ITEM RATIONALE
2008 SCHOOL HEALTH PROFILES
QUESTIONNAIRE FOR LEAD HEALTH EDUCATION TEACHERS

REQUIRED HEALTH EDUCATION

Question 1:  Is health education required for students in any of grades 6 through 12 in this school?  

Question 2:  How many required health education courses do students take in grades 6 through 12 in this school?

Question 3: Is a required health education course taught in each of the following grades in this school?

Rationale:  These questions measure the extent to which health education courses are required for students in grades 6 through 12. School health education could be one of the most effective means to reduce and prevent some of the most serious health problems in the U.S., including cardiovascular disease, cancer, motor-vehicle crashes, homicide, and suicide (1).  The Institute of Medicine (IOM) has recommended that U.S. schools require a one-semester health education course at the secondary school level (1); however, the benefits of a health education curriculum increase when students receive at least three consecutive years of quality health curriculum (2).

Question 4: If students fail a required health education course, are they required to repeat it?

Rationale:  This question measures the importance of a required health education course for students in grades 6 through 12.

Question 5:  Are those who teach health education at this school provided with the following materials?

	Rationale: This question addresses the types of information and support materials health education teachers are given in order to implement health education classes. According to the Joint Committee on National Health Education Standards, quality health education is guided by access and equity principles that call for clear curriculum direction, including goals, objectives, and expected outcomes; a written curriculum; clear scope and sequence of instruction for health education content; and plans for age-appropriate student assessment (3).

Question 6:  Does your health education curriculum address each of the following? 

Rationale: This question addresses the extent to which schools have a health education curriculum that is based on, or is consistent with, current national health education standards (3).

Question 7:  During this school year, have teachers in this school tried to increase student knowledge on each of the following topics in a required course in any of grades 6 through 12?

Rationale:  This question addresses the extent to which traditional health content areas and the prevention of health risk behaviors are taught in required courses in grades 6 through 12.

Question 8:  During this school year, did teachers in this school teach each of the following tobacco-use prevention topics in a required course for students in any of grades 6 through 12? 

Rationale: This question measures the tobacco-use prevention curricula content, and relates to the Healthy People 2010 Objective 7-2 of providing school health education to prevent health problems among middle, junior high, and high school students including those from tobacco use (4). Since most smoking is initiated by persons less than 18 years old, programs that prevent onset of smoking during the school years are crucial (5).   School-based tobacco prevention programs that address multiple psychosocial factors related to tobacco use among youth and that teach the skills necessary to resist those influences have demonstrated consistent and significant reductions or delays in adolescent smoking (5-12).  Social influence programming has reduced smoking onset by as much as 50%, with effects lasting up to 6 years, and with effects including reduction of the use of other tobacco products as well (7).  

In addition, this question measures the extent to which schools are complying with the components of the National Health Education Standards, which provide a framework for decisions about the lessons, strategies, activities, and types of assessment to include in a health education curriculum (3).

Question 9:  During this school year, did teachers in this school teach each of the following HIV, STD, or pregnancy prevention topics in a required course for students in any of grades 6, 7, or 8?

Question 10:  During this school year, did teachers in this school teach each of the following HIV, STD, or pregnancy prevention topics in a required course for students in any of grades 9, 10, 11, or 12?

Rationale:  These questions measure the HIV prevention curricula content.  HIV and sex education programs can increase knowledge about how to avoid HIV and STD infection and unintended pregnancy. Efforts to increase knowledge alone about modes of transmission and strategies for prevention do not directly lead to behavior change (13).  In order to reduce HIV, other STDs, and unintended pregnancy, programs must address perceptions of risk, intentions, communication, and skills, in addition to HIV and STD knowledge (14).  

Adolescents have different HIV prevention needs than do adults. However, because of the variability among youth with respect to cognitive and social maturity and sexual experience, interventions must be tailored to meet the unique needs of younger versus older youth or sexually naive versus experienced teens. HIV prevention interventions also have to be matched to the cognitive level of adolescents and should be designed to improve behavioral skills for risk reduction, decision making, planning, and problem solving (15).

Part of a program’s effectiveness involves its organization and presentation of activities and materials in an age appropriate and logical sequence.  A typical logical sequence includes basic information about HIV, other STDs, and pregnancy, including susceptibility and severity of HIV, other STDs, and pregnancy; discussion of behaviors to reduce vulnerability; knowledge, values, attitudes and barriers related to these behaviors; and skills needed to perform these behaviors (16).  Messages in these effective programs are appropriate to the age, sexual experience, gender and culture of the youth (14).  

