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Toward an effective school health education policy: A call for legislative and educational reform
PREVENTIVE
MEDICINE
18,
147-155 (1989)
EDITORIAL Toward
an Effective School Health Education Policy: A Call for Legislative and Educational Reform’
KENNETH A. RESNICOW, PH.D. ,’ MARIO A. ORLANDI, PH.D., AND ERNST L. WYNDER, M.D. American Health Foundation, 320 East 43rd Street, New York, New York looI
INTRODUCTION
During the past 10 years, an increasing body of research has demonstrated not only the need for but also the efficacy of school health education programs. Numerous school-based health programs have been shown to have a positive effect on a variety of health behaviors, including the use of alcohol, drugs, and cigarettes, nutrition, exercise, sexual behavior, and self-management (1, 3-7, 10, 11, 15, 22-24, 26). Despite these promising results, the degree to which such programs have been effectively disseminated and implemented on a state or national level remains disappointing. For this reason, an emerging challenge for our public health system is the diffusion, implementation, and marketing of extant health education programs. Kreuter et al. (18) summarized the problem as follows: . . . what is the practical worth of these positive indicators if there is no room or support for even innovative school health education programs in the existing curriculum? The descriptive information we have, does not indicate the existence of a vacuum in schools waiting to be filed by a proven effective approach to school health education. Rather, instead of a vacuum, there are formidable political, philosophical, and economic barriers in the field that need to be realistically acknowledged” (p. 29).
During the past 10 years, the American Health Foundation has been involved in the development and dissemination of its “Know Your Body” (KYB) Program in a number of states and abroad, across a variety of populations (26-29). An analysis the KYB implementation efforts has resulted in the delineation of an array of social, political, economic, and psychological obstacles to effective dissemination that must be both acknowledged and addressed. The purpose of this article is to provide a brief overview of these barriers and to suggest a number of specific recommendations for overcoming them. ANALYSIS
OF BARRIERS
There are two principal predisposing factors that appear to contribute significantly to these barriers. First, there is a considerable ambivalence in our society r The development of this manuscript was supported by Grant 870-0189from the Ford Foundation. 3 To whom reprint requests should be addressed. 147 OWI-7435/89 $3.00 Copyright Au lights
0 1989 by Academic Press, Inc. of repluduction in any form rescrwd.
148
RESNICOW,
ORLANDI,
AND WYNDER
toward prevention and health education. This ambivalence is, at least in part, endemic to human nature. There is a tendency for asymptomatic, ostensibly healthy individuals to underestimate their susceptibility to illness. Most people visit doctors to obtain relief from pain or to alleviate symptoms when they are sick. Such visits provide tangible results. In contrast, the benefits of prevention and health promotion programs are often intangible, delayed, and less dramatic. It is ironic that while heart disease and cancer account for nearly 70% of all adult deaths in our country annually and at least 30-60% of these deaths are preventable, the prevention of chronic diseasehas yet to evoke the same senseof urgency or crisis as have the problems of drug abuse, AIDS, and suicide prevention. Tobacco use and diets high in saturated fats alone account for at least 30% of all adult deaths each year; however, these health problems, while preventable, do not elicit the same concern as the “epidemic” of drug use. Society’s ambivalence toward prevention and health education is also reflected in the large number of states that have delineated recommendations and age-specific goals for health education, yet have not allocated sufficient funds to implement such programs. The second fundamental problem facing health education is that the development and implementation of health education programs in the United States encompassesthe contributions of numerous professions, institutions, and agencies, including researchers, book publishers, writers, educators, politicians, administrators, marketing experts, and community resources. Yet, the responsibility for orchestrating these various and often discrete components of the health education process has not been clearly assignedto, or accepted by, any particular agency or organization within this system. For example, health promotion researchers develop and evaluate interventions, but generally terminate their involvement after efficacy testing is complete. Consequently, a gap in technology transfer and program dissemination often results. This gap may in part be attributed to or at least reflected in the Federal Government’s approach to health promotion research. The National Institutes of Health, in particular the National Heart, Lung, and Blood and the National Cancer Institutes, have funded the development and evaluation of numerous risk factor reduction and health promotion curricula (15,25). However, as exemplified by the National Cancer Institute’s five-stage model of cancer control research, these agencies provide only limited funds to disseminate such programs after initial efficacy testing is complete. As delineated by Greenwald and Cullen (13), the five phases of cancer research begin with hypothesis development, methods development, controlled intervention trials, and defined population studies and conclude with demonstration projects and implementation research. Conspicuously absent from this model is a specific mechanismfor large-scaledissemination of proven interventions. The potential public health benefit of developing and evaluating health curricula, without subsequent dissemination, appears limited. There are a number of somewhat more tangible problems within our legislative and educational systems, which together comprise a set of formidable, although negotiable, barriers to school health education.
