Health Protection Fund - Year V: 1997
The majority of districts in Massachusetts follow a model of comprehensive school health education programming as is recommended throughout the research literature and that is in line with major working definitions in the field. For example, Marx and Wooley 54 write that schools with comprehensive school health education meet the following criteria:
- a documented, sequential program,
- at least one health education course,
- instruction in six key behavioral areas,
- focus on skill development,
- health education teachers adequately trained,
- designated coordinator of health education,
- involvement of parents, health professionals and other concerned community members, and
- evaluation of health education program during the past two years.
Of these, the area that may be more limited is parent involvement, which seems the most difficult for districts to attain.
Student health and learning are closely linked and for this reason students' learning can be compromised when they are not well or when their ability to focus and concentrate is limited due to health issues.55, 56, 57 The importance of this is seen in the Healthy People 2000 initiative which includes health related objectives for children and adults. Several objectives identify schools.58 Within these objectives are those that are specific to comprehensive school health education program delivery and to substance use prevention and violence prevention.
Massachusetts has for the most part met and in some cases exceeded these objectives. For example:
- Objective 8.4 calls for increasing to at least 75 percent the proportion of the nation's elementary and secondary schools that provide planned and sequential kindergarten to 12th-grade comprehensive school health education. In Massachusetts this goal has been met for elementary grades (88%), for middle school grades (81%), for the first two grades of high school, ninth and tenth (78%), but not for the last two grades of high school, eleventh and twelfth (54%).
- Objective 3.10 calls for the establishment of tobacco-free environments and inclusion of tobacco use prevention in the curricula of all elementary, middle, and secondary schools, preferably as part of comprehensive school health education. In Massachusetts, 100% of districts have a Tobacco-Free School Policy. Tobacco use prevention curricula is offered at elementary, middle, and high school and 98% of lead health teachers provide instruction at the middle and high school level to increase knowledge of tobacco use prevention.
- Objective 4.13 calls for the provision to children in all school districts and private schools, primary and secondary educational programs on alcohol and other drugs, preferably as part of comprehensive school education. While data is not available for elementary level, 99% of lead health teachers provide instruction at the middle and high school level to increase knowledge of alcohol and drug use prevention.
- Objective 7.16 calls for an increase to at least 50 percent the proportion of elementary and secondary schools that teaches nonviolent conflict resolution skills, preferably as part of comprehensive school health education. While data is not available for elementary level, 93% of lead health teachers provide skills instruction at the middle and high school level in nonviolent conflict resolution.
One area specific to the mission of the Health Protection Fund is tobacco use. Districts are in excellent shape for having policies in place for tobacco-free schools. The policies, however, are more oriented toward punishment as a consequence of violation than for tobacco prevention education. While all students are receiving tobacco prevention education, including skills for refusal, few cessation programs are in place. Those that are in place are not experiencing high completion rates. This is an area of concern.
There were a large number of statistically significant relationships (61) between program practices and reduced adolescent risk behaviors. Most of the relationships were between program practices and tobacco use and marijuana use. Fewer relationships were present between program practices and reductions in violence and alcohol use. While reductions in all behaviors were related to program practices, there were few relationships with reductions in high school alcohol use. This has been found to be the case in the research literature as well. For example, Ellickson & Bell comment that a possible reason for the inability of their prevention program to decrease alcohol use is the general acceptance of using alcohol in the United States.59 Of all the risk behaviors included in the Year V evaluation, alcohol use in high school is clearly the most wide-spread (see Appendices A and B)
Exposure to Health Curriculum, Involvement of Important Others, and Local Program Evaluation were all significantly related to reductions in student risk behaviors. Within these, some of the most compelling program practices were around hours of health education, parent and peer involvement in health education, and local program evaluation of goals and objectives. These findings show that there is a balanced approach to health education that does follow the comprehensive school health model. While there were some relationships with other components of the school health education program (e.g., health services and counseling and psychological services) they were not as salient as the model would suggest they should be. One new and promising finding was around the relationships between local program evaluation and reductions in risk behaviors. This suggests that when districts tie their programs together by a process such as defining goals, planning activities to meet those goals, and then measuring the extent to which the goals were met, over time they can target certain risk behaviors by their students and help bring the rates of those risk behaviors down.
