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Effect of self-referral instruction on grade 4 students' utilization of school nursing sevices Clough, Leslie Denise 1989

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EFFECT OF SELF-REFERRAL INSTRUCTION ON GRADE 4 STUDENTS* UTILIZATION OF SCHOOL NURSING SERVICES By LESLIE DENISE CLOUGH B.S.N., University of British Columbia, 1979. A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES School of Nursing We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October 1989 © Leslie Denlse Clough, 1989 6-7 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Nursing  The University of British Columbia Vancouver, Canada Date " 'October, 9, 1989 DE-6 (2/88) ii Abstract EFFECT OF SELF-REFERRAL INSTRUCTION ON GRADE 4 STUDENTS' UTILIZATION OF SCHOOL NURSING SERVICES This study examined the effect of self-referral instruction on Grade 4 students' utilization of school nursing services. Self-referral Is a skill needed for self-care. Adult self-care has received emphasis by consumers and health professionals. The focus on adult self-care has not, however, achieved the goal of consumers taking more responsibility for their health. It has been suggested that childhood may be the most appropriate time to teach self-care skills. A review of the literature demonstrated, however, that little Is known about child self-care and chlldrens" learning and use of the specific skills and knowledge needed to practice self-care. This study therefore contributes to a currently Inadequate knowledge base and enhances the ability of nurses to make objective decisions about Instruction of children in the use of a self-care skill, self-referral, in the school setting when nursing time is limited. This experimental study involved 78 Grade 4 students from four schools. The students were randomly assigned to a group that either would or would not be taught self-referral to the school nurse. There were two 20 minute lessons given to the experimental group, A pre and post study questionnaire was given to both groups prior to the lessons and nine weeks later at the conclusion of the study. The questionnaire collected data about the students' knowledge of the school nurse's accessibility, their willingness to self-refer, and their knowledge concerning appropriate reasons to use self-referral, Information was also collected from the nurses regarding what students used self-referral and the problems they presented, Analysis of variance and chl-square were selected as appropriate statistical methods of analysis. i i i The findings demonstrated that children who were given instruction in self-referral had significantly greater knowledge about how, when, and why to self-refer. Instruction in self-referral did not, however, encourage a significant number of children to practice this skill as only four children from the experimental group self-referred. It Is speculated from comparing the number of self-referrals between the schools that the placement of the self-referral appointment books in the schools was a factor that affected the students' decisions to self-refer, It appears It Is Important that the book be placed where the children feel comfortable writing in it. Such a place may be away from the scrutiny of adults while providing as much privacy as possible. Based upon this study's findings, implications for nursing practice and recommendations for further research were described. JV Table of Contents Abstract 11 Table of Contents iv Acknowledgements vi Chapter 1: INTRODUCTION 1 Background to the Problem 1 Problem Statement 4 Significance of the Problem 5 Potential Significance of the Study 5 Purpose 7 Definition of Terms 7 Chapter 2: REVIEW OF THE LITERATURE 9 Introduction 9 The Health Belief Model 9 The model's origins 9 The model's structure 10 The Individuals'perceptions 10 Modifying factors 10 Self-referral; Its place in the model 11 Variables Affecting Children's Health Beliefs, Behaviours and Participation In Self-Care 12 The Influence of cues to action on self-referral 12 Demographics; Age 13 Soclopsychologlcal; The family 15 Structural variable; Knowledge 18 Studies of Child-Initiated Care 20 Summary 23 Chapter 3: METHODOLOGY 25 Introduction 25 Subjects 26 Selection 26 Assignment into groups 27 Ethical considerations 27 The Research Design 28 The design 28 Delineation of variables 29 Application of the Independent variable: Instruction in Self-Referral 29 Measurement of the dependent variables 3 i V Assumptions 32 Limitations 33 Data Analysis 33 Chapter 4: FINDINGS 36 Introduction 36 Description of the Subject Population 36 Question One: Students' Knowledge of the School Nurse's Accessibility 37 Question Two: Students' Willingness to Use Self-Referral 37 Question Three: Number of Self-Referrals 38 Question Four: Type of Concerns that Lead Students to Use Self-Referral 39 Question Five: Students' Knowledge of Appropriate Self-Referral Problems 39 Summary 41 Chapter 5: DISCUSSION OF THE FINDINGS, IMPLICATIONS FOR NURSING, SUMMARY, and CONCLUSION 42 Introduction 42 Interpretation of the Findings 42 Implications for Nursing Practice 45 Recommendations for Future Research 47 Summary of the Study 48 Conclusion 50 Bibliography 51 Appendices 54 A Learning Objectives for Lessons One and Two 54 B Consent Form 55 C Covering Letter for the Consent... 56 D Explanation for the Completion of the Questionnaire 57 E Report of Self-Referral Card 58 F Questionnaire; Knowledge of Self-Referral and School Nursing Services 59 G Content for Lessons One and Two 60 vi Acknowledgements Although I wrote this thesis, Its completion Is the result of the co-operation and assistance of many people who support the need to learn more about childrens' ability to care for themselves. Specifically I am grateful to: Betty Wynne, Nursing Supervisor, Beverly Hills, Acting Nursing Supervisor, Simon Fraser Health Unit and Dr. A. Taylor, Coqultlam School District, for their assistance in implementing the study; the principals, teachers, and nurses who agreed to take time from their full schedules to participate in the study and provide valuable feedback; the children who, by their agreement to participate in the study, taught adults more about childrens' desire and ability to actively participate in their health care. I am most appreciative of the guidance, support, and suggestions I received through the process of the study and writing of the thesis from my committee Helen Elfert and Linda Leonard. My thanks also to Connie Canam for her help during the first half of the study and to Marshall AN in who provided valuable critiques of and suggestions for the research design and statistical analysis. Special thanks to Margaret Campbell for her belief In my ability to meet the challenges life presented me during my graduate work. I am in debted to my family and friends who gave me the strength and clarity of thought needed to complete the project. I am especially grateful to: Carmelita Olivotto for her loyal friendship; Pauline Clough for, among many things, being a wonderful grandmother; my husband Chris Carroll for his thoughtful critiques, skillful editing, and demonstration of the true meaning of partnership through unwavering support and confidence in my abilities; my son Brayden for reminding me of life's priorities and regularly demonstrating to me the amazing resources and capabilities children possess, even at a young age. 1 Chapter 1 Introduction Background to the Problem Health professionals, particularly those specializing in public health, recognize that If people take responsibility for their health many illnesses can be prevented or corrected at minimal financial, physical, and psychological cost. In order to assist Individuals to take responsibility for their health, public health professionals focus on health promotion. Lalonde's 1974 working document, entitled "A New Perspective on the Health of Canadians", supported the focus of public health professionals when It proposed a health promotion strategy to reduce self-Imposed risks. This strategy was to be "aimed at Informing, Influencing, and assisting both Individuals and organizations so that they will accept more responsibility and be more active in matters affecting mental and physical health" (p. 66). Public health nurses support self-care, a health promotion practice that has a similar purpose to the Lalonde report's strategy. Self-care is the "practice of activities that individuals personally initiate and perform on their own behalf In maintaining life, health, and well-being" (Orem ,1971, p. 13). According to Orem (1971), self-care Is a positive and practical learned behaviour that consists of two phases: decisions about self-care and the actions to accomplish self-care (p. 32). Orem (1971) states that the ability to initiate self-care Is one of the essential conditions for the expenditure of effort to meet self-care demands In a life situation. One of the skills an Individual needs In order to Initiate self-care Is the ability to self-refer. Self-referral is part of basic self-care (Kemper, 1980, p. 64) and includes knowing how, when, and from whom to seek help (Orem, 1971, p. 35; Kemper, 1980, p. 64). The action of self-referral is part of the repertoire of skills and Information required by the Individual in order to seek help appropriately 2 (Kemper, 1980, p. 65). It Is a skill health consumers need In order to practice self-care. Self-care has received Increased attention from both health consumers and health professionals as an Important and useful concept. Consumers began to focus on self-care In the 1960's because of the prohibitive costs of medical care, dissatisfaction with the medical care provided, and the desire to have more control over their health (Norris, 1979, p. 487). Consumers' desire to Increase control over their health was compatible with health professionals' desire for individuals to take more responsibility for their health. Health professionals felt that as Individuals took more control over their health, they would also take more responsibility for the decisions and actions pertaining to health. These decisions and actions would then have a positive influence on their health. Despite consumers and health professionals' focus on self-care, "there Is considerable evidence that the behaviours of Individuals [adults] are neither consistent with the.maintenance of their own health nor with the operation of a cost-effective, health-care system" (Lewis, C. E. & Lewis, M. A. 1982, p. 85). Part of the problem may be that health professionals have focussed their attention mainly on the adult practice of self-care. Lewis, C. E. & Lewis, M. A. (1982) state that the most appropriate time to Intervene in changing health behaviour Is during childhood (p. 86). Lalonde (1974), Tonkin (1981), and Post (1976) agree that interventions should be focussed on the school age years, specifically the five to 14 year age group, as this is the time that decisions are made that lead to a healthy or unhealthy lifestyle. If one agrees with the premises that: 1) to engender responsible behaviour It is necessary to give Individuals training in basic skills of self-management and Interpersonal communication (McAlister, 1981, p. 30); 2) the practice of 3 self-care Incorporates the basic skills that individuals need in order to take responsibility for their health; 3) school-age children are making decisions that could determine their health as adults; one Is led to the conclusion that children need to learn about and have the opportunity to practice self-care, Children, as early as eight to nine years of age (Nataproff, 1982), have the cognitive capabilities (Koster, 1983) and desire to practice self-care. Although these children need guidance from a responsible adult, they can and want to be responsible for their health care (Orem, 1971). Children first learn self-care In the home by observing how and when other family members use the health care system. While growing up, children learn in other settings, such as school, additional or Improved ways of practicing self-care. While schools should not be solely responsible for augmenting the family's Instruction of health care practices, It Is Important that schools Initiate health programs and are the focal points and co-ordinating bodies for other individuals and organizations who support health promotion (Bruhn & Nader, 1982, p. 5), An example of such a program would be one that teaches self-care skills and provides children with the opportunity to practice these skills with visiting school health professionals, Providing the opportunity for children to practice the skills of self-care, such as decision making and self-referral, would be an important part of the program because it enables them to "develop competencies that will enable [them] to assume greater responsibility for their own health" (Nader & Parcel, 1978, p. 15). It has been identified that: self-care skills are important for children to learn to maintain their health, and that giving them the opportunity to practice and use these skills assists with their becoming "responsible health consumers". Despite these Identified needs, the opportunity for children to 4 learn additional or Improved ways of practicing self-care outside the home and the opportunity to practice being health consumers seldom occurs. The practice of self-care in school Is difficult for British Columbia children because; self-care skills are seldom taught in