EDITORIAL
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Legislative Barriers
First, there is a serous shortage, and in some states a complete absence, of funding for school health programs. Second, there are few states that have developed rigorous implementation and evaluation strategies. Dissemination of any innovation requires special sensitivity to the existing political and social structures and, in the case of health education, requires the input of parents and other community members as well. Educational Barriers
Third, the role and status of health within our educational agenda are unclear. Administrators and teachers are unsure of health education’s importance and, on a more fundamental level, its place within traditional education. Given the present status of health in our educational and political agendas, we cannot expect it to compete with mathematics and English in school curricula. The secondary status of health education is understandable, as it represents an innovation within our traditional education paradigm. It is also important to recognize that health education’s potential for controversy and incompatibility with traditional education models is likely to increase as curricula place more emphasison behavioral rather than cognitive outcomes. It can also be argued that health education has been imposed on our educational system. Some of the resistance to health education may in fact be the result of educators’ lack of perceived ownership of the health education domain. Fourth, there is some confusion as to who should be teaching health. In most primary schools, classroom teachers are defacto assigned this task. The assignment of additional job responsibilities without a concomitant increase in pay or status can result in poor curriculum delivery rates because of role ambiguity or work overload. Further, even if classroom teachers are willing to teach health, they may be unable to do so without intensive training. Effective use of contemporary health promotion interventions may require an expertise quite distinct from teaching math or English. In some primary and many secondary schools, health is taught by school nurses, science teachers, physical education instructors, or health education teachers. With the exception of trained health educators, these professionals may require additional training and incentives if we expect them to adopt the role of health educator. Finally, there are few states that have developed systematic strategies to disseminate, implement, and evaluate their health programs. The selection, acquisition, implementation, evaluation, and funding of primary, and to a lesser degree secondary, school health curricula are often left up to individual schools. RECOMMENDATIONS
Recognizing these obstacles, a number of specific recommendations are offered which can help ameliorate some of the problems facing health education.
150
RESNICOW,
ORLANDI,
AND
WYNDER
Define the Role of Health Education in Our Education Agenda
Health education should become a priority within our educational agenda of equal stature to that of math and language. The commitment to health education must be long-term rather than crisis-driven. At present, health education is mandated in many states; it is not, however, truly mandatory. Local adoption of health education programs must be more rigorously monitored and enforced. Integrating health education into art, mathematics,and English curricula may help to better inculcate health into our educational system as well as reinforce classroom instruction. Assign Responsibility
Establishing a health education agency charged with consolidating and integrating the diverse elements of the health education process would help fill the gaps inherent in the current segmentedapproach to health education. The most likely candidate to fulfii this role would appear to be state educatiotiealth departments. If this agency will reside outside the education system, it must be structured in such a way that it can readily interface with the Department of Education on both the state and local levels. This agency would coordinate the wide range of tasks involved, including curriculum selection and revision, teacher training, program implementation, parent, community, and media involvement, program evaluation, and auxiliary fund raising. The establishmentof a unifying agency responsible for coordinating and evaluating health programs along with the allocation of funding may also alter teachers’ perceptions of the importance of health education. Dissemination of health education programs can also be coordinated on the federal level. The Department of Education’s Program Effectiveness Panel/ National Diffusion Network represents one such approach to centralized dissemination. Establishment of a health promotion division within the National Diffusion Network and the designation of health as a perennial priority within the Department of Education would begin to improve the dissemination process. The Department of Education should also interface with the National Institutes of Health to directly disseminate interventions that have traversed the five-phase model. Finally, the five-phaseResearchmodel of the National Institutes of Health should be broadened to include large-scaledissemination projects beyond efficacy testing and demonstration projects. Allocate Suficient Funds
Clearly, a necessary concomitant to establishing such an agency is the permanent allocation of state and/or federal funds to pay for texts, teacher training, screening, and evaluation as well as consultative and administrative personnel. In addition, the potential role of corporate America, particularly the health insurance industry, in supporting health education should be more rigorously pursued. Clarification of Teaching Responsibility
The responsibility for teaching health must be better defined in both primary
