Children's Concepts of Illness

129
British Journal of Health Psychology (2002), 7, 129 –147

© 2002 The British Psychological Society
www.bps.org.uk
Children’s concepts of illness: An intervention

to improve knowledge
Joanne M. Williams* and Lynne M. Binnie

Faculty of Education, University of Edinburgh, UK
Objectives. This study aimed to explore children’s understanding of illness and

attempted to improve their knowledge through the presentation of a factual story
and group discussions.
Design. Children’s responses to questions pertaining to three ailment types
(contagious illness, non-contagious illness and injury), for three process variables
(cause, time from cause to effect, and recovery factors), were recorded before and
after a training intervention.
Method. Children aged 4 (N = 30) and 7 years old (N = 30) were initially individually
interviewed about common ailments (contagious: chickenpox and cold;
non-contagious: asthma and cancer; injury: scraped knee and broken arm). A week
later half of the children in each age group (N = 30) were included in a small group
(N = 5) intervention where factual information about three of the ailments was
provided and children participated in guided group discussions. The remaining
control children received no intervention. All children were subsequently individually
interviewed a week later using the initial interview schedule.
Results. The 7-year-olds exhibited more sophisticated knowledge of illness at
pre-test than the 4-year-olds. Comparison of pre- to post-intervention changes
showed that children who participated in the intervention condition improved overall
in their understanding of the ailments signi cantly more than controls. However,
detailed analyses revealed a large degree of variation across the sample in terms of
post-test change for individual items.
Conclusion. Children’s understanding of illness is complex and undergoes develop-
mental changes between the ages of 4 and 7. Educational interventions that provide age-
appropriate factual information and peer group discussions regarding illness processes
might be effective in improving knowledge of illness among young children.
*Requests for reprints should be addressed to Joanne Williams, Lecturer in Psychology, Faculty of Education, St John’s Land,
Holyrood Road, Edinburgh EH8 8AQ, UK (e-mail: Jo.Williams@ed.ac.uk).
130 Joanne M. Williams and Lynne M. Binnie
There has been a ‘recent outbreak’of research concerning children’s concepts of illness
(Solomon & Cassimatis, 1999, p. 113). Understanding the content of children’s knowl-
edge will help clinicians provide age appropriate explanations of illness (Eiser, 1985)
and aid the development of age-appropriate preventative health education strategies
(Burbach & Peterson, 1986).
Children’s concepts of illness

Research into children’s illness concepts has changed in theoretical focus and method-
ology over the last two decades. ‘Traditional’ research, inspired by Piagetian stage
theory, concluded that children younger than 7 years old do not possess the cognitive
competence to reason theoretically about illness processes such as contamination and
contagion (Bibace & Walsh, 1980; Brewster, 1982; Gratz & Pilivian, 1984; Kister &
Patterson, 1980; Perrin & Gerrity, 1981; see also Bibace, Schmidt, & Walsh, 1994, for a
comprehensive review). Recently, cognitive development studies, based upon different
theoretical underpinnings and using new methodological approaches, have contra-
dicted the ndings of ‘traditional’ research. They have demonstrated that young children
do reason about the biological causal process of illness. This new approach examines
children’s concepts of illness within the context of their spontaneous na¨õ ve knowledge
and theories of biology (Medin & Atran, 1999; Siegal & Peterson, 1999; Wellman &
Gelman, 1992). As Kalish (1999) points out ‘Illness is a concept of signicance and
intriguing connections to theories of biology’ (p. 101). Within this new approach, the
illness processes of contamination and contagion have received most research attention.
Contamination involves an innocuous object being negatively affected through
contact with another object (Kalish, 1999), and many studies indicate that pre-school
children hold this concept (Siegal, 1988; Siegal & Share, 1990). However, whether
young children’s concepts of contamination are biological in the sense that they pertain
to underlying biological or physiological processes has come into question (Au, Sidle, &
Rollins, 1993; Springer & Belk, 1994). Kalish (1997), for example, concludes that pre-
school children have a poor understanding of bodily processes involved in contamina-
tion and no conception that these processes may take time to manifest.
Recent research has found that young children also have some understanding of
contagion (Siegal, 1988). Contagion entails a complex generic causal chain whereby
transmission of contaminants occurs between people (Kalish, 1999). Kalish (1996a, b)
argues that young children’s knowledge about illness revolves around a na¨õ ve ‘germ
theory’ of contagion that they rely on when making judgements about illness. Kalish
(1997) suggests that pre-schoolers understand germs as a biological causal link between
the acquisition of a symptom and subsequent transmission of illness. However,
pre-school children’s understanding of contagion and germs is limited and they often
over-generalize contagion to non-contagious illness and symptoms (Hergenrather &
Rabinowitz, 1991; Keil, 1992; Solomon & Cassimatis, 1999). Moreover, Solomon and
Cassimatis (1999) suggest that children do not view germs as biologically living things,
and also germs are not central to children’s understanding of illness. Thus, young
children may have a physical but not biological conception of infection dependent on
human action rather than on antigen transmission.
In summary, recent studies, relying on xed choice explanation and judgement
methodologies, have shown that pre-school children have more of an understanding of
illness than ‘traditional’ research had revealed, but also demonstrate that there are
limitations to young children’s illness knowledge. However, the focus on contamination
Children’s concepts of illness 131
and contagious illness has encouraged researchers to overlook the fact that children’s
experience of illness will also encompass non-contagious illness and injury. Further-
more, research has tended to focus on children’s understanding of illness causation,
ignoring other important processes such as time course from infection to symptom
onset, and factors inuencing recovery (Solomon &Cassimatis, 1999). Most importantly,
the implications of this recent wave of research for health education have not been
explored. Au, Romo, and DeWitt (1999) attempted to improve adolescents’ under-
standing of illness by structuring interventions around their theories of biology;
however, no studies have applied this framework to young children.
Interventions to improve young children’s biological knowledge

