Health Protection Fund - Year V: 1998
Introduction
Adolescent Behavior
While recent national and local studies have found that an increasing number of adolescents have engaged in most risk behaviors, these same studies have also shown that the majority of young people do not engage in these unhealthy behaviors and that adolescent participation in some behaviors has leveled off or slightly decreased.1, 2, 3 While these instances of decreases in behavior often receive less attention, they may likely be the more important findings as they document that there are adolescents who are not engaging in unhealthy behaviors.
Adolescent Behavior and School Performance
In general, schools have the opportunity to reach young people based on the amount of time students spend in the school setting. Schools have a vested interest in preventing risk behaviors that negatively impact on health founded on the link between risk behavior and impaired cognitive functioning4, 5, 6, 7and on the link between good health and better school performance.8, 9
Health Protection Fund
The Health Protection Fund (HPF) was created by a 1992 state legislative referendum that directs tax revenue on tobacco products to the Department of Elementary and Secondary Education for tobacco prevention education and cessation in the context of comprehensive school health education. Comprehensive health education meets the complex and extensive needs of today's youth through a broad-based approach that includes school, family, and community, and consists of many related health components in order to create effective programs, services, and education. An average of 24 million dollars a year of Health Protection Fund monies has been distributed through grants to Massachusetts school districts over the last four years totalling approximately $96,000,000.
Purpose of the Evaluation
The purpose of this HPF evaluation is to better understand what contributes to risk behavior decreases in Massachusetts students. The majority of the public supports health education.10 , 11 The evaluation addresses the call for evidence that these programs have an impact on Massachusetts youth, particularly in the area of tobacco use.12
Design and Analysis
Data on comprehensive school health education programs from randomly selected middle and high school lead health teachers and principals were correlated with data reported by district health coordinators on the change in each of the student risk behaviors of tobacco use, alcohol use, drug use, and violence after four years of Health Protection Fund programs. The extent to which districts were implementing elements of the local comprehensive school health education program was compared for districts that decreased and districts that increased in each of the four risk behavior areas. The data were checked for relationships with type of community as a marker for geographic and socioeconomic attributes, and with funding of HPF and other health-related grant monies. There was a relationship in a limited number of cases between a very few program practices and type of community on tobacco change groups only. To control for this, analyses in these instances were done within urban and suburban/rural districts. About half of these few relationships held in urban but not suburban/rural and about half of these few held in suburban/rural, but not urban. The majority of the relationships, however, were not influenced by type of community. Therefore, there are not major differences on how health education programs are implemented in different types of communities. There was no relationship between the amount of Health Protection Funding or other health-related grant monies per district and health education program practices nor with changes in student behavior.
Instruments
The Telephone Interview Project (TIP) was developed in 1997 by the Department of Elementary and Secondary Education to record information from the district health coordinator on the change group status of "decreased", "stayed the same", or "increased" on middle and high school student risk behaviors of tobacco use, alcohol use, drug use, and violence after four years of Health Protection Fund. This data was based on the districts' yearly needs assessments required by the HPF grant application. Information about comprehensive school health education programs was also available from the TIP.1996 School Health Education Profile (SHEP) is a nationally administered instrument developed by the Centers for Disease Control (CDC) Division of Adolescent and School Health in collaboration with state and local education agencies. The SHEP yields information about middle and high school comprehensive school health education programs and is completed by randomly selected lead health teachers and principals.
Massachusetts comprehensive school health education programs are still relatively new. As the first time the HPF evaluation has studied the relationships between program implementation practices and student impact, replication of these findings on a larger sample and more in-depth study of health education program practices will be important. What is presented here is available information that can be thought of as markers, supported by literature, about health education program practices that appear to be effective in relation to decreased student engagement in risk behavior. The findings section will first present the percentage of funds in the designated budget categories for each year of the Health Protection Fund as well as averaged across the four years. The findings section will next report on and discuss health education program practices and their relationship with lowered student risk behavior. It is important to note that these are associations which cannot be seen as cause and effect statements, but rather as informative findings which can guide future research.
