Research Papers

Primary Grade Teachers’ Knowledge and Perceptions of Head Lice Gregg M. Kirchofer, James H. Price, Susan K. Telljohann

ABSTRACT: This study examined primary grade teachers’ knowledge of head lice, perceived selfeficacy in dealing with head lice, and preferred resources of additional information on head lice. Survey data from a three-wave mailing (M=292; 60%) found that teachers needed more knowledge regarding head lice and were significantly more knowledgeable as teaching experience increased. A plurality (46%) had high efSicacy expectations scores regarding their ability to control the spread of head lice. Most (71 %)primary teachers reported they received most of their head lice information from school nurses. Most (63%) said they would like more infor- mation on how to prevent head lice infestation, and they wanted the information in the form of videotapes (68%) and brochures (51%). Only 23% provided yearly instruction reaardinn head lice. (J Sch Health. 2001:7119):448-452)

anagement of head lice has stumped parents, health M professionals, and teachers for years. Infestation of head lice can affect the child and the family financially, educationally, and psychologically. Education, recognition, communication, and early treatment all play a major role in controlling head lice transmission and infestation. In the past, diagnosis and education about head lice was consid- ered the role of the school nurse.

Each year approximately 6 to 12 million Americans are infested with head lice, and the incidence rates of those affected continue to rise.’ Most of those infested with head lice are school children between ages 5 to 12.* At present, no compulsory national reporting system exists for head lice, but outbreaks among elementary school students are frequently reported.’ According to Surveillance Data Inc.,4 nearly 80% of school districts had at least one lice outbreak in 1997. An estimated 6 million elementary students, one in four, were infested in 1997.*

Head lice is an equal opportunity parasite because it exists all around the world and in every socioeconomic group.s Lice are most commonly found in young school- aged children because of the close physical contact with playmates.6 Infestations from head lice have become more of the norm than the exception in elementary schools, child-care centers, and day camps.4 “Prevalence of head louse infestation among school-aged children is usually reported as under 10% but may be as high as 40% in certain circumstances and locations.”6(p183)

Individuals at highest risk for infestation are White girls between ages 3 and 12.5 Risk for this group has little to do with age or hygiene, but rather behaviors. Girls are often contaminated from shared use of fomites such as personal hair care items. Lice are more common among Whites than African-Americans because of the oval shape of their hair shafts.’ The oval shape makes it more difficult for the lice Gregg M. Kirchofer, MSEd? Graduate Assistant; James H. Price, PhD, MPH, FASHA, Professor, Health Education; and Susan K. TeNjohann, HSD, CHES, FASHA. Professor, Health Education, Dept. of Public Health and Rehabilitative Services, The University of Toledo, Toledo, OH 43606. This article was submitted February 7, 2001, and accepted for publication March 26, 2001.

to cling and secure their eggs to the hair shaft.’ Prevention is important when trying to limit the spread

of head lice. There are four steps in the prevention process.’ First, disclosure and communication are important in limit- ing the spread of lice from student to student and classroom to classroom. Communication is often difficult because of the stigma associated with head lice that prevents students and parents from coming forward. An atmosphere needs to be established which does not place the blame on one indi- vidual.

Second, teaching good habits is important. In most schools, the nurse is responsible for education of faculty, staff, parents, and students; however, classroom teachers should encourage practices that reduce the chance of trans- mission in the classroom. Classroom practices include plac- ing personal belongings in individual lockers, discouraging mixture of outer clothing, and stressing the importance of good hygiene.

Third, educating individuals on how to provide proper treatment is important. The proper treatment process includes use of a pediculicide, nit removal, and cleaning the environment. Fourth, appropriate follow-up procedures are important in cases of chronic infestations. Parents should perform repeated head checks every two weeks until the school and home are clear of lice.

Prevention of head lice infestation and transmission can be accomplished with the cooperation of primary care providers, school health personnel, parents, and students.l Education, recognition, communication, and early treat- ment all play a role in controlling head lice transmission and infestation. In the past, this responsibility was left to the school nurse. However, elementary teachers also need to help in this effort.* A review of literature failed to find any studies that examined the knowledge and needs of elementary school teachers in regard to head lice prevention and education. This study assessed primary grade teachers’ knowledge, perceived self-efficacy in dealing with head lice, and preferred resources for additional information on head lice.

