits associated with longevity and better health: no excessive drinking, not smoking, staying lean, sleeping 7 to 8 hours a night, exercising regularly, not eating between meals, and eating breakfast daily. H e found that study participants had about the same physical well-being as those people 30 years younger who practiced few or none o f the habits (Breslow & Breslow, 1993). Obviously, those caring for
254
Journal of Pediatric Health Care Volume 9, Number 6
VanAntwerp
children would not advocate any use of alcohol, but other habits could be encouraged without great cost to the patient. 9 SURVEY RESPONSES
Seventy-five school-aged children (46 girls, 29 boys) who had appointments for a well child examination with a nurse practitioner were surveyed. A brief explanation was given to the parent and child with instructions to complete the LQ together before the physical examination. Parents and children responded positively to completing the LQ; there were no refusals. The practice setting was a private pediatric office with 25,000 patients. Eighty-three percent of these patients were covered by traditional insurance companies or health maintenance organizations; 14% had Medicaid coverage, and 3% were self-pay. The Figure shows the findings for all 75 patients.* The following list includes the major findings: (a) Although 86% of the children reported always visiting a dentist each year, only 24% always brush their teeth twice a day. (b) Seventy-three percent of the children always sleep at least 8 hours each night; 23% usually do; 4% say sometimes. (c) Although 88% of the children report that they always wear a seat belt, only 33% always wear a bicycle helmet; 43% of the children state they never wear a bicycle helmet. (d) Twenty-one percent of the children always watch less than 2 hours of television every day; 39% answered usually; 39%, sometime. (e) Fewer than one half (49%) of the children always exercise 1 hour daily; 36%, usually; 15%, sometime. (f) Eighteen percent of the children always limit their intake of salty and high-sugar snacks; 42%, usually; 35%, sometime; 5%, never. (g) All but 2% of the children stated that they always had a working smoke detector although only 72% always had a fire extinguisher; 20% had no fire extinguisher. (h) Ninety-six percent of the children always stay away from real guns; 1% usually do; 3%, sometime. (i) All the children surveyed reported saying "no" to drugs and not drinking alcohol; 99% always say "no" to smoking cigarettes.
(j) Seventy-eight percent of the children always enjoy their family; 22% usually do. (k) Eighty-one percent of the children always like themselves just the way they are; 15% answered usually; 4%, sometime. (1) Thirty-six percent of the children always find falling asleep at night easy; 40% wrote usually; 21%, sometime; 3%, never. 9 DISCUSSION
The children surveyed at the time of their well child examination had relatively good health habits, for example, regular use of seat belts, adequate sleep, avoidance of drugs, alcohol, and cigarettes. Areas of concern included the responses to questions about bicycle helmet use, exercise, television viewing, and nutrition. Fewer than one half of the children exercise 1 hour daily; 79% report watching more than 2 hours of television daily. This reported inactivity coupled with the large number of children who do not limit their intake of salty and high-sugar snacks puts them at risk for obesity and related cardiovascular disease states. Parents usually voiced surprise if their children reported they did not "always" or "usually" fall asleep easily. Most parents did not believe this was a problem. When children were asked why they had trouble falling asleep easily, they might shrug or mention a sibling bothering them in some way, for example, "my sister's radio is too loud" or "my brother comes in and jumps on my bed." Comments by parents and children can be noted on the LQ itself where answers can later be reviewed to help the nurse practitioner understand responses more fully and identify misconceptions and the need for health education. "Kelsey" typifies many of the school-aged girls who were seen. At 9 years of age, she completed the LQ and revealed that she "usually" followed bicycle safety habits but "never" wore a bicycle helmet. She was counseled regarding bicycle safety rules and use of a helmet. Kelsey's mother was given a coupon for an approved helmet, and Kelsey was shown pictures of the various attractive helmets available. Two years later, Kelsey's LQ responses indicated she "always" followed bicycle safety rules and "always" wore a helmet. At both visits Kelsey received positive reinforcement for the health promotion and injury prevention activities she engaged in. 9 I M P L I C A T I O N S FOR PRACTICE
*The author cautions the reader to note that the purpose of sharing these responses is to inform nurse practitioners how the LQ can be useful in the primary care setting. It is not the intent of the author to assert that these responses are representative of school-aged children. The age breakdown was as follows: 16 five-year-old children, 6 six-year-old children, 12 seven-year-old children, 9 eight-year-old children, 12 nine-year-old children, 4 ten-year-old children, 4 eleven-year-old children, and 10 twelve-year-old children. Two children did not put their ages on the LQ. No attempt was made to ascertain the socioeconomic status of children who were surveyed. The reliability and validity of the LQ have not yet been established.