Funding--How Health Protection Fund Monies are Spent
Figures 1-4 below show for Year I (1993-94), Year II (1994-95), Year III (1995-96) and Year IV (1996-97) the percent of the total yearly budget devoted to each of the major budget categories. Figure 5 shows the same breakdown cumulatively averaged across Years I through IV. The majority of funding has been dedicated to teaching.
 
 Despite budget cuts, the percentage being spent in each category has remained remarkably stable. This demonstrates a consistency across HPF school health education programs throughout the state. The focus on Contractual Services (e.g., outside trainers, consultants paid hourly with no benefits, stipends) and Instructional/Professional Staff from Year I (1993-94) and continuing through Year IV (1996-97) demonstrates a focused effort by districts to have staff in place who would be available, accessible, and better able to locally provide services for students in health education. The major purchasing of materials was also done in the first year and after this districts have continued to buy materials but to a lesser extent. The monies have gone for personnel that provide students with direct services.
Themes in Resilience - Relationships between Program Practices and Student Behavior
Resilient factors derive from individual characteristics, family, community, and the school. The findings in this report focus on school-related program practices that foster resiliency; which is the ability to thrive, persevere, and maintain a positive attitude and healthy body. In the present evaluation, two major areas were found to be related to decreased student risk behavior--one in exposure to the health education curriculum and the second in the participation of important others in the school health education program. These themes parallel two of the most crucial factors necessary for resilience in health, a forum for the learning of knowledge13, 14 and the opportunity to form social support relationships with important others, such as parents,15, 16, 17 school staff,18, 19, 20and peers.21 The majority of the relationships is between health education program practices and decreases in tobacco use by students. The findings in the report are organized within these two major areas with results relative to student tobacco use presented first. All findings are statistically significant at the .05 level or better. Detailed statistical information relative to the findings and about the "stayed the same" group is found in the Appendix.
I. Exposure to Health Curriculum
A. Hours of Health Education
The starting point and often most prominent piece of comprehensive school health education programs is the offering of courses in health.
€A health education program practice found to be related to decreased student tobacco use, alcohol use, drug use, and violence was:
- more hours per year of required health education during middle school.
The finding that health instruction in the middle school years is instrumental for students not engaging in risk behavior is one of the most consistent in the literature.22, 23, 24 A sizable school health education evaluation found the full benefits of health instruction in reported practices was achieved when a commitment for classroom hours was made to a health program.25
B. The Health Curriculum Framework
Massachusetts has developed a health curriculum framework, Building Resilience,26 to assist local districts in developing and implementing comprehensive school health education programs specifically designed to foster resilience in students, with the major task to facilitate a comprehensive and sequential health curriculum for all students. With respect to the health curriculum framework, three findings emerged in relation to decreased tobacco and drug use.
€Two health education program practices found to be related to decreased student tobacco use were:
- perceptions of support from district and non-health staff for implementing the health curriculum framework, and
- a local school level directive to use a state health curriculum framework (suburban and rural districts, but not urban).
€A health education program practice found to be related to decreased student drug use was:
- perceptions of more time for curriculum planning and scheduling of courses for implementing the health curriculum framework.
School health education programs are making strides in finding their place in the educational setting and this was related to decreases in student risk behavior. The meaningfulness of this is supported by the Education Commission of the States which articulated in a handbook developed for state policy makers on school health education that when school health education has a place in the curriculum it leads to better support, time in the curriculum, and a coordinated sequential program throughout the grades.27
II. Involvement of Important Others
A. Adults
Findings of relationships between parent and school staff involvement in health education and decreased student risk behavior were present in the current evaluation study. These findings are particularly timely in light of just published results from the National Longitudinal Study on Adolescent Health (NLSAH).28 The premise of the NLSAH study involves issues of vulnerability and resilience to identify protective factors in young people's lives, 11,572 of whom participated in school and home interviews. The authors write that "of the constellation of forces that influence adolescent health-risk behavior, the most fundamental are the social contexts in which adolescents are embedded; the family and school contexts are among the most critical."29
1. Parent Involvement
Parents being involved in health education was related in several instances to decreased tobacco use for adolescents.