In addition, the appropriateness for age and HIV prevention curricula content were aligned with the National Health Education Standards (NHES), which provide a framework for decisions about the lessons, strategies, activities, and types of assessment to include in a health education curriculum (3).  The NHES, other state-level standards, and research findings from the literature on effective programs in HIV, other STD, or pregnancy prevention were used to determine the activities and materials for age appropriateness for grades 6-8 and 9-12 related to HIV prevention curricula content (3, 14-16).  

Question 11:  During this school year, did teachers in this school teach each of the following nutrition and dietary behavior topics in a required course for students in any of grades 6 through 12?

Rationale: This question measures the curricula content related to nutrition and dietary behavior. Comprehensive, sequential nutrition education using the classroom and the lunchroom can reinforce healthful eating behaviors (17,18). Nutrition education should be part of a comprehensive school health education curriculum and include concepts to promote healthy eating (19,20). This list of 15 nutrition topics is based on CDC guidelines (21) and the School Health Index (22).

Question 12:  During this school year, did teachers in this school teach each of the following physical activity topics in a required course for students in any of grades 6 through 12?

Rationale: This question measures the extent to which physical activity concepts are taught in a required health education course. Health education that includes physical activity concepts increases the likelihood of students increasing their participation in physical activity (23), reinforces what has been taught in physical education (24,25), and assists students in achieving the national health education standards (3).

HIV PREVENTION

Question 13:  During this school year, did your school provide any HIV, STD, or pregnancy prevention programs for ethnic/racial minority youth at high risk (e.g. black, Hispanic, or American Indian youth), including after-school or supplemental programs, that did each of the following?

Rationale:  This question measures whether a school addresses HIV, other STD, and pregnancy prevention through targeted efforts reaching those identified as most at-risk. Risk for HIV infection is especially notable for youth of minority races and ethnicities.  African-Americans are the largest group of young people affected by HIV, accounting for 56% of all HIV infections ever reported among those aged 13–24 by 2001 (26).  And, although only 15% of teenagers (ages 13-19) in the United States are African- Americans, they accounted for 73% of new AIDS cases reported among teens in 2004 (27). In 2002, HIV/AIDS was the number one cause of death for African- American women aged 25-34 years and the number two cause of death for all African- Americans aged 35-44 (28).  Of the more than half a million people with AIDS who have died in the U.S., 38% were African American (29).  In addition, the incidence of AIDS for adult and adolescent Latinos in 2001 was more than 3 times higher than that among their non-Hispanic white counterparts (29,30). 

Data from CDC’s 2005 National Youth Risk Behavior Survey (YRBS) show that, compared with white students and Hispanic/Latino students, black students have the highest rates of several sexual risk behaviors: 67.6% of black students had ever had sexual intercourse, compared with 43.0% percent of white students and 51.0% of Hispanic/Latino students; 47.4% of black students were currently sexually active (i.e., had sexual intercourse with 1 or more persons during the 3 months preceding the survey), compared with 32.0% of white students and 35.0% of Hispanic/Latino students; 16.5% of black students had had sexual intercourse before age 13 years, compared with 4.0% of white students and 7.3% of Hispanic/Latino students; and 28.2% of black students had had sexual intercourse with 4 or more persons during their life, compared with 11.4% of white students and 15.9% of Hispanic/Latino students (31).

In addition to effective curricula, access to valid information and products, as well as access or referral to health, social, and psychological services to prevent HIV, other STDs, and pregnancy are especially important in ethnic/racial minority communities where the higher prevalence of HIV, other STDs, and pregnancy reflects both risky adolescent sexual behaviors and system barriers to quality prevention services (32).   Factors which may influence adolescents’ access to care include health insurance, cost, convenience, confidentiality, and demographic factors such as age, gender, and ethnicity (33-35).   

COLLABORATION

Question 14:  During this school year, have any health education staff worked with each of the following groups on health education activities?

Rationale:  This question measure the extent to which health education staff work cooperatively with other components of the school health program (school health services, school mental health or social services, food service, and physical education staff) and families.  An integrated school and community approach is an effective strategy to promote adolescent health and well being (36). 

Question 15: During this school year, did your school provide parents and families with health information designed to increase parent and family knowledge of the following topics?

