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Archived Information

Student Support

Health Protection Fund - Year V: 1997

Section C: Effective Individual Comprehensive School Health Education Program Practices: Connections with Decreases in Student Risk Behaviors

There were many statistically significant relationships between comprehensive school health education program practices and decreases in the student risk behaviors of middle school and high school tobacco use, alcohol use, marijuana use, and engaging in violence in the Year V evaluation study. These findings support the effectiveness of a comprehensive health education program model. In each of the sections below are supporting research literature in italics, findings from the Year V Health Protection Fund Evaluation bulleted, followed by a comparison of Year V and IV findings.

I. Exposure to Health Curriculum

  1. 1. Hours of Health Education

    A commitment to providing classroom hours has been found to be important to achieve the full benefits of health instruction. 16, 17 A survey with over 4,700 students in grades 3-12 from 199 schools found that health knowledge, attitudes, and behaviors improved as the years of health education instruction rose 18, and intensive interventions, including many hours of programming, has been found by several meta-analyses to be most effective. 19, 20

    • More hours per year of health education in high school in the upper grades of 11th and 12th grades were significantly associated with a decrease in high school tobacco use, high school alcohol use, high school marijuana use, and high school violence.

    Comparing Year V and Year IV Findings. In Year V, there was not a relationship between more hours per year of health education in middle school and reductions in risk behaviors. In Year IV, there was a relationship between more hours per year of health education in middle school and reductions in all risk behaviors, but not a relationship with high school hours.

  2. 2. Prevention Education as Policy

    In schools that do not have clear policies about substance use, students are more likely to experiment with chemical substances. 21 In order to address risk, school policies best communicate a commitment to substance abuse prevention when they have a formal, no-use policy for students and all adults, and a health education program that includes the most promising prevention curricula. 22

    • As part of the written tobacco policy, requiring students to participate in prevention education as a consequence of violating the written tobacco policy was significantly related to a decrease in high school tobacco use. This also represents an addition of hours.

    No comparison findings are available as this is a new area of the evaluation.

  3. 3. Skills Instruction in Health Education

    One of the most widely supported findings in the health education research literature is the effectiveness of social skills training. Based on the well-researched social influences model of decision-making on behavior, social skills training has been found to be related to reductions in the onset and continuation of substance abuse. 23, 24, 25

    • A larger amount of time devoted to teaching students the skill of how to generate alternative solutions to health problems in health education was significantly related to a decrease in high school marijuana use.

    No comparison findings are available as this is a new area of the evaluation.

  4. 4. Health Curriculum Framework
    A place in the curriculum for school health has been found to be associated with better support, time in the curriculum, and a coordinated sequential program. 26 Students who received school health prevention curricula have been found to have reduced substance use compared to students who did not receive such curricula. 27, 28, 29
    • Training at the local level for teachers on matching the Massachusetts Comprehensive Health Framework to the district's health curriculum was significantly associated with a decrease in high school tobacco use.
    • Reporting that time for course scheduling was less of an obstacle in the implementation of the Health Framework was significantly related to a decrease in high school marijuana use.
    • Reporting that support by non-health staff in the district was less of an obstacle in the implementation of the Health Framework was significantly related to a decrease in high school marijuana use.

    Comparing Year V and Year IV Findings.

    In Year IV, more support for scheduling of health courses was related to a reduction in tobacco use, while in Year V, this support was related to a reduction in drug use. In both Years IV and V, more support on the local level for the Massachusetts Health Framework from non-health staff was related to a reduction in drug use.

II. A. Involvement of Important Others--Adults

  1. 1. School Staff

    Select key essential elements of comprehensive school health education were identified from a large multi-site evaluation, the School Health Education Evaluation Study. Accordingly, one of the elements identified is involvement of the other health related components of comprehensive school health education (which includes physical education, family and consumer sciences, health services, and school counseling services) in order to assure reinforcement of school health curriculum objectives. 30

    Physical Education and Family and Consumer Sciences

    • A greater frequency of coordination between health education and physical education was significantly related to a decrease in middle school violence.
    • A greater frequency of making instruction interdisciplinary between health education and family and consumer sciences was significantly related to a decrease in middle school tobacco use.