school, there are no formal systems In the schools for children to practice self-care skills, and their access to the school nurse, who Is a health professional with expertise in self-care and who visits the school regularly, Is limited because of the nurse's time restrictions. An informal self-referral system which students could use to see the nurse does exist but it Is seldom used. The investigator has observed in her practice that its lack of use does not originate from the students' lack of health concerns. In the home and community children are also seldom given the chance to use and develop self-care skills such as self-referral. In the current health care system "children are passive participants In a process dominated by adults. At some magical age without formal practice they are expected to assume responsibility for their own health....Often children shift from the role of spectator to full participant without prior graduated or scheduled practice" (Lewis, C. E. & Lewis, M. A„ 1982, p. 236). The lack of self-care education and opportunity to practice self-care skills led the investigator to ask these questions: How should a child's self-referral system be set up? To what age group would it be best to Introduce self-referral? Could and would children use a formal self-referral system when the nurse spends a limited amount of time In the school? Problem Statement The general problem which this study addresses Is nursing's lack of knowledge about school-age childrens' behaviours when seeking health care. Nurses need to learn more about childrens' use of specific self-care skills, such as self-referral and its effect on children's use of time limited school 5 nursing services. This Is Important In order to develop programmes that teach children the skills of self-care and provide opportunities which encourage children to use these skills. Significance of the Problem Health professionals' focus on adult self-care has not achieved the goal of Increased responsibility for health ( Lewis, C. E., Lewis, M. A., Lorlmer, & Palmer, 1977; Lewis, M. A., 1974). A new approach Is the teaching of self-care skills during childhood. There are two problems with this approach. Little is known about children's use of self-referral. In fact "there Is a dearth of knowledge about what children really think about health, how they perceive the relationship between health and Illness, and their own role in maintaining health" (Kalnins & Love, 1982, p. 114). More information is needed about children's use of this specific skill in order to develop and plan a formal self-referral program. It Is the investigator's opinion, based on the lack of programs about child self-care, that adults are skeptical about children's capabilities to practice self-care. Lewis, C. E. and Lewis, M. A. (1982) discuss the outcomes of this skepticism when they state that "routine or preventive health care visits are manifestations of parents' health behaviours.... and chlldrens' self-initiated care occurs only under unusual circumstances" (p. 89). The results of child self-care programmes may lessen the skepticism of adults. Currently, the only way this Information can be gathered Is by initiating and studying experimental programmes about child self-care, such as child self-referral. Potential Significance of the Study This study focusses on teaching an element of self-care, self-referral, to an age group that is developing Its health beliefs and behaviours. This focus fits well with the purpose of school health education, which is to provide learning opportunities that help students develop habits, skills, and attitudes 6 that will contribute to their optimal well-being (Redlcan, Olsen, & Baffl, 1986). Health professionals are currently present In the school setting so that children can practice self-referral. Public health nurses have the expertise to teach children the skills needed for self-care, such as self-referral. As the children have access to the public health nurse during his/her regular visits to elementary schools they can begin to practice this skill with the nurse. The children, by using a self-referral system to the school nurse, would Increase their competence In using self-referral through practice and would be able to avail themselves of the nurse's knowledge and expertise in order to learn more about health problems which concerned them. This study will also demonstrate If children are willing to use a formal self-referral system to a health professional who Is in the school for a limited amount of time. As children gain knowledge and help from the nurse, the nurse could gain Insights into the capabilities of elementary school-aged children to participate in their health care. The results of this study could encourage nurses: to develop an Increasing awareness of the capabilities of elementary school-aged children in participating In their care; to observe the need to focus on children's development of competencies and self-concept rather than the amount of health information they know; and to begin to foster a sense of competency In self-care by demonstrating the Importance of giving children a means to meet and talk with the nurse about their health concerns. The study could also demonstrate to nurses the impact they have on students despite the limited amount of time they spend in the schools. In 1990 a B.C. school health curriculum Is to be implemented and this should enable children to receive more health education (Registered Nurses Association of British Columbia, 1988). The health classes will provide general information which will assist the children to assess their general health and 7 the need for assistance with their health concerns. A self-referral system could augment the health curriculum by providing children with an opportunity to discuss personal concerns or particular topics In more depth with a health professional. A self-referral system could also identify topic areas not covered in the general teaching sessions. Purpose The purpose of this study Is to determine the effect of self-referral Instruction on Grade 4 students' utilization of school nursing services. Specifically the following questions will direct the research: 1) Does Grade 4 students' knowledge, regarding access to the school nurse, differ between those students who are and those who are not taught self-referral? 2) Are Grade 4 students willing to self-refer to the school nurse when the nurse's time In the school Is limited ? 3) Does the number of self-referrals to the school nurse from Grade 4 students differ significantly between students who are and who are not taught to self-refer? 4) Are there differences In the types of concerns presented to the school nurse by the Grade 4 students who are and who are not taught to self-refer? 5) Does Grade 4 students' knowledge about appropriate problems for self-referral differ between those students who are and those who are not taught self-referral? Definition of Terms  Self-referral. The students refer themselves to the public health nurse by making an appointment using the appointment book. 8 Grade 4 Students. Children who attend Grade 4 classes at four schools In a Greater Vancouver School District. Public Health Nurse, The nurse working In public health who is assigned to visit the school regularly. This public health nurse Is also known as the school nurse. She/he does health screening of designated classes and of children who are self-referred or referred by parents or teachers. She/he also provides health education to Individuals and groups of students, and is a resource person for teachers, parents, and children. Instruction of Self-Referral. The concept, self-referral, Is taught to the experimental groups In two, weekly, 20 minute sessions by the investigator. Learning objectives are used to plan for each lesson. (See Appendix A) 9 Chapter Two Review of Literature The literature review is divided into four parts. It briefly discusses the Health Belief Model, which provides a framework for understanding the concept of self-referral. A discussion of where the concept of self-referral fits within the framework of the model follows. The model identifies the main variables of child health behaviour that may influence childrens' use of self-referral. These are demographic, sociopsychological, and structural variables and they will be discussed next. The literature review concludes by presenting studies that specifically pertain to child-initiated care. The Health Belief Model The model's origins. The Health Belief Model developed from a set of independent, applied research problems in the 1950's and 1960's (Rosenstock, 1974, p. 328). One of the problems identified in the 1950's was the widespread failure of people to accept disease preventing measures despite the fact that they were usually offered free or at very low cost (Rosenstock, 1974, p. 328). It was recognized that to explain health behaviour, more information which would lead to a theory was needed. The model has a phenomenological orientation as the original researchers were strongly Influenced by the theories of Kurt Lewin (Rosenstock, 1974, p. 329). As a result of this orientation the model Is concerned with the subjective world of the Individual (Maiman & Becker, 1974, p. 348 ). The Health Belief Model defines health behaviour as" any activity undertaken by a person who believes himself to be healthy for the purpose of preventing disease or detecting illness In an asymptomatic stage" (Rosenstock, 1974, p. 354). Health behaviour lies on a continuum with two other modes of behaviour, illness and sick role behaviour (Rosenstock, 1974, p. 354). to The model's structure, The three main parts to the model are: the Individual's perceptions, the modifying factors, and the likelihood of action. The three parts and their interrelationship will be described. The discussion of how these three parts affect child self-referral will focus, however, on the modifying factors. An Individual's perceptions do have an effect on the decision to self-refer, but an in depth discussion of the effects is beyond the scope of this study. The individual's perceptions. The model Is based on four perceptions of an Individual's subjective world. These include the individual's perceptions of; his/her susceptibility to the disease, the seriousness of the disease, the perceived benefits of taking action against the disease, and the perceived barriers to taking action against the disease. The Individual's perceptions influence his/her action to avoid a disease (Rosenstock, 1974, p. 330-331). The Individual's two perceptions of susceptibility and seriousness, provide the energy or force to act. The Individual's perceptions of the benefits and barriers of an action suggest a preferred path of action. However, overt action may not occur without the trigger of an Instigating event (Rosenstock, 1974, p. 332). Modifying factors. Instigating events are one of two sets of variables that the model refers to as modifying factors. Another set of variables are the demographic, socioeconomic, and structural variables. Both sets of variables influence an individual's perceptions and decision to perform a particular health behaviour. Instigating events or "cues to action", as they are called In the model, are necessary to set the process of health behaviour in motion (Rosenstock, 1974, p. 332). The cues or triggers can be internal, such as perception of body states, or external, such as Interpersonal interactions (Rosenstock, 1974, p. 332). 11 The demographic, soclopsychological, and structural variables are grouped as another set of modifying factors. They serve to "condition both individual perceptions and the perceived benefits of preventive action" (Rosenstock, 1974, p. 333). The interrelationship of self-referral and the cues to action and the influence that the demographic, soclopsychological, and structural variables have on a child's use of a self-referral program will be discussed later In the literature review. Self-referral; Its place In the model. The definition given for self-care, "the practice of activities that Individuals personally Initiate and perform on their own behalf In maintaining life, health, and well-being" (Orem ,1971, p. 13), Is similar to the Health Belief Model's definition of health behaviour which Is "any activity undertaken by a person who believes himself to be healthy for the purpose of preventing disease or detecting illness In an asymptomatic stage" (Rosenstock, 1974, p. 354). The similarity between these two definitions leads the Investigator to consider the skills and actions of self-care to be health behaviours. Therefore, self-referral Is a health action. Self-referral can be one of the first actions a child takes when seeking help In order to take preventive health action. To use self-referral the child needs to view the action as being benef leal In his/her pursuit of a goal. Perceived benefits may be learning alternate solutions to a problem, having another person's opinion, and/or having an Increased feeling of Independence and having more control over one's life as one Is seeking assistance and making decisions for one's self. Examples of barriers for using self-referral may be the lack of availability of a formalized program, no health professional available to the students, not knowing when to self-refer, and the student's lack of trust or confidence in the nurse. 