There was substantial similarity of the correlation findings from the previous evaluation to the present one. Of course, districts follow a comprehensive school health education program model to various degrees and also have various degrees of success in reducing risk behaviors. One program area in particular that was striking in the degree of replication from Year IV to Year V was Involvement of Important Others--Peers. The power of positive peer influence being demonstrated so clearly is encouraging for counteracting the portrayal of peers as being mostly a negative influence on one another.
Groups of program practices were identified that together best explain the reductions in risk behavior. Using this approach allowed a more coherent understanding of the data. These groupings can help guide districts as they work toward decreasing particular behaviors. Knowing the program practices that work together the best can allow more efficiency in school health education programming decisions.
An overall theme that emerged was that the combination of a health education program that focused on knowledge and skills training and that strongly encouraged relationships with members of students' support groups, such as peers, family, and community, was strongly related to reducing substance use and violence in both younger and older adolescents.
Review of Recommendations from Year IV Evaluation
Several recommendations were generated as a result of the Year IV (1996-97 school year) evaluation. The recommendations and progress toward them will be reviewed briefly here before discussing current recommendations.
- There was a recommendation to understand more about local tobacco control programs, and understand more about cessation programs. The data collection tools of the current evaluation included more questions in this area. The Department's Health, Safety and Student Support Services unit has developed a model policy based on the tobacco-free school policies from all Massachusetts districts. Health, Safety and Student Support Services staff are actively involved with the Question 1 Advisory Council that oversees the activities of the Health Protection Fund programs, in particular, the subcommittees of Schools and Youth; Women, Girls, and Tobacco; and Evaluation. In addition, Health, Safety and Student Support Services staff work with local Massachusetts Tobacco Control Programs.
- A recommendation was made to increase exposure to the health curriculum framework within districts. There have been content institutes and numerous trainings throughout the school year on the health curriculum framework. The framework has been revised and health, physical education, family and consumer sciences education teachers and educators, school nurses, and health coordinators were actively involved in the process. All school districts including administrators had an opportunity to provide feedback in this process. Another recommendation in this area that has been implemented was to revise the HPF Mid-Year Report to more closely mirror the framework. The first round of data from this tool was collected this past spring and used by Health, Safety and Student Support Services staff in providing technical assistance to districts.
- A recommendation was made to facilitate the involvement of important others, such as parents. This past year, staff from Health, Safety and Student Support Services have been instrumental in working in the area of parental involvement, in particular father involvement.
- Finally, there were recommendations that directly involved data collection. In particular, a recommendation was to work with local districts on conducting student-based behavior needs assessments. Many districts have received technical assistance from the Department of Elementary and Secondary Education in this area. Studying both middle school and high school behaviors generated new information and will continue to be a part of the design.
Current Recommendations from Year V Evaluation
The recommendations from the current evaluation center around determining comprehensiveness of health education programs, implementing tobacco cessation, reducing alcohol and drug use, developing an approach to local program evaluation, and expanding the evaluation findings by collecting information on all districts about their comprehensive school health education programs and student risk behavior rates.
Implement Tobacco Cessation Programs
Tobacco cessation programs remain of vital importance due to the lack of success thus far to help students stop using tobacco. For example, according to the 1997 Massachusetts Youth Risk Behavior Survey60, 34% of Massachusetts students are smoking at least once a month. Three-quarters of regular smokers had tried to quit smoking at least once and one third had tried to quit three or more times, however only 16% had quit successfully. Continued involvement by districts in local Massachusetts Tobacco Control Programs and by Department staff with the Health Protection Fund Question 1 Advisory Council should occur and further, specific attempts toward understanding cessation within these groups should be made. This information should be made available to districts, either through mailings, workshops, or individual technical assistance through Department staff. Districts should work with organizations such as the American Cancer Society and American Lung Association to better understand cessation and to implement effective cessation programs, which research suggests might include a behavior modification/harm reduction approach.61 The Health Protection Fund requires that each district's School Health Advisory Council have representation from the American Cancer Society and local Boards of Health. If funding were available, demonstrations and evaluations of such cessation programs could be conducted to establish their efficacy.