The LQ can be used to study groups of patients in a practice, for example, to note trends of drug, alcohol, and tobacco use and the use of seat belts and bicycle helmets. This could assist the health care providers in a practice to develop strategies to deal with these problems. The LQ can also be used to assess the impact of health teaching and anticipatory guidance with indi-
Journal of Pediatric Health Care November-December 1995
vidual patients. The nurse practitioner can look at responses made at one visit and compare these responses made at a follow-up visit for a physical examination. The nurse practitioner may engage in research with the L Q and analyze responses on the L Q to assess whether differences are noted by age or sex or geographic locale, for example, rural versus urban dwellers. Box 2 contains a list o f resources the nurse practitioner can use to order pamphlets to distribute to families at the time o f the visit. Community-wide efforts that p r o m o t e the use o f seat belts and bicycle helmets, programs for drug prevention, and antismoking campaigns enhance the efforts made in primary care settings. Giving discount coupons for bicycle helmets at the time o f the well child examination is very helpful. In Seattle, Washington, helmet use a m o n g school-aged children increased from about 5% in 1987 to 60% in the fall o f 1993 after an extensive community-wide campaign (Rivara et al., 1994). Bicycle-related head injuries a m o n g members o f a health maintenance organization who were 5 to 14 years o f age decreased by about two thirds. Although all parts o f the campaign helped to increase bicycle helmet use and decrease injury rates, it was believed that the discount coupon program "played a central role in lowering the cost and barriers to helmet use" (Rivara et al., 1994, p.568). Giving coupons for bicycle helmets to evoke change in behavior is usually easier than persuading parents and children who are sedentary of the risks o f obesity and benefits o f increased physical activity. Available research lists that the following adult disease states derive benefit from physical exercise: coronary artery disease, systemic hypertension, obesity, emotional disorders, incapacity o f aging, osteoporosis, and diabetes mellitus (Rowland & Freedson, 1994). Rowland and Freedson (1994, p. 671) believe that "the best primary strategy for improving the long-term health o f children and adolescents through exercise may be creating a lifestyle pattern of regular physical activity that will carry over to the adult years rather than p r o m o t i n g childhood physical fitness." Identifying patients who are sedentary and discovering approaches that will trigger interest in and enjoyment o f physical exercise is critical. The L Q can assist the health care provider in the identification o f inactivity and p o o r nutrition. Eliciting information about the physical activities the child has participated in and enjoyed in the past is helpful. Equally important, barriers to exercise must be identified to form a plan o f care. For example, the child may lack interest in physical activity or perceive a lack o f time (e.g., " t o o much h o m e w o r k " ) . Lack o f regular physical activity at school is a problem for many children with a family lifestyle pattern o f overeating and inactivity. Parents' concerns about unsafe neighborhoods and the latchkey child p h e n o m e n o n also pose formidable barriers to exercise for many school-aged children. Sustain-
VanAntwerp 255 ing involvement in exercise into adulthood may be a difficult but worthwhile challenge. Another sensitive area is the issue o f guns in the home. Approaching the topic o f gun risks in the h o m e works best within the larger context o f injury prevention. The Center to Prevent H a n d g u n Violence (1994) reports that approximately 1.2 million latchkey children have access to guns when they come h o m e from school. A 1990 poll o f gun owners revealed that one half kept these guns unlocked. Although the nurse practitioner may be unable to persuade a parent to rid the h o m e o f guns, at the very least, parents should be encouraged to keep guns unloaded and locked.
T
h
e
LQ can also be used to assessthe impact of health teaching and anticipatory guidance with individual patients.
9 CONCLUSION The L Q is a tool nurse practitioners can use to p r o m o t e health and prevent injuries. Lifestyle assessment is critical to the identification o f healthy versus unhealthy lifestyles. Lifestyle assessment enhances the well child examination and can positively impact present and future health practices. 9
REFERENCES American Heart Association of Michigan. (1993). Fact sheet. Southfield, MI: Author. Breslow, L., & Breslow, N. (1993). Health practices and disability: Some evidence from Mameda County. Preventive Medicine, 22, 86-95. Brown, J. (1992). Be HEADstrong! Start a bicyclehelmet campaign! Contemporary Pediatrics, 9, 54-56, 59-60, 62, 64, 70, 72-73. Center to Prevent Handgun Violence and the AmericanAcademy of Pediatrics. (1994). Preventingfirearm injuries among children and adolescents: A public health concern. STOP: Steps to prevent firearm injury. Washington, DC: Author.
