(
Received January 28; revision accepted for publication April 16, 1970.)PRESENT ADDRESSES: (K.M.H. and R.S.H.
)
Department of Biometry, University of Kansas School of Medicine. (C.L.P. ) Yale University School of Epidemiology and Public Health, New Haven, Connecti-cut (student).ADDRESS FOR REPRINTS:
(
C.L.M.) Department of Community Medicine, Mount Sinai School of Medicine, Fifth Avenue and 100th Street, New York, New York 10029.PEDIATRICS, Vol. 46, No. 3, September 1970
ATTITUDES
TOWARD
HEALTH
AMONG
CHILDREN
OF
DIFFERENT
RACES
AND
SOCIOECONOMIC
STATUS
Carter L. Marshall, M.D., Khatab M. Hassanein, Ph.D., Ruth S. Hassanein, M.S.P.H.,
and Carol L. Paul, BA.
From the Department of Community Medicine, Mount Sinai School of Medicine, New York City
ABSTRACT. The semantic differential, a means of
measuring attitudes, was administered to 178
fourth grade students to compare attitudes toward health. One school was composed almost entirely of black children from the inner city, the other contained white children from upper middle class homes.
When the children were divided into the two groups by sex, differences between the groups were not statistically significant but there were highly
significant differences between the races. Cener-ally, white children held more positive attitudes to-ward health personnel and health institutions than black children, while on the average black children
were less concerned about sickness than white
children. Whether these differences in attitude are in some way ethnically determined or based rather on a “culture of poverty” could not be determined from this study. Pediatrics, 46:422, 1970, cmu>.
HOOD, HEALTH, ATTITUDES, RACE.
T
HE relationship between attitudes andbehavior is an uncertain one, and al-though behavior is often presumed to be a physical translation of attitudes, the evi-dence on this point is mostly of the post hoc
kind and is logically unsound. Yet unless we are prepared to accept the view that aggre-gate behavior is random and irrational, atti-hides must occupy a prominent place in
any theory of behavior. Rosenstock1
ana-lyzed the results of several studies and
pos-tulated that an individual will utilize
pre-ventive health services
(
e.g., Mantoux test-ing) according to his feelings about his ownsusceptibility, his concept of the severity of
the condition in question, and the extent to which he believes he will benefit from par-ticipation. The sum of these attitudes con-stitutes a predisposition to act or not to act; the act itself depends on a cue or trigger which may be internal (a symptom or sign)
or external (advice of a friend, a pre-em-ployment physical examination, and so forth).
It
is well known that attitudes toward health and health services vary withsocio-economic status. This was first observed by
Koos2 and has been corroborated by many
workers since Koos’ study first appeared in
1951. Although adults have been
exten-sively studied, less work has been done with children. It might be presumed that
children would reflect the attitudes of their
parents, but
it
is likely that they would alsc be influenced by their peers and by the ubiquitous television receiver. A knowledge of the variation in children’s attitudes to-ward health and health personnel should prove valuable in their medical manage-ment. In addition, interested health workers might be able to alter certain attitudesde-veloped during childhood which tend to de-crease the utilization of health services as
one grows into adulthood.
The present study is a limited one which seeks to determine the existence of attitudi-nal differences toward health among two
groups of fourth grade children.
METHODS
Fourth grade children from two public
ARTICLES 423
were selected for study. All of the children
with a few exceptions were 9 years old. The schools were chosen to reflect widely diver-gent socioeconomic groups. School A is lo-cated in the economically depressed inner city ghetto, and its students are
overwhelm-ingly poor and black. School B is situated in the most affluent area of the city and its stu-dents are upper middle class and, almost without exception, white. One hundred and
six children (62 boys and 44 girls
)
were in-eluded from school A and 74 children from school B (44 boys and 30 girls).The instrument used to measure atti-tudes was Osgood’s Semantic Differential. This method is used to discover the location of any word concept
(
e.g., “doctor”) in aconceptual space whose dimensions are
meanings rather than actual distances. Each of seven concepts
(
doctor, nurse, hos-pital, sick, me, father, policeman)
wasrated by the children on a series of 5 point
scales. At the top of each scale an adjective appeared, opposite in meaning to that at the bottom (strong-weak, smart-dumb, safe-scary, pretty-ugly, white-black,
happy-sad, clean-dirty). For each concept then, 7
scales were used, one for each of the seven adjective pairs, or 49 separate scales in total (7 concepts X 7 adjective pairs). One of the
seven scales for the concept “doctor” ap-pears below.
