Health Education: Results From the School Health Policies and Programs Study 2006
LAURA KANN, PhDa
SUSAN K. TELLJOHANN, HSD, CHESb SUSAN F. WOOLE , PhD, CHESc
BACKGROUND: School health education can effectively help reduce the prevalence of health-risk behaviors among students and have a positive inﬂuence on students’ academic performance. This article describes the characteristics of school health education policies and programs in the United States at the state, district, school, and classroom levels.
METHODS: The Centers for Disease Control and Prevention conducts the School Health Policies and Programs Study every 6 years. In 2006, computer-assisted tele-phone interviews or self-administered mail questionnaires were completed by state education agency personnel in all 50 states plus the District of Columbia and among a nationally representative sample of districts (n = 459). Computer-assisted personal interviews were conducted with personnel in a nationally representative sample of ele-mentary, middle, and high schools (n = 920) and with a nationally representative sam-ple of teachers of classes covering required health instruction in elementary schools and required health education courses in middle and high schools (n = 912).
RESULTS: Most states and districts had adopted a policy stating that schools will teach at least 1 of the 14 health topics, and nearly all schools required students to receive instruction on at least 1 of these topics. However, only 6.4% of elementary schools, 20.6% of middle schools, and 35.8% of high schools required instruction on all 14 topics. In support of schools, most states and districts offered staff develop-ment for those who teach health education, although the percentage of teachers of required health instruction receiving staff development was low.
CONCLUSIONS: Health education has the potential to help students maintain and improve their health, prevent disease, and reduce health-related risk behaviors. How-ever, despite signs of progress, this potential is not being fully realized, particularly at the school level.
Keywords: school health education; schools; school policy; surveys.
Citation: Kann L, Telljohann SK, Wooley SF. Health education: Results from the School Health Policies and Programs Study 2006. J Sch Health. 2007; 77: 408-434.
aDistinguished Fellow and Chief, Surveillance and Evaluation Research Branch, (email@example.com), Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS-K33, Atlanta, GA 30341.
bProfessor, (firstname.lastname@example.org), Department of Health and Rehabilitative Services, University of Toledo, Mail Stop #119, 2801 W. Bancroft Street, Toledo, OH 43606. cExecutive Director, (email@example.com), American School Health Association, 7263 State Route 43, P.O. Box 708, Kent, OH 44240.
Address correspondence to: Laura Kann, Distinguished Fellow and Chief, Surveillance and Evaluation Research Branch (firstname.lastname@example.org), Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS-K33, Atlanta, GA 30341.
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chool health education has been deﬁned in vari-ous, though similar ways. For example, the Cen-
ters for Disease Control and Prevention (CDC) deﬁnes health education as: ‘‘A planned, sequential, K-12 curriculum that addresses the physical, mental, emotional, and social dimensions of health. The cur-riculum is designed to motivate and assist students to maintain and improve their health, prevent disease, and reduce health-related risk behaviors. It allows stu-dents to develop and demonstrate increasingly sophis-ticated health-related knowledge, attitudes, skills, and practices. The comprehensive health education curric-ulum includes a variety of topics such as personal health, family health, community health, consumer health, environmental health, sexuality education, mental and emotional health, injury prevention and safety, nutrition, prevention and control of disease, and substance use and abuse. Qualiﬁed, trained teach-ers provide health education.’’1,2
In 2002, the 2000 Joint Committee on Health Education Terminology deﬁned health education as ‘‘the development, delivery, and evaluation of planned, sequential, and developmentally appropriate instruc-tion, learning experiences, and other activities designed to protect, promote, and enhance the health literacy, attitudes, skills, and well-being of students, pre-kindergarten through grade 12.’’3
Regardless of the exact deﬁnition, reviews of effective programs and curricula and input from experts in the ﬁeld of health education have identi-ﬁed the following characteristics of effective health education:4-14
d focuses on speciﬁc behavioral outcomes d is research based and theory driven
d addresses individual values and group norms that support health-enhancing behaviors
d focuses on increasing the personal perception of risk and harmfulness of engaging in speciﬁc health-risk behaviors, as well as reinforcing protec-tive factors
d addresses social pressures and inﬂuences
d builds personal competence, social competence, and self-efﬁcacy by addressing skills
d provides functional health knowledge that is basic, accurate, and directly contributes to health-pro-moting decisions and behaviors
d uses strategies designed to personalize information and engage students
d provides age-appropriate and developmentally appropriate information, learning strategies, teach-ing methods, and materials
d incorporates learning strategies, teaching methods, and materials that are culturally inclusive
d provides adequate time for instruction and learning
d provides opportunities to reinforce skills and posi-tive health behaviors
d provides opportunities to make positive connec-tions with inﬂuential persons
d includes teacher information and plans for profes-sional development and training that enhances effectiveness of instruction and student learning.