Centers for Disease Control. (1990). Childhood injuries in the United States. American Journal of Diseases of Children, 144, 627-646. Christoffel, K. K. (1994). Reducing violence 20- how do we proceed? American Journal of Public Health, 84, 539-541. Elders, J., Perry, C. L., Eriksen, M., & Giovino, G. A. (1994). The report of the Surgeon General: Preventing tobacco use among young people. American Journal of Public Health, 4, 543-547. Jones, N. E. (1993). Childhood residential injuries. Maternal ChiM Nursing, 28, 168-172. Rivara, F. P., Thompson, D. C., Thompson, R. S., Rogers, L. W., Alexander, B., Felix, D., & Bergman, A. B. (1994). The Seattle children's bicycle helmet campaign: Changes in helmet use and head injury admissions. Pediatrics, 93, 567-569. Rowland, T. W., & Freedson, P. S. (1994). Physical activity, fitness, and health. Pediatrics, 93, 669-671. University of Wisconsin 20- Stevens Point Foundation. (1978): Lifestyle assessment questionnaire. Stevens Point, WI: Author. VanAntwerp, C. A., & Spaniolo, A. M. (1991). Checking out children's lifestyles. Maternal Child Nursing, 16, 144-147.
M S , R N , PNP, CS
The Lifestyle Questionnaire for School-Aged Children can be used by nurse practitioners in the primary care setting to enhance assessmentand focus health teaching. A survey of 75 school-aged children seen for well child examinations is highlighted, illustrating how nurse practitioners can use the Lifestyle Questionnaire to assesslifestyle patterns and promote healthy behaviors and habits. J PEDIATRICHEALTH CARE. (1 995). 9, 2 5 1 - 2 5 5 .
C h i l d r e n ' s lifestyles affect their adult health and their current well-being. Therefore it is critical to assess lifestyle patterns during health professionals' encounters with children. Nurse practitioners, with their tradition of providing primary care and focusing on prevention, are in a unique position to positively impact children's health. Prevention saves money, and intervention programs such as campaigns to increase the use of bicycle helmets have been effective. The Lifestyle Questionnaire for School-aged Children (LQ) is a tool nurse practitioners Can use to promote health and prevent injuries. 9 THE LIFESTYLE QUESTIONNAIRE FOR SCHOOL-AGE CHILDREN
The L Q was developed by two nurse educators at Bronson School of Nursing in ICalamazoo, Michigan, in 1988. Teachers at a local elementary school contacted staffmembers at Bronson Methodist Hospital for assistance in developing a screening tool for a health fair they were planning (VanAntwerp & Spaniolo, 1991). Bronson Methodist Hospital was known in the region for sponsoring yearly child health fairs that focused on health promotion and injury prevention. The content of the L Q was based on childhood mortality and morbidity statistics and on recommendations from such organizations as the American Academy of Pediatrics. The University of Wisconsin-Stevens Point Foundation (1978) Lifestyle Assessment Questionnaire for adults was also helpful in the development of the LQ. The L Q focuses on health promotion (11 items), injury prevention (14 items), and feelings (5 items) (Box 1). The original L Q has had minor revisions; the most significant change is the addition of a Likert-type response Carol A. VanAntwerp, MS, RN, PNP, CS, is a Pediatric Nurse Practitioner for
Rambling Road Pediatrics in Kalamazoo, Michigan. Reprint requests: Carol A. VanAntwerp, MS, RN, PNP, CS, Rambling Road Pediatrics, 2490 South 1 lth St., Kalamazoo, MI 49009. Copyright 9 1995 by the National Association of Pediatric Nurse Associates and Practitioners. 0891-5245/95/$5.00 + 0 25/1/63880 JOURNAL OF PEDIATRIC HEALTH CARE/November-December 1995
scale: "never," "sometimes," "usually," or "always." The L Q was developed for use with children and their parents. Initially, the LQ served two purposes. For the child and parent, it increased awareness of activities that promote health and prevent injury. For school staff members, it provided data so that the health education needs of the students could be identified. For nurse practitioners in primary care, the L Q provides pertinent information that directs anticipatory guidance and health teaching. The nurse practitioner can quickly scan the responses and identify areas that require education. For example, the child may report wearing a seat belt, but not a bicycle helmet. Thus counseling can focus on helmet use.