Young children reason about their experience of illness (personal and vicarious) but
their na¨õ ve understandings are varied and not always in line with formal biology. Na¨õ ve
biological knowledge, however, is amenable to improvement through educational
intervention (e.g. Au et al., 1999) and, as active learners, educational interventions
should be tailored to suit children’s cognitive competencies and existing knowledge of
illness (Kalish, 1996a). One of the rst biology intervention studies was carried out by
Hatano (1990) who showed that practical experience with animals leads to improve-
ments in children’s biological knowledge. In relation to illness, this approach may not
be practical or ethical so other methods of improving biological knowledge must be
identied. Springer (1995, 1999) argues that providing children with basic biological
facts leads them to construct biological theories through the cognitive process of
inference. In an intervention study with 4-year-olds he found that providing children
with basic biological facts about birth and intrauterine development led them to
develop a ‘Na¨õ ve Theory of Kinship’. However, Williams and Afeck (1999) failed
to replicate Springer’s ndings and argue that providing factual information in storybook
form alone is not always sufcient to promote the cognitive processes involved in
learning biological concepts.
A third and promising approach to improving children’s illness knowledge involves
structured peer group discussions (Au et al., 1999). There are substantial, but contrast-
ing, theoretical grounds for its employment in attempts to promote conceptual advance
(see Doise, 1990; Doise & Mugny, 1984; Piaget, 1985; Vygotsky, 1962). These theorists
each suggest that allowing children to discuss and debate na¨õ ve concepts promotes
restructuring and renement of ideas, although they differ in their views of the cognitive
processes involved. Hatano and Inagaki (1997) also argue with specic reference to
biological knowledge that ‘. . . conceptual change is often induced by participation in
goal-directed activities and enhanced by discursive processes in a group . . .’ (p. 126).
Empirical support for the use of peer group discussion in biology interventions is
provided by Williams and Tolmie (2000) who found that discussion groups composed of
children holding different na¨õ ve inheritance concepts experienced greater improve-
ment in knowledge compared to children in groups composed of individuals with
similar ideas, or individuals working on their own through a problem-solving workbook
task. Thus, structured group work and discussions about na¨õ ve biology concepts seem
to be a productive means of fostering conceptual change. In practical terms, group work
is often already used in school health education, consequently this method would not
necessitate a change in, but rather an adaptation of, current practice.
To date, research on interventions to improve young children’s biology concepts is
rare. However, the foregoing discussion highlights that three methods are potentially
useful in promoting biology knowledge, namely the provision of: practical experience;
factual information; and peer group discussion. One productive way forward might be
to develop interventions that incorporate all three approaches in an effort to trigger
improvements in children’s knowledge of illness.
The present study

The study reported in this paper aims to describe 4- and 7-year-olds’ na¨õ ve concepts of
contagious illness, non-contagious illness and injuries, and their understanding of three
key processes: causal factors; time between cause and onset of symptoms; and recovery
factors. Thus, the present study extends existing research by broadening the focus from
exclusively examining concepts of contagious illness and causal processes. The study
also attempts to improve children’s understanding of illness by conducting an inter-
vention that incorporates the three elements found to be successful in biology
interventions. Half of the children received the age-appropriate intervention providing
indirect experience (through vignettes), factual information, and discursive processes
concerning illness. The other children received no intervention. Comparisons of post-
intervention changes in illness knowledge between children participating in the
intervention and control conditions should reveal the efcacy of the intervention.
Method
Participants
A group of 30 3- and 4-year-olds (15 boys, 15 girls: M = 4, 1; range = 3, 7 to 4,7) and a
group of 30 6-and 7-year-olds (24 boys, 6 girls: M = 7, 2; range = 6, 8 to 7,6) from a state-
run primary school were included in the study (N = 60).
Materials
Stimulus questions for pre- and post-tests
A series of questions was followed by xed choice illness explanations. Fixed-choice
response methods have been used extensively in research on children’s cognitive
development (e.g. Hatano & Inagaki, 1999). This method allows children to display
their understanding without requiring them to generate complex explanations. Young
children’s knowledge of illness is often underestimated when measured using struc-
tured interviews (Kalish, 1996a).
Questions about each of the six specic ailments explored three dimensions: causes
of illness; time from cause to effect (i.e. illness onset); and recovery factors (format of
questions based on Springer & Keil, 1991). The cold and chickenpox were selected as
examples of contagious illness; cancer and asthma were chosen as examples of non-
contagious illness; and a broken arm and a scraped knee were included as common
injuries. Previous research and piloting indicates that children have some familiarity
with, and exhibit knowledge of these exemplars (e.g. Kister & Patterson, 1980). Each
question was illustrated by a cartoon picture of a child exhibiting common symptoms of
the illness or injury at issue. The cartoons were designed to maintain children’s interest
in the task and to remind them of typical characteristics of the particular childhood
ailments.
The questions were worded as follows:
(1) Causes: ‘Here is a picture of (name). (Name) has (ailment). I am going to tell you
four reasons why (name) might have (ailment) and I want you to tell me what one
you think is the best’.
(2) Time: ‘Now how long do you think it took from (cause child chooses) to getting
(ailment)? Do you think . . .?’
(3) Recovery: ‘(Name) gets better. How do you think they got better. Do you think . . .?’
For each question three (time process variable) or four (cause and recovery process
variables) responses were presented, reecting different levels of reasoning (see
Appendix 1). Responses were coded on a scale from 3 or 4 (most accurate) to 1
(least accurate). As far as possible, given the content of each explanation, effort was
made to provide responses of a similar length and complexity, in order to reduce bias.
Responses were developed following extensive piloting. For the contagious illness
category, the word ‘germ’ was not used because children may choose this response
on the basis of familiarity with the term rather than biological knowledge. Instead
the words ‘bugs’ or ‘invisible particles’ were employed (Kalish, 1997). The levels of
responses provided were consistent across all ailment types:
Cause and recovery:
4. Biological level: knowledge of internal bodily processes.
3. Physical level: focus on external rather than internal processes.
2. Incorrect mechanism level: inappropriate mechanism for ailment in question.
1. Non-biological level: reasoning about illness in terms of psychological processes.
Time from cause to effect:
3. Biological level: knowledge about the delay factors in illness.
2. Intermediate level: some indication of delay factors in illness.
1. Non-biological level: no knowledge of delay factors in illness.
Intervention story book

