Family & Community Students & Families
1996 Massachusetts
School Health Education Profile Report

Introduction

With the creation of the Comprehensive Health Curriculum Framework, learning standards for health education have been established for Massachusetts. Support from the Health Protection Fund over the past three years has provided school districts with additional funding to acquire new staff and resources to make health a priority. However, there remains much variation in the scope and sequence of health education curricula as school districts work towards effective implementation of the new framework.

The School Health Education Profile Survey (SHEP) was developed by the Division of Adolescent and School Health (DASH) of the U.S. Centers for Disease Control (CDC) to assess the impact of state and federal resources on the implementation of comprehensive health education. The survey was first conducted in Massachusetts in 1994 with funding from the CDC to determine the status of comprehensive health education and HIV prevention education in middle and high schools throughout the Commonwealth. The results of the 1996 SHEP allow us to monitor our state's progress in implementing comprehensive health.

The SHEP survey focuses on the following key aspects of comprehensive health:

• quantity and duration of required health education courses
• student expectations for health education
• content and curricula of health education
• characteristics of HIV/AIDS prevention education programs
• professional training of health educators, and
• parental involvement in school health education.

Because the 1994 and 1996 SHEP administrations corresponds with the implementation of the Health Protection Fund, the impact of these funds is indicated by the results presented in this report. Furthermore, the SHEP results provide information to schools and to the Commonwealth to be used in setting priorities for improving the delivery of school health education.

Survey Methods

The Massachusetts School Health Education Profile Survey (SHEP), conducted in the Spring of 1996, included two questionnaires: (1) a School Principal Survey to assess the status of health education at the school level from an administrative perspective [See Appendix A], and (2) a Lead Health Education Teacher Survey to assess health education at the classroom level from an instructional viewpoint [See Appendix B]. The lead health education teacher in each school (usually the health department chair or the most senior health education teacher in the school) was identified by the school principal.

All public schools in the state containing at least two of the grades 6 through 12 were eligible for participation in the survey. These schools were sorted by estimated enrollment in the target grades before sampling, and systematic equal probability sampling with a random start was used to select schools for the survey. Four-hundred and thirty-nine schools were randomly selected to participate in the survey. Questionnaires were mailed to all selected schools, and response rates were increased via reminder postcards and phone calls to non-respondents.

Usable questionnaires were obtained from 393 principals (90%) and 383 teachers (87%). These high response rates allowed the data to be statistically weighted. This means that the results of the 1996 SHEP can be used to make inferences concerning health education characteristics of the Commonwealth's middle and high schools.

In order to distinguish differences in health education which may vary depending on the grade levels contained within participating schools, the data was separated by the CDC into three separate categories: (1) High Schools (including all 141 schools surveyed with a lowest grade of 9 or above), (2) Middle Schools (including all 204 schools surveyed with a highest grade of 9 or below) and (3) Junior/Senior High Schools (including all 49 schools surveyed with a lowest grade of 8 or below and a highest grade of 10 or above).

Most of the following findings are reported for respondents in aggregate across grades. Some data is also reported by grade or by school category. Due to the small number of schools fitting the Junior/Senior High School description and the wide variation of grade combinations contained in this category of schools, the subsequent findings will focus largely on the overall results, high school results, and middle school results, and will be indicated as such. [See Appendices A and B for an item analysis of the data broken down by school category.]

1996 School Health Education Profile Results

1. Extent Of Health Education

Providing comprehensive health education that is reinforced throughout a student's school experience is important to the health of the nation. The priority placed on health education is often indicated by whether or not it is required in schools. One of the National health objectives is to increase the proportion of the nation's elementary and high schools that provide planned and sequential quality health education to students in grades kindergarten through 12 (U.S. Department of Health and Human Services, 1990). Principals responded to questions that would monitor Massachusetts' progress towards achieving this goal.

• Ninety-seven percent of schools surveyed require health education in at least one grade (99% of middle schools, 91% of junior/senior high schools, and 95% of high schools).
• The percentage of schools requiring health education courses has increased significantly from 1994 to 1996 for each of the grades 6 through 12.