€Three health education program practices found to be related to decreased student tobacco use were:
- sending educational materials to parents to involve them in health education,
- including parents in homework assignments to involve them in health education (urban districts, but not suburban and rural), and
- including parents on the school health advisory council (suburban and rural districts, but not urban).
The National Longitudinal Study on Adolescent Health30 found that less frequent cigarette use was associated with higher levels of connectedness to parents and family members for high school students. Additionally, a greater number of shared activities between teenagers and their parents and higher levels of perceived levels of parental expectations with regard to school completion were related to lower adolescent tobacco use. The program practices described above would likely have parents and their adolescents working together. Researchers found in studying many school health education programs that in order to promote comprehensiveness, both classroom and outreach activities need to "inform, involve, and facilitate education"31 of parents and family.
There was also a relationship in the present evaluation study between parent involvement in health education and decreased violence.
€A health education program practice found to be related to decreased student violence was:
- parents participating in health education curriculum development and review.
According to researchers, the family is crucial and vital in the education of students and the views and input of the family into the health curriculum can be "extremely productive."32 The National Longitudinal Study on Adolescent Health33 found that parental and family connectedness was related to lower levels of interpersonal violence. For older adolescents, higher parental expectations for school achievement were related to lower levels of teenagers engaging in violence.
2. School Health Staff Support
The working together of school personnel creates a healthy school climate that is productive, nurturing, positive, and supportive.34 Collaboration of this type raises the likelihood that the school health program will be grounded in fundamental goals of education such as intellectual and intrapersonal skills, scientific thinking and problem-solving skills, self-assessment and self-management practices, advocacy, and participation in democratic processes.35
Two findings emerged from the evaluation with respect to school personnel working with health education teachers and decreased risk behavior in tobacco use and violence for students.
€A health education program practice found to be related to decreased student tobacco use was:
- health education teachers planning and coordinating health-related projects or activities with school health services (urban districts, but not suburban and rural).
€A health education program practice found to be related to decreased student violence was:
- health education teachers planning and coordinating health-related projects or activities with school counseling/psychological services.
Higher levels of connectedness to school were related to lower levels of both tobacco use and violence in the National Longitudinal Study on Adolescent Health.36
One additional finding revolving around adult involvement in health education was in the area of community-based organizations.
€A health education program practice found to be related to decreased student tobacco use was:
- including community-based organizations on the school health advisory council.
One of the program practices found in the literature to be essential for comprehensiveness in school health education is having the community play an active role in school health education.37
B. Peer Participation
The use of trained peer educators and student participation on the school health advisory council were related to decreases in student risk behaviors. There is substantial evidence that involving students in their own health education is a productive approach.38, 39, 40
€Two health education program practices found to be related to decreased student tobacco use were:
- using trained peer educators (suburban and rural districts, but not urban), and
- including students on the school health advisory council (urban districts, but not suburban and rural)
€Two health education program practices found to be related to decreased student alcohol use were:
- using trained peer educators to teach about health in discussion/support groups, and
- including students on the school health advisory council.
€Two health education program practices found to be related to decreased student violence were:
- using trained peer educators in conflict resolution/mediation sessions, and
- using trained peer educators in assembly programs.
Insight into how student involvement translates into reduced risk behavior may be found in the most effective approach known to prevent risk behavior in young people, the social influence model. Using peer led activities, students learn skills to deal with social pressures and about accurate normative expectations, with documented long-term effects of several years for preventing tobacco use.41, 42, 43 It is perhaps informative that the type of peer activity related to decreased student alcohol use is in a support group form, analogous to the successful program Alcoholics Anonymous. The relationship between decreased violence and conflict resolution activities was validated. The association between assembly programs and decreased violence might be driven by such programs reaching many young people at one time.