12 The act of self-referral Is seen as adding one more step to the model. The consequences of using self-referral loops back to Influence the modifying factors. The Information a student receives about a disease or health concern from the nurse, as a result of self-referring, is a structural variable. The act of self-referral could also indirectly lead to a child taking a health action as a result of being triggered by an external cue. If the child used self-referral and received advice from the health professional, the model considers this advice to be an external cue to action. This cue to action would lead the child to begin a particular health action if the cue was strong enough. As self-referral Is a health action, an Individual's decision to self-refer Is also affected by the modifying factors. The two sets of variables (modifying factors) that Influence a child's decision to self-refer will be discussed separately. Variables Affecting Children's Health Beliefs. Behaviours, and Participation in  Self-Care Many variables affect a child's health beliefs and behaviours. Three variables that have been Identified in the literature as significant for this study will be looked at: the demographic variable of age, the soclopsychologlcal variable of the family, and the structural variable of knowledge. The influence of cues to action on self-referral. The cues to action that Influence a child's use of self-referral could be many. In 1974, Rosenstock reported that little was known about how various stimuli served as cues because It was difficult to adequately measure their role of triggering action (p. 333). More study has been done since then, particularly on the effect mass media have had on health choices. A discussion of these studies' findings and specifically how, and what cues influence a child's use of self-referral is beyond the scope of this paper. 13 Demographics: age. The literature on children's use of self-care supports the idea that age Is an Important demographic variable that Influences use of self-referral. The Influence of this variable on children's use of self-referral will be discussed separately. According to Plagetlan theory, as children age they progress through four stages of cognitive development. The quality of their thoughts about health changes as a function of their cognitive development (Kalnlns & Love, 1982; Nataproff, 1982; Lewis, C. E., Lewis, ri. A., Lorlmer, & Palmer, 1977). Nataproff (1978) studied childrens' views of health in Grades 1,4, and 7. She found that as children grow older, the concepts of partial health or wellness and mental health develop. Not until children are eight to 10 years old do they understand the concept of partial health. The concept of mental health is usually not understood by children until they are 12. Nader & Parcel (1978), C. E. Lewis and M. A. Lewis (1980), Igoe (1980), and Nataproff (1980) strongly support that children be Introduced to self-care at an early age in school health. They have found that children are capable of participating In their care and In some cases are better at taking care of their health than adults. Grade 4 Is an appropriate time to introduce children to the skills of self-care, as the developmental stage and traits of this age group enable them to understand self-care. Plaget (1952) describes the cognitive developmental stage of eight to 10 year olds, the ages of Grade 4 students, as concrete operational thought. They are formulating their own perspective on the world and are able to Internalize, apply rules of logic, and use Imagery (Sclplen, Barnard, Chard, Howe, & Phillips, 1975). They are able to recognize their own faults and weaknesses. Their expanded self-confidence enables them to discover their new maturity and Increasing Independence from authority 14 figures. They are Influenced in large measure by outside contacts. They are able to think more logically and problem solve from perceptions of their health. Perrln and Gerrlty (1981) state that, "a child In concrete operational thought could be expected to link Isolated concrete symptoms to other bodily events. An example Is: understanding the association between his rash, his stomach ache and fever" (p. 842). Grade 4 Is also a good time to Introduce skills associated with self-care because of children's attitude to health and enthusiasm for learning. Nataproff (1978) found that children at this age hold positive views of health. She found they were concerned about total body shape and that they defined health as the ability to perform desired activities, not merely minimal dally activities. Nataproff's study suggests that Grade 4 children have the view of health that health professionals would like them to hold on to and hope that they will expand upon Into adulthood. Koster (1983) states that this age is an Ideal time for children to learn about the human body and changes precipitated by health behaviour. These children are motivated to use their new learning capacity. They are very curious and want to learn more about their bodies and how different events and experiences affect their body and its health ( Hussey & Hlrsh,l983, p. 23). Children's age not only affects their understanding of self-care and willingness to participate but also the frequency that they self-refer. Lewis, C. E., Lewis, M. A., Lorlmer, & Palmer, (1977) studied childrens' use of a child-Initiated health care system In an elementary school. They found that children In the lower grade level (roughly equivalent to the first and second grades) Increased their use of the self-referral system more than children aged 10-12 years. Generally, however, children In the middle grade level (roughly equivalent to the third and fourth grades) had the highest frequency of visiting the nurse, with children In the higher grade level (roughly equivalent to the 15 fifth and sixth grades) being second. Children In the lower grade level had the lowest frequency of visits with the nurse. This study Is described in detail later In the review of the literature. Nader & Brink (1981) examined the school health room visiting behaviour of 671 children, Grades Klndergarten-6, In the elementary schools of one school district, over a two year period (1976-1978) (p. 416). They came to the same conclusions as Lewis, C. E. et al., that age appears to be a significant variable for determining the frequency of visits to the nurse. Soclopsychological: the family. Soclopsychological variables have an Important Influence over development of health beliefs and choices of health behaviour. Although it was beyond the scope of this study to examine or control for this set of variables, one variable, the Influence of the family and specifically the mother, Is being Included In the literature review as It will be considered when Interpreting the study's results. One of the most Influential variables of this set Is the people with which children have contact. "Children learn about health behaviour through Imitation, modeling, Interacting with the environment, and being reinforced for certain kinds of behaviour associated with Illness and injury" (Lewis, C. E., & Lewis, M. A., 1982, p. 228). Chlldrens' families, particularly mothers, are considered to be Important role models for their chlldrens' health beliefs and behaviours. There Is some disagreement, however whether the family, and particularly the mother, has the strongest Influence on a child's health beliefs and behaviour. Dlelman, Leech, Becker, Rosenstock, & Horvath (1982) studied 854 households to determine the relationship between health beliefs and behaviour of parents and those of their children. The same study also examined the 16 variation in childrens' health beliefs and behaviour accounted for by those of their parents, independent of parental age and education level (p. 158). .Dlelman et al. (1982) reported that "childrens' health behaviours can, for the most part, be regarded as primarily developmental phenomena, some of which are linked in a general fashion to the global pattern of parental behaviour" (p. 170): It was also found that childrens' health beliefs were scarcely Influenced by parental characteristics. The primary predictors of childrens' health behaviours were found to be parental health behaviours rather than parental health beliefs (Dlelman et a l , 1982, p. 159). Dlelman et al. (1982) state the reason for this Is that "parental behaviour Is more pervasive and visible on a dally basis" and therefore Is a stronger predictor of children's health behaviour (p. 171). Mechanic (1964) also found that parental behaviours influence children's health beliefs and behaviours but that the Influence is not as strong as predicted. Mechanic (1964) studied 350 children and their mothers to Investigate the development of health attitudes and behaviours (p.444). He used a wide variety of Items and scales to obtain Information about the characteristics of mothers and their children, generalized attitudes toward health and Illness, and health and illness behaviour (p. 446). The data collected were "relevant to the general Idea that mother's attitudes and behaviour In regard to their childrens' health are Important factors molding childrens" patterns of Illness behaviour" (Mechanic, 1964, p. 451). The data did provide some support for the general Idea but the magnitude of the differences was too small and the degree of inconsistency too great to argue that the differences were of practical importance. "Certainly these maternal influences appear to be less influential than anticipated" (Mechanic, 1964, p. 451). According to Mechanic (1964) "mothers probably play a considerable role In helping children to acquire the proper patterns of 17 behaviour. But such learning is also Imparted through the Influence of siblings, peers, teachers, and the mass media" (p. 452). Mechanic (1964) states that one of the most Interesting Impressions of the study was that "the child has considerable resources to resist the Influences of particular persons within his environment" (p. 451). Lewis, C. E, et al. (1977) findings differ from Mechanic's (1964). While studying over 300 children's use of a child-Initiated health care system, Lewis, C. E. et al. (1977) also gathered information on the mother's attitude toward the new system and her awareness of Its specific elements, her perception of the child's health status during the year, the mother's own perceived health status, and the number of visits to physicians made by the mother during the past year. Lewis, C. E. et al. (1977) found significant associations between a mother's tendency to seek care for herself and for her child, and the child's pattern of use of services during the study and his/her frequency of being taken to a physician (p. 505). There was also a significant association between the mother's awareness of the system and her child's use of the services (p. 502). The mothers of children who used the system frequently knew more details about the system (p. 502). Lewis, C. E. et al. (1977) study also found that "the child's health status, as perceived by the child and as reported by the mother, were found to be highly associated" (p. 505). The findings of Lewis, C. E. et al. (1977) suggest that chlldrens' use of a child Inltlated-care system has a similar pattern to adults' utilization of the health care system. Lewis, C. E. et al. (1977) postulate several reasons for this finding: that mothers are very Important role models for the social learning of health and illness behaviour; that the child learns when to use health care services from his/her mother as she Is the main controller of these services; and that a behaviour change of chlldrens' utilization of services does not occur 18 because children are not supported in the decision-making role outside of the school setting. Despite the many different findings between Mechanic (1964) and Lewis C. E., et al. (1977) there was anecdotal evidence In Lewis, C. E. et al. (1977) study that supported Mechanic's claim that children could be resistant to their environment (i.e. mother's influence). Some parents in Lewis, c. E. et al. (1977) study noted that their children did carry over the style of Interaction taught by the study with their own private physicians and that they "demonstrated considerable ability In caring for their own minor injuries (self-care)" (p. 507). This review has discussed some maternal/parental behaviours, specifically of mothers, that are considered to strongly Influence childrens' health beliefs, behaviours, and use of services. The behaviours presented are not the only ones available for consideration. They were chosen because they Illustrate the differing opinions about this variable. Structural variable; Knowledge. The structural variable of knowledge refers to the knowledge the child has regarding the disease or health behaviours. While health professionals can teach children the Information required to make a positive health decision, they cannot assume that this will lead children to make positive health choices. The health professional cannot ensure how or If children will use the Information they are given. The effectiveness of traditional health education has been questioned. Traditional health education Is focussed primarily on content, or the learning of health related information (Parcel, Nader, & Rogers, 1980, p. 36). It has been found that this focus (too much "talk and chalk") does not effectively change health behaviours (McAllster, 1981; Reld, 1984). 