• For students in grades 6 through 12, required health education courses are most often scheduled in the 6th, 7th, and 8th grades. There is a rapid decline in the percentage of schools that schedule required health education courses after the 9th grade. These trends are consistent in both the 1994 and 1996 data despite increases in the overall percentage of schools requiring health education courses in grades 6 through 12.

Principals were asked to report the amount of health education provided to students at their schools, in terms of (1) the total number of years of classroom health instruction, and (2) the total number of required health education courses offered.

• Eighty-six percent of schools require one half year or more of health education, and 62% require one year or more of health education. [See Figure 2]
• There are no statistically significant changes from 1994 to 1996 in the total number of years of required health education students receive.

• Fourteen percent of schools require less than one half year of classroom instruction in health education.
• The majority of schools surveyed (94%) require students to take at least one separate health education course. This represents a 20% increase from 1994.
• In addition, 46% of schools require students to take a course divided between health education and one other subject (such as health education and physical education).
• The percentage of schools requiring health education units that are integrated into other subjects (such as home economics/family and consumer science, biology or other sciences, or physical education) increased significantly from 46% in 1994 to 78% in 1996.
• Sixty-four percent of schools also require students to partake in health-related programs or activities which occur outside of the classroom.

Implications

Increases in the number of schools that require health education in grades 6 through 12 indicate that schools are recognizing the importance of making health a part of students' educational experience at all grade levels. However, the net amount of time devoted to health has not increased. The wide variations in the amount of health education observed indicate that some schools are not providing health education to students at all grade levels. This is particularly true for grades 10 through 12, in which the prevalence of required health education drops rapidly. This trend demands concern in light of the results of the 1995 Youth Risk Behavior Survey (YRBS), which indicate that substance use and sexual behaviors increase significantly during the high school years. In order to reinforce positive health messages introduced in the lower grades, consistent and continuing health education throughout all grades is important to achieve.

2. Expectations For Health Education

Principals were asked a series of questions to measure the extent to which health education holds comparable expectations to other academic subjects.

• From 1994 to 1996, there has been a statistically significant increase in the overall percentage of schools that require a health education course for graduation or promotion, from 39% to 55%. Specifically, health education graduation requirements increased significantly from 13% to 35% for middle schools and from 71% to 85% for high schools.
• Thirty-five percent of middle schools, 56% of junior/senior high schools, and 85% of high schools require a health education course for graduation or promotion. These differences by type of school are statistically significant.
• Of all schools surveyed that require a health education course for graduation or promotion, 17% of middle schools and 87% of high schools require students who fail the course to take it again. (Note: Most middle schools maintain different grading, promotion procedures and graduation requirements from those maintained in high schools).

Implications

The observed increases in required health courses for graduation/promotion indicate that more schools are considering health an integral part of a student's education. This increase is likely to have been prompted by the development of the Health Curriculum Framework and Health Assessment Development Committee.

3. Content Of Health Education

A critical element in the effectiveness of school health education is the use of a documented, planned, and sequential curriculum for health education (Allensworth & Kolbe, 1987). Teachers were asked to describe the materials they used to plan their school health education lessons.

• School curriculum guidelines/frameworks (78%), district curriculum guidelines/frameworks (69%), and state curriculum guidelines/frameworks (61%) are the materials that the majority of teachers to use in required health education courses. Fewer teachers use commercially developed health education curricula (32%) and teachers' guides to student textbooks (29%).
• In addition to the above materials, almost all teachers report using newspapers and magazines (96%), teacher-developed lesson plans (98%), and audiovisual materials to supplement the curricula in required health education courses at their schools.
• Materials used in planning the curricula of required health education courses do not differ widely depending on whether a school is a middle, junior/senior, or high school.

The CDC recommends that teachers address topics in health education that correspond to the six leading causes of morbidity and mortality for youth:

1. behaviors that results in unintentional and intentional injuries (physical violence, weapon-carrying, suicide, lack of helmet use, and drinking and driving),
2. tobacco use,
3. alcohol and other drug use,
4. sexual behaviors that result in sexually transmitted disease (including HIV) and unintended pregnancy,
5. poor dietary behaviors, and
6. lack of physical activity. The Massachusetts Youth Risk Behavior Survey collects data on high school students to monitor the prevalence of these behaviors over time. Lead health education teachers were asked if their teaching aimed to increase students' knowledge and improve students' attitudes with respect to these and other health-related topics.