This evaluation may assist in program development and policy decision making by identifying relationships between comprehensive school health education program implementation and reduced student risk behaviors. In general, researchers in the field of health education are calling for evaluation around the effectiveness of various intervention programs44, 45 In particular, local groups are interested in evaluation demonstrating effective use of monies specific to the Massachusetts Health Protection Fund.46, 47
Following designs used in the field of comprehensive school health evaluation, health education program practices were investigated to determine which were related to changes in student risk behavior after four years of HPF. The findings revealed that decreases in tobacco use, alcohol use, violence, and drug use have occurred for some adolescents and that there are effective health education program practices related to these decreases. Exposure to health curriculum and activities that promote relationships among students, their peers, and adults such as school-based health professionals, parents, and community members dedicated to health education were at the forefront of effective programs. The findings are in line with published health education research literature, reiterated below.
Exposure to health curriculum: Both classroom teaching and implementation of the health curriculum framework were related to decreases in student risk behavior. To highlight research cited in the body of the report, studies in the area of effective comprehensive school health education support having a solid health curriculum and students having exposure to this curriculum.48, 49, 50
Involvement of Important Others: Parent involvement, school staff support, community member representation, and peer participation were all related to decreases in student risk behavior. Involving parents in the health education curriculum is important in students receiving frequent exposure to positive health messages.51, 52 The National Longitudinal Study on Adolescent Health 53 found the strongest result to be that adolescents reporting feeling close and connected to their families were the least likely to engage in risk behavior. Collaboration between members in the school setting enhances health and academics.54 Connectedness with school was found to be a protective factor for teenagers not engaging in risky behavior in the National Longitudinal Study on Adolescent Health.55 Peer programs are known to be among the most effective in preventing risk behaviors56, 57 and effective school health programs have students involved in the presentation and delivery of the program.58 Further, large scale studies of resilience have found that social support is a protective factor and related to higher academic achievement.59,60, 61
What has been found to be effective in other studies of school health education programs is also effective in Massachusetts school health education programs, reiterating consistent trends.
While much work remains and replication is essential, particular note can be made of the many relationships between health education program practices and decreases in tobacco use as well as decreases in other unhealthy behaviors in adolescents. The differences between health education program practices in urban districts and in suburban/rural districts and reduced tobacco use for students will need subsequent study. For now, it appears that those practices in urban settings revolve around students participating in health-related activities outside of the school day, parent involvement through home-based activities, and health-related services more likely to be offered in larger school districts; while the practices related to decreased tobacco use in suburban/urban settings may be explained by a somewhat less fixed milieu where implementation of the health curriculum framework may occur more quickly, parent involvement is more school-based, and students are more involved in the daytime activities of the school. However, by far the majority of the health education practices are similar across districts.
Most informative may be that these changes were observed in the context of a comprehensive school health education approach, the approach established by the legislation for the Health Protection Fund. In future, more attention should be given to building an expanded and more complete understanding of the effective program practices found in this study. Resiliency is not only linked to behaviors that determine a healthy lifestyle, but to cognitive functioning. In this way, the work done by comprehensive school health education programs supports school districts in improving student academic achievement.
Tobacco
Tobacco is the focal point of the Health Protection Fund. The majority of the relationships in the evaluation were between program practices and decreases in student tobacco use. The following activities would promote and reinforce the place of tobacco prevention education and cessation in comprehensive school health education programs:
€gather more detailed information of schools' tobacco control programs relative to decreases in student tobacco use.
€focus on the identification of and recognition of how successful tobacco cessation programs are implemented and maintained.
Health Curriculum Framework - Building Resilience
Exposure to concepts and learning standards contained in the Health Curriculum Framework was related to decreases in student risk behaviors. The following activities would promote further implementation by districts and provide for more fine-tuned study of the effective program practices identified:
€support districts' implementation of the Health Curriculum Framework through content institutes and other professional development opportunities.
€revise the Health Protection Fund Mid-Year Report to mirror the framework and collect information on the status of health education program implementation of districts.