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and secondary schools. If in the primary grades, we want classroom teachers to effectively teach health, we must acknowledge that this responsibility may be inconsistent with their perceived job description and professional skills. The task assignmentof teaching health must emanatefrom an explicit policy designed and endorsed by teachers and their unions rather than a de facto assumption. We must investigate and then ameliorate teacher’s objections and obstacles to teaching health. If we want classroom teachers to add health to their teaching repertoire and job description, they must be adequately trained and motivated. In-service days should be set aside specifically to focus on health curricula. Improved curriculum delivery can also be achieved by altering teachers’ subjective norms regarding their personal health. Programs such as the Seaside Health Promotion Conference or local school-site health promotion programs may be effective means to modify teachers’ values and commitment to their health and ultimately their attitudes toward health education. Along these lines, the American Health Foundation over the past 5 years, as part of the annual KYB screening, has invited teachers to have their height, weight, blood pressure, and cholesterol level assessedat the same time as their students. Teacher participation in these screeningstypically has averaged around 70%. Involving teachers in this way appears to improve curriculum delivery rates. In secondary schools we need to clarify the roles of nurses, physical education instructors, science teachers, and health educators. We should also investigate the costs and benefits of using health educators rather than classroom teachers in primary grades. This would obviate many of the obstacles associated with utilization of classroom teachers. The need for trained health educators may become more apparent as curricula begin to incorporate more cognitive, affective, and behavioral rather than didactic components. Apply Rigorous Criteria for Curriculum Selection
Curriculum selection should be guided by rigorous criteria such as those enumerated in the consensus statement of the National Professional School Health Organizations (19). The goal of health education is to modify skills and behavior, not simply to impart knowledge. Thus, information-based science texts should not be used as health texts. Further, we recommend a shift toward curricula that emphasize utility vs abstract knowledge. There is mounting evidence (11) that only those health curricula that include skills building and affective education, in addition to health information modules, should be considered for dissemination. In general, a curriculum should inculcate an internal health locus of control in addition to providing topic specific didactic, affective, and behavioral instruction. Use of broad-based rather than single-component curricula should instill attitudes and skills applicable to both health- and non-health-related behaviors. Our experience suggeststhat curricula which include consumable student workbooks and well-designed, user-friendly teacher manuals are preferable. If a curriculum requires auxiliary materials, they must be made readily available. Comprehensive health education programs should have a positive impact on students’ attitudes toward school, self, and society. Ideally, health education
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should begin during primary grades when children’s attitudes, values, and habits are perhaps more malleable. Apply Structured Assessment Criteria
Assessment of students’ knowledge, attitudes, behaviors, and biomedical risk factors will help to determine individual as well as aggregate change. Perhaps schools could be ranked by health knowledge or even behavioral indices. A grade based upon health knowledge, or a health profile index based upon attitude and behavior, may be useful. In response to these needs, the American Health Foundation developed a “National Health Test” for grades 1 through 9, which examines students’ knowledge, attitudes, and behaviors across a wide range of content areas including smoking, substanceuse, nutrition, exercise, first aid, accident prevention, and dental care. At present, norms based upon a range of U.S. school systems are being established so that schools can gaugetheir students’ relative health education needs. In addition, these instruments can be used to assessprogram effect as well as to generate student grades. As documented by Kolbe (17), health status and health behavior may impact on cognitive performance. Further evidence demonstrating a link between implementation of health curricula and improvements in academic performance, attendance, or self-esteemis needed. Curriculum dissemination research suggeststhat administrators may be more likely to adopt health education programs if they provide tangible benefits which satisfy existing needs such as improving student performance, attendance, morale, and parent satisfaction. At present, however, many of the schools that have adopted KYB have typically been innovative schools, with administrators who fit the “early adopter” profile. Ultimately, health education must be perceived as beneficial by all educators. Curriculum delivery rates can also be assessedby student examination as well as by teacher logs, self-report questionnaires, and classroom observation. Such assessmentmay be particularly important during the first few years of curriculum adoption when teachers’ attitudes and habits are being solidified. Finally, health education will be viewed differently if there are contingencies for curriculum delivery. Utilize Marketing
Strategies
Health education needs to be repackaged. Often, health education is perceived as a list of do’s, don’ts, and warnings with aversive immediate costs and only intangible, delayed benefits. Clearly, if the ambivalence to school health education is to be overcome, we must modify the perceived benefits and risks of healthpromoting and health-compromising behaviors. In short, we must alter the image of health education. Social marketing strategies that emphasize the positive, short-term psychological, social, and biologic benefits of health-promoting behavior may help alter the perceived social and psychological costs and benefits among students, teachers, and parents. We must redefine the perceived social consequences of engaging in health-compromising and health-enhancing behaviors, in
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effect creating positive peer pressure. Health educators should be trained to exploit adolescents’ natural rebelliousness and desire for independence. As Flay suggests(8,9), massmedia can be used to supplement classroom health education activities. Specifically, local media support of health education programs can stimulate parental involvement, reinforce knowledge and values presented in the classroom, combat health-compromising commercial messages, stimulate classroom discussion, and, at times, serve as the principal intervention. Zntegrate Health within the School Environment and Community