The National Health Education Standards provide a framework for designing or selecting health educa-tion curricula and allocating instructional resources, as well as providing a basis for the assessment of stu-dent achievement. The National Health Education Standards also offer students, families, and commu-nities concrete expectations for health education. The Joint Committee on National Health Education Standards released the ﬁrst set of standards in 1995.15 The National Health Education Standards Review and Revision Panel released the following updated set of 8 standards in 2007:16
1. Students will comprehend concepts related to health promotion and disease prevention to enhance health.
2. Students will analyze the inﬂuence of family, peers, culture, media, technology, and other fac-tors on health behaviors.
3. Students will demonstrate the ability to access valid information and products and services to enhance health.
4. Students will demonstrate the ability to use inter-personal communication skills to enhance health and avoid or reduce health risks.
5. Students will demonstrate the ability to use decision-making skills to enhance health.
6. Students will demonstrate the ability to use goal-setting skills to enhance health.
7. Students will demonstrate the ability to practice health-enhancing behaviors and avoid or reduce health risks.
8. Students will demonstrate the ability to advocate for personal, family, and community health.
Research has shown that school health education can effectively help reduce the prevalence of health-risk behaviors among students and have a positive inﬂuence on students’ academic performance. For example, a tobacco-use prevention program reduced by about 26% the number of students who started smoking during grades 7-9;17 a comprehensive inter-vention that included health education in public ele-mentary schools that serve high-crime areas in Seattle, Washington, was associated with increased student commitment to school, reduced misbehavior in school, and improved academic achievement, plus fewer risk-taking behaviors such as violence and heavy drinking;18 and the Coordinated Approach to Child Health curriculum slowed increases in the number of Hispanic students who were overweight or at risk of becoming overweight when it was
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implemented in elementary schools in a low-income community in El Paso, Texas.19
SELECTED FEDERAL SUPPORT AND RELATED RESEARCH
Support for school health education comes from many sources. Through February 2008, the CDC’s Division of Adolescent and School Health will be supporting education agencies and health agencies to help build and strengthen their capacity for improving child and adolescent health within the following 6 priority areas, all of which include school health education activities:
d Human immunodeﬁciency virus (HIV) prevention— CDC funds education agencies in 48 states, the District of Columbia, 7 territories, and 17 large urban school districts to help schools prevent sex-ual risk behaviors that result in HIV infection, especially among youth who are at highest risk.
d Coordinated school health programs—CDC funds 23 state education agencies, and through them their state health agencies, to build state education agency and state health agency partnerships and their capacity to implement and coordinate school health programs across agencies and within schools and to help schools reduce chronic disease risk factors, including tobacco use, poor nutrition, and physical inactivity.
d Abstinence—CDC funds 11 state education agen-cies to help schools increase the efﬁciency and impact of their efforts to help young people abstain from sexual risk behaviors.
d Asthma—CDC funds 1 state and 7 local education agencies to implement demonstration programs that help schools reduce asthma episodes and asthma-related absences.
d Professional development—CDC funds 2 state edu-cation agencies to help schools reduce health prob-lems among youth by planning and delivering professional development opportunities that build the capacity of other funded agencies to support the expansion, improvement, and sustainability of their school health programs.
d Food safety—CDC provides funding for 1 state education agency to implement a demonstration program that helps schools reduce food-borne illnesses.
The CDC also funds 30 national nongovernmental organizations to provide capacity building services to these funded agencies. In addition, many programs at the CDC have developed instructional materials that can be used by teachers for school health edu-cation20 and some support state programs that include school health education activities.