The Timing of Health Education
A health education program in all grades is the key component of a comprehensive school health education program. In order for the prevention message to be best assimilated, research supports the middle school years as among the most important for students in receiving instruction in health topics. The relationship found in the evaluation between required middle school health education and decreased risk behavior was in line with such research. The following activities are specific to addressing the timing of delivery:
€review the amount of health education offered at all grades and compare the amount offered in the middle grades with other grades.
€consider making the health education program most intensive during middle school years.
Involvement of Important Others
A central component of resiliency supported by the literature is meaningful relationships with others. This theme was prominent in the evaluation through the relationship between school staff, parents, and peers being involved in health education activities and decreases in student risk behavior. Activities that would facilitate these relationships would be:
€focus on collaboration and coordination of activities and instruction between health education teachers and other health-related programs--specifically, these would be the physical education teacher, school health services, and school counseling and psychological services.
€expand health-related activities in which parents can participate, both at home (e.g., receiving materials, homework assignments) and at school (e.g., being involved on the School Health Advisory Committee).
€encourage peer educators' work with students in health related activities and student involvement on the School Health Advisory Committee.
Needs Assessment
Not all districts have adequate information about their students' behavior. Using nationally or state specific data may not be accurate on a district level. Using disciplinary records tends to underestimate behavior. The following activities would facilitate more accurate tracking of changes in student behavior over time which is critical to seeing relationships with program practices:
€provide support for health coordinators' efforts to advocate in the local community for student behavior needs assessment. Help them articulate both the point of view of the necessity of a student-based needs assessment for the HPF grant application and its usefulness for knowing the rates of behavior for young people in their own community in order to plan better programs.
€train health coordinators on the administration of such needs assessment. Offer a list of contacts of companies that can reasonably do data entry and basic frequencies for districts.
€engage in work between the Department of Elementary and Secondary Education liaisons and health coordinators to effectively present the needs assessment findings, their meaning, and their possible uses to various school and community audiences.
1.Commission on Substance Abuse Among America's Adolescents. (1997). Columbia University, New York, NY.
2. Rosenberg, M. (1997). National Center for Injury Prevention and Control. Atlanta, GA.
3. Adolescent Tobacco Use in Massachusetts: Trends Among Public School Students. (1997). Massachusetts Department of Public Health. Boston, MA.
4. Iversen, L. I. (1979). The Chemistry of the Brain. Scientific American, September, 1979.
5. Jaffe, J. H. (1980). Drug Addiction and Drug Abuse. In A.G. Gilman, L. S. Goodman, & A. Gilman (Eds.), The Pharmacological Basis of Therapeutics (6th ed.) (535-584). New York, NY: Macmillan.
6. Squire, L. R. (1987). Memory and Brain. New York, NY: Oxford University Press.
7. US Department of Health and Human Services. (1988). The Health Consequences of Smoking: Nicotine Addiction. A Report to the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Health Promotion and Education, Office on Smoking and Health. DHHS Publication No. (CDC)888-8406.
8.Council of Chief State School Officers. (1989). A Concern About... Meeting the Health Needs of Children and Youth, Particularly those At Risk for School Failure. Concerns, Issue XXVII, October.
9. National School Boards Association, American Association of School Administrators, American Cancer Society, & the National School Health Education Coalition. (1996). Be a Leader in Academic Achievement.
10. Elam, S., & Rose, L. (1995). The 27th annual Phi Delta Kappa Gallup Poll of the public's attitudes toward the public schools. Phi Delta Kappan, September, 41-56
11. Torabi, M., & Crowe, J. (1995). National public opinion on school health education: Implications for the health care reform initiatives. Journal of Health Education, 26, 260-266.
12. Begay, M. & Glantz, S. (1997). Question 1: Tobacco education outlays from the 1994 fiscal year to the 1996 fiscal year: Comprehensive school health education programs. Tobacco Control Archives, UCSF Library and Center for Knowledge Management.
13. 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.
14. Davis, R, Gonser, H., Kirkpatrick, M., Lavery, S., & Owen, S. (1985). Comprehensive School Health Education: A Practical Definition. Journal of School Health, 55, 335-339.