It is clear that effective health education programs, in addition to imparting knowledge, should provide students with the skills, environment, and resources (12) necessary for positive health behavior. Thus, health education programs should involve physical education and food service departments. Physical education programs, particularly those in inner city schools, must be improved. The school environment should allow for health habits consistent with curriculum guidelines. Thus, a trend toward reducing fat and sugar intake and increasing fiber intake should be reflected in school lunch programs, vending machines, and classroom snacks. No-smoking policies should be instituted throughout the school. Further, as school health programs encompass both educational and social interventions, they should be viewed and structured as collaborative efforts among schools, parents, community and religious leaders, civic agencies, physicians, politicians, psychologists, and local media. Specifically, parents can be involved via newsletters, school-site screenings, health workshops, and takehome activities. Local health-care providers, politicians, athletes, media personalities, etc., can be used to promote curricula and health activities. Conduct Further Implementation and Dissemination Research
Finally, the implementation process, which includes such issues as community, administrative, teacher, and parental resistance should be more rigorously investigated and quantified. Understanding and overcoming these obstacles may require a separate expertise and technology. How best to ensure adequate curriculum delivery rates as well as teacher, student, and administrative enthusiasm deserves systematic investigation. It is important to keep in mind that while the principal initial step toward an effective health education policy is obtaining funding for materials and personnel, it is equally important to develop strategies to assure acceptable implementation rates. CONCLUSION
In summary, a shift in the political, educational, and institutional responsibilities and commitment toward health education is called for. In contrast to existing policies, health promotion must become an integral, compulsory component of our educational agenda. We should designateone supervisory aegis to consolidate the various segmentsof the health education process. An important first step to achieving these ends is the establishment of legislation mandating and funding state sponsored health education. A model of such
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legislation has been suggestedby the American Health Foundation and is contained in this issue of Preventive Medicine. Specifically, funds must be made available for curriculum materials, teacher training and support, evaluation, and biomedical screening. Ideally, every school should be afforded a health educator/coordinator. The consequencesof teaching or not teaching health should be modified. We should elevate the status and profile of health education within our education agenda. Over the past two decades our knowledge of the behavioral antecedents of disease and our ability to alter these behaviors early in life have increased dramatically. Yet, to date we have failed to develop an effective public health education policy that exploits these advances. The medical costs attributable to tobacco use, a high-fat diet, drug and alcohol abuse, sexually transmitted diseases,and physical inactivity amount to billions of dollars annually. The social costs are impossible to quantify. While initiating an effective health education policy will entail significant up-front expenditures, the long-term benefits of health education will far outweigh the short-term costs. In this editorial, we have attempted to delineate some of the barriers that account for our inadequate health education policy and have offered some possible solutions to help bridge the gap between what needs to be done and what we are doing. REFERENCES 1. Bell, C. S., and Battjes,R. (Eds). “Prevention Research:Deterring Drug Abuse amongChildren and Adolescents,” NIDA ResearchMonograph63, DHHS Publication No. (ADM) 85-1334. U.S. Departmentof Health and Human Services,Washington,DC, 1985. 2. Bensley,L. B. Reaffiig the needfor parentinvolvementin health education.J. SchoolHeafrh 55, 38-39(1985). 3. Botvin, G. J., Baker, E., Renick, N. L., Filazzola, A. D., and Botvin, E. M. A cognitivebehavioral approachto substanceabuseprevention. Addict. Behav. 9, 137-147(1984). 4. Botvin, G. J., and Eng, A. The efficacy of a multicomponent approach to the prevention of cigarettesmoking.Prev. Med. 11, 199-211(1982). 5. Coates,T. J., Jeffery, R. W., and Slinkard, L. A. Heart healthy eating and exercise:Introducing and maintaining changesin health behaviors.Amer. J. Public Health 71, 15-23(1981). 6. Coates,T. J., Perry, C., Killen, J., and Slinkard, L. A. Primary prevention of cardiovascular diseasein children and adolescents,in “Medical Psychology: Contributions to Behavioral Medicine” (C. K. Prokopand L. A. Bradley, Eds.), pp. 157-l%. AcademicPress,New York, 1981. 7. Evans, R. I., Henderson,A. H., Hill, P. C., and Raines,B. E. Current psychological,social, and educationalprogramsin control and prevention of smoking:A critical methodologicalreview. Atherosclerosis Rev. 6, 203-245 (1979). 8. Flay, B. R. Massmedialinkageswith school-basedprogramsfor drug abuseprevention. .I. School Health 56, 4024 (1986). 9. Flay, B. R., and Sobel, J. L. The role of massmedia in preventing substanceabuse, in “heventing Adolescent Drug Abuse: Intervention Strategies” (T. J. Glynn et al., Eds.), NIDA ResearchMonograph 147, Washington,DC, 1983. 10. Play, B. R. Psychosocialapproachesto smokingprevention: A review of findings. Health Psycho/. 4, 449-488(1985). 11. Gilchrist, L. D., Snow, W. H., Lodish, D., and Schinke, S. P. The relationship of cognitive and behavioral skills to adolescenttobaccosmoking.J. School Health 55, 132-134(1985). 12. Green, L. W. Modifying and developinghealth behavior. Annu. Rev. Public Health 5, 215-236 (1984).
