Foster parent decision making and the HBM
Running Head: FOSTER PARENT DECISION-MAKING AND THE HBM
Foster parent decision-making and the Health Belief Model
Lin Marklin
Western Michigan University
A note about the APA format.
I realize that many of my in-text citations should be shortened when the citations appears a second time in the paper.
The strategy that works best for me is to get all my sentences and paragraphs into final order, and then do the final edit of my in-text citations.
Abstract
Foster children have more mental health needs than children in the general population (Blumberg, & Landsverk, 1996). The number of children in foster care is mounting, and children with high mental health needs are becoming a larger percentage of this population. Despite a strong need for services, many children in foster care have mental health needs that are unmet (Rosenfeld, Pilowsky, & Fine, 1997). Foster parents are primarily responsible for securing mental health services, but health communication research into the variables that influence a foster parent’s decision to use mental health services is lacking. The Health Belief Model (HBM) could be insightful in understanding these parental decisions. This study will assess the contribution of the variables described in the Health Belief Model (HBM) to foster parents’ decisions regarding mental health services.
The Foster Care System
History
Providing care for children with abusive, neglectful, or indigent parents has long been a concern in this nation, and some form of foster care has been in place in America since colonial time. In the 1600’s and 1700’s abused, neglected, and poverty-sticken children were placed either in the poorhouses or with other families as indentured servants, to be released upon adulthood (Schor, 1982). In the 1800’s orphanages became popular repositories for these children, and this remained the choice until the first two decades of the twentieth century. In response to a desire to better meet the needs of abused, neglected, or poverty-striken children, a 1909 White House conference acknowledged that home environments were preferable to institutions, and poverty did not predetermine removal from the home. American law makers then responded to the desire to better serve these children by opening up the public purse, and by the 1920’s, all states had all some form of Aid to Families of Dependent Children (Schor, 1982). With the use of federal and state monies, many at-risk children were able to remain at home. For the next thirty years, children were placed in foster care primarily in response to family illness, extreme poverty, or parental mental illness (dosReis, Zito, Safer, & Soeken, 2001; Schor, 1982), and foster care was a final safety net for families in medical or financial crisis. The causes for foster care placement changed throughout the 1960’s and the 1970’s, and in the early 1980’s, it was reported that parental abuse and neglect was “one of, if not the most important, precipitating circumstances” (Schor, 1982, p. 523). Finally, in August 1997, the National Center for Policy Analysis indicated that a larger number of placements since 1987 were the result of parental abuse and neglect (Craig, & Herbert, 1997). Increasingly, prolonged exposure to emotionally and mentally damaging environments are the precursors to placement for many foster children today, and the reason for placement can have a great influence on the child’s mental health (e. g., Blumberg, & Landsverk, 1996; Rosenfeld, Pilowsky, & Fine, 1997; Zima, Bussing, Yang, & Belin, 2000). The current foster care system is a reflection of society’s basic desire to meet the needs of “the nation’s most vulnerable children” (Craig, & Herbert, 1997, p. 1), but the task of caring for such children is becoming more complicated due to the changing pre-placement factors.