• With respect to increasing knowledge and improving attitudes, the topics most often covered are: alcohol and other drug use prevention, tobacco use prevention, HIV prevention, disease prevention and control, and dietary behaviors and nutrition.

• Teachers least often reported covering the following topics: cardiopulmonary resuscitation (CPR), death and dying, and dental and oral health.
• From 1994 to 1996, there were statistically significant increases in the percentage of teachers teaching to increase students' knowledge in a variety of important health topics. (Note: Data from 1994 not available for all topics) [See Figure 4]
• In comparison with middle school teachers, high school health teachers are significantly more likely to teach the following topics:
  • cardiopulmonary resuscitation (CPR) (49% of middle school teachers vs. 70% of high school teachers);
  • pregnancy prevention (75% vs. 93%);
  • reproductive health (83% vs. 94%);
  • sexual harassment (84% vs. 91%);
  • sexually transmitted disease (STD) prevention (89% vs. 98%); and
  • suicide prevention (62% vs. 75%).

• The majority of health educators report teaching the following skills: decision-making (99%), refusal skills (97%), communication (92%), non-violent conflict resolution (90%), goal-setting (88%), analysis of media messages (88%), and stress management skills (80%).
• No statistically significant differences exist by type of school (middle, junior/senior high, and high school) in terms of teachers' reports of skills instruction.

Implications

The vast majority of Massachusetts middle, junior/senior, and high school health educators are providing instruction in the topics related to priority health risk behaviors for youth. Furthermore, it appears that teachers have expanded the breadth of their instruction to include more topics than in previous years. Increases in the number of topics covered have not been accompanied by increases in the total amount of health education students receive in health class. However, there have been increases in health education coverage in other classes besides health.

4. Extent And Content Of HIV/AIDS Instruction

Results from the 1995 Massachusetts Youth Risk Behavior Survey indicate that Massachusetts high school students are at risk for HIV infection through intravenous drug use and unprotected sexual behavior: 2.8% of all students had used injected drugs, and only 55.9% of sexually active students used a condom the last time they had sexual intercourse (YRBS, 1996).

In 1990, the Massachusetts Board of Education approved a formal policy urging local school districts to create programs which make instruction about AIDS/HIV available to all Massachusetts student at each grade level. According to the Board, such a program should include: local policies regarding AIDS/HIV prevention education, parent and community education, staff development, curriculum and instruction, and student involvement (Board of Education, 1990). In addition, the Board's policy statement recommended that all school districts consider making condoms available to students.

A. HIV/AIDS Required Education

• Eighty-seven percent of all schools surveyed (85% of middle schools, 81% of junior/senior high schools, and 93% of high schools) require HIV/AIDS education in one or more grades.

• For each of grades 6 through 12, there have been statistically significant increases from 1994 to 1996 in the percentage of schools requiring HIV/AIDS education. [See Figure 5]
• HIV/AIDS education is most often taught in the 7th, 8th, and 9th grades. After the 9th grade, the percentage of schools requiring HIV/AIDS education decreases dramatically. This trend mirrors a similar trend found in 1994.
• Despite these achievements, other areas in health education have remained stable from 1994 to 1996. Requirements for HIV/AIDS prevention education continue to remain lowest for the higher grades, a time when adolescent health risk behaviors rise most dramatically.

• Required HIV/AIDS education units/lessons are most often taught in health education (96%), biology or other science classes (47%), and family life education/life skills classes (31%).
• From 1994 to 1996 there have been significant increases in the percentage of schools which report required HIV/AIDS education units/lessons in classes other than health education (including biology or other science classes, home economics, physical education, social sciences, and family life education or life skills classes).
• In comparison with middle schools, high schools are more likely to require HIV/AIDS education in social sciences, language arts, physical education, and special education classes.

B. Topics of Required HIV/AIDS Instruction

• With respect to HIV/AIDS-related topics, teachers were most likely to teach basic facts about HIV/AIDS (100%) and transmission routes, including needle-sharing behaviors (99%) and sexual behaviors (96%) that transmit HIV infection. Teachers were least likely to report teaching about correct use of condoms (54%) and the effectiveness of condoms (76%).