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13. Greenwald,P., and Cullen, J. W. The New Emphasisin CancerControl. J. Nurl. CancerInst. 74, 543-551(1985). 14. Hurd, P. D., Johnson, C. A., Pechacek,T., Bast, L. P., Jacobs, D. R., and Luepker, R. V. Prevention of cigarettesmokingin seventhgradestudents.J. Behav. Med. 3, 15-28(1980). 15. Iammarino, N. K., and Weinberg,A. D. Cancerprevention in the schools..Z.School Health 55, 86-95 (1985). 16. Lohrmann, D. K., Gold, R. S., and Jubb, H. School health education: A foundation for school health programs..Z.School Health 57, 420-425 (1987). 17. Kolbe, L. J., et al. Appropriate functions of health education in schools: Improving health and cognitive performance,in ‘Child Health Behavior: A Behavioral PediatricsPerspectii(N. Kraisinger, J. Arasteli, and M. Cataldo, Eds.), Wiley, New York, 1986. 18. Kreuter, M. W., Christenson,G. M., Davis, R. School health educationresearch:Future issues and challenges.J. School Health 54, 27-32 (1984). 19. National ProfessionalSchool Health Education Organizations.Comprehensiveschool health education. J. School Health 54, 312-315(1984). 20. Olds, R. S., and Eddy, J. M. Negativehealth messagesin schools.J. School Health 56, 334336 (1986). 21. Owen, S. L., Kirkpatrick, M. A., Lavery, S. W., Gonser, H. L., Nelson, S. R., Davis, R. L., Mason, E. F., and Connell, D. B. Selectingandrecruiting health programsfor the schoolhealth educationevaluation. J. School Health 55, 305-308 (1985). 22. Perry, C., Killen, J., Telch, M., Slinkard, L. A., and Danaher,B. G. Modifying smokingbehavior of teenagers:A school-basedintervention. Amer. J. Public Health 70, 722-725 (1980). 23. Schinke, S. P. School-basedmodel for preventing teenagepregnancy.Sot. Work Educ. 4, 34-42 (1982). 24. Schinke, S. P., Blythe, B. J., Gilchrist, L. D., and Burt, G. A. Primary prevention of adolescent pregnancy.Sot. Work Groups 4, 121-135(1981). 25. Stone,E. J. School-basedhealth researchfunded by the national heart, lung, and blood institute. J. School Health 55, 168-174(1985). 26. Walter, H. J., Hofman, A., Vaughan, R., and Wynder, E. L. Modification of risk factors for coronary heart disease. The New England Journal ofMedicine 318, 1093-1100(1988). 27. Williams, C. L., Arnold, C. B., and Wynder, E. L. Primary prevention of chronic diseasebeginning in childhood. Prev. Med. 6,344-357 (1977). 28. Williams, C. L., Carter, B. J., Arnold, C. B., and Wynder, E. L. Chronic diseaserisk factors amongchildren: The “Know Your Body” Study. J. Chronic Dis. 32, 505-513(1979). 29. Williams, C. L., Carter, B. J., and Eng, A. The “Know Your Body” Program:A developmental approachto health education and diseaseprevention. Prev. Med. 9, 371-383(1980).
MEDICINE
18,
147-155 (1989)
EDITORIAL Toward
an Effective School Health Education Policy: A Call for Legislative and Educational Reform’
KENNETH A. RESNICOW, PH.D. ,’ MARIO A. ORLANDI, PH.D., AND ERNST L. WYNDER, M.D. American Health Foundation, 320 East 43rd Street, New York, New York looI
INTRODUCTION
During the past 10 years, an increasing body of research has demonstrated not only the need for but also the efficacy of school health education programs. Numerous school-based health programs have been shown to have a positive effect on a variety of health behaviors, including the use of alcohol, drugs, and cigarettes, nutrition, exercise, sexual behavior, and self-management (1, 3-7, 10, 11, 15, 22-24, 26). Despite these promising results, the degree to which such programs have been effectively disseminated and implemented on a state or national level remains disappointing. For this reason, an emerging challenge for our public health system is the diffusion, implementation, and marketing of extant health education programs. Kreuter et al. (18) summarized the problem as follows: . . . what is the practical worth of these positive indicators if there is no room or support for even innovative school health education programs in the existing curriculum? The descriptive information we have, does not indicate the existence of a vacuum in schools waiting to be filed by a proven effective approach to school health education. Rather, instead of a vacuum, there are formidable political, philosophical, and economic barriers in the field that need to be realistically acknowledged” (p. 29).
During the past 10 years, the American Health Foundation has been involved in the development and dissemination of its “Know Your Body” (KYB) Program in a number of states and abroad, across a variety of populations (26-29). An analysis the KYB implementation efforts has resulted in the delineation of an array of social, political, economic, and psychological obstacles to effective dissemination that must be both acknowledged and addressed. The purpose of this article is to provide a brief overview of these barriers and to suggest a number of specific recommendations for overcoming them. ANALYSIS
OF BARRIERS
There are two principal predisposing factors that appear to contribute significantly to these barriers. First, there is a considerable ambivalence in our society r The development of this manuscript was supported by Grant 870-0189from the Ford Foundation. 3 To whom reprint requests should be addressed. 147 OWI-7435/89 $3.00 Copyright Au lights
0 1989 by Academic Press, Inc. of repluduction in any form rescrwd.
148
RESNICOW,
ORLANDI,
AND WYNDER
toward prevention and health education. This ambivalence is, at least in part, endemic to human nature. There is a tendency for asymptomatic, ostensibly healthy individuals to underestimate their susceptibility to illness. Most people visit doctors to obtain relief from pain or to alleviate symptoms when they are sick. Such visits provide tangible results. In contrast, the benefits of prevention and health promotion programs are often intangible, delayed, and less dramatic. It is ironic that while heart disease and cancer account for nearly 70% of all adult deaths in our country annually and at least 30-60% of these deaths are preventable, the prevention of chronic diseasehas yet to evoke the same senseof urgency or crisis as have the problems of drug abuse, AIDS, and suicide prevention. Tobacco use and diets high in saturated fats alone account for at least 30% of all adult deaths each year; however, these health problems, while preventable, do not elicit the same concern as the “epidemic” of drug use. Society’s ambivalence toward prevention and health education is also reflected in the large number of states that have delineated recommendations and age-specific goals for health education, yet have not allocated sufficient funds to implement such programs. The second fundamental problem facing health education is that the development and implementation of health education programs in the United States encompassesthe contributions of numerous professions, institutions, and agencies, including researchers, book publishers, writers, educators, politicians, administrators, marketing experts, and community resources. Yet, the responsibility for orchestrating these various and often discrete components of the health education process has not been clearly assignedto, or accepted by, any particular agency or organization within this system. For example, health promotion researchers develop and evaluate interventions, but generally terminate their involvement after efficacy testing is complete. Consequently, a gap in technology transfer and program dissemination often results. This gap may in part be attributed to or at least reflected in the Federal Government’s approach to health promotion research. The National Institutes of Health, in particular the National Heart, Lung, and Blood and the National Cancer Institutes, have funded the development and evaluation of numerous risk factor reduction and health promotion curricula (15,25). However, as exemplified by the National Cancer Institute’s five-stage model of cancer control research, these agencies provide only limited funds to disseminate such programs after initial efficacy testing is complete. As delineated by Greenwald and Cullen (13), the five phases of cancer research begin with hypothesis development, methods development, controlled intervention trials, and defined population studies and conclude with demonstration projects and implementation research. Conspicuously absent from this model is a specific mechanismfor large-scaledissemination of proven interventions. The potential public health benefit of developing and evaluating health curricula, without subsequent dissemination, appears limited. There are a number of somewhat more tangible problems within our legislative and educational systems, which together comprise a set of formidable, although negotiable, barriers to school health education.