Rationale:  This question measures whether schools are providing health information to students’ families. School programs that engage parents and link with the community yield stronger positive results. Studies aimed at preventing childhood overweight, treating childhood overweight, and promoting physical activity and healthy eating have demonstrated more success when targeting the parent and child versus targeting the child alone (37,38).  School-based tobacco prevention programs and community interventions involving parents and community organizations have a stronger impact over time when working in tandem rather than as separate, stand-alone interventions (10).  Assessments of successful school-based asthma management programs indicate that with increased knowledge, parents can assist their children in better managing their asthma (39-41).  Parents also are teenagers’ primary sex educators, able to capitalize on teachable moments when youth may be more open to learning new information (42).  Parents can continue prevention messages delivered in school, thereby enhancing the likelihood of sustained behavioral changes (43). Increased communication affects both parenting and health practices of parents.  Communicating information on healthy lifestyles aims to reinforce the child’s coursework at school, facilitate communication with parents about school activities, and increase parent knowledge of healthy living (44,45).

PROFESSIONAL DEVELOPMENT

Question 16:  During the past two years, did you receive professional development (such as workshops, conferences, continuing education, or any other kind of in-service) on each of the following topics? (HIV)

Rationale:  This question measures the extent to which professional development has been received by the lead health teacher responsible for teaching about HIV/AIDS. As new information and research on prevention is available, those responsible for teaching about HIV/AIDS should periodically receive continuing education about HIV and other STD infections to assure they have the most current information about how widespread HIV and other STDs are, effective prevention and health education intervention strategies, and priority populations identified as most at-risk for HIV and other STD infection (14,47,48)

Effective implementation of school health education is linked directly to adequate teacher training programs (49).  School health education designed to decrease students’ participation in risk behaviors requires that teachers have appropriate training to develop and implement school health education curricula (49).  Staff development activities for health education teachers need to focus on teaching strategies that both actively engage students and facilitate their mastery of critical health information and skills (50).

Question 17:  During the past two years, did you receive professional development (such as workshops, conferences, continuing education, or any other kind of in-service) on each of the following topics?

Question 18:  Would you like to receive professional development on each of these health education topics?

Question 19:  During the past two years, did you receive professional development (such as workshops, conferences, continuing education, or any other kind of in-service) on each of the following topics? 

Question 20:  Would you like to receive professional development on each of these topics? 

Rationale:  These questions address the importance of professional development for teachers.  It is vitally important that teachers be well prepared when they begin teaching and that they continue to improve their knowledge and skills throughout their careers. (51). Districts that have made improvements in their professional development activities have seen a rise in student achievement (52,53). Staff development is associated with increased teaching of important health education topics (54). The Institute of Medicine’s Committee on Comprehensive School Health Programs in Grades K-12 recommended that health education teachers should be expected to participate in ongoing, discipline-specific in-service programs in order to stay abreast of new developments in their field (1).  

PROFESSIONAL PREPARATION

Question 21:  What was the major emphasis of your professional preparation?

Question 22:  Currently, are you certified, licensed, or endorsed by the state to teach health education in middle school or high school?

Question 23:  Including this school year, how many years of experience do you have teaching health education classes or topics?

Rationale:  These questions measure the extent to which lead health education teachers are formally trained in the topic of health education as well as the teaching experience and credentials of the lead health education teacher.  Health education teachers need to be academically prepared and specifically qualified on the subject of health (50).  In addition, pre-service training in health education is associated with increased teaching of important health education topics (54). 

REFERENCES

1. Institute of Medicine.  Schools and Health: Our Nation’s Investment.  Washington, DC: National Academy Press, 1997.

2. Lohrmann DK, Wooley SF.  Comprehensive School Health Education.  In: Marx E, Wooley SF, eds.  Health is Academic.  New York: Teachers College Press, 1998:43–66.