Several other federal agencies also support school health education throughout the nation. The US
Department of Education, through the Ofﬁce of Safe and Drug Free Schools, funds drug and violence pre-vention and activities that promote the health and well being of students in elementary and secondary schools.21 State and local education agencies carry out most activities, many of which focus on school health education. The US Departments of Education, Health and Human Services, and Justice fund the Safe Schools/Healthy Students program to prevent violence and substance abuse among youth and within schools and communities.22 The US Depart-ment of Health and Human Services also supports abstinence education with 3 programs, all of which include school health education activities: the Ado-lescent Family Life Abstinence Education Demon-stration Projects,23 Section 510 State Abstinence Education Program,24 and the Community-Based Ab-stinence Education Program.25
Healthy People 2010 Objective 7-2a to ‘‘increase the proportion of middle, junior high, and senior high schools that provide school health education to pre-vent health problems in the following areas: unin-tentional injury; violence; suicide; tobacco use and addiction; alcohol and other drug use; unintended pregnancy, HIV/AIDS, and STD infection; unhealthy dietary patterns; inadequate physical activity; and environmental health’’ articulates further federal-level support for health education.26
State and local agencies and many nongovern-mental organizations also support school health edu-cation. Universities and other research organizations conduct studies to document the effectiveness of school health education and its impact on students’ health and educational outcomes. This research pro-vides a framework for advocating for further federal, state, and local support for school health education and is often the key to helping decision makers understand the value of making room in the over-crowded and testing-focused curriculum for school health education. Most of these studies focus on only 1 or 2 content areas, but taken together, they provide evidence of the impact that school health education can have and its critical role, along with the other components of the school health program, in helping students improve health, prevent disease, and reduce risks.
The School Health Policies and Programs Study (SHPPS) was conducted previously in 199427 and again in 2000.28 The 1994 study focused only on middle schools and high schools. The 2000 study assessed health education in elementary schools, middle schools, and high schools. Both studies pro-vided a comprehensive assessment of health educa-tion at the state, district, school, and classroom levels, but they are now out of date. Other studies since 2000 have examined various aspects of school health education nationwide. For example, the
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National Association of State Boards of Education’s Center for Safe and Healthy Schools maintains an extensive database of state school health policies on 38 major school health topics in 6 major categories including curriculum and instruction,29 and the Guttmacher Institute monitors state-level policies on sex education and sexually transmitted diseases (STD)/HIV education.30 However, no other studies since SHPPS 2000 are national in scope, cover most aspects of health education, and address the state, district, school, and classroom levels.
This article describes for the ﬁrst time ﬁndings from SHPPS 2006 about state- and district-level health education standards and guidelines; elemen-tary school, middle school, and high school instruc-tion; professional preparation; stafﬁng and staff development; collaboration; evaluation; and health education coordinators. At the school level, this arti-cle describes health education requirements; elemen-tary school, middle school, and high school instruction; stafﬁng and professional development; and collaboration. At the classroom level, this article describes elementary school, middle school, and high school instruction; teaching methods; and stafﬁng and staff development. In addition, the article describes changes in key health education policies and programs from 2000 to 2006. While this article is primarily descriptive in nature, the CDC intends to conduct more detailed analyses and encourages others to conduct their own analyses using the ques-tionnaires and public-use data sets available at www.cdc.gov/shpps.
Detailed information about SHPPS 2006 methods is provided in ‘‘Methods: School Health Policies and Programs Study 2006’’ elsewhere in this issue of the Journal of School Health. The following section provides a brief overview of SHPPS 2006 methods speciﬁc to the health education component of the study.
SHPPS 2006 assessed health education at the state, district, school, and classroom levels. State-level data were collected from education agencies in all 50 states plus the District of Columbia. District-level data were collected from a nationally represen-tative sample of public school districts. School-level data were collected from a nationally representative sample of public and private elementary schools, middle schools, and high schools. Classroom-level data were collected from teachers of randomly selected classes covering required health instruction in elementary schools and randomly selected re-quired health education courses in middle schools and high schools.
The state- and district-level questionnaires as-sessed school health education policies for grades K-12. Both questionnaires assessed use of school health education standards and guidelines; required health education instruction at the elementary school, mid-dle school, and high school levels; stafﬁng and staff development; collaboration between health educa-tion staff and other agency and organization staff; and the educational background and credentials of the person who oversees or coordinates school health education for the state or district. The state-level questionnaire also collected data on student assessment practices and the district-level question-naire also collected data on evaluation of health education and how health education is promoted among families, school personnel, and the media.
Because the entire district-level questionnaire took longer than 20-30 minutes to complete and covered such a wide range of topics that a single respondent might not have sufﬁcient knowledge to complete it, the questionnaire was divided into 5 modules: (1) standards and guidelines, (2) elementary school instruction, (3) middle/junior high school instruction, (4) senior high school instruction, and (5) stafﬁng and staff development, collaboration, promotion, evaluation, and health education coor-dinator.
The school-level health education questionnaire assessed health education practices in elementary schools, middle schools, and high schools. Speciﬁ-cally, the questionnaire assessed use of school health education standards, guidelines, and objectives; re-quired health instruction; stafﬁng and staff develop-ment; collaboration between health education teachers and other school and community person-nel; promotion of health education among families and students; and the educational background and credentials of the person who oversees or coordi-nates health education at the school.