DOCTOR
Strong
5
4
3
2
1
Weak
Seven concepts were rated against seven
adjective pairs in this study-concepts : doc-ton, nurse, hospital, sick, me, father, police-man; adjective pairs : smart-dumb, safe-scary, strong-weak, pretty-ugly, white-black,
happy-sad, clean-dirty.
The concepts “me,” “father,” and
“police-man” are not health-related but were
in-cluded in the study as a rough check on
validity. These concepts are considered
cul-turally related and it was expected that
dif-ferences would appear between the two ethnic and socioeconomic groups with re-spect to these concepts. If no differences were observed on these nonhealth related concepts, the results observed with respect to health related concepts might be dubi-ous. This cross-cultural technique to pro-vide a rough estimate of validity has been described by Maclay and Ware,4 and by
Kumata and Schramm.5 Use of the semantic differential as a measure of health attitudes
has been carried out by Jenkins,6 but as far
as we know similar studies with children
have not been done.
Data derived from the use of the
seman-tic differential can be analyzed in many ways. Jenkins relied on simple percentages while Kumata and Schramm subjected the data to factor analysis. Mean scores for each scale could be compared using the
stu-dent’s t-test, but this statistic cannot be
used to test the difference between the groups for the concept as a whole. For this reason, Hotelling’s T2 was calculated. This
method of analysis is essentially a multivan-iate t-test which takes into account all
scales for each concept simultaneously.
RESULTS
The results are presented in Table I. This
table presents the values of Hotelling’s T2 for the seven concepts described above and for nine comparisons of these concepts
(
white-Negro, male-female, and so forth).Values for T2 are marked by an asterisk or cross depending on the level of statistical
significance. The most striking characteristic
is the consistent difference found between the races. For every concept the “distance”
between blacks and whites as measured by
the T2 is highly significant statistically. The statistical significance of the cultural con-cepts between the two groups tends to sup-port the equally significant differences ob-served with respect to the health-related concepts. The observed racial differences are
be-TABLE I (cont.)
Comparison Concept Hotelling’s T2
tween the schools since in each school one race is overwhelmingly preponderant
(
96%black at School A and 96% white at School
B
).
Sexual differences were not significant except when different sexes of different races were compared to each other in which case the differences were highly significant. The only significant difference between the sexes(with both races combined) was for the
concept “me.” The kinds of difference
be-TABLE I
VALUES FOR HOTELLING’S T’ FOR SEVEN
CONCEPTS AND NINE COMPARISONS
Comparison Concept Hot elling’s T’
Negro Male
Negro Female-Negro Male
Caucasian Female-Caucasian Male Negro Female-Caucasian Male Negro Female-Caucasian Female Doctor Nurse Hospital Sick Me Father Policeman Overall Doctor Nurse Hospital Sick Me Father Policeman Overall Doctor Nurse Hospital Sick Me Father Policeman Overall Doctor Nurse Hospital Sick Me Father Policeman Overall 31.85* 11.66 1.69 18.71f 99 97* 67 .06* 18.79t 449 77* .63 7 .6 7.47 6.80 19 .4t 6.51 4.70 90.01 8.94 5.26 8.77 4.43 21.48f 2.79 10.14 182.65 26.60* 25 .56* 32.89* 3337* 168.09* 101.69* 18.25t 59849*
School A-School B
Caucasian-Negro
Female-Male
Caucasian Male-Negro Male Doctor Nurse Hospital Sick Me Father Policeman Overall Doctor Nurse Hospital Sick Me Father Policeman Overall Doctor Nurse Hospital Sick Me Father Policeman Overall Doctor Nurse Hospital Sick Me Father Policeman Overall 63 79* 35 95* 31 .85* 38.64* 161.00* 135.34* 31 .05* 457.03* 56 35* 34 35* 34.78* 37.36* 234.36* 163 .68* 34 53* 558.19* S .70 5.52 10.60 6.13 33 45* 5.55 3.35 73.40 33 .30* 23 18.79f 15.61 141.98* 90 .82* 22 #{149}95* 43845*
* Significant at the 1% level, p<0.01.
t Significant at the 5% level, p <0.05.
