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Health Education: Results From the School Health Policies and Programs Study 2006

Posted on: Saturday, 22 December 2007, 06:00 CST

By Kann, Laura Telljohann, Susan K; Wooley, Susan F

ABSTRACT BACKGROUND: School health education can effectively help reduce the prevalence of health-risk behaviors among students and have a positive influence on students' academic performance. This article describes the characteristics of school health education policies and programs in the United States at the state, district, school, and classroom levels.

METHODS: The Centers for Disease Control and Prevention conducts the School Health Policies and Programs Study every 6 years. In 2006, computer-assisted telephone interviews or self-administered mail questionnaires were completed by state education agency personnel in all 50 states plus the District of Columbia and among a nationally representative sample of districts (n = 459). Computer- assisted personal interviews were conducted with personnel in a nationally representative sample of elementary, middle, and high schools (n = 920) and with a nationally representative sample of teachers of classes covering required health instruction in elementary schools and required health education courses in middle and high schools (n = 912).

RESULTS: Most states and districts had adopted a policy stating that schools will teach at least 1 of the 14 health topics, and nearly all schools required students to receive instruction on at least 1 of these topics. However, only 6.4% of elementary schools, 20.6% of middle schools, and 35.8% of high schools required instruction on all 14 topics. In support of schools, most states and districts offered staff development for those who teach health education, although the percentage of teachers of required health instruction receiving staff development was low.

CONCLUSIONS: Health education has the potential to help students maintain and improve their health, prevent disease, and reduce health-related risk behaviors. However, despite signs of progress, this potential is not being fully realized, particularly at the school level.

Keywords: school health education; schools; school policy; surveys.

Citation: Kann L, Telljohann SK, Wooley SF. Health education: Results from the School Health Policies and Programs Study 2006. J Sch Health. 2007; 77: 408-434.

School health education has been denned in various, though similar ways. For example, the Centers for Disease Control and Prevention (CDC) defines health education as: "A planned, sequential, K-12 curriculum that addresses the physical, mental, emotional, and social dimensions of health. The curriculum is designed to motivate and assist students to maintain and improve their health, prevent disease, and reduce health-related risk behaviors. It allows students to develop and demonstrate increasingly sophisticated health-related knowledge, attitudes, skills, and practices. The comprehensive health education curriculum includes a variety of topics such as personal health, family health, community health, consumer health, environmental health, sexuality education, mental and emotional health, injury prevention and safety, nutrition, prevention and control of disease, and substance use and abuse. Qualified, trained teachers provide health education."1,2

In 2002, the 2000 Joint Committee on Health Education Terminology defined health education as "the development, delivery, and evaluation of planned, sequential, and developmentally appropriate instruction, learning experiences, and other activities designed to protect, promote, and enhance the health literacy, attitudes, skills, and well-being of students, pre-kindergarten through grade 12."3

Regardless of the exact definition, reviews of effective programs and curricula and input from experts in the field of health education have identified the following characteristics of effective health education:4-14

* focuses on specific behavioral outcomes

* is research based and theory driven

* addresses individual values and group norms that support health- enhancing behaviors

* focuses on increasing the personal perception of risk and harmfulness of engaging in specific health-risk behaviors, as well as reinforcing protective factors

* addresses social pressures and influences

* builds personal competence, social competence, and self- efficacy by addressing skills

* provides functional health knowledge that is basic, accurate, and directly contributes to health-promoting decisions and behaviors

* uses strategies designed to personalize information and engage students

* provides age-appropriate and developmentally appropriate information, learning strategies, teaching methods, and materials

* incorporates learning strategies, teaching methods, and materials that are culturally inclusive

* provides adequate time for instruction and learning

* provides opportunities to reinforce skills and positive health behaviors

* provides opportunities to make positive connections with influential persons

* includes teacher information and plans for professional development and training that enhances effectiveness of instruction and student learning.

