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Student Support, Career & Education Services

Health Protection Fund - Year V: 1997

Executive Summary

This report comprises the findings from the fifth year of an ongoing evaluation of the Massachusetts Health Protection Fund Grant Program. The Health Protection Fund (HPF) was created by a 1992 state legislative referendum that directs a portion of tax revenue on tobacco products to the Department of Elementary and Secondary Education to be used for comprehensive school health education with a focus on tobacco prevention education and cessation. Comprehensive school health education programs teach fundamental health concepts and encourage healthy behaviors through a broad-based approach that includes school, family, and community and that consists of many related health components in order to provide effective programs. As certain risk behaviors can negatively impact on academic performance, schools have a considerable interest in preventing such risk behaviors and encouraging healthy ones. A comprehensive school health education model has been found to be one approach that helps meet this objective.¹

Budget Allocations and Comprehensive Health Education Programs and Services

The total amount of the Health Protection Fund for Year V (1997 school year) for all districts that participated in the grant program was $21,058,473. The amount of the Health Protection Fund for Year I (1993 school year) was $26,749,172; for Year II (1994 school year) $24,105,090; for Year III (1995 school year) $23,985,971; and for Year IV (1996 school year) $20,974,568. From Year I to Year V, this is a total of $116,873,274, with an average per year of $23,374,654 that has been distributed to Massachusetts school districts. The monies were allocated in the following way within districts:

The distribution among budget categories has remained stable over the course of the grant. The majority of the Health Protection Fund monies have been used throughout the five years of the grant for personnel to provide a comprehensive health education program.

Goals of the Year V Evaluation of the Health Protection Fund Grant Program

The major goals of the Year V evaluation were to:

• Document the extent to which districts are following a comprehensive school health education program (CSHEP) model.
• Identify the CSHEP practices and activities related to reductions in tobacco use in adolescents.
• Identify the CSHEP practices and activities related to reductions in alcohol use, marijuana use, and violence in adolescents.
• Determine the extent of similarity of such findings from Year IV to Year V.
• Identify groups of program practices related to reductions in risk behaviors.

Methodology

Data on comprehensive school health education programs in Massachusetts were used both to provide information on program practices and to determine their relationship to reductions in risk behaviors in middle and high school students. There was a return rate of 84% for the evaluation survey. In-depth analyses were conducted on a subsample of districts (21% of the 84%) that had available student behavior-based needs assessment rates for the risk behaviors from the first year of the Health Protection Fund and from the fifth year. Student risk behaviors were measured as substance use being any use within the last 30 days and violence as being in a physical fight in the last 12 months. It is important to note that the findings that are associations cannot be seen as cause and effect statements. Due to the fact that these analyses are based on a program that has only been in place a few years and is just now yielding outcome data, some of the analyses are necessarily still exploratory. However, as there was similarity of findings from the previous evaluation ², it is with growing confidence that these results are presented.

Findings

General Comprehensive School Health Education Programs

• Students in elementary school received an average of 27 hours of health education per year, students in middle school received an average of 33 hours per year, and students in high school received an average of 25 hours per year. For high school, the most hours were received in the ninth grade (33 hours) with a drop in the twelfth grade to 18 hours.
• Locally, districts required an average minimum of 56 hours of health education for graduation from high school.

Tobacco Prevention Education and Cessation Efforts

Policy Implementation

92% include that students are suspended or expelled,
72% require students' parents/guardians to meet with school officials,
48% include that students must participate in prevention education,

Tobacco Prevention Education Instruction

• 98% of middle and high schools teach tobacco use prevention.
• Of these, 100% have a tobacco education curriculum that includes refusal skills.

Tobacco Cessation

• 63% of districts offered cessation programs for students.
• Districts reported an annual average of 10 hours for cessation programs for students.
• Within those districts with a cessation program, no participation was reported by 13% of districts. Between 1 and 38 students participating was reported by 72% of districts. The remaining 15% of districts reported that the number of participants ranged from 40 to 157 students.
• Of those participating in cessation programs, 61% of students completed the cessation program.

It should be noted that if there were few violations, then there would likely be few participants based on research that shows the capability of cessation programs to recruit and retain members is very low, especially for adolescents who must attend on a mandatory basis.³ However, cessation should not be tied so closely to violation.

Correlational Findings

Comprehensive School Health Education Programs and Reductions in Tobacco Use

High School

Among the program practices significantly related to decreases in high school tobacco use over the course of the Health Protection Fund were:

• Exposure to health curriculum, such as number of health education hours received in the upper grades, a tobacco policy that required students to participate in prevention education when in violation of the policy, and training for teachers on matching the health curriculum framework with their current health education curriculum.
• Involvement of important others, such as parents and the public health department on the school health advisory council, and peer involvement through peer health education programs and student representation on the school health advisory council.