    School Health Services and School Counseling/Psychological Services

    • A greater frequency of collaboration to provide services to students between health education and school health services was significantly related to a decrease in middle school marijuana use.
    • Any collaboration to provide services to students between health education and school counseling/psychological services was significantly related to a decrease in high school marijuana.

    Academic Teachers

    Teachers of other subjects are critical in assuring comprehensiveness of school health programs as well. One of the identified essential elements from the School Health Education Evaluation study is that school health curricula should be planned and taught in attentive coordination with other subjects. 31 The design of programs can be such that teachers of other subjects have a very active role. For example, one multi-year drug abuse prevention program that was effective in sustaining reduced marijuana and tobacco use three years later is designed to be delivered in health, science, or social studies classes. 32
    • A greater frequency of interdisciplinary instruction of health and science and technology, health and history social science, health and mathematics, and health and English language arts was significantly related to a decrease in middle school marijuana use.

    Comparing Year V and Year IV Findings. In comparing Year V with Year IV, collaboration between health education and school health services was related to a reduction in tobacco use, while in Year V, to a reduction in marijuana use. In Year IV, collaboration between health education and school counseling/ psychological services was related to a reduction in violence, in Year V, this collaboration was related to a reduction in marijuana use.

  2. 2. Parents
    According to the School Health Education Evaluation essential elements: "The family is vital and crucial in the education of children and family members' views and inputs into the school health curriculum and classroom experience can be extremely productive". 33 School-based approaches that involve parents directly or that have parent involvement activities that complement the school health program have been found to be effective in reducing substance abuse and violence. 34, 35, 36, 37 Research suggests that involvement for youth in unhealthy and antisocial conduct is less likely when strong bonds to family and school exist. 38, 39
    • Parents participating in health education curriculum development and review in an ongoing way was significantly related to a decrease in middle school tobacco use and middle school alcohol use
    • Parents being included in health homework assignments in an ongoing way was significantly related to a decrease in middle school tobacco use.
    • Parents being represented on the school health advisory council was significantly related to a decrease in both middle and high school tobacco use.

    Comparing Year V and Year IV Findings. Comparing Year V with Year IV, in both Years IV and V, parents participating in health education curriculum development and review was related to a reduction in violence, parents being involved in health homework assignments was related to a reduction in tobacco use, and parents being represented on the school health advisory council was related to a reduction in tobacco use.

  3. 3. Community Members
    From the School Health Education Evaluation, an essential element is that the community should play an active role in school health education. 40 Several studies have found that religious or spiritual connectedness for youth is one of the protective factors that is related to less engagement in unhealthy risk behaviors, such as acting out and substance use. 41, 42, 43 The influence of such connectedness is suggested by writers as operating through both parents and faith-based groups being able to foster a sense of belonging and connectedness that promotes positive relationships with adults and peers and positive social experiences. 44
    • The public health department being represented on the school health advisory council was significantly related to a decrease in high school tobacco use
    • Clergy being represented on the school health advisory council was significantly associated with a decrease in middle school tobacco use, middle school alcohol use, middle school marijuana use, and high school violence.

    Comparing Year V and Year IV Findings. In both Year IV and V, community members being active on the school health advisory council was related to a reduction in tobacco use.

II. B. Involvement of Important Others--Peers

Studies of individual evaluations and meta-analyses of evaluations of programs that are peer-led or include peer-led components have demonstrated such programs to be effective in preventing and reducing substance use and violence. 45, 46, 47, 48 During peer interaction, students learn attitudes and skills through modeling and reinforcement, and receive support, opportunities, and models for prosocial development. 49

  1. 1. Peer Health Educators

    Percent Served

    • There was a significant relationship between a greater percent of students served by trained health peer educators and a decrease in high school marijuana use.

    Settings

    • Peer educators working with students in health courses was significantly related to a decrease in high school marijuana use, middle school tobacco use, and high school tobacco use.
    • Peer educators working with students in conflict resolution/mediation sessions was significantly associated with a decrease in middle school tobacco use, middle school alcohol use, middle school marijuana use, and middle school violence.
    • Peer educators working with students in discussion or support groups was significantly related to a decrease in high school marijuana use, high school tobacco use, high school violence and middle school violence.