The National Health Education Standards provide a framework for designing or selecting health education curricula and allocating instructional resources, as well as providing a basis for the assessment of student achievement. The National Health Education Standards also offer students, families, and communities concrete expectations for health education. The Joint Committee on National Health Education Standards released the first set of standards in 1995 is The National Health Education Standards Review and Revision Panel released the following updated set of 8 standards in 2007:16

1. Students will comprehend concepts related to health promotion and disease prevention to enhance health.

2. Students will analyze the influence of family, peers, culture, media, technology, and other factors on health behaviors.

3. Students will demonstrate the ability to access valid information and products and services to enhance health.

4. Students will demonstrate the ability to use interpersonal communication skills to enhance health and avoid or reduce health risks.

5. Students will demonstrate the ability to use decision-making skills to enhance health.

6. Students will demonstrate the ability to use goalsetting skills to enhance health.

7. Students will demonstrate the ability to practice health- enhancing behaviors and avoid or reduce health risks.

8. Students will demonstrate the ability to advocate for personal, family, and community health.

Research has shown that school health education can effectively help reduce the prevalence of healthrisk behaviors among students and have a positive influence on students' academic performance. For example, a tobacco-use prevention program reduced by about 26% the number of students who started smoking during grades 7-9;17 a comprehensive intervention that included health education in public elementary schools that serve high-crime areas in Seattle, Washington, was associated with increased student commitment to school, reduced misbehavior in school, and improved academic achievement, plus fewer risk-taking behaviors such as violence and heavy drinking;18 and the Coordinated Approach to Child Health curriculum slowed increases in the number of Hispanic students who were overweight or at risk of becoming overweight when it was implemented in elementary schools in a low-income community in El Paso, Texas.19

SELECTED FEDERAL SUPPORT AND RELATED RESEARCH

Support for school health education comes from many sources. Through February 2008, the CDC's Division of Adolescent and School Health will be supporting education agencies and health agencies to help build and strengthen their capacity for improving child and adolescent health within the following 6 priority areas, all of which include school health education activities:

* Human immunodeficiency virus (HTV) prevention-CDC funds education agencies in 48 states, the District of Columbia, 7 territories, and 17 large urban school districts to help schools prevent sexual risk behaviors that result in HIV infection, especially among youth who are at highest risk.

* Coordinated school health programs-CDC funds 23 state education agencies, and through them their state health agencies, to build state education agency and state health agency partnerships and their capacity to implement and coordinate school health programs across agencies and within schools and to help schools reduce chronic disease risk factors, including tobacco use, poor nutrition, and physical inactivity.

* Abstinence-CDC funds 11 state education agencies to help schools increase the efficiency and impact of their efforts to help young people abstain from sexual risk behaviors.

* Asthma-CDC funds 1 state and 7 local education agencies to implement demonstration programs that help schools reduce asthma episodes and asthma-related absences.

* Professional development-CDC funds 2 state education agencies to help schools reduce health problems among youth by planning and delivering professional development opportunities that build the capacity of other funded agencies to support the expansion, improvement, and sustainability of their school health programs.

* Food safety-CDC provides funding for 1 state education agency to implement a demonstration program that helps schools reduce food- borne illnesses. The CDC also funds 30 national nongovernmental organizations to provide capacity building services to these funded agencies. In addition, many programs at the CDC have developed instructional materials that can be used by teachers for school health education20 and some support state programs that include school health education activities.

Several other federal agencies also support school health education throughout the nation. The US Department of Education, through the Office of Safe and Drug Free Schools, funds drug and violence prevention and activities that promote the health and well being of students in elementary and secondary schools.21 State and local education agencies carry out most activities, many of which focus on school health education. The US Departments of Education, Health and Human Services, and Justice fund the Safe Schools/ Healthy Students program to prevent violence and substance abuse among youth and within schools and communities.22 The US Department of Health and Human Services also supports abstinence education with 3 programs, all of which include school health education activities: the Adolescent Family Life Abstinence Education Demonstration Projects,23 section 510 State Abstinence Education Program,24 and the Community-Based Abstinence Education Program.25