3. The Joint Committee on National Health Education Standards. National Health Education Standards: Achieving Excellence (2nd Edition). Atlanta: American Cancer Society, 2007.
4. U.S. Department of Health and Human Services, Healthy People 2010: Understanding and Improving Health 2nd edition. Washington, DC: U.S. Government Printing Office, November 2000.
5. U.S. Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. 
6. U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000.
7. Sussman S. School-based tobacco use prevention and cessation: where are we going? American Journal of Health Behavior 2001; 25(3):191-9.
8. Dent CW, Sussman S, Stacy AW, Craig S, Burton D, Flay BR.  Two-year behavior outcomes of project towards no tobacco use. Journal of Consulting and Clinical Psychology 1995; 63(4): 676-677.
9. Botvin GJ, Baker E, Dusenbury L, Botvin EM, Diaz T. Long-term follow-up results of a randomized drug abuse prevention trial in a White middle-class population. Journal of the American Medical Association 1995; 273(14):1106-1112.
10. Lantz PM, Jacobson PD, Warner KE, Wasserman J, Pollack HA, Berson J, Ahlstrom A. Investing in youth tobacco control: a review of smoking prevention and control strategies. Tobacco Control 2000; 9:47-63.
11. Rooney BL, Murray DM. A meta-analysis of smoking prevention programs after adjustment for errors in the unit of analysis. Health Education Quarterly 1996; 23(1):48-64.
12. Bruvold WH. A meta-analysis of adolescent smoking prevention programs. American Journal of Public Health 1993; 83(6):872-80.
13. Coyle SL, Boruch RF, Turner CF (Eds.). Evaluating AIDS prevention programs (Expanded Ed.). Washington, DC: National Academy Press, 1991.

14. Kirby D, Laris BA, Rolleri L. Sex and HIV education programs for youth: Their impact and important characteristics.  Washington DC: Family Health International, 2006.  Available at www.etr.org/recapp/programs/SexHIVedProgs.pdf.

15. Pedlow CT, Carey MP.  Developmentally appropriate sexual risk reduction interventions for adolescents: rationale, review of interventions, and recommendations for research and practice. Annals of Behavioral Medicine 2004; 27(3):172-184.

16. Kirby D, Rolleri L, Wilson MM. Tool to Assess the Characteristics of Effective Sex and STD/HIV Education Programs. Washington, DC: Healthy Teen Network, 2007.

17. Food and Nutrition Board, Institute of Medicine, Committee on Prevention of Obesity of Children and Youth, Schools. In: JP Koplan, CT Liverman and VI Kraak, Editors, Preventing Childhood Obesity: Health in the Balance. National Academy Press, Washington, DC, 2005, pp. 237–284.

18. American Dietetic Association, Society for Nutrition Education, and American School Food Service Association. Nutrition services: an essential component of comprehensive school health programs. Journal of Nutrition Education and Behavior 2003; 35(2):57-67.

19. Ralston K, Buzby J, Guthrie J. A Healthy School Meal Environment. United States Department of Agriculture, Economic Research Service, Food Assistance and Nutrition Research Report Number 34-5. Available at: http://www.ers.usda.gov/publications/fanrr34/fanrr34-5/fanrr34-5.pdf. 

20. US Department of Agriculture. Changing the Scene: Improving the School Nutrition Environment. Available at: http://www.fns.usda.gov/tn/Resources/changing.html. 

21. CDC. Guidelines for school health programs to promote lifelong healthy eating.  MMWR 1996; 45(No. RR-9).

22. CDC. School health index. Atlanta, GA: US Department of Health and Human Services, CDC, 2006. Available at http://www.cdc.gov/healthyyouth/shi

23. Hoelscher D, Feldman H, Johnson C, et al. School-based health education programs can be maintained over time: results from the CATCH institutionalization study. Preventive Medicine 2004; 38(5):594-606.

24. Pate RR, Davis MG, Robinson TN, Stone EJ, McKenzie TL, Young JC. Promoting physical activity in children and youth: a leadership role for schools. Circulation 2006; 114:1-11.

25. Pate R, Pratt M, Blair SN et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. Journal of the American Medical Association 1995; 273(5):402-7.

26. CDC. HIV Prevention in the Third Decade. Atlanta, GA: US Department of Health and Human Services, CDC; 2003. Available at http://www.cdc.gov/hiv/HIV_3rdDecade/.  

27. CDC. HIV/AIDS Surveillance Report, 2004. Vol. 16. Atlanta, GA: US Department of Health and Human Services, CDC; 2005:1–46. 

28. Anderson RN, Smith BL.  Deaths: leading causes for 2002. National Vital Statistics Reports 2005; 53(17):67–70.

29. CDC.  Diagnosis of HIV/AIDS—32 states, 2000-2003. MMWR 2004 53:1106-1110.

30. CDC. National Center for HIV, STD and TB Prevention, Divisions of HIV/AIDS Prevention. HIV/AIDS among Hispanics, 2007. Available at http://www.cdc.gov/hiv/pubs/facts/hispanic.htm. 

31.  Eaton DK, Kann L, Kinchen S, et al.  Youth risk behavior surveillance—United States, 2005.  MMWR 2006; 55(No. SS-5).