15. Resnick, M., Bearman, P., Blum, R., Bauman, K., Harris, K, Jones, J., Tabor, J., Beuhring, T., Sieving, R., Shew, M., Ireland, M., Bearinger, L., Udry, J. (1997). Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health. Journal of the American Medical Association, 278, 823-832.
16. Davis, R, Gonser, H., Kirkpatrick, M., Lavery, S., & Owen, S. (1985). Comprehensive School Health Education: A Practical Definition. Journal of School Health, 55, 335-339.
17. Council of Chief State School Officers. (1992). A Concern About...Families and comprehensive health education program. Concerns, Issue XXXVI, July.
18. Resnick, M., Bearman, P., Blum, R., Bauman, K., Harris, K, Jones, J., Tabor, J., Beuhring, T., Sieving, R., Shew, M., Ireland, M., Bearinger, L., Udry, J. (1997). Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health. Journal of the American Medical Association, 278, 823-832.
19. Davis, R, Gonser, H., Kirkpatrick, M., Lavery, S., & Owen, S. (1985). Comprehensive School Health Education: A Practical Definition. Journal of School Health, 55, 335-339.
20. Schultz, E. (1987). School climate: Psychological health and well-being in school. Journal of School Health, 57, 432-36.
21. US Department of Health and Human Services. (1994). Preventing Tobacco Use Among Young People: A Report to the Surgeon General. US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS Publication No.S/N 017-001-00491-0.
22. Botvin, G. (1986). Substance abuse prevention research: Recent developments and future directions. Journal of School Health, 56, 369-374.
23. Chassin, L., Presson, C, & Sherman, S. (1985). Stepping backward in order to step forward: An acquisition-oriented approach to primary prevention. Journal of Consulting and Clinical Psychology, 53, 612-622.
24. Glynn, T. (1992). Improving the health of U.S. children: The need for early interventions in tobacco use. Preventive Medicine: An International Journal Devoted to Practice & Theory, 22, 513-519.
25. 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.
26. Massachusetts Department of Elementary and Secondary Education. (1996). The Massachusetts Comprehensive Health Curriculum Framework: Building Resilience Through Comprehensive Health. Publication No. 17811-51-5M-4/96-ESIS W/S.
27. Noak, M. (1981). Recommendations for School Health Education-A Handbook for State Policymakers. Education Commission of the States, 26-28. Denver, CO.
28. Resnick, M., Bearman, P., Blum, R., Bauman, K., Harris, K, Jones, J., Tabor, J., Beuhring, T., Sieving, R., Shew, M., Ireland, M., Bearinger, L., Udry, J. (1997). Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health. Journal of the American Medical Association, 278, 823-832.
29. Ibid
30. Ibid
31. Davis, R, Gonser, H., Kirkpatrick, M., Lavery, S., & Owen, S. (1985). Comprehensive School Health Education: A Practical Definition. Journal of School Health, 55, 335-339.
32. Ibid
33. Schultz, E. (1987). School climate: Psychological health and well-being in school. Journal of School Health, 57, 432-36.
34. Davis, R, Gonser, H., Kirkpatrick, M., Lavery, S., & Owen, S. (1985). Comprehensive School Health Education: A Practical Definition. Journal of School Health, 55, 335-339.
35. Resnick, M., Bearman, P., Blum, R., Bauman, K., Harris, K, Jones, J., Tabor, J., Beuhring, T., Sieving, R., Shew, M., Ireland, M., Bearinger, L., Udry, J. (1997). Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health. Journal of the American Medical Association, 278, 823-832.
36. Davis, R, Gonser, H., Kirkpatrick, M., Lavery, S., & Owen, S. (1985). Comprehensive School Health Education: A Practical Definition. Journal of School Health, 55, 335-339.
37. Blackburn, H., Luepker, R., Kline, F., Bracht, N., Carlaw, R., Jacobs, D., et al. (1984). The Minnesota heart health program. In J. Matarazzo, S. Weiss, J. Herd, & N. Miller (Eds.), Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. John Wiley and Sons, Inc. New York: NY.
38. Botvin, G. (1986). Substance abuse prevention research: Recent developments and future directions. Journal of School Health, 56, 369-374.