19 Health professionals can, however, choose a theory on which to base their teaching and an Interaction style that Is conducive to children taking responsibility for their health. This Is social learning theory. The literature strongly supports using social learning theory as a theoretical framework on which to base health teaching (Parcel et al, 1980; Lewis, C. E. et al 1977; Lewis, M. A., 1974; Igoe, 1980 ). Programs based on this theory appear to be more effective at changing health behaviours. This approach focuses more on the process by which goal-directed behaviour Is learned. "The use of social learning theory as a framework would change the emphasis to a type of teaching that would lead to an experience of success for children In making decisions about health-related behaviour" (Parcel et al., 1982, p. 36). Parcel et al. (1982) gave child-Initiated care as an example of social learning (p. 36). Encouraging the use of child self-referral (part of child-Initiated care) in a school setting "involves a conscious effort [on the part of health care providers, teachers, and parents] to shift from doing things for children to reinforcing their willingness and ability to do things for themselves In regard to their health" (Parcel et al., 1982, p. 36). It gives children the opportunity to practice a skill and learn appropriate times to use the health system. Lewis, C. E. & Lewis, M. A. (1982) agree that when health professionals Incorporate social learning Into their transactions with children they support the children's use of self-care (p. 96). Health professionals have some control over the type of transactions they have with children. When health professionals use transactions that minimize chlldrens' dependency on the professional, the responsibility for ones' health switches from the health professional to the children (Lewis, C. E. & Lewis, M. A., 1982, p. 96). To foster children taking this responsibility, Lewis, C. E. & Lewis, M. A. (1982) state that childrens' self-concepts and feelings of competency In using self-care should become the target for care, but needs due to growth and development should not be ignored. Children should be encouraged to talk to nurses and physicians so that they learn how to express their needs. There are several studies that focus on children's use of child-initiated care. Generally, these studies have used social learning as one of their theoretical bases. Studies of Child-Initiated Health Care There were only five studies found that Included child self-referral or child-Initiated care. Two studies specifically examined the effects of programs which taught the two skills, self-referral and decision making (Lewis, C. E, Lewis, M. A, Lorimer, & Palmer, 1977; Lewis, C. E, Lewis, M. A, 1982). One study examined the effects of teaching self-referral to a small number of Grade 4 children (Clough, 1980). Two other studies were found which used child-Initiated care but they did not describe nor examine self-referral specifically (Igoe, 1980; Nader & Brink, 1981). Only Igoe's (1980) study will be included because It supports the idea that children are willing to participate In their health. C. E. Lewis, Ii. A. Lewis, Lorimer, & Palmer (1977) have been the main researchers of child-Initiated care. In 1972, they began a two year study of over 300 children's use of a child-Initiated health care system In an elementary school. The school was the laboratory school for the Department of Education at the University of California In Los Angeles. There were three levels In the school rather than grades and the children's ages ranged from 5 to 14 (Lewis, C. E. et a l , 1977, p. 500). Children In all levels participated in the study. 21 Prior to the study a school nurse had been In attendance at the school five half days per week. In the fall of 1972 the nurse's work at the school was increased to full-time. The two objectives of the study were: ...To develop and test a conceptual framework describing factors affecting childrens' health related beliefs and behaviours...,; to examine the effect of Involving children In the processes of their own care by establishing a (relatively) adult-free system in an elementary school where children were able to Initiate their own visits to a school nurse practitioner and subsequently be involved In the decision-making related to the treatment and disposition of their problem. (Lewis, C. E. et al, 1977, p. 500). A self-referral system (card care system) was used In the study so that children could go to see the nurse without asking permission from the teacher. The emphasis of the study, however, was on the participation of children In the decision-making process of care and the study of the patterns of service use. In relation to the self-referral system, Lewis, C. E. et al. (1977) found most children were capable of participation In child-Initiated care and that "even nonusers were aware of the change in the nature of the transaction" (p. 505). Lewis, C. E, & Lewis, M. A. (1980) state that "It [child-initiated care] did provide an exquisitely sensitive diagnostic screen for children who were having problems in any aspect of their lives" (p.l 46). Some children used the self-referral system frequently. Over half the services were used by 15% of the children. Lewis, C. E. & Lewis, M. A. (1980) considered these children to be the pediatric analog to Kaiser's "worried well" (p. 146). These children were biologically healthy but came to seek assistance for problems that were not susceptible to medical Interventions (Lewis, C. E .& Lewis M. A., 1980, p. 146). They used the health care system as a major coping mechanism. This observation led to the finding that "children who were high users had poor self-concept and seemed to have problems in making decisions In general, not Just about the use of health services" (p. 146). it was suggested in their study that the card care system (self-referral process) should be tested Individually In schools more representative of the population (Lewis, C. E. et al., 1977, p. 506). In 1976 Lewis, C. E. & Lewis, M. A. replicated their first study. The second study was done in a unified school district outside of Los Angeles with some modifications to the study design. The number of participants In the study was not stated In the brief report but appeared to be large as Lewis, C. E. & Lewis, M. A. (1982) state that only children In the third and fourth grade were pre and post tested because of the size of the study population (p. 147). Full-time nursing services were available in all four schools (Lewis, C. E. & Lewis, Ii. A. 1982, p. 229). Only brief summaries of this study's findings could be found by the investigator. They were that: the card care system proved feasible in settings where almost half of the children and families received Aid for Dependent Children, that children did not abuse the privilege, and that the patterns of utilization were comparable to the Initial study (Lewis, C. E. & Lewis, fi. A., 1982, p. 229). It Is not known If there were any differences between the school that used only the card care system and the school that combined the card care system with the child's Involvement In decision making. Clough (1981) studied Grade 4 children's ability to use a self-referral system when nursing service was limited to one half day per week. The study Included 22 children who were divided Into a treatment and control group. The referral system Included a card care system and an appointment book. Clough found that the children were capable of using the formal self-referral system after four, 20 minute lessons. Igoe (1980) reported the success of a project called Project Health PACT (Participatory and Assertive Consumer Training). PACT originated as a result of 23 a school nurse practitioner's observations. She found that children hired to serve as subjects for nurses learning to perform examinations, behaved more assertively than those children seen In her regular clinic. The three objectives of Project Health PACT were to; prepare the student for assertive, participative, health consumer roles, develop reciprocal relationships between health consumers and health providers, and to tailor delivery of professional services to consumer needs. Students in eight fifth grade classes from three different school districts In Colorado participated In the project. Students in each class were randomly assigned to one of four groups. Each group was exposed to different portions of the learning materials which presented five steps. The five steps taught active participation of children In their health care and emphasized the decision making process. The project used the self-referral process of an appointment book. No detailed account of this referral process was provided. Statistically significant ( p<.05) differences were found among the four treatment groups for the three districts. The experimental group that received the most exposure to the five steps consistently outperformed the other groups. All three groups who received exposure to the five steps demonstrated significantly greater knowledge about consumerism than the control group. The materials of Project Health PACT were deemed effective in preparing youth to assume a new role and set of responsibilities as health consumers (Igoe, 1980, p. 2016). Summary Self-referral, as described by the Health Belief Model, Is a health behaviour that Is affected by modifying factors which are the cue to action and the demographic, soclopsychological, and structural variables. Self-referral can also Indirectly affect the modifying factors by changing them. This Is because the Interaction children have with the health professional, as a result of self-referral, can lead them to gain knowledge about a disease and receive advice. The studies reviewed indicate that Grade 4 students are curious about their health and have the cognitive abilities to be Involved In self-care (Nataproff, 1978; Koster, 1983). The studies by Lewis, C. E. et al. (1977) and Igoe (1980) indicate that children have Individual health concerns and have used self-referral as a means to have their health concerns or questions answered. These studies have combined the two phases of child-Initiated care, self-referral and the decision making process. It Is not known what effect the self-referral process alone has on children's participation In self-care. Lewis. C. E. et al. (1977) have suggested that this be tested. It would also be helpful to replicate Clough's (1980) study to determine If children are willing to use a self-referral system when nursing services are limited. Chapter 3 Methodology Introduction This study was primarily concerned with Investigating Grade 4 student's use of a self-referral system to the school nurse and the effect of chlldrens' use of self-referral on school nursing services. Specifically, the following questions directed the study; 1) Does Grade 4 students' knowledge, regarding access to the school nurse, differ between those students who are and those who are not taught self-referral? 2) Are Grade 4 students willing to self-refer to the school nurse when the nurse's time in the school is limited? 3) Does the number of self-referrals to the school nurse, from Grade 4 students differ significantly between students who are and who are not taught to self-refer? 4) Are there differences In the types of concerns presented to the school nurse by the Grade 4 students who are and who are not taught to self-refer? 5) Does Grade 4 students' knowledge about appropriate problems for self-referral differ between those students who are and those who are not taught self-referral? This chapter describes the study's subjects which includes the process used for their selection, their assignment Into groups, and ethical considerations. A description of the study's experimental design follows. Lastly, the tools and methods used to collect and analyze the data are described. 26 Subjects Selection. The sample was taken from four, public, elementary schools which are In a Greater Vancouver School Board's jurisdiction. The investigator estimated that the Grade 4 population In the four schools would provide initial contact with 120-140 children and that this population would result in the required 80-100 children for the study. The School Board's Director of Curriculum, Assessment, and Instruction requested and was given the opportunity to select the schools so that staff would be able to support the study and meet Its requirements. To limit the amount of disruption to classes, it was agreed that only those classes with Grade 4 student's would be Included In the study. This resulted In Grade 4 student's who were In split-grade classes (eg. Grade 4 and 5 students In classrooms together) being excluded. Other children excluded were those who entered or left a class during the study and those who were absent when the prestudy questionnaire was administered. This decision was made because the treatment variable, Instruction In Self-Referral, was Introduced immediately after the prestudy questionnaire, Inclusion of a school in the study was also contingent on the school nurse's agreement to participate, After the four potential schools were chosen by the School Board's Director of Curriculum, Assessment, and Instruction, the Nursing Supervisor of the Health Unit spoke to the school's nurses to receive their consent to participate In the study. One hundred and twenty-four Grade 4 students were given consent forms (Appendix B), with covering letters ( Appendix C) to take home to their parents. The class teacher distributed the consent forms and gave frequent reminders to the students to return the consent form by the specified date (which was five days after the forms were distributed). The teachers and 27 Investigator answered questions and provided further clarification concerning the purpose of the study for parents who contacted them. Those Grade 4 students whose parents provided written consent for their participation In the study and who themselves agreed were Included, Assignment Into groups. All participating students were assigned a number for identification purposes only. In each class the students were randomly assigned to group A l , the experimental group, or A2, the control group, by using their assigned number and random selection tables, At the conclusion of the study, each group had 39 randomly assigned students remaining. Ethical considerations. Prior approval for this study was obtained from the University of British Columbia's Ethical Review Committee Consent for Research. The rights of the participants were protected In the following ways: 1) Approval for the study was obtained from the School Board and Health Unit In the community where the study took place, ' 2) Consent to participate In the study was received from the principals and Grade 4 teachers who work In the selected schools and the nurse who serves the school. 