32. Gilliland L, Scully, J..  STI-HIV Prevention: A Model Program in a School-Based Health Center.  Nursing Clinics of North America 2005; 40:681-688.

33. Ginsburg KR, Slap GB, Cnaan A, et al..  Adolescents’ perceptions of factors affecting their decisions to seek future healthcare.  Journal of the American Medical Association 1995; 273:1913-8.

34. Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE.  Influence of physican confidentiality assurances on adolescents’ willingness to disclose information and seek future healthcare.  Journal of the American Medical Association 1997; 278:1029-34.

35. Lieu T, Newacheck P, McManus M.  Race, ethnicity, and access to ambulatory care among US adolescents.  American Journal of Public Health 1993; 83:960-5.

36. Allensworth D, Kolbe L. The comprehensive school health program: state of the art.  Journal of School Health 1987; 63:14–20.

37. Golan M, Crow S. Targeting parents exclusively in the treatment of childhood obesity: long-term results. Obesity Research 2004;12:357-361.

38. Epstein LH, Voloski A, Wing RR, McCurley J. Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychology 1994;13:373-83.

39. Splett PL, Erickson CD, Belseth SB, Jensen C. Evaluation and sustainability of the healthy learners asthma initiative. Journal of School Health 2006; 76(6):276-282.

40. Erickson, CD, Splett PL, Mullett SS, Jensen C, Belseth SB. The healthy learner model for student chronic condition management-Part II: The Asthma Initiative." Journal of School Nursing 2006; 22(6):319-329.

41. Levy M., Heffner B, Stewart T, Beeman G. The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations for asthma. Journal of School Health 2006; 76(6):320-324.

42. Szapocznik J, Coatsworth JD. An ecodevelopmental framework for organizing risk and protection for drug abuse: A developmental model of risk and protection. In M Glantz & CR Hartel (Eds.), Drug Abuse: Origins and Interventions (pp. 331–366). Washington, DC: American Psychological Association, 1999.

43. Pequegnat W, Szapocznik J. The role of families in preventing and adapting to HIV/AIDS: Issues and answers. In W Pequegnat & J Szapocznik (Eds.), Working with families in the era of HIV/AIDS. Thousand Oaks, CA: Sage Publications, 2000.

44. Nader PR, Sellers De, Johnson CC, Perry CL, Stone EJ, Cook KC, Bebchuk J, Luepker RV. The effect of adult participation in a school-based family intervention to improve children's diet and physical activity: the Child and Adolescent Trial for Cardiovascular Health. Preventive Medicine 1996;. 25:455-464.

45. Perry CL, Luepker RV, Murray DM, Kurth C, Mullis R, Crockett S, Jacobs DR. Parent involvement with children's health promotion: the Minnesota Home Team. American Journal of Public Health 1988; 78(9):1156-1160.

46. Hopper CA, Gruber MB, Munoz KD, Herb RA. Effect of including parents in a school-based exercise and nutrition program for children. Research Quarterly for Exercise and Sport. 1992; 63(3):315-321.

47. Center for AIDS Prevention Studies (CAPS) and the AIDS Research Institute, University of California, San Francisco. What Works Best in Sex/HIV Education?  San Francisco: University of California San Francisco, 2006.  

48. Council of Chief State School Officers. What Education Leaders Should Know About Forming Partnerships to Prevent Sexual-Risk Behaviors in School-Aged Youth.  Washington, DC: Author, 2005.

49. Allensworth, D. Health education: state of the art.  Journal of School Health 1993; 63:14–20.

50. National Commission on the Role of the School and the Community to Improve Adolescent Health.  Code Blue: Uniting for Healthier Youth.  Alexandria, VA: National Association of State Boards of Education, 1990.

51. Public Education Network. Teacher Professional Development: A Primer for Parents and Community Members.  Washington, DC:  Public Education Network, 2004.

52. Togneri W, Anderson SE. Beyond Islands of Excellence: What Districts Can Do to Improve Instruction and Achievement in all Schools. Washington, DC: Learning First Alliance, 2003. 

53. Miles KH, Darling-Hammond L. Rethinking the Allocation of Teaching Resources: Some Lessons From High-Performing Schools. Philadelphia: Consortium for Policy Research in Education, 1997.

54. Jones SE, Brener ND, McManus T.  The relationship between staff development and health instruction in schools in the United States.  American Journal of Health Education 2004; 35:2-10.