Implement Alcohol and Drug Use Reduction Programs
Alcohol use in particular is widespread and districts appear to have had little success in reducing use by high school students. There are many substance use/abuse curricula available that have had rigorous evaluations and been found to be effective, both in the short-term and the long-term. Many follow a social influence model. Consideration could be given by the Department to provide funding through the Health Protection Fund for a group of districts to implement the most promising alcohol and drug programs. These districts could then be compared to a group of districts similar in background that did not implement the programs that would serve as a comparison. This would yield data about the capability of the programs to reduce alcohol and drug use for Massachusetts youth and help districts make choices about how to designate spending for curricula materials. If districts are not interested in purchasing curricula, the findings would provide information for a local program to be designed utilizing the principles of the effective models.
Use Information about the Health Curriculum Framework, Health Education Assessment Feedback, and Student Behavior Rates as an Approach to Local Program Evaluation
The better the local evaluation the more likely reductions in risk behaviors were to be present. There are several components that should be in place for an effective local program evaluation and on which districts should receive assistance. Districts should receive training on implementing the health curriculum framework 62 which is organized by content area with measurable learning standards and guiding principles for implementing a comprehensive school health education program. Technical assistance and training should be provided on the health education assessment tool for local assessment that the Department has made available through the Health Protection Fund Mentor Program. The tool is made possible through the Council for Chief State School Officers State Collaborative for Assessment Student Standards initiative.63, 64 A critical piece of local evaluation is conducting at regular intervals a student behavior-based survey, particularly one that asks students confidentially about the extent to which they engage on a regular basis (not just lifetime, which can be a one time experimentation) in the major risk behaviors of tobacco use, alcohol use, marijuana use, and violence. A short survey can accomplish this objective. Districts can gain an immense amount of information and develop and refine their comprehensive school health education programs by following such an approach because it may help them to show the links between program practices and positive changes in student risk behaviors on the local level.
Continue and Expand Understanding of the Extent and Effectiveness of Comprehensive Health Education Programs
To increase the value of the state evaluation to districts, having good data from all districts is essential. Below are areas of program practices in which continued and expanded understanding on all districts is needed:
- The extent to which districts use a social influences-based approach to health education, particularly for risk behaviors, as this is recognized as an effective model in the research literature,
- The mechanisms through which peer health education and parental involvement in health education operate,
- The number of students that receive various health education services,
- The amount of instruction in the specific prevention topics of tobacco use, marijuana use, alcohol use, and violence,
- How various components of the comprehensive school health education program have changed over the course of the Health Protection Fund from the perspective of the health coordinator, and
- Expanded information on student behavior-based needs assessment data, including the rates, the grade levels the rates are based on, and the percent of students surveyed.
With 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 following evaluation an emphasis now be placed on collecting such data for all districts in the Commonwealth. The next evaluation will be of the sixth year of the Health Protection Fund grant program. Going into Year VI with two years of documented replication, the next round of data collection is expected to also serve as even more evidence that these program practices are indeed related to reductions in risk behaviors. At that point, with three years of solid information about program practices and better information in the area of the student risk behavior rates, it will be more feasible to recommend that districts implement certain program practices in order to facilitate the reduction of risk behaviors for their students.
It is vital to continue to study the relationships between program practices and reductions in specific risk behaviors by identifying the groups of program practices that together best explain the reductions. By using the approach of studying program practices in relation to specific risk behaviors, districts can customize their programming by risk behavior as they have been asked to do in the Health Protection Fund grant program as well as other program initiatives funded through Health, Safety and Student Support Services at the Massachusetts Department of Elementary and Secondary Education.
The Massachusetts Department of Elementary and Secondary Education has funded an evaluation of the Health Protection Fund grant program since its inception in 1993. A commitment to long-term evaluation of the Health Protection Fund will inform and improve programs as well as provide for program accountability.
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