    Activities

    • Within conflict resolution/mediation sessions, a decrease in middle school tobacco use, middle school alcohol use, and middle school violence was significantly related to talking with students about personal problems as the one type of activity the peer educators engaged in the most.
    • Within assembly programs, a decrease in high school tobacco use was significantly associated with demonstration of health skills as the one type of activity the peer educators engaged in the most.
    • Within discussion or support services, a decrease in high school tobacco use was significantly associated with giving information about risk behavior as the one type of activity the peer educators engaged in the most. In this setting, a decrease in high school marijuana use was significantly related to demonstration of health skills as the one type of activity the peer educators engaged in the most.
  2. 2. Students on the School Health Advisory Council
    • Students being represented on the School Health Advisory Council was significantly associated with a decrease in middle school tobacco use and middle school violence.

    Comparing Year V and Year IV Findings. In comparing Year V with Year IV, in both years using peer health educators to teach health was related to a reduction in tobacco use, alcohol use, and violence, using peer health educators in conflict resolution/mediation sessions was related to a reduction in violence, using peer health educators in discussion/support groups was related to a reduction in alcohol use, and students being represented on the school health advisory council was related to a reduction in tobacco use.

III. Local Program Evaluation

One essential element that was derived from the School Health Education Evaluation study is that the classroom health experiences for students should have specific goals and objectives to be achieved by students and staff. 50 Researchers in this area strongly advise that in order to evaluate specific prevention efforts, goals and objectives that are clear as well as the techniques employed to measure success are required. 51,52 A major review of 127 evaluations of drug abuse prevention programs revealed that those prevention programs that united intensive inservice programs with rigorous evaluations may have aided in the prevention of drug abuse. 53

  • Having the district's written improvement plan (Education Reform) include goals and objectives for comprehensive health education was significantly related to a decrease in middle school tobacco use, middle school alcohol use, middle school marijuana use, and middle school violence.
  • A formal evaluation with documentation of health-related school policies was significantly associated with a decrease in middle school tobacco use.
  • A formal evaluation with documentation of written goals, objectives, or outcomes in health education was significantly related to a decrease in middle school tobacco use and middle school violence.
  • A formal evaluation with documentation of the health education curriculum was significantly associated with a decrease in high school marijuana use.
  • A formal evaluation with documentation of staff development/inservice training in health education was significantly related to a decrease in middle school tobacco use.

No comparison findings are present as Local Program Evaluation was not measured in Year IV.

Summary of Findings for Individual Program Practices and Reductions in Risk Behaviors

The pattern of findings of significant relationships between program practices and reductions in student risk behaviors fell into the areas of Exposure to Health Curriculum, and Involvement of Important Others. Additionally, program practices within the area of Local Program Evaluation were a major contributor to reductions in risk behaviors.

Several of the program practices were related to reductions in multiple behaviors. In particular, these were more hours of health education in the upper high school grades, health education and physical education working closely together, peer health education in small group settings, and goals and objectives for health education being a part of the district's written improvement plan.

While both high school and middle school risk behaviors decreased, overall the relationships between program practices and reductions in risk behaviors were present somewhat more often for middle school behaviors. Reductions in risk behaviors seen most often across middle school and high school were for tobacco and marijuana use, followed by violence, and then alcohol. For middle school, the most reductions were for tobacco use and violence. For high school the most reductions were for tobacco and marijuana use.

There is evidence that the relationships between the comprehensive school health education program practices and reductions in risk behaviors found in this sample of Massachusetts school districts are in line with findings from well-designed, controlled studies as well as meta-analyses and literature reviews in the field of health education programming and evaluation.

Summary of Findings for Year V and Year IV Comparisons

There was considerable consistency between the findings of last year (Year IV) and the current year (Year V) in the identification of effective comprehensive health education program practices. There were many matches between the reductions in behaviors and program practices. There were a few changes in the specific behaviors that the program practices were related to from Year IV to Year V.