EDITORIAL
149
Legislative Barriers
First, there is a serous shortage, and in some states a complete absence, of funding for school health programs. Second, there are few states that have developed rigorous implementation and evaluation strategies. Dissemination of any innovation requires special sensitivity to the existing political and social structures and, in the case of health education, requires the input of parents and other community members as well. Educational Barriers
Third, the role and status of health within our educational agenda are unclear. Administrators and teachers are unsure of health education’s importance and, on a more fundamental level, its place within traditional education. Given the present status of health in our educational and political agendas, we cannot expect it to compete with mathematics and English in school curricula. The secondary status of health education is understandable, as it represents an innovation within our traditional education paradigm. It is also important to recognize that health education’s potential for controversy and incompatibility with traditional education models is likely to increase as curricula place more emphasison behavioral rather than cognitive outcomes. It can also be argued that health education has been imposed on our educational system. Some of the resistance to health education may in fact be the result of educators’ lack of perceived ownership of the health education domain. Fourth, there is some confusion as to who should be teaching health. In most primary schools, classroom teachers are defacto assigned this task. The assignment of additional job responsibilities without a concomitant increase in pay or status can result in poor curriculum delivery rates because of role ambiguity or work overload. Further, even if classroom teachers are willing to teach health, they may be unable to do so without intensive training. Effective use of contemporary health promotion interventions may require an expertise quite distinct from teaching math or English. In some primary and many secondary schools, health is taught by school nurses, science teachers, physical education instructors, or health education teachers. With the exception of trained health educators, these professionals may require additional training and incentives if we expect them to adopt the role of health educator. Finally, there are few states that have developed systematic strategies to disseminate, implement, and evaluate their health programs. The selection, acquisition, implementation, evaluation, and funding of primary, and to a lesser degree secondary, school health curricula are often left up to individual schools. RECOMMENDATIONS
Recognizing these obstacles, a number of specific recommendations are offered which can help ameliorate some of the problems facing health education.
150
RESNICOW,
ORLANDI,
AND
WYNDER
Define the Role of Health Education in Our Education Agenda
Health education should become a priority within our educational agenda of equal stature to that of math and language. The commitment to health education must be long-term rather than crisis-driven. At present, health education is mandated in many states; it is not, however, truly mandatory. Local adoption of health education programs must be more rigorously monitored and enforced. Integrating health education into art, mathematics,and English curricula may help to better inculcate health into our educational system as well as reinforce classroom instruction. Assign Responsibility
Establishing a health education agency charged with consolidating and integrating the diverse elements of the health education process would help fill the gaps inherent in the current segmentedapproach to health education. The most likely candidate to fulfii this role would appear to be state educatiotiealth departments. If this agency will reside outside the education system, it must be structured in such a way that it can readily interface with the Department of Education on both the state and local levels. This agency would coordinate the wide range of tasks involved, including curriculum selection and revision, teacher training, program implementation, parent, community, and media involvement, program evaluation, and auxiliary fund raising. The establishmentof a unifying agency responsible for coordinating and evaluating health programs along with the allocation of funding may also alter teachers’ perceptions of the importance of health education. Dissemination of health education programs can also be coordinated on the federal level. The Department of Education’s Program Effectiveness Panel/ National Diffusion Network represents one such approach to centralized dissemination. Establishment of a health promotion division within the National Diffusion Network and the designation of health as a perennial priority within the Department of Education would begin to improve the dissemination process. The Department of Education should also interface with the National Institutes of Health to directly disseminate interventions that have traversed the five-phase model. Finally, the five-phaseResearchmodel of the National Institutes of Health should be broadened to include large-scaledissemination projects beyond efficacy testing and demonstration projects. Allocate Suficient Funds
Clearly, a necessary concomitant to establishing such an agency is the permanent allocation of state and/or federal funds to pay for texts, teacher training, screening, and evaluation as well as consultative and administrative personnel. In addition, the potential role of corporate America, particularly the health insurance industry, in supporting health education should be more rigorously pursued. Clarification of Teaching Responsibility
The responsibility for teaching health must be better defined in both primary