The intervention storybook ‘How Craig, Bobby and Sophie Got Better’ consisted of
three stories written for the present study. Each story was based on one pre-test
exemplar from each of the three categories of ailment. The book comprised three
unconnected short stories: Bobby contracting chickenpox (contagious), Craig having an
asthma attack (non-contagious); and Sophie falling and scraping her knee (injury). The
stories emphasized the cause of the ailments, the time from cause to effect, and recovery
factors. The style of the story and illustrations contained in the book were similar to
commercial children’s books to ensure that the book was appropriate for, and appealing
to, children aged 4 and 7 years.
Group discussion prompts

Standardized group questions and prompts were employed during the small group
discussions to encourage dialogue between the children about illness and injury (see
Appendix 2). While sitting in story groups, the interviewer asked each child in turn four
standard questions: ‘What do you think (ailment) is like?’ ‘Why do you think (name) got
(ailment)?’ ‘How long do you think it took from (cause children chose) to getting
(ailment)?’, and ‘What do you think made (name’s ailment) get better?’
Guided discussions were designed to involve three elements:
(1) Similarities and differences in children’s responses to the individual questions
were highlighted in order to enhance cognitive conict (Piaget, 1985) and pro-
mote subsequent discussion among the children.
(2) Children were then asked to discuss as a group the responses to each question to
facilitate their learning of biology (see Williams & Tolmie, 2000).
(3) Children were nally required to come to a consensus regarding what they felt
was the best answer to each question, as this has been shown to promote group
learning (Howe & Tolmie, 1999).
Procedure
Pre-test interviews
All children were interviewed individually with the order of ailments and xed choice
answers randomized for each child to reduce order effects. If children failed to recall the
answers provided, or if their attention was distracted, the response options were
repeated in the same order one additional time. Children were not provided with any
feedback concerning the correctness of their answers during the interview. On average
interviews took 10 minutes, with no child taking more than 15 minutes. Children were
highly motivated and engaged in the task, and the pictures employed successfully
focused their attention on the questions.
Allocation into intervention groups

Half of the children in each age group were randomly selected into intervention or
control conditions. Two independent t tests revealed no signicant differences in pre-
test scores between the intervention and control children for each age. Those in the
intervention condition were assigned to same-age groups of ve resulting in three
groups of 4-year-olds (N = 15) and three groups of 7-year-olds (N = 15). The interven-
tion groups were constructed to ensure that a wide range of knowledge of illness was
exhibited within each group as measured by the pre-tests. Gender was not taken into
consideration during group construction for both practical (the small number of 7-year-
old girls included in the study) and theoretical reasons. Previous research has found
no gender differences in biology knowledge (Williams & Afeck, 1999) and illness
concepts in particular (Charman & Chandiramani, 1995; Iannotti, O’Brien, & Haynie,
1999).
Storybook interventions
The intervention took place 1 week after pre-test. The intervention groups were taken
one at a time to a separate room and asked to listen carefully to the three short stories
comprising the storybook. The stories were presented in a standard order to each
group: chickenpox (contagious), asthma (non-contagious), and scraped knee (injury).
After every story each child in the group was asked individually the rst ‘symptom
knowledge’ intervention question in front of the group. The second question relating
to ‘causes’ was asked and responses were recorded (using pen and paper) allowing
the interviewer to remind children of their ideas. If children did not offer an answer, the
question was repeated once more. When all children had been asked the individual
question the interviewer then prompted: ‘do you all think that everyone has the same
idea?’ then the interviewer highlighted existing conicts and agreements by repeating
the answers provided by the children and indicating explicitly where conict and
agreement had arisen. Children were then instructed to discuss their answers and come
to an agreement on the best answer. This standard questioning and discussion format
was repeated for the two remaining discussion questions (time from cause to effect;
and recovery factors) in turn. The whole procedure was repeated for each of the three
short stories. Overall the interventions lasted between 20 and 30 minutes, with younger
children completing the task more quickly. All children appeared to enjoy the stories
and accompanying pictures. They were eager to participate and discuss their ideas
about illness, often huddling together to debate the main issues enthusiastically. The
presence of the interviewer did not appear to stie children’s discussions or distract
them from the task.
Post-tests
One week after the group interventions, all children were individually interviewed
using the same materials and procedures as for the pre-test.
Results
The results are presented rst in terms of age differences in pre-test scores. Analysis
of the effects of the intervention are then presented comparing 4- and 7-year-olds and
intervention and control children in terms of their pre- to post-test difference scores
(post-test minus pre-test scores). In line with Springer and Keil (1991) it was reasoned
that the levels of explanation associated with the response choices conformed to an
interval scale and thus data were analysed using parametric statistics. In addition, each
child was classied in terms of amount of improvement following the intervention
(improved, no change, or regressed). Analysis of these re-coded data using x2 tests
considered associations between categories of improvement and age and intervention
condition separately.
Pre-test scores
Table 1 illustrates the patterns of responses for each item. For the Causes of illness
across all items, the preferred type of explanation among 4-year-olds was level 2,
whereas 7-year-olds preferred explanations at levels 3 and 4. In relation to Time, 4-year-
olds most often chose level 2 explanations whereas 7-year-olds selected explanations at
levels 3 and 1 most frequently. For Recovery factors, the majority of 4-year-olds chose
level 2 whereas 7-year-olds most often chose level 3.
A series of independent t tests were computed to test for age differences in levels
of explanation, for each item separately. As Table 2 shows, 7-year-olds selected signi-
cantly higher levels of explanations than 4-year-olds for all items except for chicken-
pox time, chickenpox recovery, cold time, and asthma time.
Pre- to post-test change