3) Only those Grade 4 students whose parents provided written consent for their participation in the study and who themselves agreed were included. 4) A description of the study and an explanation of the Investigator's expectations of the students ( Appendix C) was provided for the parents and students with the consent form ( Appendix B). 5) Prior to completion of the prestudy questionnaire, the Investigator verbally described the study to the students. (Appendix D) At this time the students were Informed of their right to withdraw from the study then or at any time throughout the study. They were advised that non-participation would not affect the care they would receive from the school nurse nor the Instruction they would receive from their teacher. 6) Participating students were each assigned a number to provide anonymity. The numbers were used as Identification on the questionnaires and for data analysis. The Investigator was the only person to have access to the key for the coding. 7) The nurses maintained confidentiality of a student's concern unless there was need for Intervention from another health professional or a threat existed to the child's health or welfare (le. sexual/physical abuse). In the occurrence of one of these situations, the school nurse was requested to follow the established procedure for the school district and health unit. The nurse was also requested to discuss the course of action with the child. This was to maintain trust and support while appropriate help was sought. 8) The school nurse was requested to keep completed "Reports of Self-Referral Cards" (Appendix E) in her off Ice at the health unit. The Investigator contacted the nurse every four weeks to arrange for collection of the reports. 9) Students were given clear Instructions during the two lessons not to record the reasons for wishing to see the nurse In the appointment book. It was explained to them that this was to maintain confidentiality of their concerns. 10) The nurses were requested to see all students who self-referred, regardless of their grouping assignment. Teachers were also requested to answer questions from any students regarding self-referral. The Research Design This study used an experimental design. The properties a study must have In order to use this this design are: "at least one of the Independent variables Is a treatment variable, and subjects are randomly assigned to this treatment variable" (Arlln, 1989, p. 10). This design was chosen as the questions leant themselves to subjects being randomly assigned to two groups, Al the experimental group and A2, the control group, and the independent variable, Instruction In Self-Referral, Is a treatment variable. Delineation of variables. The Independent variable Is Instruction In Self-Referral for group, A l . The dependent variables in the study are: a) the number of self-referrals made In 9 weeks by Grade 4 students to the nurse as recorded by the school nurse on the Report of Self-Referral Card (Appendix E). b) the student's knowledge of the accessibility of the school nurse as measured by the pre and post study responses to the questionnaire. (Appendix F) c) the student's willingness to self-refer as measured by the pre and post study responses to the questionnaire. (Appendix F) d) the types of health concerns presented by Grade 4 students using the self-referral process. e) the student's knowledge of appropriate self-referral problems as measured by the poststudy responses to the questionnaire. ( Appendix F) Application of the Independent variable, Instruction In Self-Referral. The Investigator met with the teachers and nurses at each of the four schools prior to the start of the study In order that consistency of the teacher's and nurse's roles were maintained during the study. The study was briefly described and the referral system and Its use, the roles of the teachers and nurses In the study, the necessary time commitment, and the frequency of nursing visits were discussed. The teachers agreed that their role In the study was to provide, upon request, clarification and assistance for any student who wished to self-refer. The nurses agreed that their role In the study was to provide assistance to any student who used self-referral, The four nurses agreed to visit their schools once per week throughout the study period and to continue to offer the routine school health programmes as established by the school board and health unit. Immediately prior to the first lesson, the self-referral system, which comprised the appointment book, was established. The appointment book was anchored in a room accessible to all Grade 4 students. Attempts were made to place the books where students would have privacy while making appointments and to limit scrutiny of adults as much as possible. In three schools the nurses' rooms were being used for other purposes and there were no other free rooms. The only available place to put the book was In the office. The books were placed so that students could use them without asking for them. In the fourth school the book was placed In the nurse's room. A list of Instructions describing the use of the book were written In the Inside cover. Students In group Al were taught how to use the system during the first lesson. The Investigator met with group Al for 20 minutes once a week for 2 weeks. The learning objectives (Appendix A) were used to plan for the two lessons. The content of the lessons (Appendix G) was written on cards. The cards were used during each lesson to maintain consistency of Instructional content for each group. The lessons were taught the same time of day for each school throughout the study. The students were taught how, when, and why to use the appointment book. In all schools the students were shown where the book was kept. Students In the three schools where the book was In the office were reassured during the two lessons that the office staff and principal agreed to the book's placement and their access to It. The teachers and nurses both participated briefly in the first teaching session. The teachers discussed their roles In the self-referral process and their agreement for the study to occur with their students. The nurses discussed the services they could offer to the students and their role in the 31 self-referral process, Each nurse told the students they would: check the appointment books at the start of each visit, call the student down to the office to see her by using the Individual classroom's address system to provide more privacy for the student, each student would be seen Individually, and no times would be given for the appointments so the students would not be kept waiting outside of their classrooms to see the nurse. Measurement, of the dependent variables. An Instrument entitled "Knowledge of Self-Referral and School Nursing Services" (Appendix F) was developed by the investigator to measure the student's: knowledge of the school nurse's accessibility, knowledge of appropriate reasons to self-refer, and willingness to self-refer. This questionnaire was used for both the pre and poststudy test. The questions were scrutinized by two child education specialists and a public health nurse for content validity. The Instrument was pretested with 10 Grade 4 students to check for ease of understanding. No modifications were necessary. The Investigator administered all the pre and poststudy testing. She began the administration of all testing by giving an explanatory statement about the test. (Appendix D) The prestudy questionnaire was completed simultaneously, by both groups within each school, Immediately prior to the study commencing In that school. Each child was given the questionnaire marked with his/her code number on the top right hand corner. This enabled the Investigator to compare the Individual and group responses to the individual and group number of self-referrals, while maintaining confidentiality. The Investigator was responsible for matching the code on the questionnaire with the correct child. Questionnaires of children In group A2 were also marked at the top with a red dot to enable the Investigator to quickly Identify those children In the control group. Once the children completed the prestudy questionnaire, the Investigator requested children, whose questionnaires were marked with a red dot to raise their hands. These children's questionnaires were collected and they were thanked for their participation. The investigator then requested children without red dots (group Al) to line up at the classroom door. The Investigator collected the questionnaires and then took these children to another room to teach them self-referral. The poststudy questionnaire was completed, simultaneously by both groups within each school, 9 weeks after the first teaching session. The questionnaire was completed In 10 minutes. After the questionnaires were collected, the Investigator offered to answer any questions the children had about the study, She also asked the students If the placement of the appointment book made any difference to their use of self-referral. A tool, the "Report of Self-Referral Card" (Appendix E), was also designed by the Investigator. It was used to collect information about students who used self-referral. The nurses In each school were given a supply of the cards and Instructions for the cards use. The nurse completed a report card after seeing any child who was referred to her. The nurse indicated on the card the child's name and grade, who initiated the referral, and the nature of the concern. The investigator called the nurses at 4 week intervals to determine If there had been any referrals, to discuss any concerns or findings, and to make arrangements to collect any report cards. Assumptions. 1. Grade 4 children are In the cognitive developmental stage of concrete operational thought (Plaget, 1952), 2. Grade 4 children are capable of understanding the concept of health (Nataproff, 1978), 3. Grade 4 children, living In the study area, are not currently using a formal self-referral process to see the school nurse. 4. The school nurse treats all self-referrals with equal Importance and indicates concern and willingness to assist the student. Limitations. 1. The study's 9 week data collection period could limit the findings, as data was not available to determine long-term patterns of self-referral use. 2. Students in the experimental group may understand the process of self-referral but may not need to use the service during the study. 3. Children In the control group and In other grades may also use self-referral as a result of seeing the process or hearing about the study. 4. Testing effects may Influence the results of the control group's post-test scores. 5. The questionnaire," Knowledge of Self-Referral and School Nursing Services", Is limited in scope and has an unknown reliability. 