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and secondary schools. If in the primary grades, we want classroom teachers to effectively teach health, we must acknowledge that this responsibility may be inconsistent with their perceived job description and professional skills. The task assignmentof teaching health must emanatefrom an explicit policy designed and endorsed by teachers and their unions rather than a de facto assumption. We must investigate and then ameliorate teacher’s objections and obstacles to teaching health. If we want classroom teachers to add health to their teaching repertoire and job description, they must be adequately trained and motivated. In-service days should be set aside specifically to focus on health curricula. Improved curriculum delivery can also be achieved by altering teachers’ subjective norms regarding their personal health. Programs such as the Seaside Health Promotion Conference or local school-site health promotion programs may be effective means to modify teachers’ values and commitment to their health and ultimately their attitudes toward health education. Along these lines, the American Health Foundation over the past 5 years, as part of the annual KYB screening, has invited teachers to have their height, weight, blood pressure, and cholesterol level assessedat the same time as their students. Teacher participation in these screeningstypically has averaged around 70%. Involving teachers in this way appears to improve curriculum delivery rates. In secondary schools we need to clarify the roles of nurses, physical education instructors, science teachers, and health educators. We should also investigate the costs and benefits of using health educators rather than classroom teachers in primary grades. This would obviate many of the obstacles associated with utilization of classroom teachers. The need for trained health educators may become more apparent as curricula begin to incorporate more cognitive, affective, and behavioral rather than didactic components. Apply Rigorous Criteria for Curriculum Selection
Curriculum selection should be guided by rigorous criteria such as those enumerated in the consensus statement of the National Professional School Health Organizations (19). The goal of health education is to modify skills and behavior, not simply to impart knowledge. Thus, information-based science texts should not be used as health texts. Further, we recommend a shift toward curricula that emphasize utility vs abstract knowledge. There is mounting evidence (11) that only those health curricula that include skills building and affective education, in addition to health information modules, should be considered for dissemination. In general, a curriculum should inculcate an internal health locus of control in addition to providing topic specific didactic, affective, and behavioral instruction. Use of broad-based rather than single-component curricula should instill attitudes and skills applicable to both health- and non-health-related behaviors. Our experience suggeststhat curricula which include consumable student workbooks and well-designed, user-friendly teacher manuals are preferable. If a curriculum requires auxiliary materials, they must be made readily available. Comprehensive health education programs should have a positive impact on students’ attitudes toward school, self, and society. Ideally, health education
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should begin during primary grades when children’s attitudes, values, and habits are perhaps more malleable. Apply Structured Assessment Criteria
Assessment of students’ knowledge, attitudes, behaviors, and biomedical risk factors will help to determine individual as well as aggregate change. Perhaps schools could be ranked by health knowledge or even behavioral indices. A grade based upon health knowledge, or a health profile index based upon attitude and behavior, may be useful. In response to these needs, the American Health Foundation developed a “National Health Test” for grades 1 through 9, which examines students’ knowledge, attitudes, and behaviors across a wide range of content areas including smoking, substanceuse, nutrition, exercise, first aid, accident prevention, and dental care. At present, norms based upon a range of U.S. school systems are being established so that schools can gaugetheir students’ relative health education needs. In addition, these instruments can be used to assessprogram effect as well as to generate student grades. As documented by Kolbe (17), health status and health behavior may impact on cognitive performance. Further evidence demonstrating a link between implementation of health curricula and improvements in academic performance, attendance, or self-esteemis needed. Curriculum dissemination research suggeststhat administrators may be more likely to adopt health education programs if they provide tangible benefits which satisfy existing needs such as improving student performance, attendance, morale, and parent satisfaction. At present, however, many of the schools that have adopted KYB have typically been innovative schools, with administrators who fit the “early adopter” profile. Ultimately, health education must be perceived as beneficial by all educators. Curriculum delivery rates can also be assessedby student examination as well as by teacher logs, self-report questionnaires, and classroom observation. Such assessmentmay be particularly important during the first few years of curriculum adoption when teachers’ attitudes and habits are being solidified. Finally, health education will be viewed differently if there are contingencies for curriculum delivery. Utilize Marketing
Strategies
Health education needs to be repackaged. Often, health education is perceived as a list of do’s, don’ts, and warnings with aversive immediate costs and only intangible, delayed benefits. Clearly, if the ambivalence to school health education is to be overcome, we must modify the perceived benefits and risks of healthpromoting and health-compromising behaviors. In short, we must alter the image of health education. Social marketing strategies that emphasize the positive, short-term psychological, social, and biologic benefits of health-promoting behavior may help alter the perceived social and psychological costs and benefits among students, teachers, and parents. We must redefine the perceived social consequences of engaging in health-compromising and health-enhancing behaviors, in
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effect creating positive peer pressure. Health educators should be trained to exploit adolescents’ natural rebelliousness and desire for independence. As Flay suggests(8,9), massmedia can be used to supplement classroom health education activities. Specifically, local media support of health education programs can stimulate parental involvement, reinforce knowledge and values presented in the classroom, combat health-compromising commercial messages, stimulate classroom discussion, and, at times, serve as the principal intervention. Zntegrate Health within the School Environment and Community