A two-way ANOVA (mixed design) was computed to test for differences in global
difference scores (total post-test score minus total pre-test score across all ailments
and processes) as a function of age (4 vs. 7-year-olds) and intervention condition
Table 1. Pre-test scores (rounded percentages) for each level of response and each item by age (the
most selected response in each age group is indicated by bold type)
Contagious Non-contagious Injury
Chicken Scraped Broken

Cold pox Cancer Asthma knee arm
Level of response 4 yr 7 yr 4 yr 7 yr 4 yr 7 yr 4 yr 7 yr 4 yr 7 yr 4 yr 7 yr
Causes
4 10 13 0 20 7 43 0 27 20 53 10 73
3 37 80 27 67 17 23 3 27 40 37 30 20
2 47 7 53 13 10 30 63 43 27 10 33 7
1 7 0 20 0 67 3 33 3 13 0 27 0
Time
3 20 17 20 13 20 10 23 60 37 73 27 80
2 50 20 50 33 47 33 33 27 23 20 47 17
1 30 63 30 53 33 57 43 13 40 7 27 3
Recovery
4 7 3 3 13 13 60 3 50 7 33 13 37
3 37 30 30 83 7 37 23 47 40 60 33 43
2 43 67 40 3 53 3 50 3 40 7 40 20
1 13 0 27 0 27 0 23 0 13 0 13 0
Note: The higher the numerical value in the ‘level of response’ column the more advanced the level of
response.
(intervention vs. control). There was a main effect of age (F(1, 56) = 5.12, p = .03) with
4-year-olds improving most (means: 4 years 3.57, 7 years = 1.37). There was also a
main effect of condition (F(1, 56) = 9.95, p = .003) with children in the intervention
condition showing the greatest pre-to post-test improvement regardless of age (means:
intervention = 4.0, control = 0.93). There was no interaction affect between inter-
vention condition and age.
Post hoc independent t tests examined age differences between levels of pre-to post-
test improvement for each item individually. As Table 2 illustrates, 4-year-olds showed
signicantly greater post-intervention improvement in explanations only for asthma
recovery, cancer cause, cancer recovery, and scraped knee recovery. Similar analyses
were performed to compare pre- to post-test improvements between intervention and
control groups. The intervention groups improved signicantly more than controls only
in relation to cold cause (t(58) = 2.31, p < .05) and it should be noted that this single
signicant nding may be due to chance.
Children were additionally classied (based on difference scores) as improving,
exhibiting no change, or regressing in scores as a result of the intervention. Chi-square
analyses examined associations between levels of post-test change and age, and then
condition, for each item. Table 3 shows signicant associations between age and levels
of improvement for cold recovery ( x2 (2) = 6.79, p < .05), asthma cause ( x2 (2) = 9.33,
p < .01), asthma recovery ( x2 (2) = 8.64, p < .05), cancer cause ( x2 (2) = 8.98, p < .05),
scraped knee recovery ( x2 (2) = 6.13, p < .05), and broken arm cause ( x2 (2) = 6.82,
Table 2. Mean pre-test and post-test scores for each illness item as a function of age
Pre-test Post-test
Age Pre-post age

4 years 7 years t tests 4 years 7 years t tests
Chickenpox Cause 2.50 3.07 3.46** * 2.57 3.30 ± 0.85