Healthy People 2010 Objective 7-2a to "increase the proportion of middle, junior high, and senior high schools that provide school health education to prevent health problems in the following areas: unintentional injury; violence; suicide; tobacco use and addiction; alcohol and other drug use; unintended pregnancy, HIV/AIDS, and STD infection; unhealthy dietary patterns; inadequate physical activity; and environmental health" articulates further federal-level support for health education.26

State and local agencies and many nongovernmental organizations also support school health education. Universities and other research organizations conduct studies to document the effectiveness of school health education and its impact on students' health and educational outcomes. This research provides a framework for advocating for further federal, state, and local support for school health education and is often the key to helping decision makers understand the value of making room in the overcrowded and testing- focused curriculum for school health education. Most of these studies focus on only 1 or 2 content areas, but taken together, they provide evidence of the impact that school health education can have and its critical role, along with the other components of the school health program, in helping students improve health, prevent disease, and reduce risks.

The School Health Policies and Programs Study (SHPPS) was conducted previously in 199427 and again in 2000.28 The 1994 study focused only on middle schools and high schools. The 2000 study assessed health education in elementary schools, middle schools, and high schools. Both studies provided a comprehensive assessment of health education at the state, district, school, and classroom levels, but they are now out of date. Other studies since 2000 have examined various aspects of school health education nationwide. For example, the National Association of State Boards of Education's Center for Safe and Healthy Schools maintains an extensive database of state school health policies on 38 major school health topics in 6 major categories including curriculum and instruction,29 and the Guttmacher Institute monitors state-level policies on sex education and sexually transmitted diseases (STD)/HIV education.30 However, no other studies since SHPPS 2000 are national in scope, cover most aspects of health education, and address the state, district, school, and classroom levels.

This article describes for the first time findings from SHPPS 2006 about state- and district-level health education standards and guidelines; elementary school, middle school, and high school instruction; professional preparation; staffing and staff development; collaboration; evaluation; and health education coordinators. At the school level, this article describes health education requirements; elementary school, middle school, and high school instruction; staffing and professional development; and collaboration. At the classroom level, this article describes elementary school, middle school, and high school instruction; teaching methods; and staffing and staff development. In addition, the article describes changes in key health education policies and programs from 2000 to 2006. While this article is primarily descriptive in nature, the CDC intends to conduct more detailed analyses and encourages others to conduct their own analyses using the questionnaires and public-use data sets available at www.cdc.gov/ shpps.

METHODS

Detailed information about SHPPS 2006 methods is provided in "Methods: School Health Policies and Programs Study 2006" elsewhere in this issue of the Journal of School Health. The following section provides a brief overview of SHPPS 2006 methods specific to the health education component of the study.

SHPPS 2006 assessed health education at the state, district, school, and classroom levels. Statelevel data were collected from education agencies in all 50 states plus the District of Columbia. Districtlevel data were collected from a nationally representative sample of public school districts. School-level data were collected from a nationally representative sample of public and private elementary schools, middle schools, and high schools. Classroom- level data were collected from teachers of randomly selected classes covering required health instruction in elementary schools and randomly selected required health education courses in middle schools and high schools.

Questionnaires

The state- and district-level questionnaires assessed school health education policies for grades K12. Both questionnaires assessed use of school health education standards and guidelines; required health education instruction at the elementary school, middle school, and high school levels; staffing and staff development; collaboration between health education staff and other agency and organization staff; and the educational background and credentials of the person who oversees or coordinates school health education for the state or district. The statelevel questionnaire also collected data on student assessment practices and the district- level questionnaire also collected data on evaluation of health education and how health education is promoted among families, school personnel, and the media.

Because the entire district-level questionnaire took longer than 20-30 minutes to complete and covered such a wide range of topics that a single respondent might not have sufficient knowledge to complete it, the questionnaire was divided into 5 modules: (1) standards and guidelines, (2) elementary school instruction, (3) middle/junior high school instruction, (4) senior high school instruction, and (5) staffing and staff development, collaboration, promotion, evaluation, and health education coordinator.