It is clear that effective health education programs, in addition to imparting knowledge, should provide students with the skills, environment, and resources (12) necessary for positive health behavior. Thus, health education programs should involve physical education and food service departments. Physical education programs, particularly those in inner city schools, must be improved. The school environment should allow for health habits consistent with curriculum guidelines. Thus, a trend toward reducing fat and sugar intake and increasing fiber intake should be reflected in school lunch programs, vending machines, and classroom snacks. No-smoking policies should be instituted throughout the school. Further, as school health programs encompass both educational and social interventions, they should be viewed and structured as collaborative efforts among schools, parents, community and religious leaders, civic agencies, physicians, politicians, psychologists, and local media. Specifically, parents can be involved via newsletters, school-site screenings, health workshops, and takehome activities. Local health-care providers, politicians, athletes, media personalities, etc., can be used to promote curricula and health activities. Conduct Further Implementation and Dissemination Research
Finally, the implementation process, which includes such issues as community, administrative, teacher, and parental resistance should be more rigorously investigated and quantified. Understanding and overcoming these obstacles may require a separate expertise and technology. How best to ensure adequate curriculum delivery rates as well as teacher, student, and administrative enthusiasm deserves systematic investigation. It is important to keep in mind that while the principal initial step toward an effective health education policy is obtaining funding for materials and personnel, it is equally important to develop strategies to assure acceptable implementation rates. CONCLUSION
In summary, a shift in the political, educational, and institutional responsibilities and commitment toward health education is called for. In contrast to existing policies, health promotion must become an integral, compulsory component of our educational agenda. We should designateone supervisory aegis to consolidate the various segmentsof the health education process. An important first step to achieving these ends is the establishment of legislation mandating and funding state sponsored health education. A model of such
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legislation has been suggestedby the American Health Foundation and is contained in this issue of Preventive Medicine. Specifically, funds must be made available for curriculum materials, teacher training and support, evaluation, and biomedical screening. Ideally, every school should be afforded a health educator/coordinator. The consequencesof teaching or not teaching health should be modified. We should elevate the status and profile of health education within our education agenda. Over the past two decades our knowledge of the behavioral antecedents of disease and our ability to alter these behaviors early in life have increased dramatically. Yet, to date we have failed to develop an effective public health education policy that exploits these advances. The medical costs attributable to tobacco use, a high-fat diet, drug and alcohol abuse, sexually transmitted diseases,and physical inactivity amount to billions of dollars annually. The social costs are impossible to quantify. While initiating an effective health education policy will entail significant up-front expenditures, the long-term benefits of health education will far outweigh the short-term costs. In this editorial, we have attempted to delineate some of the barriers that account for our inadequate health education policy and have offered some possible solutions to help bridge the gap between what needs to be done and what we are doing. REFERENCES 1. Bell, C. S., and Battjes,R. (Eds). “Prevention Research:Deterring Drug Abuse amongChildren and Adolescents,” NIDA ResearchMonograph63, DHHS Publication No. (ADM) 85-1334. U.S. Departmentof Health and Human Services,Washington,DC, 1985. 2. Bensley,L. B. Reaffiig the needfor parentinvolvementin health education.J. SchoolHeafrh 55, 38-39(1985). 3. Botvin, G. J., Baker, E., Renick, N. L., Filazzola, A. D., and Botvin, E. M. A cognitivebehavioral approachto substanceabuseprevention. Addict. Behav. 9, 137-147(1984). 4. Botvin, G. J., and Eng, A. The efficacy of a multicomponent approach to the prevention of cigarettesmoking.Prev. Med. 11, 199-211(1982). 5. Coates,T. J., Jeffery, R. W., and Slinkard, L. A. Heart healthy eating and exercise:Introducing and maintaining changesin health behaviors.Amer. J. Public Health 71, 15-23(1981). 6. Coates,T. J., Perry, C., Killen, J., and Slinkard, L. A. Primary prevention of cardiovascular diseasein children and adolescents,in “Medical Psychology: Contributions to Behavioral Medicine” (C. K. Prokopand L. A. Bradley, Eds.), pp. 157-l%. AcademicPress,New York, 1981. 7. Evans, R. I., Henderson,A. H., Hill, P. C., and Raines,B. E. Current psychological,social, and educationalprogramsin control and prevention of smoking:A critical methodologicalreview. Atherosclerosis Rev. 6, 203-245 (1979). 8. Flay, B. R. Massmedialinkageswith school-basedprogramsfor drug abuseprevention. .I. School Health 56, 4024 (1986). 9. Flay, B. R., and Sobel, J. L. The role of massmedia in preventing substanceabuse, in “heventing Adolescent Drug Abuse: Intervention Strategies” (T. J. Glynn et al., Eds.), NIDA ResearchMonograph 147, Washington,DC, 1983. 10. Play, B. R. Psychosocialapproachesto smokingprevention: A review of findings. Health Psycho/. 4, 449-488(1985). 11. Gilchrist, L. D., Snow, W. H., Lodish, D., and Schinke, S. P. The relationship of cognitive and behavioral skills to adolescenttobaccosmoking.J. School Health 55, 132-134(1985). 12. Green, L. W. Modifying and developinghealth behavior. Annu. Rev. Public Health 5, 215-236 (1984).
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