Figure 7: HIV Topics Cover in Health Education, 1994 and 1996

• From 1994 to 1996, statistically significant increases were reported in the percent of teachers covering HIV/AIDS related topics such as: reasons for choosing abstinence, group attitudes toward risk behaviors, information on HIV testing, and compassion and support for people living with HIV/AIDS. The only two topics for which coverage did not increase significantly from 1994 to 1996 were: correct use and the effectiveness of condoms. [See Figure 7]
• In comparison with middle schools, high schools are significantly more likely to teach about a wide range of HIV-related topics, such as:
  • correct use of condoms (30% of middle schools vs. 81% of high schools)
  • condom effectiveness (59% vs. 94%)
  • statistics on adolescent death/disability related to HIV (78% vs. 95%), and
  • information on HIV testing and counseling (72% vs. 97%).

C. School Policies Regarding HIV/AIDS

• The percentage of schools that have a written policy on students and/or staff with HIV/AIDS increased significantly from 57% in 1994 to 72% in 1996.
• Written school policies on HIV/AIDS are most likely to include the following topics: procedures for maintaining confidentiality (99%), procedures on worksite safety (95%), and procedures to protect HIV-infected students and school staff from discrimination (94%). Policies are least likely to include: procedures for evaluating the health status of HIV-infected students and school staff (67%), and a statement about the inappropriateness of routine testing of students and school staff for HIV infection (39%).

• The majority of school HIV/AIDS policies include statements in support of HIV/AIDS prevention education for students (83%) and staff (81%).

D. Barriers to Teaching about HIV/AIDS

• Seventy-one percent of teachers report at least one or more difficulties with respect to teaching about HIV/AIDS. This represents an increase from the 48% in 1994 who reported difficulties teaching HIV/AIDS.
• The difficulties most often reported by teachers include: other demands on class time (45%), large class size (33%), insufficient teaching materials (18%), and parental concern or opposition (18%). Teachers were least likely to report lack of comfort teaching about HIV risk behaviors (4%) as a difficulty.

Implications

The percentage of schools requiring HIV/AIDS education has increased from 1994 to 1996. The expansion of HIV/AIDS education to include a wider range of relevant topics, and the integration of HIV/AIDS education into other subjects is encouraging. However, few schools require HIV/AIDS education at every grade level, and correct use of condoms remains the least taught aspect of HIV education. In order to improve the implementation of required HIV/AIDS education, schools may benefit from addressing the numerous barriers health educators perceive to teaching about HIV/AIDS.

5. Health Education Coordination And Teaching Staff

A crucial element in quality school health education is coordination by a professional trained specifically in health (National Commission on the Role of the School and the Community in Improving Adolescent Health, 1989).

• In 56% of schools surveyed, health education is coordinated by a district level health education coordinator. In the remaining schools, health is most often coordinated by the department chairperson (14%), a health education teacher (14%), or principal/other administrator (6%).
• The percentage of principals who report that there is no one who coordinates health at their school decreased significantly from 12% in 1994 to 4% in 1996.

With respect to health education, training in methodology, theory and practice is necessary for the development and implementation of complex curricula to increase knowledge, improve attitudes, and develop skills for engaging in healthy behaviors (Allensworth, 1993). The use of appropriately trained teachers with health education as their primary assignment facilitates the implementation of quality health education (Butler, 1993). In 1994 the Massachusetts Board of Education and the Department of Elementary and Secondary Education implemented new regulations for the certification of educational personnel in order to improve and maintain quality standards of instruction across the Commonwealth.

• Nine out of ten lead health education teachers (90%) are currently certified to teach health education in the grades they now teach. This represents a significant increase from the 80% in 1994.
• 7% of lead health education teachers reported that they "didn't know" whether or not Massachusetts offered certification in health education, and 2% believed that no certification is offered in the state.
• The majority of respondents received their professional training in either health education (24%), physical education (11%), or both health and physical education (41%). [See Figure 9]
• High school health educators were significantly more likely to have received training in both health and physical education (47%) in comparison with middle school health educators (36%).

• Nearly three quarters (73%) of lead health education teachers have ten or more years of overall teaching experience. However, only 43% of teachers have been teaching health education for that long.