Foster Children
Foster children are at high risk for mental disorders due to the risk factors of their pre-placement environment and as a result of their post-placement separations and losses. The fact that foster children have more mental health needs than children in the general population has been shown by numerous studies (e.g., Blumberg, & Landsverk, 1996; Bondy, & Davis, 1990; dosReis, Zito, Safer, & Soeken, 2001; Pilowsky, 1995). Mental health professionals have indicated that intervention, usually indicative of moderate to severe mental health disorders, is necessary for up to 57% of foster children as compared to a maximum of 22% of children in the general population (Blumberg, & Landsverk, 1996). A study of 213 California foster children found that 80% of those children had developmental, behavioral, and emotional problems which have been linked to mental health disorders (Schneiderman, & Connors, 1998). The behavioral and emotional problems of many foster children are significant (Pilowsky, 1995). Furthermore, many of these same children are at risk for developing additional or more severe behavioral and emotional problems due to the abusive, neglectful, or drug-using home environments that most likely brought the children into the foster care system (e. g., Blumberg, & Landsverk, 1996; Rosenfeld, et al., 1997). Adding to these risk factors for mental disorders is the fact that a large portion of foster children come from poverty-stricken environments where criminality, violence, and maternal drug abuse is prevalent (Pilowsky, 1995). Potentially compounding the pre-placement risk factors is the foster care placement itself where children experience a temporary or permanent separation from parents, neighborhoods, school systems, religious organizations, and a potential loss of sibling and cultural ties (Schneiderman, & Connors, 1998). Thus, the actual movement into and potential subsequent movements within the foster care system could be seen as traumatic even though the relationship between placement into foster care and children’s mental health is not well documented (Orme, 2001). It is essential that foster children get assistance is dealing with the mental trauma of past neglect and abuse and with multiple losses precipitated by placement in foster care (Bondy, & Davis, 1990). Because children in foster care generally come from chaotic home situations, and the placement into foster care is often seen as traumatic, foster children are more predisposed to mental disorders.
Despite exhibiting a need for mental health services, research continues to show that children in foster care have mental health needs that are unmet (e.g., Halfon, Mendonca, & Berkowitz, 1995; Titterington, 1990). Orme (2001) reports mental health services are not being secured for a large percentage of foster children who have been identified as having an urgent need for such services. While a previous California study (e.g., Halfon, Mendonca, & Berkowitz, 1995) indicated that between 35-57% of foster children needed mental health intervention services, when Blumberg & Landsverk (1996) looked at 1, 352 children in the San Diego foster care system, only 17% were receiving services. These findings were based on payment/usage records within the San Diego Mental Health System, the only provider for Medicaid services, so two reasons were offered for the discrepancy: private insurance companies were paying for mental health use by foster children or there was a considerable amount of unmet need (Blumberg, & Landsverk, 1996). Because the foster care agency is the legal guardian of the children in care, and foster parents have no legal status with regard to their foster children, it would seem doubtful that private insurance could account for a large portion of the 18% to 40% of the studied population that was not receiving mental health services paid for by state monies. Takayama, Bergman, & Connell (1994) found that in the state of Washington 25% of studied foster children were receiving Medicaid funded mental health services in a population were twice that number children were judged to have the need for such services. Tittterington (1990) and Bondy (1990) both argue for the need to change the foster care system in order to better provide for the large number of foster children who exhibit mental health disorders but are not receiving any type of mental health services. It is clear that children in foster care have unmet mental health needs, and understanding why these need are unmet can be the first step in identifying potential strategies to rectify this situation.
Meeting the mental health needs of foster children is a two-fold imperative due to the growth in the number of foster children and the changing demographics within the current foster child population. The number of children in foster care is large, and historically, it has been growing. Research has indicated that that the number of children in foster care has increased dramatically. In the 14 year period between 1982 and 1996, the number of children in care more than doubled from 262 000 to 526,112 (dosReis, Zito, Safer, & Soeken, 2001; Craig, & Herbert, 1997; Orme, 2001). According to the National Center for Policy Analysis, a total of 725,000 children received some type of foster care service in 1996 (Craig, & Herbert, 1997). In addition to the size of the foster care population, the changing characteristics of foster children are another area of concern. Orme (2001) postulates that the mental health needs within the foster care population might experience an increase due solely to the changing demographic of the children who remain in care for an extended time. In 1997, the U.S. Congress enacted the Adoption and Safe Families Act with the goal of moving children more quickly through the system (Craig, & Herbert, 1997). There is now a one-year time frame for returning children to families who can appropriately care for them or placing the children for adoption. Once available for adoption, children with relatively low mental health needs are often the first to be placed, and children with higher mental, educational, and emotional needs are often passed over (Orme, 2001). Therefore, the population of children who remain in foster care for an extended period of time will increasingly be those are not easily adopted due to mental, physical, emotional, and behavioral disorders (Orme, 2001). Thus the demographic within the growing foster care population will probably evolve to have a greater portion of children with even more severe mental health needs. This change in demographic will most certainly alter the types of care that foster parents must provide for these children, and mental health is a priority service that these children will need (Orme, 2001). Therefore, understanding why the mental health need of many current foster children are unmet is important if foster care professionals want to better meet the mental health needs of foster children.