6. The study's findings cannot be generalized beyond the study participants described. Data Analysis The data were collected from the pre and post study questionnaire and the Report of Self-Referral Cards. The questions of the pre and post study questolnnalre were organized Into three sections. Analysis of variance and chl-square were selected as the appropriate statistical methods of analysis (M. Arlln, personal communication, August 13, 1989). Data from the report cards were described. Statistical significance was accepted at the alpha level of p. <.05 for all statistical analyses. Section One consisted of questions one, three, four, and five and provided Information about the students' knowledge of the school nurse's accessibility. This section was scored by giving one point for each question answered correctly and zero points for Incorrect answers. The student's knowledge of the accesslbllty of the school nurse, a continuous dependent variable, was a composite score of the answers. The pre and post test scores from Section One were analyzed by analysis of variance (ANOVA) using the Statistical Package for the Social Sciences; Extended Version, (SPSS-X)TH. Instruction in Self-Referral was the treatment variable with two levels, Al and A2. Analysis of covarlance was the original statistical method chosen for Section One, with the pretest scores being the covarlate. However, the regression coefficient was not of great enough significance to permit use of this method of analysis ( Arlin, personal communication, August 13, 1989). Section Two consisted of the responses to question two in the pre and post test. The responses Indicated the students' willingness to use self-referral. Chi- square was used to analyze the responses (A l / A2 by response). Section Three consisted of question six and It Indicated the student's knowledge of appropriate problems for self-referral by the number of appropriate problems students Identified. It was also analyzed by using chl-square, ( A1/A2 by response). The student's responses to Section 3 were combined Into three categories to meet the requirement that "fewer than 20% of the cells should have an expected frequency of less than five" (Slegel, 1956, p. 176). Students giving response number six (none of the above, Appendix F) and those students Identifying one problem about which they would talk to the nurse, were placed In Category 1. Students Identifying two to three problems were placed In Category 2 and those Identifying four problems or giving response number five ( all of the above) were placed In Category 3. The numbers of self-referrals made during the nine week study were tabulated for each group from the Self-Referral Report Cards. Chi-square was used to determine If there was a significant difference in the number of referrals made betweeen the two groups. As the numbers of self-referrals were small the types of concerns were described. Chapter 4 Findings This chapter presents the study's findings In five parts. Firstly, the subject population Is described. The answers to the five questions that directed the study are answered in order and presented next. Question One, which Is concerned with the students' knowledge regarding access to the nurse, Is answered by the findings of Section One of the questionnaire. Question Two, which is concerned with the students' willingness to self-refer, is answered by the findings of Section Two. Question Three which queries If the number of self-referrals will differ significantly between students who are and are not taught to self-refer, Is answered by the data collected from the Report of Self-Referral Cards. Question Four which queries If there are differences in the types of concerns presented to the school nurse by students who are and are not taught to self-refer, Is answered by the data from the Report of Self-Referral Card. Question Five which is concerned with the student's knowledge of appropriate health concerns Is answered by the findings of Section Three of the questionnaire. A description of the concerns that led students to use self-referral are presented In this part. Description of the Subject Population One hundred and five consents were returned of the 124 distributed (84%). Of the consent forms returned, 83 of 105, or 79% of the parents or guardians gave consent for their child to participate in the study. Five students whose parents gave consent were excluded: two students left the school during the study, one student was absent for the prestudy questionnaire, and two students withdrew from the study after the Investigator gave the explanation of the questionnaire at the beginning of the study (Appendix D). Seventy-eight Grade 4 students, 62.9% of the 124 students originally approached, participated In the study and were Included In the results. All participants were English-speaking students In Grade 4 who resided In the same district as the school. It was beyond the scope of this study to gather Information about the socioeconomic status of each child's family. The range of socioeconomic levels in the community is low middle to middle class. Question One; Students' Knowledge of the School Nurse's Accessibility The first question that directed the study was: Does Grade 4 students' knowledge, regarding access to the school nurse, differ between those students who are and those who are not taught self-referral? The answer to this question Is found In the analysis of Section One of the questionnaire. The participants completed all the questions In Section One of the pre and post questionnaire. The mean pretest score of group Al was X= 1.62. The mean pretest score for group A2 was X= 1.74. ANOVA of the pretest scores revealed that there was no significant difference between the two groups' knowledge regarding access to the school nurse prior to administration of the Independent variable, £ (1, 76)= 0.4962, p. > .05. The mean posttest score of group Al was X = 3.10. The mean posttest score for group A2 was X= 2.00. ANOVA revealed that Grade 4 students who were taught Self-Referral ( group Al) showed significantly greater knowledge regarding access to the school nurse than students who were not taught Self -Referral, (group A2), £( 1, 76) = 28.331, p. < .05. Question Two: Students' Willingness to Use Self-Referral This part answers the study's second question: Are Grade 4 students willing to self-refer to the school nurse when the nurse's time in the school is limited ? The findings of Section Two of the questionnaire answer this question. Reviewing Section Two's data from the prestudy questionnaire, prior to its analysis with chl-square, the Investigator observed that the majority of the students in both groups, (Al, 74% and A2, 71%) Indicated a willingness to use self-referral. Analysis by chl-square of the pretest data indicated that there was no significant difference in the two groups' willingness to self-refer prior to administration of the independent variable, Instruction In Self-Referral, X 2 (1, N= 78) = 0.065160, p_>.05. The Investigator also observed that the student's willingness to use self-referral remained relatively constant for the two groups In the poststudy questionnaire, (76% of Al and 69% of A2). There appeared to be no change In group A l's willingness to self-refer despite administration of the treatment variable and their now being aware of the nurse's visiting schedule. Analysis by chi-square of the poststudy questionnaire supported the investigator's observations. Providing the students with information about the nurse and her visiting schedule did not make a significant difference in the Grade 4 students' willingness to use self-referral, X 2 (1, M= 78) =0.586464, p_>.05. Question Three: Number of Self-Referrals The study's third question was: Does the number of self-referrals to the school nurse from Grade 4 students differ significantly between students who are and who are not taught to self-refer? The data collected from the Report of Self-Referral Cards answers this question. There were eight self-referrals made during the study. Seven of the eight referrals were made by four Grade 4 students who were in group A l . In group Al 10.25% of the students self-referred. Three boys and one girl referred themselves, two of the boys and the girl referred themselves twice. One self-referral was made by a Grade 5 student. All self-referrals were made from one school. No self-referrals were made by students In group A2. 39 Despite only Grade 4 students In group Al using self-referral, analysis by chl-square of the number of children who self-referred revealed that Instruction In Self-Referral did not make a significance difference In the Grade 4 children's use of self-referral, X 2 (1,N= 78) = 2.385134. The answer to Question Three may not be that simple, however, as there appears to be another factor that affected the student's use of self-referral. This factor will be discussed in the next chapter. Question Four: Types of Concerns that Lead Students to Using Self-Referral Question Four was: Are there differences in the types of concerns presented to the school nurse by the Grade 4 students who are and who are not taught to self-refer ? As only students in group Al used self-referral, this question cannot be answered. A description of the types of concerns that initiated students to self-refer is Included in the next part. Question Five: Students' Knowledge of Appropriate Self-Referral Problems The fifth question that directed the study was: Does Grade 4 students' knowledge about appropriate problems for self-referral differ between those students who are and those who are not taught self-referral? The answer to this question Is found In the analysis of Section Three of the questionnaire. A chi-square test of Section Three's posttest data revealed that Grade 4 students who were given Instruction In Self-Referral were able to Identify a significantly greater number of appropriate problems for self-referral than could the Grade 4 students In the control group, A2, X? (2, M = 78) = 7.268572, p_ <.05. Students who did use self-referral presented the nurse with concerns that were and were not listed on the questionnaire. The diversity in the types of concerns that lead the four children to self-refer support the findings that students in group Al appear to know more reasons to use self-refer than children In the control group. These children presented both emotional and physical problems to the nurse. Specifically, the physical problems presented by three different students were problems with vision, left hip pain that radiated Into the knee and ankle, and a bunion (left crooked toe) that was causing discomfort. In these three cases the children were referred to physicians. One child presented twice with emotional concerns to the nurse. One concern was regarding the child's fear of needles and blood tests, the other concern was the child's feelings about the hospitalization of the mother of the child's daycare provider, due to a heart attack. The nurse assisted the child with both these concerns and did not feel It was necessary to refer the child. The nurse followed up the referrals made for the three cases with the following results: The student's vision was within normal limits but as the child was on medication that could affect the child's vision the nurse suggested that It be checked yearly. The child's left hip pain was diagnosed through x-rays and blood tests as an infection In the left hip Joint. The child was placed on medication and his/her activities were restricted. The child with the bunion would be having surgery In the next year, It Is Important to note that despite the child with the left hip Infection having reporting It to his/her mother and physician, It was not Investigated until the child visited with the nurse and the nurse discussed the concern with the mother. The nurse reported that the mother had felt that the child's actions were not Indicative of the pain he/she described and therefore she had not sought help. It Is difficult to speculate why the physician did not investigate the child's complaint. Two of the above students made appointments with the nurse again. The student with the bunion returned to see the nurse to have it bandaged to decrease the discomfort and the student who first presented with the left hip pain returned to see the nurse about a sore and some Itchiness. Both of these referrals were dealt with solely by the nurse. Summary This chapter answered the overall question" What is the effect of self-referral Instruction on Grade 4 students utilization of school nursing services?, and the five specific questions that directed the study by presenting the analysis of the data from the three sections of the questionnaire and the data from the Report of Self-Referral Cards. It was found that: Grade 4 students who were taught self-referral showed significantly greater knowledge regarding access to the school nurse than students who were not taught self-referral; Instruction in Self-Referral did not make a significant difference in the Grade 4 students* willingness to use self-referral; Although four students In group Al from one school used self-referral for diverse concerns, Instruction In Self-Referral did not make a significant difference in the Grade 4 student's use of self-referral; There was Insufficient data to determine If there was any significant difference In the types of concerns the two groups presented to the nurse; Instruction In Self-Referral did make a significant difference to the students' knowledge of appropriate problems for self-referral. 