39. Glynn, T. (1989). Essential elements of school-based smoking-prevention programs. Journal of School Health, 59, 181-188.
40. Best, J., Thomson, S., Santi, S., Smith, E., Brown, K. (1988). Preventing cigarette smoking among school children. In L. Breslow, J. Fielding, L. Lave (Eds.), Annual Review of Public Health, Volume 9. Annual Reviews, Inc., Palo Alto: CA.
41. Botvin, G., & Botvin, E. (1992). Adolescent tobacco, alcohol, and drug abuse: Prevention strategies, empirical findings, and assessment issues. Journal of Development and Behavioral Pediatrics, 13, 290-301.
42. Flay, B., Koepke, D., Thomson, S., Santi, S., Best, J. & Brown, K. (1989). Six-year follow- up of the first Waterloo school smoking prevention trial. American Journal of Public Health, 79, 1371-1376.
43. Fors, S., & Doster, M. (1985). Implications of results: Factors for success. Journal of School Health, 55, 332-334.
44. Israel, B., Cummings, K., Dignan, M., Heaney, C., Perales, D., Simons-Morton, B., Zimmerman, M. (1995). Evaluation of health education programs: Current assessment and future directions. Health Education Quarterly, 22, 364-389.
45. Begay, M. & Glantz, S. (1997). Question 1: Tobacco education outlays from the 1994 fiscal year to the 1996 fiscal year: Comprehensive school health education programs. Tobacco Control Archives, UCSF Library and Center for Knowledge Management.
46. Tobacco Oversight Council. (March & May, 1997). Minutes from the Tobacco Oversight Council Meeting. Boston, MA.
47. Allensworth, D. & Kolbe, L. (1987). The Comprehensive School Health Program: Exploring an Expanded Concept. Journal of School Health, 57(10), 409-412.
48. Davis, R, Gonser, H., Kirkpatrick, M., Lavery, S., & Owen, S. (1985). Comprehensive School Health Education: A Practical Definition. Journal of School Health, 55, 335-339.
49. 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.
50. Allensworth, D. (1993). Health education: State of the art. Journal of School Health, 63, 14-20.
51. Kolbe, L. (1993). An essential strategy to improve the health and education of Americans. Preventive Medicine, 22, 544-560.
52. Resnick, M., Bearman, P., Blum, R., Bauman, K., Harris, K, Jones, J., Tabor, J., Beuhring, T., Sieving, R., Shew, M., Ireland, M., Bearinger, L., Udry, J. (1997). Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health. Journal of the American Medical Association, 278, 823-832.
53. Davis, R, Gonser, H., Kirkpatrick, M., Lavery, S., & Owen, S. (1985). Comprehensive School Health Education: A Practical Definition. Journal of School Health, 55, 335-339.
54. Resnick, M., Bearman, P., Blum, R., Bauman, K., Harris, K, Jones, J., Tabor, J., Beuhring, T., Sieving, R., Shew, M., Ireland, M., Bearinger, L., Udry, J. (1997). Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health. Journal of the American Medical Association, 278, 823-832.
55.Botvin, G. (1986). Substance abuse prevention research: Recent developments and future directions. Journal of School Health, 56, 369-374.
56. Flay, B., Koepke, D., Thomson, S., Santi, S., Best, J. & Brown, K. (1989). Six-year follow- up of the first Waterloo school smoking prevention trial. American Journal of Public Health, 79, 1371-1376.
57. Glynn, T. (1989). Essential elements of school-based smoking-prevention programs. Journal of School Health, 59, 181-188.
58. Werner, E., & Smith, R. (1982). Vulnerable, but invincible. New York, NY: McGraw-Hill.
59. Parker, G., Cowen, E., Work, W., & Wyman, P. (1990). Test correlates of stress resilience among urban school children. Journal of Primary Prevention, 11, 19-35.
60. Garmezy, N. (1991). Resiliency and vulnerability to adverse developmental outcomes associated with poverty. American Behavioral Scientist, 34, 416-430.
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