Caseworkers and Foster Parents
Caseworker advocate for the needs of the foster children, but caseworker also has assorted other duties that in effect remove the caseworker from the day-to-day life experiences of the foster children. The case worker has a multitude of responsibilities in the life of the foster child that can include but are not limited to preparing legal documents for hearings, testifying in court cases, coordinating family visits, interacting with biological parents, assessing the needs of the biological family, developing a plan to meet those needs, supervising the biological parents progress toward goals, facilitating and coordinating access to social services, health care, and medical treatment for both the biological parents and the foster family, working with the school system to develop service plans for the foster children, and helping the foster care agency decide what is in the best interest of the foster child (Kessler, & Greene, 1999; Zlotnick, Kronstadt, & Klee, 1999). Caseworkers view themselves as case managers who often are relying on the information provided by knowledgeable others in order to make informed decisions on behalf of the foster children (J. A. Tamer, personal communication, October 23, 2001). While the caseworker is definitely interested in the well-being of the individual foster child, larger issues within the biological family and paperwork required by the state agency and the courts often consume much of the caseworker’s attention (Kessler, & Greene, 1999). The caseworker is advocating for the foster child on a larger plane and can be uninformed of the day to day struggles of the individual foster child.
A child in foster care may interact with the caseworker, but no adult is more responsible for the care of the child than the foster parent. The foster parent is the individual on the front line managing, evaluating, and engaging the child, and as such it is the foster parent who plays the pivotal role in the life of the foster child (Orme, 2001). Most agencies view foster parents as part of the professional team with unique and valuable insights into the needs of the foster child (Titterington, 1990). Caseworkers look to the foster parents for information and guidance regarding the health status of children in care: The foster parent is a valuable resource for the caseworker, and the caseworker often relies on the foster parent to adequately evaluate and report the health concerns of the children in care (J. A. Tamer, personal communication, October 23, 2001; Zlotnick, Kronstadt, & Klee, 1999). Foster parent can contribute meaningfully to the development of the children service plans (Titterington, 1990). In addition, it the service plan that helps determine the foster child’s use of health related services, and this is especially true for mental health services. The role of the foster parent in reporting mental health concerns and advocating for mental health services is crucial for early utilization of mental health services (J. A. Tamer, personal communication, October 23, 2001). While caseworkers may eventually recognize and treat mental health disorders, the foster parent is the crucial link between the foster child and mental health services. The vital role of the foster parent in the foster child’s health is obvious (Orme, 2001), but unfortunately many foster parents are not making the needed connection.
As previously stated, there is an unmet need for mental health services among foster children and some research seems to suggest that foster parents may be a weak link in the chain connecting foster children to mental health services (Blumberg, & Landsverk, 1996; Bondy & Davis, 1990; dosReis, Zito, Safer, & Soeken, 2001). If foster parents are in some way failing to get their foster children needed mental health services, then understanding the variables that influence foster parent decision-making could be insightful. Research has shown that foster parents are not securing the mental health services that their children need (Halfon, Mendonca, & Berkowitz, 1995; Horwitz, Owens, & Simms, 2000). It is unclear if the basis for this lack of services is due solely to a failure to acknowledge a mental health problem or if the failure is also related to some of the variables of the HBM, such as perceived risk appraisal, perceived benefits and barriers, cues to action, and perceived self-efficacy. Research has shown that foster parents are less likely than health care professionals to diagnose mental health problems in foster children (Horwitz, Owens, & Simms, 2000). Foster parents report that 47% of the children in their care need mental health services (Zima, et al., 2000), yet professional diagnosticians report that this need is as high as 80% (Halfon, Mendonca, & Berkowitz, 1995; Horwitz, Owens, & Simms, 2000). This lack of diagnosing the problem seems almost contradicted by the fact that foster parents most commonly reported mental health services as the service their child needed most (Zima, Bussing, Yang, & Belin, 2000), and these parents specifically identified needs for counseling services (Zima, Bussing, Yang, & Belin, 2000). More research is needed into the variables that impact the role foster parents play in securing mental health services for foster children.