448 Journal of School Health November 2001, Vol. 71, No. 9

METHODS Subjects

A simple national random sample of 500 first and third grade primary school teachers was selected as potential respondents. The random sample was obtained from the Information on Public Schools and School Districts in the United States web site.9

instrument A 38-item instrument was developed for the survey. A

comprehensive review of literature on head lice was used to develop questionnaire items. Subsequently, the question- naire was sent to a group of six published authorities, three in head lice and three in survey research, to help establish content validity. Suggestions to reword several items were used to produce the final instrument. To establish stability reliability, the questionnaire was given to a convenience sample of 28 elementary teachers on two occasions one week apart. The Spearman rho correlation coefficient was .65. Internal reliability assessed by Cronbach alpha was .68.

Except for three items, (years teaching, grade presently teaching, state currently living in), the survey items were

Table 1 Demographics of Responding Teachers

Item N C 4

Gender Male Female

Age 20-29 30 - 39 40 - 49 50 - 59 60+

Education Bachelors Masters Education specialist Oodorate

First Third

School Setting Inner city Suburban Rural

Years of Experience

Grade Currently Teaching

1 - 10 11 -20 21 -39

Region of School Northeast Midwest West South

n=292

15 (5.1) 277 (94.9)

32 (1 1 .O) 59 (20.2)

110 (37.7) 81 (27.7) 10 (3.4)

143 (49.0) 130 (44.5)

15 (5.1) 2 (0.7)

159 (54.5) 128 (43.8)

56 (19.2) 122 (41.8) 112 (38.4)

103 (35.2) 84 (28.8)

104 (35.6)

51 (17.3) 98 (33.6) 54 (18.5) 89 (30.6)

closed-format design. Respondents were requested to select from a series of potential choices to an item or to circle how much they agreed or disagreed with items (strongly agree = 1 to strongly disagree = 5) . The final 10 questions were demographic items, including age, gender, school location, educational background, years of teaching experi- ence, grade presently teaching, state in which they teach, if they had cases of lice in their classes, and how many days a week the school nurse was at their school.

The study utilized Bandura’s Self-Efficacy Model to investigate primary school teachers’ perceived self-efficacy for preventing head lice transmission in the classroom. Bandura’s Self-Efficacy Model consists of three compo- nents: 1) efficacy expectations, one’s belief regarding the ability to perform certain behaviors to produce a desired outcome; 2) outcome expectations, one’s belief that performing the behaviors will result in specific outcomes; 3) outcome value, the degree of importance one ascribes to the outcome. Five items comprised the efficacy expecta- tions subscale, and the possible range of scores was 0 to 20. Five items also comprised the outcome expectations subscale, and the possible range of scores was 0 to 20. The outcome value subscale was comprised of two items, with a possible range of 0 to 8. The questionnaire also contained 11 items to investigate primary school teachers’ knowledge of head lice.

Table 2 Primary School Teachers’ Knowledge of Head Lice

Answered Correctly

Item N CN

Most children who have head lice come from poor families.

Most children who have head lice come from families who are not clean.

African-Americans are more likely than Caucasians to get head lice.

Anyone who comes into contact with a person infested with head lice should be treated.

You can get head lice from your pets.

Itching the head is a clear sign of head lice.

You can get head lice eggs (nits) from dirt.

Children usually get head lice at school.

The best medication for head lice is prescribed by a doctor.

Head lice can fly, jump or hop.

Head lice are a greater problem today than they were 25 years ago.

277 (94.9)

246 (84.2)

239 (81.8)

170 (58.2)

167 (57.2)

157 (53.8)

153 (52.4)

152 (52.1)

149 (51 .O)

122 (41.8)

83 (28.4)

n=292 * All the answers to the above items were disagree.

Journal of School Health 9 November 2001, Vol. 71, No. 9 449

Procedure A three-wave mailing procedure was used during fall

2000. Initially, each of the 500 primary school teachers was mailed a copy of the survey on colored paper, a hand- signed cover letter describing the purpose of the study, a stamped and preaddressed return envelope, and a $1 incen- tive. Surveys returned as undeliverable were not replaced. Approximately two weeks after the first mailing, nonre- sponding primary school teachers received a second hand- signed cover letter, which encouraged those who had not responded to respond. Another copy of the survey and a stamped, preaddressed return envelope also was included in the second mailing. Two weeks after the second mailing, nonrespondents were sent a post card, which again encour- aged nonresponding primary school teachers to respond. The SPSS statistical package was used for all data analysis. Level of significance was determined a prion’ at .05.