T h e nurse practitioner can quickly scan the responses and identify areas that require education. i
9 HEALTH A N D INJURY RISKS
Injuries cause almost 40% of the deaths among children 1 to 4 years of age and almost 70% of all deaths of children 5 to 14 years of age. Injuries lead to 20% of all hospitalizations among children (Center for Disease Control, 1990). Four hundred thousand children and adolescents are seen in emergency rooms each year as a result of bicycle-related injuries; 600 of these victims die. Head injury is the leading cause of hospital admission as the result of bicycle injuries and the number one contributor to death and severe morbidity (Brown, 1992). Yet bicycle helmets can reduce the risk of bicycle-related head injuries by 85% (Rivara et al., 1994). Residential injuries, responsible for 2,700 deaths of children through age 14 years in 1989 ( Jones, 1993), are an important cause of death and injury. House fires, suffocation and asphyxiation, falls, and poisoning are the most common causes of fatal injuries in the home (Jones, 1993). Christoffel (1994) reports that suicide and homi251
252
Journal of Pediatric Health Care Volume 9, Number 6
VanAntwerp
• BOX 1
Lifestyle Questionnaire for School-aged Children Please place check mark in the column to the right that describes how often you do the activity on the left. (see meaning of terms below)
Never
Sometimes
Usually
Always
1
2
3
4
ACTIVITIES THAT PROMOTE HEALTH
1. I sleep at least 8 hours every night. 2. I brush my teeth twice a day. 3. I visit the dentist every year. 4. I watch less than 2 hours of TV every day. 5. I exercise (running, biking, swimming, active sports) 1 hour every day. 6. I eat fruits every day. 7. I eat vegetables every day. 8. I limit my intake of salty snacks and high-sugar snacks. 9. I have a physical examination every 2 or 3 years. 10. I say "no" to smoking cigarettes. 11. I stay away from alcohol.
5% 1% 1%
4% 35% 70/o 39%
23% 36% 6% 39%
73% 24% 86% 21%
1% 1% 5% 3%
15o/0 15O/o 190/0 35% 10%
36% 25% 36% 42% 22% 1%
49o/0 59% 44o/0 18O/o 65% 90o/0 1000/0
3% 3%
12% 18% 30% 13% 10% 6% 8% 3% 1% 21%
lO/o 5% 1%
3% 12%
88O/o 81% 63% 87% 33% 86% 86% 97% 96% 76% 1000/0 98% 72% 83%
17% 22% 40% 19% 15%
62% 780/o 36% 720/o 81%
INJURY PREVENTION
12. I wear a seat belt in an automobile. 13. I look both ways when crossing streets. 14. I follow bike safety rules. 15. I stay away from lighters or matches. 16. I wear a helmet when I go on bike trips. 171 swim with a buddy. 18. I wear a life jacket when I ride in a boat. 19. I take medicine only with my parent's permission. 20. I stay away from real guns. 21. I tell my parents where I am going. 22. I say "no" to drugs. 23. Our home has a smoke detector that works. 24. Our home has a fire extinguisher. 25. If there is a fire, I know a safe way out of my house.
1% 1%
6%
43% 1% 2%
14% 5% 4%
1% 20% 4%
FEELINGS
21%
26. I think it is okay to cry. 27. I enjoy my family. 28. It is easy for me to fall asleep at night. 29. My appetite is good. 30. I like myself just the way I am.
3% 1%
21% 8O/o 4%
*Copyrighted by Anna Mae Spaniolo and Carol VanAntwerp, 1988; Bronson School of Nursing, Kalamazoo, MI. Revised 1993 Never: Not ever done. Your a g e : Sometimes: Occasionally, as I feel the need, I do this. Usually: Most of the time, but not always, I do this. Always: With rare exceptions, I do this all the time.