Chickenpox Time 1.90 1.53 ± 1.91 1.93 1.90 ± 1.36
Chickenpox Recovery 2.37 2.37 0.00 2.27 2.63 ± 1.58
Cold Cause 2.07 3.07 6.05** * 2.50 3.10 1.96
Cold Time 1.90 1.60 ± 1.62 2.30 1.97 0.13
Cold Recovery 2.10 3.10 5.85** * 2.43 3.10 1.72
Asthma Cause 1.63 3.07 5.71* * * 2.1 3.27 1.13
Asthma Time 1.87 1.53 ± 1.83 1.80 1.60 ± 0.72
Asthma Recovery 2.07 3.57 7.45** * 2.40 3.33 2.64*
Cancer Cause 1.7 2.77 5.59* * * 2.3 2.7 2.93* *
Cancer Time 1.8 2.47 3.36** * 1.83 2.47 0.14
Cancer Recovery 2.07 3.47 7.90** * 2.67 3.43 2.59*
Scraped Knee Cause 2.67 3.43 3.57** * 2.70 3.60 ± 0.75
Scraped Knee Time 1.97 2.67 3.56* * * 2.2 2.83 0.31
Scraped Knee Recovery 2.40 3.27 4.74** * 2.67 3.13 2.04*
Broken Arm Cause 2.23 3.67 6.86** * 2.60 3.70 1.18
Broken Arm Time 2.00 2.77 4.68** * 2.10 2.83 0.15
Broken Arm Recovery 2.47 3.17 3.28* * 2.37 2.23 ± 0.62
*p < .05, * *p < .01, ** *p < .001.

Note: ‘Age t tests’ compare pre-test scores between 4- and 7- year- olds. ‘Pre-post age t tests’ compare
difference scores (post-test minus pre-test) between 4- and 7- year- olds. Both columns provide t values
and signi cance levels.
p < .05). These analyses indicated more improvement and less regression at post-test
among the 4-year-olds. Table 4 shows there were no signicant associations between
intervention condition and level of post-intervention change.
Discussion
All children selected responses to the items in a way that suggests they were drawing
upon na¨õ ve concepts of illness by age 4. However, it should be noted that the forced-
choice explanation method has limitations. In this study, children may have chosen the
explanation that included salient words such as ‘medicine’, ‘caught it’ and ‘bugs’.
Alternatively, they may have simply repeated the last option given, or regurgitated one
they could remember. They may also have responded to the length or complexity of
the responses provided, ‘making different explanation types comparable with respect to
the informativeness of the explanation . . . is no easy matter’ (Carey, 1995, p. 297), and
this may have introduced bias into the data. All these ways of responding to the
questions fail to focus on the conceptual content of the explanation provided. However,
systematic patterns of response were evident in these data, indicating that children
were, indeed, responding on the basis of their underlying na¨õ ve concepts of illness.
Table 3. Percentage (N ) of children in each age group showing different levels of pre- to post-test
change for each illness item
4 years 7 years
Improved No change Regressed Improved No change Regressed
Chickenpox Cause 33.3(10) 40.0(12) 26.7(8) 30.0(9) 63.3(19) 6.7(2)

Chickenpox Time 30.0(9) 40.0(12) 30.0(9) 43.3(13) 43.3(13) 13.3(4)
Chickenpox Recovery 26.7(8) 43.3(13) 30.0(9) 33.3(10) 53.3(10) 13.3(4)
Cold Cause 43.3(13) 46.7(14) 10.0(3) 20.0(6) 63.3(19) 16.7(5)
Cold Time 48.3(14) 27.6(8) 24.1(7) 40.0(12) 46.7(14) 13.3(4)
Cold Recovery* 36.7(11) 50.0(15) 13.3(4) 10.0(3) 80.0(24) 10.0(3)
Asthma Cause* * 50.0(15) 46.7(14) 3.3(1) 40.0(12) 26.7(8) 33.3(10)
Asthma Time 23.3(7) 50.0(15) 26.7(8) 20.0(6) 70.0(21) 10.0(3)
Asthma Recovery* 36.7(11) 53.3(16) 10.0(3) 20.0(6) 36.7(11) 43.3(13)
Cancer Cause* 56.7(17) 36.7(11) 6.7(2) 23.3(7) 46.7(14) 30.0(9)
Cancer Time 33.3(10) 43.3(13) 23.3(7) 23.3(7) 53.3(16) 23.3(7)
Cancer Recovery 53.3(16) 26.7(8) 20.0(6) 23.3(7) 50.0(15) 26.7(8)
Scraped Knee Cause 20.0(6) 63.3(19) 16.7(5) 30.0(9) 53.3(16) 16.7(5)
Scraped Knee Time 33.3(10) 46.7(14) 20.0(6) 23.3(7) 63.3(19) 13.3(4)
Scraped Knee Recovery* 36.7(11) 43.3(13) 20.0(6) 10.0(3) 66.7(20) 23.3(7)
Broken Arm Cause* 50.0(15) 20.0(6) 30.0(9) 23.3(7) 50.0(15) 26.7(8)
Broken Arm Time 33.3(10) 43.3(13) 23.3(7) 16.7(5) 70.0(21) 13.3(4)
Broken Arm Recovery 36.7(11) 20.0(6) 43.3(13) 33.3(10) 40.0(12) 26.7(8)
*p < .05, * *p < .01.
The pre-test results indicate that for almost all of the items there was a signicant age
improvement in knowledge between 4 and 7 years. These age changes indicate an
increasingly biological understanding of illness and injuries. This developmental
improvement is congruent with the ndings of many other studies (Kalish, 1997;
Perrin & Gerrity, 1981; Siegal, 1988). Nevertheless, responses were not at ceiling level
even among 7-year-olds; consequently, there is scope for interventions to improve
knowledge at these ages.
Within this pattern of general age improvement, there were four items that showed
no change in response with age: chickenpox time, chickenpox recovery, cold time, and
asthma time. Lack of change in these items highlights children’s comparative difculty
in understanding time course factors. Inspection of responses revealed that 7-year-olds
expected ailment onset to be immediate regardless of ailment type. In consequence
they were sometimes correct (i.e. injuries); however, for other items this led to the
lowest score (e.g. contagious). These ndings support and extend Kalish’s (1997)
conclusion that children generally predict that all outcomes of illness will occur immedi-
ately and thus they have ‘a poor understanding of the actual bodily processes involved’
(p. 79). In this study children were found to have a comparatively more sophisticated
understanding of illness causes. This can be explained with reference to Sigelman,
Maddock, Epstein, and Carpenter (1993), who suggest that children are more likely to
encounter information about the causes of illness than other illness processes. Further-
more, Kalish (1998) argues strongly that young children specically seek out causal
information and that this is a central element of their development of illness concepts.
Table 4. Percentage (N ) of children in each intervention condition showing different levels of pre- to
post-test change for each illness item
Intervention Control
Improved No change Regressed Improved No change Regressed
Chickenpox Cause 33.3(10) 50.0(15) 16.7(5) 30.0(9) 53.3(16) 16.7(5)