RESULTS Demographics of Teachers

A total of 292 primary grade teachers (60%) from a possible 494 responded; six of the 500 questionnaires were undeliverable. These primary grade teachers were primarily female (95%) and taught first grade (55%). A plurality of teachers held a bachelor’s degree (49%), taught in suburban schools (42%), and were 40 to 49 years of age (38%) (Table 1). Only 20% reported they had taken a health education methods course.

Knowledge of Head Lice A series of 11 knowledge questions, primarily myths

regarding head lice, with a response format of “agree,” “unsure,” or “disagree” were included on the questionnaire. The correct response for all the questions was “disagree.”

Three items were correctly answered (“disagree”) by most teachers: head lice is primarily in poor families (95%), head lice is found mainly in families who are not clean (84%), and African-Americans are more likely than Whites to get head lice (82%) (Table 2). Two items were answered incor- rectly by most teachers: head lice can fly, jump, or hop (42%), and head lice are a greater problem today than they were 25 years ago (28%). The other six items were answered correctly by about one-half the teachers (51% to 58%) (Table 2).

A t-test for grade taught (first vs. third) and knowledge about head lice was not significant (M=6.6, SD=2.4 and M=6.6, S k 2 . 2 , respectively). In addition, a t-test by level of education (bachelor’s vs. graduate degree) and knowl- edge about head lice was not significant (M=6.3, SD=2.4 and M=6.8, SD=2.3, respectively). An analysis of variance (ANOVA) for years of experience (1-10 years, 1 1-20 years, 21-39 years) and knowledge about head lice was significant (F=ll.O86, df=2,288, pc.001). Post-hoc Tukey t-tests found those with the least experience (1-10 years) were less knowledgeable than those with 11-20 years of experience (M=5.8, SD=2.2 vs. M=6.7, SD=2.2, respectively) and less knowledgeable than those with the most experience (M=7.3, SD=2.4). Another ANOVA for school setting (inner city, suburban, rural) and knowledge about head lice was significant (F=3.764, df=2,287, p=.02). Post-hoc Tukey t-tests found that suburban teachers (M=6.3, SD=2.4) were significantly less knowledgeable than rural (M=7.0, SD=2.3) teachers.

Perceived Self-Efficacy of Head Lice Control A plurality (46%) of primary grade teachers had a high

efficacy expectations score (scored 15 or more from a potential 20) regarding their ability to control the spread of head lice (Table 3). Approximately two-thirds to three-

Table 3 Primary School Teachers’ Perceived Self-Efficacy Toward the Prevention of Head Lice Infestation

Item Agree Disagree N (“YO) N (Yo)

Efficacy ExpeFtations I feel I have enough knowledge about head lice to create an environment that reduces transmission. 233 (79.8) I believe I have enough knowledge to dispel any myths and misperceptions. I believe I can accurately recognize signs and symptoms. I believe I have enough knowledge and skills to adequately recognize head lice infestation. I feel I am able to recommend to parents OTC treatments.

36 (12.4) 215 (73.6) 50 (17.1) 205 (70.3) 51 (17.5) 203 (69.5) 54 (18.5) 157 (53.8) 94 (32.2)

Outcome Expectations I believe that preventing transmission helped by recognizing signs and symptoms. Proper instruction establishes classroom environment that reduces transmission. I believe I have enough knowledge and skills to recognize infestation on students. I believe that preventing transmission of head lice can be helped by dispelling myths. I believe that preventing transmission helped by recommending reliable and effective OTC treatments.

268 (91.8) 10 (3.4) 262 (89.7) 11 (3.4) 255 (87.4) 13 (4.4) 220 (75.3) 27 (9.3) 219 (75.0) 25 (8.6)

Outcome Value I think it is important for elementary teachers to help prevent infestation. I think it is important for elementary teachers to teach.