Middle School

Among the program practices significantly related to decreases in middle school tobacco use over the course of the Health Protection Fund were:

• Involvement of important others, such as interdisciplinary instruction between health and family and consumer sciences teachers, parent involvement through participation on the school health advisory council, in health curriculum development and review, and with health homework, and community involvement through the school health advisory council.
• Local evaluation, such as the district's written improvement plan including goals for comprehensive school health education and local evaluation of health-related school policies and of staff development in health education.

Comprehensive School Health Education Programs and Reductions in Alcohol Use, Marijuana Use, and Engaging in Violence for High School and Middle School. Among the program practices significantly related to decreases in high school and middle school alcohol use, marijuana use, and violence, those that were most often seen were:

• A working relationship between health education and other school staff and academic teachers to provide health education instruction.
• Active peer health education programs.
• Involvement of adults, such as parents and clergy.

Similarity of Findings from the Current Evaluation and Last Year's Evaluation

Matches between program practices and reductions in behaviors were found in the program practices within the areas of exposure to health curriculum and involvement of important others in health education. Measuring local evaluation is new to the Year V evaluation. Of the 14 relationships from Year V and Year IV that could be compared, there were matches on 12.

Groups of Effective Program Practices

It can be useful to know the extent to which the decreases in student risk behaviors can be understood in terms of groups of program practices. For all the behaviors, with the exception of high school alcohol use, significant statistical combinations of groups of program practices were generated that explained from between 22% to 31% of the decrease in the risk behaviors.

Behaviors Where Reductions Were Seen

The majority of reductions in student risk behaviors were in tobacco use and marijuana use, followed by violence, and then alcohol use. There were slightly more reductions in middle school behaviors than in high school behaviors. One area of concern is that there were few instances of reductions in high school alcohol use. According to the latest Massachusetts Youth Risk Behavior Survey (1997)⁴, alcohol use in high school is the most common risk behavior of those measured in the evaluation.

General Conclusions

Massachusetts school districts follow a model of comprehensive school health education programming according to the major working definitions in the field ⁵ and have met several Healthy 2000 school-related objectives around providing a comprehensive school health education program whose purpose is to reduce and prevent substance use and violence.⁶

In line with the purpose of the Health Protection Fund, there are well-developed tobacco-free schools policies and good tobacco prevention education in districts. Work is needed in tobacco cessation.

There were many significant relationships between reductions in student risk behaviors and comprehensive school health education program practices. Some of the most compelling findings were around hours of health education, parent, peer, and community involvement in health education, and local evaluation of program goals and objectives. This reflects balanced programs and a theme of protective factors for students from within the individual, family, community, and school.

There was substantial similarity from the previous evaluation findings to the current findings, which allows a body of knowledge to be built and more confidence in the findings to be held.

There was identification of groups of program practices that together best explained the reductions in risk behaviors, which could facilitate efficiency in school health education programming decisions.

Recommendations

Districts should work with organizations such as the American Cancer Society, and the Department should continue to be actively involved in the Health Protection Fund Advisory Council committees to help districts provide effective tobacco cessation programs that engage students.

A consideration should be made by the Department to provide funds for a program and control group of districts to implement the most promising alcohol and drug prevention programs in order to determine their success in Massachusetts and inform districts on curricula decisions.

Local program evaluation efforts should continue and include information on comprehensive school health education program practices, particularly as found in the revised Massachusetts Comprehensive Health Curriculum Framework, local health education assessment, and data from student-based behavior surveys that ask students confidentially the extent of their most frequent involvement in risk behaviors.

Expansion of findings is key. There are now two years worth of data yielding very similar results of relationships between comprehensive school health education program practices and reductions in student risk behaviors. It is recommended that for the next phase of the evaluation an emphasis be placed on collecting data on the relationships between effective comprehensive school health education program practices and reductions in adolescent risk behaviors in all districts across the Commonwealth.

References

1. U.S. Department of Health and Human Services. (1998). School Health: Findings from Evaluated Programs, 2nd Edition. Washington, DC: Author.
2. McManis, D. (1998). Year IV Evaluation of the Health Protection Fund. Malden, MA: Massachusetts Department of Elementary and Secondary Education.
3. US Department of Health and Human Services. (1994). Preventing Tobacco Use among Young People: A Report to the Surgeon General. Washington, DC: Author.
4. Goodenow, C. (1998). Massachusetts Youth Risk Behavior Survey, 1997. Malden, MA: Massachusetts Department of Elementary and Secondary Education.
5. Marx, E.M., & Wooley, S.F. (1998). Health is Academic. New York, NY: Teachers Press.
6. United States Department of Health and Human Services. (1998). Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: Author.

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