42 Chapter 5 Discussion of the Findings. Implications for Nursing, Summary, and Conclusions This chapter Interprets the results of the findings and discusses the study's limitations. The Interpretation of the results takes Into account this study's findings as well as the studies discussed in the literature review. The study's Implications for nursing practice and recommendations for further research follow. Lastly, the Investigation Is summarized and the study's conclusions are presented. Interpretation of the Findings The answer to the study's first question Indicates that the two 20 minute lessons were of sufficient length and appropriate content to assist the students to learn information about the nurse's accessibility. The facts that no children in the study's schools had used self-referral previously and that only children In group Al self-referred also support the teaching of this information If a self-referral program Is to be Initiated. Knowledge of self-referral however, does not appear to be sufficient to encourage student's use of self-referral as few students in group Al used self-referral during the study. This leads one to query what other factors Influenced the student's use of self-referral. Reluctance to self-refer does not appear to be a strong factor that influenced group Al 's decision to not self-refer. A moderately high percentage of children in both groups indicated they were willing to use self-referral in the pre and post questionnaire. The studies of Lewis, C. E. et al. (1977) and Igoe (1980) support this study's finding that children are willing to self-refer. The fact that Instruction in Self-Referral did not change the level of group Al 's willingness to self-refer could be attributed to the high number of students willing to self-refer at the start of the study. The level of willingness not changing could also be attributed to other factors such as the children's peers, family, or a reluctance to actively participate In one's health having a stronger Influence over the children's behaviour. As it is beyond the scope of this study to understand why the students were or were not willing to use self-referral, these other factors are speculative. There was no comment from the children that the frequency of the nursing visits hindered their use of self-referral but the Investigator did not explicitly ask for this Information. The frequency of nursing visits does not appear to have hindered the student's use of self-referral in one of the schools. The school In which four Grade 4 students used self-referral had the same frequency of nursing visits as did the other schools. According to the analysis of Question Five, the ability of group Al to Identify a greater number of appropriate problems for self-referral does not appear to be a factor that would have a negative Influence on the number of self-referrals in this study. As group Al was able to Identify more problems which were appropriate for self-referral this group should have had more opportuntles to self-refer. The diversity of the concerns that were presented to the nurse and the appropriateness of the self-referrals also provided evidence that some children could Identify appropriate concerns and that they understood, how, when, where, and why to use self-referral very well. The child with the left hip pain's willingness to self-refer, despite the unwillingness of his/her mother and physician to agree that he/she had a problem, is an example of a child with a good understanding of self-referral and willingness to use this process. This child's persistence In receiving assistance also supported Mechanic's (1964) finding that children can be reslstent to their environment. In this case the environment was the mother's and physician's Initial refusal to Investigate the child's problem. The question that remains Is what is the difference between those children in group Al who did use self-referral and those children in group Al that did not use self-referral? The studies of Lewis, C. E. et al. (1977) and Igoe did not agree with the low numbers of self-referrals received In this study. Students In their studies did use self-referral frequently. These studies directed the Investigator to look at factors from this study's design that may have Influenced the low number of children who used self-referral In this study. The small number of self-referrals may be the result of several limitations of this study. One of these limitations pertains to the placement of the appointment book. It was the Investigator's intention to place all the appointment books In rooms that had little adult scrutiny and that provided some privacy to the students while they made appointments. Unfortunately, due to space restrictions and the multi-purpose function that most nurse's rooms have been used for, this type of placement was only possible In one school. The Investigator noticed that all the self-referrals were from this one school. Speculating that the placement of the appointment book may have Influenced the children's use of self-referral, the Investigator Informally gathered Information about the book's placement after the posttest. The investigator asked If the students liked where the book was placed and If Its placement effected their use of self-referral. The Grade 4 students In the school that used self-referral were satisfied with the book's placement. The general Impression from the Grade 4 students in the other schools was that they did not feel comfortable going into the office to use the book, despite being given approval to do so. Several children readily agreed that they would have self-referred If the book had been placed elsewhere. There was no consensus between the schools as to where the book should be placed other than It should not be In the office. This information provides evidence that the placement of the appointment book could have been a factor that influenced the Grade 4 student's use of self-referral. This study's finding supports the emphasis that Lewis, C. E. et al. (1977) placed on the need to limit adult involvement as much as possible if a child-initiated care system is to work. Another limitation of the study that could have Influenced the number of self-referrals was the length of the study. The timing of the study may have been when this group of students felt healthy and did not have concerns. This limitation was also Identified by several of the Al students. They stated that self-referral was a good Idea but wondered what to do if they had a problem after the study was over. The time of nine weeks appears to not have been long enough to establish an accurate estimate of Grade 4 students' willingness to use self-referral. Implications for Nursing Practice Prior to Incorporating any Implications for nursing practice that this study provides, public health nursing needs to assess the needs of the community, establish the short and long term health objectives of the community, and determine how these objectives could best be achieved. If public health nurses choose to use the school as a focal point for Initiating programs, agree that teaching and encouraging the use of self-care will assist the meeting of the community's health objectives, and decide that providing one to one assistance for children is one means to reach their objectives then this study provides several Implications for nursing practice. Elementary school-age children, specifically those in Grade 4, are an appropriate age group to begin instruction of one of the skills required for self-care, self-referral. Grade 4 children are able to learn about the process of self-referral with minimal instruction, indicate a willingness to use the process, and make appropriate self-referrals that assist them taking actions to 46 Improve their health. The study's findings suggest that Instruction In Self-Referral encouraged Grade 4 children to use self-referral. Instruction In Self-Referral for Grade 4 children may not, however, be solely sufficient to encourage their practice of this skill. Other factors appear to influence Grade 4 children's use of self-referral and nurses must consider these when establishing a self-referral program. One factor for nurses to consider when setting up a self-referral program is the environment In which students make appointments. There Is supporting evidence from this study that Grade 4 students need as much privacy as possible while making appointments and that the appointment system needs to be as free as possible from adult scrutiny. To provide this environment nurses may need to consider establishing an area in the school that the children know is the nurse's and to which the children have free access. One factor that does not appear to significantly Influence Grade 4 children's use of self-referral, particularly In the school where eight referrals were received, is the frequency of the nurse's school visits. All schools were visited weekly by the nurse. The limitations on the nurse's time did not appear to deter the students from using self-referral. The nurse who received the self-referrals stated she enjoyed the program and would like to continue It next year. She indicated that she had been impressed by the children's ability to use the process and that they did not Increase her work load. She also indicated that she supported the self-referral process because some of the problems the children presented to her would not have been detected by anyone else until the symptoms had progressed. This nurse's response to the program suggests that she felt made it a difference to the health of the children In her school and the limits on her nursing time did not affect her ability to assist the children. The principal and teacher in the school where self-referral was used also expressed support for Grade 4 children's use of self-referral. The teacher was impressed with the Grade 4 children's ability to use the process and requested that the principal Investigate the possibility of Implementing self-referral in the school so that children in all the grades may have access to all the health professionals that visit the school. Enlarging the self-referral program to Include all the health professionals has Implications for the nurse's role In self-referral. As the nurse would be part of the school health team of professionals, the teacher may be the best person to provide the general lessons regarding the self-referral process. The health professionals, including the nurse, could then visit the classes once to Introduce themselves and describe to the students the services available. They would then be available to accept self-referrals during their regularly scheduled visiting times. Recommendations for Future Research As a result of the study's findings and limitations the Investigator suggests that the study be repeated with the following changes: the study's time period be lengthened significantly, and the children select the place for the appointment book according to a consensus of where they feel most comfortable using it. If this study is repeated with the above suggestions, in view of the restrictions on school nursing time, It would be valuable to know If the number of self-referrals Is manageable In the nursing time available. To put the self-referral program In the context of other community health programs, it would be helpful to know If the nurses feel the time this type of care takes is warranted, considering Its effectiveness In reaching the community's health goals, As one of the schools was Interested In Implementing a self-referral program to school health professionals for all Its students, It may be Important to investigate the effects of the teacher providing the instruction In self-referral. As self-referral Is a health concept would children use the process if It was presented by a teacher Instead of a nurse? Would there be a difference In the children's use of the service depending on the support the process Is given by the teacher? Little is known about children's perceptions of self-referral and the factors that they perceive as Influencing their participation in their health care. A qualitative study would be useful to explore these areas. Other research questions were proposed to the investigator as a result of the comments from the nurse who assisted the children who self-referred: Does a nurse's encouragement of children's active participation in their health care lead her/him to use principles of social learning? Do nurses who support self-referral encourage the children to take responsibility for their health in other ways? Do nurses' opinions of children as health consumers change as a result of working with children who self-refer? Summary of the Study This experimental study involved 78 Grade 4 students from four schools that were selected from a Greater Vancouver School District. The students were randomly assigned to a group that either would or would not be taught self-referral to the school nurse. There were two 20 minute lessons given to the experimental group (Al). A pre and post study questionnaire was given to both groups prior to the lessons and nine weeks later when the study concluded. The questionnaire collected data about the students' knowledge of the school nurse's accessibility, their willingness to use self-referral, and the students' knowledge of appropriate problems for slef-referral. Information was also collected from the nurses regarding what students used self-referral and the problems they presented. Analyses of the findings showed the experimental group ( Al) had significantly greater knowledge about the accessibility of the school nurse and could Identify a significantly greater number of appropriate problems for self-referral than the control group (A2). Instruction in Self-Referral did not, however Increase Group Al 's willingness to use self-referral. This may be because the majority of the students In both groups indicated a willingness to use self-referral at the beginning of the study. There was not a significant difference between the experimental (Al) and control group's (A2) use of self-referral despite an Increase In Al 's knowledge about the accessibility of the nurse and In the reasons to seek his/her assistance. There were seven self-referrals from four children in the experimental group during the study. The seven referrals came from one school. The low numbers of self-referrals may have been because reported willingness to self-refer does not equate with actual use of self-referral. There also appeared to be