The school-level health education questionnaire assessed health education practices in elementary schools, middle schools, and high schools. Specifically, the questionnaire assessed use of school health education standards, guidelines, and objectives; required health instruction; staffing and staff development; collaboration between health education teachers and other school and community personnel; promotion of health education among families and students; and the educational background and credentials of the person who oversees or coordinates health education at the school.

The classroom-level health education questionnaire assessed general characteristics of health education classes or courses; specific content taught; teaching methods; and the educational background, credentials, and recent staff development of health education teachers.

Data Collection and Respondents

State- and district-level data were collected by computer- assisted telephone interviews or self-administered mail questionnaires. Designated respondents for each of 7 school health program components (ie, health education, physical education and activity, health services, mental health and social services, nutrition services, healthy and safe school environment, and faculty and staff health promotion) completed the interviews or questionnaires. At the state level, the state-level contact designated a single respondent for each questionnaire. At the district level, the district-level contact could designate a different respondent for each questionnaire or questionnaire module. All designated respondents had primary responsibility for, or were the most knowledgeable about, the policies and programs addressed in the particular questionnaire or module.

After a state- or district-level contact identified respondents, each respondent was sent a letter of invitation and packet of study- related materials. Each packet contained a paper copy of the questionnaire (s) so that respondents could prepare for the interview and provided a toll-free number and access code that respondents could use to initiate the interview. Respondents were told that the questionnaire (s) could be used in preparation for their telephone interview or completed and returned if self- administration was preferred. One week after packets were mailed to respondents, trained interviewers from a call center placed calls to them to schedule and conduct telephone interviews. In April 2006, telephone interviewing ceased and most of the remaining state- and district-level data collection occurred via a mail survey. All remaining respondents were mailed paper questionnaires and return envelopes; however, interviewers remained available for any respondents who chose to contact the call center.

At the end of the data collection period (October 2006), 88% of the completed state-level health education questionnaires had been completed via telephone interviews and 12% as paper questionnaires. For the completed district-level questionnaires, module 1 was completed via telephone interview 51% of the time; module 2, 54%; module 3, 50%; module 4, 51%; and module 5, 52%. School-level and classroom-level data were collected by computer-assisted personal interviews. During recruitment, the principal or another schoollevel contact designated a faculty or staff respondent for each questionnaire or module, who had primary responsibility for or the most knowledge about the particular component. The principal or school-level contact could designate a different respondent for each questionnaire or module. For the school-level health education interview, the most common respondents were health education teachers, physical education teachers, or other teachers.

At the classroom level, respondents to the computer-assisted personal interviews were those health education teachers whose elementary school class or middle school or high school course was selected during the sampling process. All school-level and classroom- level interviews were completed between January and June 2006.

Response Rates

One hundred percent (n = 51) of the state education agencies completed the state-level health education questionnaire. District eligibility for each module was determined prior to beginning the interview; 720 districts were eligible for each of modules 1 and 5, 697 districts were eligible for module 2, 695 for module 3, and 663 for module 4. Of the 720 districts eligible to complete any health education questionnaire module, 64% (n = 459) completed at least 1 module. At the school level, 1338 schools were eligible for the health education interview; 69% (n = 920) of these schools completed the interview. At the classroom level, 967 classes or courses were selected for the health education interview; teachers of 94% (n = 912) of these classes or courses completed the interview.

Data Analysis

Data from state-level questionnaires are based on a census and are not weighted. District-, school-, and classroom-level data are based on representative samples and are weighted to produce national estimates. Two weights were constructed for analysis of classroom data. The first weight is appropriate for making inferences to schools nationwide based on the aggregation of classroom data within each school. The second weight is appropriate for making inferences to required elementary school classes or required middle school and high school courses nationwide based on the data about the individual classes or courses.