The classroom-level health education question-naire assessed general characteristics of health edu-cation classes or courses; speciﬁc content taught; teaching methods; and the educational background, credentials, and recent staff development of health education teachers.
Data Collection and Respondents
State- and district-level data were collected by computer-assisted telephone interviews or self-administered mail questionnaires. Designated respondents for each of 7 school health program components (ie, health education, physical educa-tion and activity, health services, mental health and social services, nutrition services, healthy and safe school environment, and faculty and staff health
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promotion) completed the interviews or question-naires. At the state level, the state-level contact des-ignated a single respondent for each questionnaire. At the district level, the district-level contact could designate a different respondent for each question-naire or questionnaire module. All designated respondents had primary responsibility for, or were the most knowledgeable about, the policies and programs addressed in the particular questionnaire or module.
After a state- or district-level contact identiﬁed respondents, each respondent was sent a letter of invitation and packet of study-related materials. Each packet contained a paper copy of the question-naire(s) so that respondents could prepare for the interview and provided a toll-free number and access code that respondents could use to initiate the interview. Respondents were told that the question-naire(s) could be used in preparation for their telephone interview or completed and returned if self-administration was preferred. One week after packets were mailed to respondents, trained inter-viewers from a call center placed calls to them to schedule and conduct telephone interviews. In April 2006, telephone interviewing ceased and most of the remaining state- and district-level data collection occurred via a mail survey. All remaining respond-ents were mailed paper questionnaires and return envelopes; however, interviewers remained available for any respondents who chose to contact the call center.
At the end of the data collection period (October 2006), 88% of the completed state-level health edu-cation questionnaires had been completed via tele-phone interviews and 12% as paper questionnaires. For the completed district-level questionnaires, mod-ule 1 was completed via telephone interview 51% of the time; module 2, 54%; module 3, 50%; module 4, 51%; and module 5, 52%.
School-level and classroom-level data were col-lected by computer-assisted personal interviews. During recruitment, the principal or another school-level contact designated a faculty or staff respondent for each questionnaire or module, who had primary responsibility for or the most knowledge about the particular component. The principal or school-level contact could designate a different respondent for each questionnaire or module. For the school-level health education interview, the most common respondents were health education teachers, physi-cal education teachers, or other teachers.
At the classroom level, respondents to the computer-assisted personal interviews were those health education teachers whose elementary school class or middle school or high school course was selected during the sampling process. All school-level and classroom-level interviews were completed between January and June 2006.
One hundred percent (n = 51) of the state educa-tion agencies completed the state-level health educa-tion questionnaire. District eligibility for each module was determined prior to beginning the inter-view; 720 districts were eligible for each of modules 1 and 5, 697 districts were eligible for module 2, 695 for module 3, and 663 for module 4. Of the 720 dis-tricts eligible to complete any health education ques-tionnaire module, 64% (n = 459) completed at least 1 module. At the school level, 1338 schools were eligible for the health education interview; 69% (n = 920) of these schools completed the interview. At the classroom level, 967 classes or courses were selected for the health education interview; teachers of 94% (n = 912) of these classes or courses com-pleted the interview.
Data from state-level questionnaires are based on a census and are not weighted. District-, school-, and classroom-level data are based on representative samples and are weighted to produce national esti-mates. Two weights were constructed for analysis of classroom data. The ﬁrst weight is appropriate for making inferences to schools nationwide based on the aggregation of classroom data within each school. The second weight is appropriate for making inferences to required elementary school classes or required middle school and high school courses nationwide based on the data about the individual classes or courses.
Because of missing data, the denominators for each estimate vary slightly. Figures 1-3 in Appendix 1 of this issue of the Journal of School Health show the estimated standard error associated with an observed estimate from the district-, school-, and classroom-level health education questionnaires.
To analyze changes between SHPPS 2000 and SHPPS 2006, many variables from SHPPS 2000 were recalculated so that the denominators used for both years of data were deﬁned identically. In most cases, this denominator included all states, districts, or schools rather than a subset of states, districts, or schools. As a result of this recalculation, percentages previously reported for SHPPS 200028 might differ from those reported in this article. Only estimates from 2000 and 2006 based on this same denomina-tor should be compared.
Because state-level data are based on a census, statistical tests for differences between 2000 and 2006 are not appropriate. Therefore, this article highlights changes over time meeting at least 1 of 2 criteria: (1) the difference was greater than 10 per-centage points or 2) the 2006 estimate increased by at least a factor of 2 or decreased by at least half as
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