Exact matches between program practices and behavior reductions were found mainly in the major areas of Exposure to Health Curriculum and Involvement of Important Others. Of the 14 relationships from Year IV to Year V that could be compared, there were matches on 12. Of these 12, in the majority of cases there was an exact match between the program practice and the reduction of the same type of behavior.

Section D: Groups of Effective Program Practices

The next section allows for further understanding of the program practices as they are related to reductions in thespecific student risk behaviors.

It can be useful to know which program practices as a group are related to the decreases in risk behaviors and to know the extent to which the decreases in student risk behaviors can be understood in terms of these groups of program practices. The following section presents information in these areas. The program practices presented within groups still independently relate to reductions in risk behaviors, but all of these program practices being in place are related to greater reduction than any one of them alone. Additionally, knowing how much of the decrease in the risk behaviors can be accounted for by program practices adds a layer of understanding to the relationships between effective comprehensive school health education program practices and reductions in student risk behaviors.

As above, the program practices are those in place in Year V. Like the approach that generated the findings in the section above, this is a statistical approach that is based on correlation. When generating groups, a fewer number of program practices will be retained. The number of districts with complete pre-post behavioral outcome data also determines the number of program practices that can be included in a group. Only program practices that were significantly related to decreases in risk behaviors were included in this analysis and only significant overall statistical models are presented. The program practices are presented within the groups in the order of their explanatory strength.

Middle School Tobacco Use

28% of the decrease that occurred from Year I to Year V in middle school tobacco use can be accounted for by the program practices of:

  • a formally documented local evaluation of written goals, objectives, and/or outcomes in health education,
  • peer health educators working with students in health education courses/classes, and
  • a greater frequency of interdisciplinary instruction between health education and family and consumer sciences education.

High School Tobacco Use

25% of the decrease that occurred from Year I to Year V in high school tobacco use can be accounted for by the program practices of:

  • parents being represented on the school health advisory council,
  • peer health educators working with students in discussion/support groups, and
  • training provided to teachers on matching the district's current health curriculum with the Health Curriculum Framework.

Middle School Alcohol Use

31% of the decrease that occurred from Year I to Year V in middle school alcohol use can be accounted for by the program practices of:

  • peer health educators working with students in conflict resolution/mediation sessions,
  • clergy being represented on the school health advisory council, and
  • parents participating in health education curriculum development and review in an ongoing way.

High School Alcohol Use

Due to the few number of significant relationships between program practices and reductions in high school alcohol use, a significant model could not be generated.

Middle School Marijuana Use

22% of the decrease that occurred from Year I to Year V in middle school marijuana use can be accounted for by the program practices of:

  • a greater frequency of interdisciplinary instruction between health education and science and technology,
  • peer health educators working with students in conflict resolution/mediation sessions, and
  • a greater frequency of interdisciplinary instruction between health education and history social sciences.

High School Marijuana Use

29% of the decrease that occurred from Year I to Year V in high school marijuana use can be accounted for by the program practices of:

  • a greater percent of health education skills instruction devoted to generating alternative solutions to health problems,
  • peer health educators working with students in health courses/classes,
  • a greater number of health education hours received in the 11th grade,
  • reporting that time for course scheduling was less of an obstacle in the implementation of the Health Curriculum Framework, and
  • a greater percent of students served by peer health educators.

Middle School Violence

23% of the decrease that occurred from Year I to Year V in middle school violence can be accounted for by the program practices of:

  • coordination between health education and physical education, and
  • peer health educators working with students in discussion/support groups.

High School Violence

30% of the decrease that occurred from Year I to Year V in high school violence can be accounted for by the program practices of:

  • peer health educators working with students in discussion/support groups,
  • receiving health education in non-health classes/courses (such as academics), and
  • clergy being represented on the school health advisory council.

Summary of Findings around Effective CSHE Program Practices

Overall, what these groups of effective program practices have most in common are:

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

With respect to the program practices in terms of strength of explanatory power, the peer health education program practices were most substantial. The amount of the decrease in the student risk behaviors that can be explained by this approach that viewed program practices as a group ranged from 22% to 31%. Being able to understand more fully almost a quarter to almost a third of these decreases can be useful information in the planning of comprehensive school health education programs.

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Last Updated: October 1, 1999
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