The most beneficial research could come from utilizing the Health Belief Model (HBM) as a guide for analyzing foster parents decisions either to seek and not to seek mental health services for their foster children. The socioeconomic (Blumberg, & Landsverk, 1996), demographic (Garland, Besinger, & Bridgett, 1997), and educational variables (dosReis, Zito, Safer, & Soeken, 2001) that influence the utilization of mental health services by foster parents have been investigated. Previous research has not focused on beliefs and attitudes. It has been noted that getting foster parents to actively participate in the mental health treatment of their foster children is a reoccurring challenge (Bondy, & Davis, 1990). It would be useful to see if this reluctance was tied to attitudes. Understanding the beliefs and perceptions of foster parents could prove insightful into understanding why the mental health need of many current foster children are unmet. Such attitudinal insights could be useful if foster care professionals want to develop strategies for gaining foster parents’ compliance when it comes to using mental health services for their foster children.
Health Belief Model
History
The HBM has a definitive origin, but the originating author is sometimes misleadingly listed as Rosenstock. The Winter 1974 issue of Health Education Monographs is often viewed as the seminal authority for the original HBM. In the introduction, Becker explains the mandate that resulted in the explication of the HBM: a subcommittee for the 1971-1973 project entitled “Sociological Aspects of Health and Health Services” was charged to elaborate “the best model or models available for predicting such seemingly diverse activities as preventative health action, medical care utilization, delay in seeking care, and compliance with medical regimes” (Becker, 1974, p, ii). The resulting Health Belief model was an explication of a model developed in the early 1950s by a group of social psychologists working for the U.S. Public Health Service (French, & Kurczynski, 1992). Rosenstock (1974) clearly credits Hochbaum for the initial HBM research in his 1952 study of TB screening where Hochbaum was attempting to predict individual use of x-ray screening for this asymptomatic disease in the face of public apathy. In detailing the development of the HBM, Rosenstock goes on to chronicle Kegeles’ contribution with his studies of preventative dental care, and also mentioned is the 1960 Leventhal, Hochbaum, and Rosenstock study of Asian influenza. While Rosenstock’s article in the Winter 1974 issue of Health Education Monographs is often viewed as the seminal authority for the original HBM, another article in that same issue perhaps more accurately attributes the origins to “Hochbaum, Leventhal, Kegeles, and Rosenstock” (Maimam, & Becker, 1974, p. 336). Regardless of the possible confusion over the original authorship, the model has extreme clarity in the variables it views as predictive of health behaviors.
The variables of the original HBM are generally accepted and widely used in the research community although some modification has been deemed necessary. Perhaps due to the broad scope of the original mandate and the expertise and diverse fields of interest of the eight publishing authors of the seminal Winter 1974 issue, the resulting HBM is the theory used most often when studying health-related behaviors (Lai, Hamid, & Cheng, 1999; McIntosh, & Kubena, 1996; Petosa, & Jackson, 1991). Janz and Becker (1984) noted that among all the theoretical models of health-related behaviors, the HBM is the leader in terms of research projects and confirmation of constructs. The HBM articulated by Rosenstock in the Winter 1974 Health Education Monographs indicates that individuals’ health behaviors focuses on four cognitive dimensions: (1) perceived susceptibility, (2) perceived seriousness, (3) perceived benefits of taking action and barriers to taking action, and (4) cues to action. Rosenstock further points out that the first three variables had been researched previously, but the final variable of cues to action had not been carefully studied, but it was deemed essential to complete the model. However, it later became evident that the components of self efficacy were also influencing health behaviors, so many subsequent researchers modified the model slightly to include a self-efficacy variable to measure the individual’s perceptions about his/her ability to carry out the recommended course of action (Jurich, & Adams, 1992). In 1990, Rosenstock himself argued for including self-efficacy in an expanded HBM (quoted in Lux, & Petosa, 1994, p. 487). Often researchers using the Health Belief Model will routinely include a measurement of perceptions of self-efficacy (e.g., Eisen, & Zellman, 1992; McIntosh, & Kubena, 1996; Neff, & Crawford, 1998). This modification by some researchers has complimented the original variables of the widely used HBM.