Teacher training is associated with enhanced implementation and delivery of health education (Connell, Turner, and Mason, 1985). The effectiveness of a health education program relies on opportunities for teachers to receive continuing training about new health information and teaching strategies.

• During the past two years, teachers most often attended inservice trainings on the following topics: conflict resolution/violence prevention (75%), sexual harassment (62%), HIV prevention (61%), tobacco use prevention (58%), and alcohol and other drug use prevention (56%).

• The topics on which teachers would most like inservice trainings in the future are: suicide prevention (77%), death and dying (62%), and conflict resolution/violence prevention (62%). Conflict resolution/violence prevention and suicide prevention were the top two topics on which teachers desired inservice training in 1994 as well. (Data on need for training in death and dying are not available for 1994). [See Figure 10]
• School/district support for health education-related inservice training and staff development for health education teachers increased significantly from 1994 to 1996. [See Figure 11]

The integration of peer educators into school health education is an effective teaching strategy (Allensworth, 1993). Trained peer educators may address attitudes and model behaviors in a manner which is more acceptable to students.

• Sixty percent of schools surveyed use trained peer educators. Of these schools using peer educators, 78% use them in conflict resolution/mediation sessions, 77% use them in health-related discussion or support groups, 58% use them in health assemblies, 38% use them in health fairs, and 36% use them in health education courses.

Implications

Substantial increases in school/district support for health education inservice training and staff development opportunities in health are encouraging, because the effectiveness of health instruction depends on current knowledge of health information and promotion strategies. However, teachers report a continued need to receive further training, especially in the areas of suicide prevention and violence prevention. Principals and other administrators are encouraged to continue to support professional development for health educators and coordinators.

6. Parental Involvement In School Health Education

An important factor in the success of school health education is support from parents. Administrators and educators may gain the support of parents by being aware of parental concerns and involving parents in health education. Furthermore, involving parents in the health education curriculum is critical in providing students with frequent exposure to consistent messages about health (Allensworth, 1993; Kolbe, 1993).

• Parents are represented on 100% of school health advisory councils.
• Sixty percent of principals reported receiving positive feedback from parents regarding health education. In contrast, 6% reported receiving feedback which was equally balanced between positive and negative, and only 1% reported receiving mainly negative parental feedback with respect to health education. (Thirty-three percent received no parental feedback.)
• Parental feedback was similar among middle schools, junior/senior high schools, and high schools, and did not change significantly from 1994 to 1996.

• Eighty-six percent of schools allow students to be exempted or excused by parental request from all or parts of a required health education course. More middle schools (91%) than high schools (79%) allow such exemptions by parental request.
• In schools which allowed students to be exempt from health education by parental request, 91% of principals reported that fewer than 1% of students were actually excused in their schools. Only 1% of principals reported that 6% or more students were excused from any part of a required health education course due to parental request.

Involving parents in health education and incorporating their feedback into the curriculum aids educators in meeting the needs of students while simultaneously increasing parental support for health education. Teachers were asked about strategies for parental involvement, as well as about positive and negative parental feedback they had received.

• The percentage of teachers who involve parents in required health education courses in their schools increased significantly from 1994 to 1996. [See Figure 12]
• Expansion of health content due to parental feedback was considerably more frequent than restriction of content for every health topic on the survey. [See Table 1]
• Significant increases were reported from 1994 to 1996 in the percentage of teachers expanding coverage of the following topics due to parental feedback:
  • alcohol and other drug use prevention (from 12% in 1994 to 28% in 1996)
  • conflict resolution/violence prevention (from 15% to 26%)
  • dietary behaviors and nutrition (from 7% to 20%)
  • physical activity and fitness (from 2% to 11%)
  • suicide prevention (from 3% to 13%), and
  • tobacco use prevention (from 14% to 25%).
• High school teachers were significantly more likely than middle school teachers to expand coverage of pregnancy prevention due to parental feedback (9% vs. 18%). Similarly, middle school teachers were more likely to limit coverage of this topic due to parental feedback.

The Massachusetts Board of Education strongly recommends that schools play a leadership role in developing educational programs on HIV/AIDS for parents and other community members in order to reinforce positive messages presented in the health education classroom.