* Agree = I or 2; Disagree = 4 or 5 on a 5-point scale. n = 292

255 (87.4) 13 (4.4) 210 (71.9) 24 (8.3)

450 Journal of School Health November 2001, Vol. 71, No. 9

fourths of teachers perceived they could do most (4 of 5 ) of the activities to reduce head lice (Table 3). An even greater portion of teachers (66%) perceived that the five activities on the questionnaire would be very effective (scored 15 or more from a potential 20) in preventing transmission of head lice. Teachers valued preventing head lice infestation (87%) more than they valued the importance of teaching about head lice (72%).

A series of t-tests for grade taught by efficacy expecta- tions, outcome expectations, and outcome values found no significant differences. A second series of t-tests for level of education by efficacy expectations, outcome expectations, and outcome values also were not significantly different. A series of ANOVAs for years of experience by efficacy expectations (F=3.596, df=2,288, p=.02), outcome expecta- tions (F=0.843, df=2,288, p=.43), and outcome values (F=1.369, df=2,288, p=.26) found one significant differ- ence. Post-hoc Tukey t-tests for efficacy expectations found that those with the least experience (1-10 years) were significantly less likely than those with 11-20 years of experience (M=12.5, SD=4.7 vs. M=14.0, SD4.1, respec- tively) and those with 21-39 years of experience (M=14.0, SD=4.3) to believe they could do the things to reduce the transmission of head lice. A second series of ANOVAs for school setting by efficacy expectations, outcome expecta- tions, and outcome values were not significant.

Table 4 Information on Head Lice for Primary School Teachers

Item N (‘‘4

Sources of Information Used’ School nurse General media Inservice Professional journals Professional preparation classes Professional conferences Other (personal experience,

health department, lice products, etc.)

Further Information Desired’ Prevention Treatments Signs and symptoms Myths and misconceptions Transmission Diagnosis Other (alternative treatments,

home disinfection, etc.)

Preferred Format of Further Information’ Videotape Brochures Self-instruction book Structured teaching unit Web site Newsletters Guest speakers Audiotapes Annotated bibliography Other

208 (71.2) 58 (19.9) 26 (8.9) 18 (6.2) 8 (2.7) 5 (1.7)

65 (22.3)

184 (63.0) 166 (56.8) 156 (53.4) 156 (53.4) 155 (53.1) 123 (42.1)

7 (2.4)

197 (67.5) 150 (51.4) 103 (35.3) 54 (1 8.5) 50 (17.1) 44 (15.1) 40 (13.7)

6 (2.1) 2 (0.7) 2 (0.7)

n=292 Teachers could select more than one choice.

Instruction Regarding Head Lice Teachers were asked how often (never, only when cases

of infestation arise, each year regardless of infestation) they provide head lice instruction. Teachers were most likely (43%) to offer instruction only when infestation occurred. One-third (34%) of the teachers never provided instruction, and 23% always provided instruction regarding head lice.

If teachers did not offer instruction regarding head lice, they were asked to select from a list of six possible alterna- tives with the sixth being “other.” These primary grade teachers responded most often that they did not have enough time in their teaching schedule (24%) and they did not think about it (24%). Some 16% perceived there was not enough information available on the topic, 15% perceived it was not part of their job, and 8% did not perceive head lice to be an important topic.

A series of t-tests was conducted between those who never taught about head lice and those who taught about it every year by their levels of knowledge, efficacy expecta- tions, outcome expectations, and outcome values regarding head lice. A significant difference (t=-5.83, p=.OOl) in knowledge was found in which those who always taught about head lice were significantly more knowledgeable than those who never taught about head lice (M=7.64, SD=2.03 vs. M=5.61, SD=2.33, respectively). Those who always taught about head lice had significantly higher effi- cacy expectations (M=15.48, SD=3.64 vs. M= 10.91, SD=4.92, respectively), outcome expectations (M= 16.30, SD=3.33 vs. M=15.04, SD=3.08, respectively), and outcome values (M=6.83, SD=1.35 vs. M=5.24, SD=1.59, respectively) compared to those who never taught about head lice.

Sources of Information on Head Lice Teachers were asked to select from a list of six potential

choices and a category labeled “other” where they received most of their information about head lice. Most teachers received their information from school nurses (7 1 %) followed by the general media (20%) (Table 4).

When asked to select from a list of six topics on head lice and a category labeled “other” from which they would like to receive more information, most teachers cited prevention information (63%) (Table 4). Teachers were least interested in receiving more information on how to diagnose (42%) kids with head lice infestations.