The health belief model has been used with other variables of interest and in a variety of settings, but the basic utility of the components of the theory remain. The HBM is flexible enough to incorporate other variables, so various studies have incorporated variables such patient self-advocacy (Brashers, Haas, & Neigig, 1999), locus of control (Stein, & Fox, 1992), perceptions of physician efficacy (Becker, Maiman, Kirscht, Haefner, Drachman, & Taylor, 1979), the value placed on health (Becker, Maiman, Kirscht, Haefner, & Drachman, 1979; Girvan, & Reese, 1990), and optimism (Lai, Hamid, & Cheng, 1999), Within the health communication field, much work has been done on the demographic and HBM variables influencing specific health behaviors such as decreasing one’s blood pressure (Taylor, 1979), wearing a bike helmet (e.g., McAleese, & Scantling, 1996; Witte, Stokols, Ituarte, & Schneider, 1993), changing one’s diet, (e.g., Chew, Palmer, & Kim, 1998; Frewen, & Schomer, 1994; McIntosh, & Kubena, 1996), practicing safe sex (e.g., Jurich, & Adams, 1992; Maticka-Tyndale, 1991; Mattson, 1999; Petosa, & Jackson, 1991; Wulfert, & Wan, 1995), and participating in health care decisions (e.g., Brashers, Haas, & Neigig, 1999; Kroll, Rothert, Davidson, Schmitt, Holmes-Rovner, Padonu, & Reischl, 2000; Rimal, Ratzan, Arntson, & Freimuth, 1997). Speaking to the resiliency of the HBM is the fact that although is has been implemented in a large variety of research settings and disciplines, the core components have not changed (Kar, Alcalay, & Alex, 2001; Lai, Hamid, & Cheng, 1999). In addition to remaining constant, the four main variables are also backed by decades of research. Janz and Becker (1984) reviewed 46 studies conducted from 1974 and 1984 and found that four main variables were well supported as predictive of health behaviors. The ranking of significant association was found to be as follows: barriers 89%, susceptibility 81%, benefits 78%, and severity 65% (Janz, & Becker, 1984). These four variables comprise three of the four originally articulated cognitive dimensions, with cues to action being the fourth, and decades of research have proven both the utility and versatility of the HBM as articulated by Rosenstock in 1974.
The broad utilization of this model since its inception has allowed for some basic trends to emerge regarding it’s utility in all settings. The model is less successful in when the health behavior is not connected with a specific threat, such as annual physical exams and flossing (McIntosh, & Kubena, 1996). Second, with preventative health behaviors, some components of the model are more useful than others in predicting behaviors (Janz, & Becker, 1984). Some studies have found that perceptions of benefits and barriers are more highly associated with health behaviors than perceptions of severity and susceptibility (McIntosh, & Kubena, 1996), and, in reviewing 46 studies between 1974 and 1984, Janz and Becker (1984) found severity to have the lowest association with behavior. Finally, The HMB has shown the greatest predictive value when investigating specific short-term health behaviors, e.g. genetic testing of fetuses (O’Connor, & Cappelli, 1999) or getting a flu shot (McIntosh, & Kubena, 1996). The components of the HBM are all useful in predicting behavior, but some components are more useful than others and the circumstances of the research also influence overall utility of the model.