Chickenpox Time 43.3(13) 36.7(11) 20.0(6) 30.0(9) 46.7(14) 23.3(7)
Chickenpox Recovery 36.7(11) 46.7(14) 16.7(5) 23.3(7) 50.0(15) 26.7(8)
Cold Cause 40.0(12) 56.7(17) 3.3(1) 23.3(7) 53.3(16) 23.3(7)
Cold Time 34.5(10) 48.3(14) 17.2(5) 53.3(16) 26.7(8) 20.0(6)
Cold Recovery 23.3(7) 63.3(19) 13.3(4) 23.3(7) 66.7(20) 10.0(3)
Asthma Cause 46.7(14) 36.7(11) 16.7(5) 43.3(13) 36.7(11) 20.0(6)
Asthma Time 30.0(9) 56.7(17) 13.3(4) 13.3(4) 63.3(19) 23.3(7)
Asthma Recovery 33.3(10) 43.3(13) 23.3(7) 23.3(7) 46.7(14) 30.0(9)
Cancer Cause 43.3(13) 46.8(14) 10.0(3) 36.7(11) 36.7(11) 26.7(8)
Cancer Time 33.3(10) 50.0(15) 16.7(5) 23.3(7) 46.7(14) 30.0(9)
Cancer Recovery 43.3(13) 36.7(11) 20.0(6) 33.3(10) 40.0(12) 26.7(8)
Scraped Knee Cause 33.3(10) 60.0(18) 6.7(2) 16.7(5) 54.7(17) 26.7(8)
Scraped Knee Time 23.3(7) 63.3(19) 13.3(4) 33.3(10) 46.7(14) 20.0(6)
Scraped Knee Recovery 26.7(8) 60.0(18) 13.3(4) 20.0(6) 50.0(15) 30.0(9)
Broken Arm Cause 43.3(13) 33.3(10) 23.3(7) 30.0(9) 36.7(11) 33.3(10)
Broken Arm Time 30.0(9) 53.3(16) 16.7(5) 20.0(6) 60.0(18) 20.0(6)
Broken Arm Recovery 30.0(9) 33.3(10) 36.7(11) 40.0(12) 26.7(8) 33.3(10)
The pre-test data also indicate that knowledge of injury exemplars (scraped knee
and broken arm) was more advanced at both ages than knowledge of contagious and
non-contagious illness exemplars. This might be the result of more extensive direct
experience or injury, or because examples of minor trauma involve fewer complex and
unobservable bodily processes than the exemplars of contagious and non-contagious
illness included in this study. This nding highlights children’s ability to conceptual-
ize injuries, a fact which has been overlooked by previous research (an exception
being Coppens, 1986). Compared to injuries, knowledge of the contagious and non-
contagious illness exemplars was less well-developed among children in this study.
It has been suggested that children’s difculty with non-contagious illness causation
may reect an over-extension of the concept of contagion to non-contagious ailments
(Kister & Patterson, 1980) in this study this was especially the case in relation to asthma.
There is little evidence, in the pre-test data, to suggest that children hold a ‘germ
theory’ of illness across the range of exemplars used in this study. Instead these data
suggest the existence of potentially three overlapping but somewhat distinct under-
standings of illness, each of which improves with age: a theory of contagious illness;
a theory of injuries; and factual knowledge of non-contagious illness. Children of each
age group appeared to respond to both contagious illnesses (chickenpox and the cold)
with similar reasoning, suggesting that this knowledge may be theoretically driven
although not fully biological. Thus, seven 7-year-olds primarily selected mechanistic and
physical responses, not internal biological explanations. Understanding of contagion is
likely to become more biological with age as children increasingly attend to specic
details of individual agents of infection (Kalish, 1999). We contend that children also
have a rmly established theory of injury that is also based on a behavioural/mechanistic
understanding. This explanatory framework provides children with all the information
they require of injuries in order to arrive at correct predictions and explanations, thus
there is less scope for a genuinely biological theory to emerge for this ailment type.
Finally, in relation to non-contagious illness, children chose different types of responses
for asthma and cancer. This might signal that there is less theoretical structure
to children’s understanding of non-contagious illness because there is no single unify-
ing biological cause or effect in these ailments. For non-contagious illness, we propose
that children may develop their ideas on the basis of accretion of facts about a range
of separate illnesses without developing an over-arching theoretical framework, as they
seem to do for contagious illness and injury. As a consequence they may on occasion
misapply their theory of contagion to non-contagious illness (e.g. asthma in this study).
Future research on illness should explore not only contagion but also injury and non-
contagious illness. Kalish (1999) has stated that ‘. . . infection [contamination and
contagion] denes illness for young children’. However, it is clear from the ndings
reported here that it may be inappropriate to assume, based on the evidence available,
that na¨õ ve theories of contagion are central to children’s understanding of illness as
a whole.
Turning to patterns of change at post-test, there was overall improvement in
scores at post-test for both ages, showing that familiarity with the interview materials
and the cognitive processes concerning illness which these provoke, aided learning.
Importantly, however, there was a signicant age difference in the amount of global
improvement in understanding at post-test, with 4-year-olds showing greater levels of
improvement than 7-year-olds. This implies that 4-year-olds are ‘ready’ (Watson, 1998) to
learn about illness concepts and possibly other biological concepts too. The implica-
tion is that introducing health education to young children is not only appropriate
but may also help to develop a rmer basis for understanding illness on which to build
later educational input.
Importantly, this study showed that providing 4- and 7-year-olds with indirect
experience and correct factual information, accompanied with a guided peer discussion
about illness, signicantly increased their knowledge, compared to a control group.
Unfortunately, in the present study it is impossible to unpack which specic aspects
of the intervention were associated with conceptual advance. Was the key factor the
factual information provided in the story, or group discussion, or specic aspects of
group discussions? Further research to explore these issues is required in order to
develop age-appropriate health education interventions and also arrive at a clearer
understanding of the process of conceptual change in relation to illness, and biology
more generally. From these data it is also extremely difcult to attribute the general
advancements among the training group to improvements in understanding of specic
ailment types or illness processes. These data suggest that overall there were incre-
mental changes in most items in favour of improvement; however, no clear pattern
emerged. Thus further research is also necessary to explore whether improvements in
knowledge are primarily the result of improvement in trained exemplars, or
whether children learn new knowledge from the specic exemplars included in the
intervention which they use to generate theories that are subsequently applied across
various types of illnesses.
Asecond approach to analysing these data was to classify children in each condition
as exhibiting improvements, no change, or regression, as a function of the intervention.
Analyses for each item separately revealed no associations between levels of change and
intervention condition. Thus patterns of change were broadly similar across the two
conditions, with substantial numbers showing no change (ranging from 8 to 20 out of
30 children), followed by improvement (ranging from 4 to 16 children), and nally
regression (1 to 11 children). These analyses indicated that within the general global
improvement of the training condition as indicated by analysis of means, there were
a signicant number of children who did not show an increase in knowledge for
individual items as a function of the intervention. Furthermore, the nding that some
children’s knowledge regressed following the intervention highlights the potential
dangers of providing health education that is not adequately structured around
children’s existing knowledge, fails to take account of their illness experience, or fails
to actively engage them in the task. Further research is required to establish which,
if any, of these factors contributes to children’s lack of progress.
In conclusion, young children exhibit a great deal of na¨ve
õ knowledge about illness.
In the strictest sense this knowledge would not be classed as biological; however,
according to Hergenrather and Rabinowitz (1991) their na¨õ ve knowledge forms the
‘primary conceptual and explanatory framework’ (1991, p. 956) from which a more
biological theory develops. With increased experience (direct and indirect) of illness,
children gradually become aware of the physiological and biological processes involved
in the cause, time course and recovery factors involved in different types of illness.
Providing children with factual information concerning illness and the opportunity to
discuss their ideas and understandings of illness is potentially productive in assisting
this process. However, the intervention has to be closely tailored to children’s existing
knowledge. More research is required in order to elaborate the processes involved in
learning about illness so as to reduce the possibility of children failing to improve or
even regressing in knowledge following educational interventions.
Acknowledgements
The authors would like to thank Iain Wallace for his assistance during the collection of data for this
study.
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Received 15 November 1999; revised version received 30 October 2000
Appendix 1: Fixed-choice response options
Contagious illness
· Chickenpox
Causes
4. She breathed the same air as her friend who had chickenpox and the tiny
living things in the air got into her body and fought her good cells, giving
her spots.
3. She touched her friend who had chickenpox and the chickenpox bugs got onto
her skin, giving her spots.
2. She had eaten too many sweets.
1. She had not done her homework and was worried about it.
Time
3. She carried on playing with her friend, then went to school feeling ne, then after
a few days she got chickenpox.
2. She carried on playing with her friend for a few hours, then she got chickenpox.
1. She got chickenpox straight away as she was playing with her friend.
Recovery
4. The good cells in her body killed the bad enemy cells.
3. She put cream on her chickenpox spots making them go away.
2. She put a bandage on which cured her.
1. Just by wanting to she made the chickenpox go away.
· Cold
Causes
4. She breathed the same air as a friend who had a cold and the invisible things in
the air got into her body where they started to ght good cells.
3. She went out in the cold and the cold got up her nose and made her feel ill.
2. She had been eating too many sweets.
1. She had not done her homework and was worried about it.
Time
3. She felt ne for a few days, went to school then she got the cold.
2. She carried on playing for a few hours feeling ne then she got the cold.
1. Straight away as she was playing with her friend she got the cold.
Recovery
4. The good cells in her body killed the bad enemy cells.
2. She rubbed some cream on her nose and the cold went away.
3. She took some medicine which cured her.
1. Just by wanting to she made the cold go away.
Non-contagious illness
· Asthma
Causes
4. Pollution touched the tubes in his lungs making them too narrow to get
enough air through.
3. Pollution touched the skin on his chest and made it hard for him to breathe.
2. He touched and breathed the same air as a friend who had asthma and caught it
off him.
1. He had not done his homework and was worried about it.
Time
3. He felt bad straight away.
2. He carried on for a few hours then felt bad.
1. He felt ne for a few days then felt bad.
Recovery
4. He breathed in medicine that helped the tubes in his lungs to open again.
3. He rubbed cream onto his chest which helped him breathe easier.
2. He put a bandage on his chest which cured him.
1. Just by wanting to he could make the asthma attack go away.
· Cancer
Causes
4. The smoke from too many cigarettes stopped his lungs cleaning themselves,
turning good cells in his lungs into a lump of bad cells.
3. The smoke from too many cigarettes touched the skin on his chest and gave him
cancer.
2. He touched his friend who had cancer and caught it off him.
1. He was worried about work.
Time
3. He got cancer a long time afterwards.
2. He got cancer a few hours later.
1. He got cancer straight away.
Recovery
4. Special medicine killed the lump of bad cells and made the cancer go away.
3. He rubbed cream on his chest which made the cancer go away.
2. He put on a bandage which cured the cancer.
1. Just by wanting to he made the cancer go away.
Injury
· Broken arm
Causes
4. He fell off a climbing frame and banged his arm hard on the ground which made
the bone break.
3. He fell off a climbing frame and hit his arm on the ground.
2. He shared food with a friend who had a broken arm and caught if off him.
1. He had not done his homework and was worried about it and this made his arm
break.
Time
3. His arm broke straight away.
2. His arm broke a few hours later.
1. His arm broke a few days later.
Recovery
4. Cells inside the bone grew again and joined the bone back together.
3. A plaster cast made the arm get better.
2. He took some medicine which cured him.
1. Just by wanting to he could make his arm get better.
· Scraped knee
Causes
4. She fell over a sharp rock which cut the tubes in the skin which carry blood and
made the blood come out.
3. She fell over a sharp rock which touched her skin and made the blood come out.
2. She shared food with friend who had a cut and caught it off him.
1. She had not done her homework and was worried about it and this cut her knee.
Time
3. She started to bleed straight away.
2. She started to bleed a few hours later.
1. She started to bleed a few days later.
Recovery
4. Good cells in the blood made a sticky plug which went hard and helped the cut
get better.
3. A plaster made the cut get better.
2. She took some medicine which cured her.
1. Just by wanting to she made the cut get better.
Appendix 2: Discussion script