Doctor 29.57*
Nurse 21.48t
Hospital 18.88t
Sick 28.06*
Me 134.65*
Father 98 79*
Policeman 28.84*
Overall 709 77*
* Significant at the 1% level, p < 0.01.
t Significant at the 5% level, p < 0 05.
Dumb
Scary
Weak
Ugly
Black
Sad
Dirty
Smart
Safe
Strong
Pretty
White
Happy
Clean
234
SCALE
SCORE
Dumb
Scary
Weak
UgI y
Black
Sad
Dirty
Smart
Safe
Strong
Pretty
White
Happy
Clean
I
234
SCALE
SCORE
ARTICLES 425
ing measured by the T2 can be graphically
illustrated as in Figures 1 and 2. These fig-ures depict the disparity between the groups
for the concept “sick” and appear quite
dif-fenent depending on whether one compares male to the “distance” between blacks and whites as female or black to white.
In general, white children when
corn-pared to black children regarded “doctor”
as smarter, safer, about as strong, uglier,
whiter, happier, and cleaner. The same
held true for “nurse” and for “hospital.” The pattern was reversed, however, with respect
to “sick.” Black children saw “sick” as
smar-ten, safer, stronger, prettier, happier, and
cleaner than white children. Although it is
difficult to interpret with any degree of
cer-titude the exact nature of these differences,
we feel that the results described above suggest that white children hold more
posi-five views of health than black children. At the same time, however, white children felt more apprehensive about sickness.
Paren-thetically, black children were more positive
about themselves
(smart,
pretty, strong, and so forth) than were white children buthad more negative attitudes toward
“father” and “policeman.”
COMMENT
The results of this study demonstrate
atti-tude differences between fourth grade
white and black children with respect to
health which are highly significant statisti-cally. These findings were expected and serve to emphasize again the importance of childhood in fixing attitudes. Because all of
the white children were affluent and all the
black children were poor it is impossible to separate the effects of poverty from effects
that may be ethnically influenced. In other words, are the important attitude determi-nants to be found in “black culture,” in the so-called “culture of poverty,” or in a
corn-bination of the two? A study of black chil-dren and white children of similar socioeco-nomic status would be most helpful in this regard.
Whether the differences originate from cultural factors that are based primarily on
BLACK vs. WHITE
C-)
Fic. 1. Differences with respect to the concept “sick” by race.
ethnicity or poverty, these differences in
children are consistent with respect to
adults.2 On the other hand, the relatively high regard black children have for
them-MALE
vs.
FEMALE(-)
selves in contrast to their views of their fa-thens and of the police is not surprising in view of the increasing leadership role black youths have assumed in the civil rights movement in reaction to the “Tomishness”
of their parents.
The semantic differential has much to recommend it as a research instrument.
Un-like interview schedules, it is easily
admin-istened to large groups of people
simultane-ously with very little manpower. It is less subject to interviewer bias, requires no in-terviewing skills, and is quite inexpensive.
Its great failing lies in the fact that while
attitudinal differences are easily brought to
light with proper statistical analysis, the precise nature of the observed differences is
often difficult to determine. Nevertheless, it
is of great value as a first approach to a re-search problem because of its ability to
as-certain the presence or absences of differ-ences which might generate hypotheses
warranting further investigation.
REFERENCES
1. Rosenstock, I.: Why people use health services.
Milbank Memorial Fund Quarterly, 44:94,
Part 2, 1966.
2. Koos, E. : Health of Regionville, New York:
Columbia University Press, 1951.
3. Osgood, C. E., Suci, C. J., and Tannenbaum, P.
H. : The Measurement of Meaning. Urbana,
Illinois: University of Illinois Press, 1957. 4. Maclay, H., and Ware, E. E.: Cross-cultural use
of the semantic differential, Behav. Sci. 6: 185, 1961.
5. Kumata, H., and Schramm, W.: A Pilot study of
cross-cultural meaning. Public Opinion
Quart., 20:229, 1956.