If teachers wanted more information about head lice, they were asked to select from a list of nine formats and an “other” category. Teachers who wanted more information wanted it in the form of videotapes (68%) and brochures (51%) (Table 4). Teachers were least interested in obtaining head lice information by annotated bibliographies (<1%) and audiotapes (2%).

DISCUSS I O N The responding primary grade teachers needed more

information regarding head lice. One-half the teachers incorrectly answered one-half the items on the knowledge quiz. Most teachers seemed to gain their knowledge about head lice by personal experience, because the more teach- ing experience they had the more knowledgeable they were. Level of education (bachelor’s vs. graduate degrees) had no effect on knowledge of head lice. This finding may indicate

Journal of School Health November 2001, Vol. 71, No. 9 451

an absence of head lice information in professional training programs. Teachers claimed that the information they had on head lice was primarily obtained from school nurses. This finding may indicate that more time and effort are needed for school nurses to share their information on head lice with primary grade teachers.

Most primary grade teachers perceived they had a high self-efficacy with regard to head lice. Yet, less than three of four teachers valued the importance of teaching about head lice. Because head lice infestations are not serious health problems, and more of a nuisance, teachers may have perceived the issue as less important a topic about which to teach.

Approximately one-half the teachers desired further information regarding head lice. They desired more infor- mation on prevention, treatment, transmission, and myths regarding head lice. This finding seems to indicate that these teachers are interested in doing a better job at reduc- ing head lice infestations. These teachers also wanted to gain this knowledge in simple, flexible, and convenient formats like videotapes and brochures. They did not seem to be interested in web sites and newsletters.

Finally, the limitations of this study should be explored. First, data were collected using self-report questionnaires which could have led to some teachers responding in a socially desirable manner. However, since the survey was anonymous this approach should have minimized that possibility. Second, the limited return rate may have resulted in a nonresponse bias. If so, then the survey respondents likely represent teachers who are more inter- ested and informed about head lice, representing a threat to internal validity of the study. Third, the monothematic nature of the survey may have caused some primary grade teachers to respond in a unique manner (response set bias). Fourth, the survey was a closed-format instrument, which did not attempt to obtain additional information from respondents. Thus, some perceptions of head lice and desire for other sources of information may not have been addressed by the current survey. If so, this fact also repre- sents a potential threat to internal validity of the study.

CONCLUSION Findings from the survey suggest several recommenda-

tions for improving the control of head lice by primary grade teachers. The social and educational costs of head lice infestations for elementary school children also dictate that schools need to be more involved in preventing and eliminating head lice infestations. Teacher education and school inservice programs should do a better job in prepar- ing elementary teachers to deal with this issue. Results from this study indicate that teachers with more knowledge and with higher self-efficacy scores are significantly more likely to teach about head lice.

Schools should acquire videotapes and brochures for primary grade teachers dealing with prevention, treatments, transmission, and myths regarding head lice. School nurses, the primary source of head lice information for primary grade teachers, need to help coordinate more intense and comprehensive inservice education programs on head lice for primary grade teachers.

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Statement of Purpose

The Journal of School Health, an official publication of the American School Health Association, publishes material related to health promotion in school settings. Journal readership includes administrators, educators, nurses, physicians, dentists, dental hygienists, psychologists, counselors, social workers, nutritionists, dietitians, and other health professionals. These individuals work cooperatively with parents and the community to achieve the common goal of providing children and adolescents with the programs, services, and environment necessary to promote health and improve learning.

Commentaries, Teaching Techniques, and Health Service Applications. Primary consideration is given to manuscripts related to the health of children, adolescents, and employees in public and private preschools, child day care centers, kindergartens, elementary schools, middle level schools, and senior high schools. Manuscripts related to college-age young adults are considered if the topic has implications for preschool through high school health programs. Relevant international manuscripts are also considered.

Prior to submitting a manuscript, prospective authors should review the most recent "Guidelines for Authors," printed periodically in the Journal. Copies may also be obtained from the Journal office, P.O. Box 708, Kent, OH 44240, or electronically from treed@ashaweb.org.

Contributed manuscripts are considered for publication in the following categories: Articles, Research Papers,

452 Journal of School Health November 2001, Vol. 71, No. 9