Now we’re going to talk about (ailment).
(A) (In troductory que s tion ) Wh at do y ou thin k (ailm e n t) is like ?
(child’s name), what do you think (ailment) is like? (Repeat for each child)
Okay that’s good now I’m going to ask you another question.
(B) Wh y do you th in k (n am e ) got (ailm en t)?
(child’s name), why do you think (name) got (ailment)? (Repeat for each child)
Okay, do you all think everyone has the same idea?
YES Yes, that’s right you do all have the same idea
No, you don’t all have the same idea
NO Yes, that’s right you do all have different ideas
No, you do all have the same idea
Remember, (child’s name), said that (name) got (ailment) because (response). (Repeat
each child’s response)
What do you all think is the best idea?
I would like you all to talk about this between yourselves, and then tell me the idea that
you all think is the best, okay? On you go then.
Okay, that’s good, now I’m going to ask you another question.
(C) How lon g do you th in k it took (n am e ) from (caus e ch ild ch oos e s ) to ge t
(ailm e n t)?
(child’s name), how long do you think it took (name) from (cause child chooses) to get
(ailment)? (Repeat for each child)
Remember, (child’s name), said that (name) (ailment) got better because (response).
(Repeat each child’s response).
What do you think is the best idea?
you all think is the best, okay? On you go then.
Okay, that’s good, now I’m going to ask you another question.
(D) Wh at do you th in k m ade (n am e ) (ailm e n t) ge t be tte r?
(child’s name), how long do you think it took for (name) to get better from (ailment)?
(Repeat for each child).
Remember, (child’s name), said that it took (response) for (name) to get better from
(ailment). (Repeat each child’s response).
What do you think is the best idea?
you all think is the best okay? On you go then.
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129