Little research has been done in the health communication field applying the HBM to decisions to use mental health services. A basic belief of the HBM is that engaging in health behavior is a function of how motivated the person is to act (perceived susceptibility and perceived seriousness) and the perceived efficacy of the recommended behavior (perceived benefits and perceived barriers) (Chew, Palmer, & Kim, 1998). If this motivation to act and perception of solution efficacy help determine health related behaviors, then it would seem that they are involved in the decision to seek mental health services, which is a health related behavior. However, research relating the HBM to utilization of mental health services is lacking. In the social sciences, much work has been done on the help seeking-steps that people utilize prior to successfully attaining health care services (Blumberg, & Landsverk, 1996; Zima, Bussing, Yang, & Belin, 2000), and specific to this project, much work has been done on the use of mental health services by foster children (Bondy, & Davis, 1990; Schneiderman, & Connors, 1998; Takayama, Bergman, & Connell, 1994). What is missing is research on how foster parent perceptions and beliefs influence their willingness and ability to secure much needed health services for their foster children. If foster children are identified as needing mental health services, and Medicare provides payment for such services, why are researchers still reporting a large unmet need (e.g., Blumberg & Landsverk, 1996; Halfon, Mendonca, & Berkowitz, 1995; Zima, Bussing, Yang, & Belin, 2000)? The HBM could provide some insight into this problem.
Purpose and Constructs
The purpose of this study is to assess the how well the variables of a modified HBM -adding the variable of self-efficacy-can explain foster parents’ decisions to either utilize or not utilize mental health services for their foster children. The framework for this study will be 1) perceived risk appraisal 2) perceived benefits and barriers, 3) cues to action and 4) perceived self-efficacy.
Perceived risk appraisal
Perceived risk appraisal is a compilation of perceived susceptibility and perceived severity (Mattson, 1999) Perceived susceptibility is defined as a person’s subjective belief about vulnerability to a specific health condition (Rosenstock, 1974). Perceived seriousness is defined as a person’s belief about the severity of a specific health condition (Rosenstock, 1974).
H1: Foster parents’ perceived susceptibility of foster children to mental health disorders will be positively associated with foster parents’ use of mental health services for their foster children.
H2: Foster parents’ perceived severity of the mental health needs of foster children will be positively associated with foster parents’ use of mental health services for their foster children.
Perceived benefits of taking action and barriers to taking action
Perceived benefits are defined as a person’s belief about the relative effectiveness of proscribed methods to decrease susceptibility to or the threat of a specific health condition (Rosenstock, 1974). Perceived barriers are defined as any perceived negative consequences that interferes with the ability of an individual to engage in certain behaviors (Rosenstock, 1974). Researchers have enumerated several categories of barriers that are anticipated to appear in this study, and this list would include, but not be limited to, time, cost, social stigma, pain, and inconvenience (e.g., Chew, Palmer, & Kim, 1998; Rosenstock, 1974).
H3: Foster parents’ perception of the number of benefits of mental health services by foster children will be positively associated with foster parents’ use of mental health services for their foster children.
H4: Foster parents’ perception of the number of barriers to the use of mental health service by foster children will be negatively associated with foster parents’ use of mental health services for their foster children.
Cues to action
Cues to action are triggers that cue an individual to engage in a specific health behavior (Rosenstock, 1974). Rosenthal (1974) further states that such cues can be both external (e.g., media messages and interpersonal messages) or internal (e.g., perception of ill-health), but this study will focus on external messages because the foster parent is acting on the behalf of the foster children an will not be queried as to the internal cues of said children
H5: The number of cues to action received by a foster parent will be positively associated with foster parents’ use of mental health services for their foster children.