other factors that Influenced the children's use of self-referral, as those children who self-referred were from the same school. One of the factors may have been the placement of the appointment book. In the school where the children used self-referral the book was not In the office but in a medical room. The self-referrals that were made were for legitimate concerns. The teacher, prlnlcpal, and nurse were Impressed with the children's use of the process and will be Investigating the possibility of its continued use In the following school year. The nurse felt that the process was very useful as she would otherwise not have known the children's concerns and she was able to assist the children with their concerns despite restrictions on school nursing time. 50 Conclusions Two 20 minute lessons In self-referral Increased the Grade 4 children's knowledge about this specific self-care skill and the reasons for its use. As there were few self-referrals despite significant changes In the children's knowledge levels, it appeared there were other factors that also Influenced the children's use of the skill. It Is speculated from comparing the number of self-referrals between the schools that the placement of the appointment books in the schools Is one of these factors. It appears It Is Important that the book be placed where the children feel comfortable writing In It. Such a place may be away from the scrutiny of adults while providing as much privacy as possible. The children who used self-referral Impressed their teachers and the nurse with their ability to identify appropriate concerns and use the self-referral process. The nurse felt that she was able to assist these children with problems that would have otherwise gone unknown to her. She was also able to give this assistance despite the restrictions on her school nursing time. The findings support that Instruction In Self-Referral did significantly change the Grade 4 children's knowledge about how, when, and why to self-refer. It did not however encourage a significant number of children to practice this skill. Perhaps by ensuring that children feel comfortable In the environment in which they make the appointments, children will be encouraged to put their knowledge of this skill into practice. Bibliography 51 Arlin, M. (1989). Notes from Statistics 592. Unpublished manuscript, University of British Columbia, Department of Educational Psychology, Faculty of Education, Vancouver, British Columbia. Blazek, B, &McClellan, M. S. (1983). The effects of self-care instruction on locus of control in children. Journal of School Health. 53 (9). 554-556. Brown, F. L, Amos, J. R, & Mink, 0. 6. (1975). Statistical concepts: A basic program. ( 2nd ed.). New York: Harper & Row. Bruhn, J. G, & Nader, P. R. (1982). The school as a setting for health education, health promotion, and health care. Family and Community Health. 4(4), 57-69. Clough, L. D. (1981). Effect of a public health nurse's teaching technique of  self-referral on the initiation of self-referral and Internal locus of  control of grade 4 students. Unpublished manuscript, University of British Columbia, Continuing Education, Vancouver, British Columbia. Dlelman, T. E, Leech, S , Becker, M. H, Rosenstock, I. M, & Horvath, W. J. (1980). Dimensions of children's health beliefs. Health Education Quarterly. 2(3), 219-238. Dielman, T. E, Leech, S, Becker, M. H, Rosenstock, I. M, & Horvath, W. J. (1982). Parental and child health beliefs and behaviour. Health Education  Quarterly. 2(2 &3), 156-173. Gochman, D. S. (1971). Some correlates of children's health beliefs and potential health behaviour. Journal of Health and Social Behaviour. 12, 148-154. Hussey, G. G, & Hirsh, A. M. (1983). Health education for children. Topics in  Clinical Nursing. ^(1), 22-28. Igoe, J. (1980). Project health PACT In action. American Journal of Nursing. SO, 2016-2021. Iverson, D. C. (1981). Promoting health through the schools: A challenge for the eighties. Health Education Quarterly. &.(!), 6-10. Kalnins, I, & Love, R. (1982). Children's concepts of health and illness and implications for health education: An overview. Health Education Quarterly. £.(2 & 3), 104-115. 52 Kemper, D. W. (1980), Medical self-care: A stop on the road to high level wellness. Health Values. ±(2), 63-68. Koster, M. K. (1983). Self-care: health behaviour for the school-age child. Topics in Clinical Nursing. 5_( 1), 29-40. Lalonde, M. (1974). A new perspective In the health of Canadians: A working  document. Ottawa: Information Canada. Lewis, C. E., & Lewis M. A. (1980). Child-initiated health care. Journal of  School Health, March, 144-148. Lewis, C. E., & Lewis M. A. (1982). Children's health related decision making. Health Education Quarterly. 9. (2 &3), 225-237. Lewis, C.E., & Lewis, M. A. (1982). Determinants of children's health-related beliefs and behaviours. Family and Community Health. 4(4), 85-96. Lewis, C. E., Lewis, M. A., Lorimer, A. & Palmer, B. B. (1977). Child-initiated care: The use of school nursing services by children in an adult free system. Pediatrics. 6_Q (4), 499-507. Lewis, M. A. (1974). Child-initiated care. American Journal of Nursing. 74, 652-655. Maiman, L. A. & Becker, M. H, (1974). The Health Belief Model; Origins and correlates in psychological theory, Health Education Monographs, 2.(4), 336-353. McAlister, A.I. (1981). Social and environmental influences on health behaviours. Health Education Quarterly. fi_(1), 25-31. McGinnls, J. M. (1981). Health problems of children and youth: A challenge for the schools. Health Education Quarterly. £ ( i ) , n- i4. Mechanic, D. (1964). The Influence of mothers on their children's health attitudes and behaviour. Pediatrics. 2X 444-453. Mullen, P. D. (1981). Children as a national priority: Closing the gap between knowledge and policy. Health Education Quarterly. ^(1), 15-24. Nader, P. R. & Brink, S. 6. (1981). Does visiting the school health room teach appropriate or inappropriate use of health services? American Journal of  Public Health. IX 416-419. Nader, P. R. & Parcel, 6. S. (1978). Competence: The outcome of health and education. In P. R. Nader (Ed.) Options for school health: Meeting  community needs, (pp. 1-17). Maryland: Aspen Systems. 53 Nataproff, J. N. (1982). A developmental analysis of children's ideas of health. Health Education Quarterly. £(2&3), 130-141. Nataproff, J. N. (1978). Children's view of health: A developmental study. American Journal of Public Health, M, 995-1000. Norris, C. M. (1979). Self-care. American Journal of Nursing. 2&, 486-489. Orem, D. (1971). Nursing: Concepts of practice. New York: McGraw Hill. Parcel, 6. S , Nader, P. R, & Rogers, P. J. (1980). Health locus of control and health values: Implications for school health education. Health Values. 4 (1), 32-37. Perrin, E. C, & Gerrlty, P. S. (1981). There's a demon in your belly: Children's understanding of Illness. Pediatrics. 62 (6), 841-848. Piaget, J. (1952). The origin of intelligence in children. New York: International Universities Press. Polit, D. & Hungler, B. (1978). Nursing research: Principles and methods. Toronto: Lippincott. Post, S. (1976). A Canadian Institute of child health: A feasabllltv study. Toronto, Ontario: The Sick Children Foundation. Redlcan, K. J , Olsen, L. K, & Baffi, C. R. (1986). Organization of school health programs. New York: Mactilllan. Registered Nurses Association of British Columbia (1988). Position  statement: Health education in schools. RNABC, February. Reid, D. (1984). Learning good health. World Health. Januarv-Februarv. 5-7. Rosenstock, I. M, (1974). Historical origins of the Health Belief Model. Health Fducatlon Monographs. 2 (4), 328-335 Scipien, G. M, Barnard, M, Chard, M. A , Howe, J , & Phillips, P. J. (1975). Comprehensive pediatric nursing, (pp. 157-167). New York: McGraw Hill. Siegel, S. (1956). Nonparametric statistics for the behavioural sciences. New York: McGraw-Hill. Tonkin, R. S. (1981). Child health profile: British Columbia. Vancouver: Friends of the McCreary Centre Society. Appendix A Learning Objectives for Lessons One and Two Lesson One 1. Knows the researcher and the school nurse. 2. Knows the nursing services and visiting times of the nurse . 3. Knows the definition of self-referral. 4. Knows how to self-refer. 5. Knows the teacher agrees to the students keeping appointments with the school nurse. Lesson Two 1. Knows when to use self-referral. ( eg, vision, hearing screening, answers to health questions) 2. Demonstrates ability to use the self-referral process by role playing. Appendix B 55 Consent Form I have received the consent form and covering letter describing a study entitled, "Effect of Self-Referral Instruction on Grade 4 Students' Utilization of School Nursing Services". I consent/ do not consent to have my child participate in this study, conducted by Leslie D. Clough. Signed: Name of Child: Parent or Guardian Appendix D 57 Explanation for the Completion of the Questionnaire The following explanation of the questionnaire will be given to the students orally, Immediately prior to Its completion: My name is Leslie Clough. I am a nurse who is studying at the University of British Columbia. I would like to know what you know about the school nurse and the services she can offer you. Part of the study is the answering of some questions that I will give you in a few minutes. It will take 10 minutes to answer the questions. Do not put your name on the paper. I have put special numbers at the top of each paper so I will know the answers you gave but no one else will know how you answered. Your parents have agreed for you to be in my study. If you do not want to be In the study please tell me. You do not have to be in it and no one will be upset If you decide not to be included. It Is also alright If you decide later that you do not want to continue to be in the study. Please tell me or your teacher. At the completion of the questionnaire, the following directions will be given: You are divided into two groups. Some of the questionnaires are marked with a red dot at the top. The dots tell me what group you are in. Will the students whose papers have a red dot at the top please give their papers to me. Thank-you for your help. Those of you who do not have dots please line up at the door. Appendix E Report of Self-Referral Card Child's Name: Teacher: Grade: Referral made by: (circle one) student, teacher, parent Subject of concern or question: 59 Appendix F Questionnaire: Knowledge of Self-Referral and School Nursing Services Please answer the questions by circling the best answer. 1. State how often the nurse visits the school each week. If you do not know the answer write 0. 2.1 would ask or have asked to see the school nurse about a problem of mine. Yes No 3.1 have to ask permission from my teacher before I can go to see the school nurse. Yes No 4.1 have to ask permission from my parents before I can see the school nurse. Yes No 5. If I wanted to see the school nurse, I could make an appointment to see her myself. Yes No 6, If I visited the school nurse I could talk to her about: ( circle the answers that you think are right for you) i) having my ears or eyes tested il) getting a needle ill) how my body works Iv) how to feel good v) all of the above answers vi) none of the above Appendix 6 Content for Lessons One and Two Lesson One 1. Introduction of investigator: - Name, occupation. 2. Purpose of meeting: - To tell students about a way to get help with health problems. (Making an appointment with the public health nurse who visits the school) 3. Introduce and discuss nurse's role: - How many of you know a nurse visits the school every week? - Introduce nurse, discuss times she/he visits the school, services she/he can offer. Write nurse's name, visiting times, and services available on the board. - Discuss services the nurse cannot offer and why, e.g. first aid. - Introduce Idea of confidentiality and discuss how It will be maintained by the nurse, 4 Introduce and discuss self-referral: - How many of you have visited the nurse about any health problems or questions? - How many of you know that you can arrange to see the nurse without asking your parents or teachers? - Define self-referral. - Review reasons a student may wish to see the nurse. 5. Introduce method of self-referral by using the appointment book: - Display book and illustrate how to make appointment. - Discuss where book will be kept, when students can make appointments, and how the nurse will arrange the appointments with the students. - Discuss methods to ensure confidentiality of the students' concerns. 6. Have teacher briefly discuss his/her role In self-referral process and his/her agreement for the students to self-refer. Lesson Two 1. Review: - What self-referral is. - Who the nurse is and when she visits. - Reasons to self-refer. - How to self-refer. 2. Exercise: - Purpose; the child can describe how she/he feels better than anyone else and self-referral enables her/him to do this, - Children go into pairs, one child describes for two minutes how they felt the last time he/she was i l l , the other child listens. - Listener tells class what he/she heard, child who described feelings says If listener Is correct. 3. Role-play: - Investigator plays role of the nurse, child volunteers to come and discuss a health problem with the nurse. 4. Review how and when to make an appointment and where the book is kept. 

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