• Fewer than one third of schools (29%) provided HIV/AIDS education for parents during the 1995-1996 school year.
• Sixteen percent of schools sent educational materials to parents, 14% provided school programs on HIV/AIDS for parents, 12% sent letters or newsletters on HIV/AIDS to parents, and 11% invited parents to attend a class on HIV/AIDS.

Table 1: Expansion and Restriction Health Topic Coverage due to Parental Feedback

• The percentage of schools providing school programs on HIV/AIDS for parents decreased significantly from 24% in 1994 to 14% in 1996.
• Schools which provided HIV/AIDS education for parents were more likely to receive mainly positive feedback from parents regarding health education in general (70%) than schools which did not provide HIV/AIDS education for parents (54%).

Implications

Teachers' increased efforts to include parents in health education indicate a recognition of the importance of parental involvement and support. Very few teachers were asked to limit the content of their required health education courses due to parental feedback, and even fewer principals reported receiving mainly negative feedback regarding health education.

Conclusions

According to the results of the 1996 SHEP, Massachusetts has made significant progress in improving health education of students in grades 6 through 12 since 1994. Significantly more schools are requiring health education at every grade level, teachers are increasing coverage of many important health topics, HIV/AIDS prevention education is occurring at more grade levels, and parents are becoming more involved in health education. In addition, health and HIV/AIDS prevention education are becoming integrated into other subjects besides health, and support for teacher training has increased dramatically. All of these accomplishments set the stage for improvements in the quality of health education for Massachusetts youth.

Despite these achievements, some areas in health education have remained stable from 1994 to 1996. Though health education is being offered by more schools in more grades, requirements for both health education and HIV/AIDS prevention education continue to remain lowest for the higher grades, a time when adolescent health risk behaviors rise most dramatically. Additionally, the total amount of time a student spends in required health education courses has not increased in proportion to the increase in the number of grades in which health education occurs.

In just two years, positive results from the increased emphasis on health education has been documented clearly by the results of the School Health Education Profile Survey. These accomplishments provide a strong base for the further improvement and implementation of lasting, quality health education for students across the Commonwealth.

References

Allensworth, D. (1993). Health Education: State of the Art. Journal of School Health, 63(10), 14-20.

Allensworth, D. & Kolbe, L. (1987). The Comprehensive School Health Program: Exploring an Expanded Concept. Journal of School Health, 57(10), 409-412.

Connell, D., Turner, R., & Mason, E. (1985). Summary of Findings of the School Health Education Evaluation: Health Promotion Effectiveness, Implementation, and Costs. Journal of School Health, 55(8), 316-321.

DeFriese, G., Crossland, D., MacPhail-Wilcox, B., & Sowers, J. (1990). Implementing Comprehensive School Health Programs: Prospects for Change in American Schools. Journal of School Health, 60(4), 182-187.

Kolbe, L. (1993). An Essential Strategy to Improve the Health and Education of Americans. Preventive Medicine, 22(4), 544-560.

Lavin, A. (1993). Comprehensive School Health Education: Barriers and Opportunities. Journal of School Health, 63(1), 24-27.

Massachusetts Board of Education (1990). Policy on AIDS/HIV Prevention Education.

Massachusetts Department of Elementary and Secondary Education (1996). Massachusetts 1995 Youth Risk Behavior Survey Results.

National Commission on the Role of the School and the Community in Improving Adolescent Health (1989). Code Blue: Uniting for Healthier Youth. Alexandria, VA: National Association of State Boards of Education.

U.S. Public Health Service (1990). Healthy People 2000: Health Promotion and Disease Prevention Objectives. Washington, DC: U.S. Department of Health and Human Services, Public Health Service 91-50212.

Acknowledgments

Shari M. Kessel, AIDS/HIV Research Coordinator for the Department of Elementary and Secondary Education, was the principal investigator of the 1996 Massachusetts School Health Education Profile Survey and the author of this report.

The Massachusetts Department of Elementary and Secondary Education extends its thanks to the 393 principals and 383 health educators who participated in the 1996 SHEP. We would also like to thank the Division of Adolescent and School Health (DASH) at the U.S. Centers for Disease Control and Prevention (CDC) which provided funding for this research, and the staff of Westat, Inc. who provided valuable technical assistance.