Perceived self-efficacy
Perceived self-efficacy is the individual’s belief that s/he is able to perform certain behaviors (Bandura, 1977). Self-efficacy can be seen as perceived self-confidence (Kroll, Rothert, Davidson, Schmitt, Holmes-Rovner, Padonu, & Reischl, 2000). Bandura (1977) stated that individuals will attempt behaviors within their perceived capabilities and avoid behaviors that are perceived to be outside of their capabilities. The construct of self-efficacy has often been incorporated into studies utilizing the HBM (e.g., Eisen, & Zellman, 1992; Lux, & Petosa, 1994; McIntosh, & Kubena, 1996; Neff, & Crawford, 1998). The rationale for incorporating self efficacy into studies of the HBM is that self –efficacy is an impacting variable because when individuals are confident in their ability to perform a certain healthy behavior, those individuals are more likely to engage in health behavior than individuals with less self efficacy (Mattson, 1999).
H6: Foster parents’ perceived self-efficacy in using the mental health system will be positively associated with foster parents’ use of mental health services for their foster children.
Methods
Participants
The study takes place in a Northern-Midwest state in a county of approximately 238,000 residents, with a major metropolitan area of 120,000 people. The participants will be 60 foster parents from two large foster care agencies, one state run and the other privately run. All foster parents hold a current foster care license and either currently have children in their home or have cared for children within the past three months. All participants will have had at least one foster care placement that was at least three months in duration. The sixty participants will be solicited randomly, based on a combined alphabetical listing of the two agencies. In two-parent homes, the foster parent who self identified as being most active in the advocacy of medical and educational needs of the foster children will be the parent who participates
Survey Instruments
40 item Parent Rating Scale
Self-Efficacy Scale
Health Belief Model Scale
Interview Protocol
6-8 focus groups with 8-10 participants
Procedure
Explain clearly procedures for the laboratory or field. 2 pages
The participants will be solicited at random. The private agency utilizes 75 foster parents, and the state agency private agency utilizes 103 foster parents, for a total of 178 potential participants. The names of foster parents from both agencies will complied onto one list, and a computer program will be used to randomly select names until a total of 120 are selected. Invitations to participate will be mailed to these 120 licensed foster homes. (See Appendix A) The letter includes an explanation of the project, the requirement for participation, an appeal to the perceived need to enhance parent/worker communication, and an incentive of free movie tickets for the entire family upon completion of the focus interview. The letter ends with instructions to phone for an interview time. In addition, a phone call will be made 4 days after the mailings, inquiring about the foster parent’s willingness to participate, and appointments will be made for interview times. If more than 60 foster homes meet the requirements of the study and are willing to participate, then the interview schedule will be expanded. If fewer than 50 foster parents agree to participate, the names of the unsolicited parents will be used to randomly solicit 20 additional participants.
The primary foster parent of the participating foster children will be asked to complete a survey. A portion of the survey will include the Parent Rating Scale portion of the Child Behavior Checklist to help identify the degree of foster child behavior problems. This acting-out behavior subscale focuses on impulsivity, aggression, and disruptiveness (Hightower, Work, & Cowen, 1986) and these behaviors have been useful in identifying mental health disorders (Zima, Bussing, Yang, & Belin, 2000). The acting-out behavior subscale is a five point Likert-type scale, and previous users have identified participants “as being aware of a behavior problem if they rated the child at or below the 15th percentile” (Zima, Bussing, Yang, & Belin, 2000), so I will follow that model and rate children in the 15th percentile and below as having been identified with mental health needs. The Parent Rating scale is usually used in conjunction with the Teacher Rating scale which was implemented in study of “a large, ethnically diverse sample of children from 22 elementary schools” with a reliability Alpha of .85-.91 and a high validity (Acting Out domain: r = .85) (Hightower, Work, & Cowen, 1986 ). A later studies implied the usefulness of this scale for determining the mental health needs for children in foster care, but did not report an Alpha (Zima, Bussing, Yang, & Belin, 2000).
In addition to the acting-out behavior subscale (Parent Rating Scale), participating foster parents will complete a survey with open ended questioned measuring 1) perceptions of mental health issues 2) perceptions of the specific mental health needs of the children in their care 3) perceptions of the efficacy of the mental health care 4) perceptions of their ability to successfully advocate for mental health services 5) behavioral and emotional cues of children in their direct care.