cide cause about 22% o f the deaths in the childhood and adolescent years and 35% o f all injury deaths. African American male teens are especially vulnerable to death caused by the use of firearms. In the United States, 14 children and adolescents die in gun-related homicides, suicides, and accidents each day (Center to
Your grade:
Your sex: M
F
Prevent Handgun Violence, I994). The common belief is that keeping a gun in the home will protect family members and property from crime. Unfortunately, research suggests that keeping a gun in the home may have unexpected dangerous consequences for families. Eighty-eight percent o f children who are hurt or killed
Journal of Pediatric Health Care November-December 1995
VanAntwerp 253
•
BOX 2
RESOURCES
American Academy of Pediatrics, Division of Publications, 141 Northwest Point Blvd., P.O. 927, Elk Grove, IL 60009-0927 Growing Up Healthy--Fat, Cholesterol and More Alcohol: Your Child and Drugs A Guide to Children's Dental Health Tobacco Use: A Message to Parents and Teens Bicycle TIPP Economy Pack Growing Up Drug Free: A Parents Guide to Prevention Free booklet on how to talk with children about drugs. Telephone (800)-624-0100 National Federation of Parents for a Drug - Free Youth. P.O. Box 3878 St. Louis, MO 63122 Provides information on starting parent peer groups. TIPP Information: Sandoz Pharmaceuticals Corporation Bicycle Safety Dept. 59 Rte. 10, Bldg. 701, 3rd. Floor East Hanover, NJ 07936-1951 Telephone (800)-765-TIPP 10 Tips To Health Eating for Kids International Food Information Council 1100 Connecticut Ave., N.W. Suite 430 Washington, DC 20036 STOP Program and Straight Talk About Risks: A Pre K - 12 Curriculum for Preventing Gun Violence. Center to Prevent Handgun Violence National Headquarters 1225 Eye Street, N.W. Room 1150 Washington, DC 20005 Telephone (202)289-7319 Fax (202)408-1851
in accidental shootings are shot in their own homes or in the homes o f friends or relatives (Center to Prevent Handgun Violence, 1994). The American Heart Association Fact Sheet (1993) estimates that nine million children under the age o f 5 years live with at least one smoker and that every day 3,000 young people begin smoking. Most teen smokers are addicted to nicotine. Those teens who become addicted to tobacco increase their risk for smoke-related illnesses and premature death. The Surgeon General's report on preventing tobacco use among young people warns that nearly all first use o f tobacco occurs by age 18 years (Elders, Perry, Eriksen, & Giovino, 1994). Tobacco is often the first drug used by young people who later use illicit drugs and engage in other risktaking behaviors. The report concludes that adolescence is a critical time o f life to prevent tobacco use and its consequences because the years from 10 to 18 are
when initiation, regular use, and dependence begin (Elders et al., 1994). It is clear from this brief review that American children are at risk for injury and that tobacco use and second-hand smoke are problems for millions. To find support for the benefits o f a healthy lifestyle, it is helpful to look at the work o f Dr. Lester Breslow, physician and professor emeritus at the University of California at Los Angeles. H e has conducted a 30-year research project o f people who are leading long, healthy lives. He has identified seven lifestyle habits associated with longevity and better health: no excessive drinking, not smoking, staying lean, sleeping 7 to 8 hours a night, exercising regularly, not eating between meals, and eating breakfast daily. H e found that study participants had about the same physical well-being as those people 30 years younger who practiced few or none o f the habits (Breslow & Breslow, 1993). Obviously, those caring for
254
Journal of Pediatric Health Care Volume 9, Number 6
VanAntwerp
children would not advocate any use of alcohol, but other habits could be encouraged without great cost to the patient. 9 SURVEY RESPONSES
Seventy-five school-aged children (46 girls, 29 boys) who had appointments for a well child examination with a nurse practitioner were surveyed. A brief explanation was given to the parent and child with instructions to complete the LQ together before the physical examination. Parents and children responded positively to completing the LQ; there were no refusals. The practice setting was a private pediatric office with 25,000 patients. Eighty-three percent of these patients were covered by traditional insurance companies or health maintenance organizations; 14% had Medicaid coverage, and 3% were self-pay. The Figure shows the findings for all 75 patients.* The following list includes the major findings: (a) Although 86% of the children reported always visiting a dentist each year, only 24% always brush their teeth twice a day. (b) Seventy-three percent of the children always sleep at least 8 hours each night; 23% usually do; 4% say sometimes. (c) Although 88% of the children report that they always wear a seat belt, only 33% always wear a bicycle helmet; 43% of the children state they never wear a bicycle helmet. (d) Twenty-one percent of the children always watch less than 2 hours of television every day; 39% answered usually; 39%, sometime. (e) Fewer than one half (49%) of the children always exercise 1 hour daily; 36%, usually; 15%, sometime. (f) Eighteen percent of the children always limit their intake of salty and high-sugar snacks; 42%, usually; 35%, sometime; 5%, never. (g) All but 2% of the children stated that they always had a working smoke detector although only 72% always had a fire extinguisher; 20% had no fire extinguisher. (h) Ninety-six percent of the children always stay away from real guns; 1% usually do; 3%, sometime. (i) All the children surveyed reported saying "no" to drugs and not drinking alcohol; 99% always say "no" to smoking cigarettes.