British Journal of Health Psychology (2002), 7, 129 –147

Children’s concepts of illness: An intervention

Joanne M. Williams* and Lynne M. Binnie

Objectives. This study aimed to explore children’s understanding of illness and

Children’s concepts of illness

Interventions to improve young children’s biological knowledge

The present study

Intervention story book

Group discussion prompts

Allocation into intervention groups

Pre- to post-test change

Contagious Non-contagious Injury

Chicken Scraped Broken

Age Pre-post age

Chickenpox Cause 2.50 3.07 3.46** * 2.57 3.30 ± 0.85

*p < .05, * *p < .01, ** *p < .001.

Improved No change Regressed Improved No change Regressed

Chickenpox Cause 33.3(10) 40.0(12) 26.7(8) 30.0(9) 63.3(19) 6.7(2)

*p < .05, * *p < .01.

Improved No change Regressed Improved No change Regressed

Chickenpox Cause 33.3(10) 50.0(15) 16.7(5) 30.0(9) 53.3(16) 16.7(5)

Received 15 November 1999; revised version received 30 October 2000

Appendix 1: Fixed-choice response options

Appendix 2: Discussion script

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Children's Concepts of Illness

Children's Concepts of Illness

p < .05, *p < .01, ** *p < .001.

p < .05, *p < .01.