Participating foster parents also will be part of a focus group. The questions will be open ended, and they will elicit answers about foster children in general. Interviews will be tape recorded and transcribed. A coding scheme will be developed to interface with the afore-mentioned five basic tenets of the HBM and will also include a code for self-efficacy. Two coders will code all transcripts and cross-referenced for agreement in coding.
Measurement
Survey Instruments
Closed-Ended Survey Questions. Perceived risk appraisal will be operationalized as perceived susceptibility plus perceived seriousness. On the surveys, perception of both susceptibility and seriousness are measured on a 5-point Likert-type scale. Once the reverse coded items are inverted, summing the numbers will reveal each individual’s perception of risk. Perceived benefits of taking action and barriers to taking action will be operationalized as perceived benefits minus perceived barriers. On the surveys, perceptions of both benefits and barriers are measured on a 5-point Likert-type scale. Once the reverse coded items are inverted, summing the numbers for each category and then subtracting the barriers total from the benefits total will produce an integer that reflects the individuals’ perception of benefits of taking action and barriers to taking action. Cues to action will be operationalized as the number of times an individual self-reports on an open ended survey question that a professional or non-professional recommended mental health services for the children in their care. Perceived self-efficacy I still need to develop this one
Open ended Survey Questions. Mental health problems will be operationalized as the number of concerns that a foster parent self-reports about a foster child’s behavior or feelings. In addition any foster parent who indicates at least one such concern will be classified as cognizant of a potential mental health problem. Perceived need for mental health services will be operationalized as the number of mental health services a foster parent indicates a foster child needs. In addition any foster parent who indicates at least one such service will be classified as cognizant of a need for mental health services. Referral to mental health services will be operationalized as the number of times an individual self-reports that a professional or non-professional recommended mental health services for the children in their care, and individuals reporting at least one professional recommendation will by classified as having been referred. In addition, these referrals to mental health services also will be categorized as cues to action. Use of mental health services will be operationalized by the number of self-reported use of the mental health service system, and individuals reporting the use of at least one mental health service, will be classified as having secured mental health services for the foster children in her/his care.
Interview Coding
Mental health problems. When asked what type of problems the typical foster child will have in school, parents who indicate a concern about a foster child’s behavior or emotions will be classified as cognizant of a potential mental health problem.
Need for mental health services. When asked what type of services the typical foster child need, parents who have at least one response of counseling for problems with feelings/behavior, medication for problems with feelings/behavior, psychiatric care, or training to care for the child’s emotional or behavioral problems will be classified as cognizant of a potential need for mental health services.
Referral to mental health services. When asked who suggested that their foster children receive treatment for a problem with behavior or emotions, parents who have at least one response of a professional referral for counseling will be classified as having been referred to obtain mental health services.
Use of mental health services. When asked what treatments for a problem with behavior and/or emotions their foster children had received, parents who list a mental health service will be classified as having obtained mental health services for their foster child
Benefits
For perceived benefits of mental health services, foster parents will be asked, “Thinking about foster children in general, what are the benefits for getting kids mental health services?” follow up question, “On a scale of 1-5, with 1 being absolutely no benefit and 5 being tremendously beneficial, would you rate the benefits of the mental health services that foster children typically use?” Responses to the open ended questions will be coded into categories of educational benefit, recreational benefit, behavioral benefits, emotional benefits, and family peace benefits. Each participant will be asked to give an individual response to the closed-ended question, and the response will be treated like a response on a Likert-type scale.
Perceived Barriers
For perceived barriers to mental health services, foster parents will be asked, “Thinking about foster children in general, what are the negative aspects for getting kids mental health services?” follow up question, “On a scale of 1-5, with 1 being extremely negative and 5 being no negative aspects, how would you rate the negative aspects of using mental health services for foster children?” Responses to the open ended questions will be coded into categories of time, cost, social stigma, pain, and inconvenience. Each participant will be asked to give an individual response to the closed-ended question, and the response will be treated like a response on a Likert-type scale
Self-efficacy
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