(j) Seventy-eight percent of the children always enjoy their family; 22% usually do. (k) Eighty-one percent of the children always like themselves just the way they are; 15% answered usually; 4%, sometime. (1) Thirty-six percent of the children always find falling asleep at night easy; 40% wrote usually; 21%, sometime; 3%, never. 9 DISCUSSION
The children surveyed at the time of their well child examination had relatively good health habits, for example, regular use of seat belts, adequate sleep, avoidance of drugs, alcohol, and cigarettes. Areas of concern included the responses to questions about bicycle helmet use, exercise, television viewing, and nutrition. Fewer than one half of the children exercise 1 hour daily; 79% report watching more than 2 hours of television daily. This reported inactivity coupled with the large number of children who do not limit their intake of salty and high-sugar snacks puts them at risk for obesity and related cardiovascular disease states. Parents usually voiced surprise if their children reported they did not "always" or "usually" fall asleep easily. Most parents did not believe this was a problem. When children were asked why they had trouble falling asleep easily, they might shrug or mention a sibling bothering them in some way, for example, "my sister's radio is too loud" or "my brother comes in and jumps on my bed." Comments by parents and children can be noted on the LQ itself where answers can later be reviewed to help the nurse practitioner understand responses more fully and identify misconceptions and the need for health education. "Kelsey" typifies many of the school-aged girls who were seen. At 9 years of age, she completed the LQ and revealed that she "usually" followed bicycle safety habits but "never" wore a bicycle helmet. She was counseled regarding bicycle safety rules and use of a helmet. Kelsey's mother was given a coupon for an approved helmet, and Kelsey was shown pictures of the various attractive helmets available. Two years later, Kelsey's LQ responses indicated she "always" followed bicycle safety rules and "always" wore a helmet. At both visits Kelsey received positive reinforcement for the health promotion and injury prevention activities she engaged in. 9 I M P L I C A T I O N S FOR PRACTICE
*The author cautions the reader to note that the purpose of sharing these responses is to inform nurse practitioners how the LQ can be useful in the primary care setting. It is not the intent of the author to assert that these responses are representative of school-aged children. The age breakdown was as follows: 16 five-year-old children, 6 six-year-old children, 12 seven-year-old children, 9 eight-year-old children, 12 nine-year-old children, 4 ten-year-old children, 4 eleven-year-old children, and 10 twelve-year-old children. Two children did not put their ages on the LQ. No attempt was made to ascertain the socioeconomic status of children who were surveyed. The reliability and validity of the LQ have not yet been established.
The LQ can be used to study groups of patients in a practice, for example, to note trends of drug, alcohol, and tobacco use and the use of seat belts and bicycle helmets. This could assist the health care providers in a practice to develop strategies to deal with these problems. The LQ can also be used to assess the impact of health teaching and anticipatory guidance with indi-
Journal of Pediatric Health Care November-December 1995
vidual patients. The nurse practitioner can look at responses made at one visit and compare these responses made at a follow-up visit for a physical examination. The nurse practitioner may engage in research with the L Q and analyze responses on the L Q to assess whether differences are noted by age or sex or geographic locale, for example, rural versus urban dwellers. Box 2 contains a list o f resources the nurse practitioner can use to order pamphlets to distribute to families at the time o f the visit. Community-wide efforts that p r o m o t e the use o f seat belts and bicycle helmets, programs for drug prevention, and antismoking campaigns enhance the efforts made in primary care settings. Giving discount coupons for bicycle helmets at the time o f the well child examination is very helpful. In Seattle, Washington, helmet use a m o n g school-aged children increased from about 5% in 1987 to 60% in the fall o f 1993 after an extensive community-wide campaign (Rivara et al., 1994). Bicycle-related head injuries a m o n g members o f a health maintenance organization who were 5 to 14 years o f age decreased by about two thirds. Although all parts o f the campaign helped to increase bicycle helmet use and decrease injury rates, it was believed that the discount coupon program "played a central role in lowering the cost and barriers to helmet use" (Rivara et al., 1994, p.568). Giving coupons for bicycle helmets to evoke change in behavior is usually easier than persuading parents and children who are sedentary of the risks o f obesity and benefits o f increased physical activity. Available research lists that the following adult disease states derive benefit from physical exercise: coronary artery disease, systemic hypertension, obesity, emotional disorders, incapacity o f aging, osteoporosis, and diabetes mellitus (Rowland & Freedson, 1994). Rowland and Freedson (1994, p. 671) believe that "the best primary strategy for improving the long-term health o f children and adolescents through exercise may be creating a lifestyle pattern of regular physical activity that will carry over to the adult years rather than p r o m o t i n g childhood physical fitness." Identifying patients who are sedentary and discovering approaches that will trigger interest in and enjoyment o f physical exercise is critical. The L Q can assist the health care provider in the identification o f inactivity and p o o r nutrition. Eliciting information about the physical activities the child has participated in and enjoyed in the past is helpful. Equally important, barriers to exercise must be identified to form a plan o f care. For example, the child may lack interest in physical activity or perceive a lack o f time (e.g., " t o o much h o m e w o r k " ) . Lack o f regular physical activity at school is a problem for many children with a family lifestyle pattern o f overeating and inactivity. Parents' concerns about unsafe neighborhoods and the latchkey child p h e n o m e n o n also pose formidable barriers to exercise for many school-aged children. Sustain-
VanAntwerp 255 ing involvement in exercise into adulthood may be a difficult but worthwhile challenge. Another sensitive area is the issue o f guns in the home. Approaching the topic o f gun risks in the h o m e works best within the larger context o f injury prevention. The Center to Prevent H a n d g u n Violence (1994) reports that approximately 1.2 million latchkey children have access to guns when they come h o m e from school. A 1990 poll o f gun owners revealed that one half kept these guns unlocked. Although the nurse practitioner may be unable to persuade a parent to rid the h o m e o f guns, at the very least, parents should be encouraged to keep guns unloaded and locked.
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LQ can also be used to assessthe impact of health teaching and anticipatory guidance with individual patients.
9 CONCLUSION The L Q is a tool nurse practitioners can use to p r o m o t e health and prevent injuries. Lifestyle assessment is critical to the identification o f healthy versus unhealthy lifestyles. Lifestyle assessment enhances the well child examination and can positively impact present and future health practices. 9
REFERENCES American Heart Association of Michigan. (1993). Fact sheet. Southfield, MI: Author. Breslow, L., & Breslow, N. (1993). Health practices and disability: Some evidence from Mameda County. Preventive Medicine, 22, 86-95. Brown, J. (1992). Be HEADstrong! Start a bicyclehelmet campaign! Contemporary Pediatrics, 9, 54-56, 59-60, 62, 64, 70, 72-73. Center to Prevent Handgun Violence and the AmericanAcademy of Pediatrics. (1994). Preventingfirearm injuries among children and adolescents: A public health concern. STOP: Steps to prevent firearm injury. Washington, DC: Author.
Centers for Disease Control. (1990). Childhood injuries in the United States. American Journal of Diseases of Children, 144, 627-646. Christoffel, K. K. (1994). Reducing violence 20- how do we proceed? American Journal of Public Health, 84, 539-541. Elders, J., Perry, C. L., Eriksen, M., & Giovino, G. A. (1994). The report of the Surgeon General: Preventing tobacco use among young people. American Journal of Public Health, 4, 543-547. Jones, N. E. (1993). Childhood residential injuries. Maternal ChiM Nursing, 28, 168-172. Rivara, F. P., Thompson, D. C., Thompson, R. S., Rogers, L. W., Alexander, B., Felix, D., & Bergman, A. B. (1994). The Seattle children's bicycle helmet campaign: Changes in helmet use and head injury admissions. Pediatrics, 93, 567-569. Rowland, T. W., & Freedson, P. S. (1994). Physical activity, fitness, and health. Pediatrics, 93, 669-671. University of Wisconsin 20- Stevens Point Foundation. (1978): Lifestyle assessment questionnaire. Stevens Point, WI: Author. VanAntwerp, C. A., & Spaniolo, A. M. (1991). Checking out children's lifestyles. Maternal Child Nursing, 16, 144-147.