Because of missing data, the denominators for each estimate vary slightly. Figures 1-3 in Appendix 1 of this issue of the Journal of School Health show the estimated standard error associated with an observed estimate from the district-, school-, and classroom-level health education questionnaires.

To analyze changes between SHPPS 2000 and SHPPS 2006, many variables from SHPPS 2000 were recalculated so that the denominators used for both years of data were defined identically. In most cases, this denominator included all states, districts, or schools rather than a subset of states, districts, or schools. As a result of this recalculation, percentages previously reported for SHPPS 200028 might differ from those reported in this article. Only estimates from 2000 and 2006 based on this same denominator should be compared.

Because state-level data are based on a census, statistical tests for differences between 2000 and 2006 are not appropriate. Therefore, this article highlights changes over time meeting at least 1 of 2 criteria: (1) the difference was greater than 10 percentage points or 2) the 2006 estimate increased by at least a factor of 2 or decreased by at least half as compared with the 2000 estimate. At the district, school, and classroom levels, t tests were used to compare SHPPS 2000 and SHPPS 2006 prevalence estimates. However, to account for multiple comparisons, this article only highlights changes over time meeting at least 2 of 3 criteria: (1) a p value less than .01 from the t test, (2) a difference greater than 10 percentage points, or (3) the 2006 estimate increased by at least a factor of 2 or decreased by at least half as compared with the 2000 estimate. A p value less than .01 was used as the sole criterion for reporting on statistically significant differences based on means and medians between 2000 and 2006. Note that not all variables meeting these criteria are presented in this article.

RESULTS

Health Education at the State and District Levels

Standards and Guidelines. Most (74.5%) states had adopted a policy stating that districts or schools will follow national or state health education standards or guidelines. An additional 7.8% of states had adopted a policy encouraging districts or schools to follow national or state health education standards or guidelines. Among all states, 72.0% required or encouraged districts or schools to follow health education standards or guidelines based specifically on the National Health Education Standards.16 To improve district or school compliance with any national or state health education standards or guidelines, 87.8% of the 42 states that required or encouraged following national or state standards or guidelines used staff development for health education teachers, 56.4% included health education when the state did onsite reviews in school districts for overall compliance with educational standards or guidelines, 34.2% used written reports from districts or schools to document compliance, and 14.3% included health education in statewide assessments or testing.

Most (79.3%) districts also had adopted a policy stating that schools will follow national, state, or district health education standards or guidelines. An additional 5.6% of districts had adopted a policy encouraging schools to follow national, state, or district health education standards or guidelines. Among all districts, 66.0% required or encouraged schools to follow health education standards or guidelines based specifically on the National Health Education Standards.16 To improve school compliance with any national, state, or district health education standards or guidelines, 87.5% of the 84.9% of districts that required or encouraged schools to follow national, state, or district standards or guidelines used teacher evaluations or classroom monitoring, 78.1% used staff development for health education teachers, 74.2% used teachers to mentor other teachers, and 53.9% used written reports from schools to document compliance with health education standards or guidelines.

Elementary School Instruction. Nationwide, 70.6% of states had adopted goals, objectives, or expected outcomes for elementary school health education. Similarly, among districts nationwide that provide elementary school instruction, 70.2% had adopted goals, objectives, or expected outcomes for elementary school health education. Almost two thirds or more of states and more than half of districts had adopted goals and objectives for elementary school health education that addressed the knowledge and skills articulated in the National Health Education Standards,16 such as accessing valid health information and health-promoting products and services; advocating for personal, family, and community health; analyzing the influence of culture, media, technology, and other factors on health; comprehending concepts related to health promotion and disease prevention; practicing health-enhancing behaviors and reducing health risks; using goalsetting and decision-making skills to enhance health; and using interpersonal communication skills to enhance health (Table 1).

Nationwide, 88.2% of states had adopted a policy stating that elementary schools will teach at least 1 of the 14 health topics (chosen to reflect the leading causes of mortality and morbidity among both youth and adults and other important public health issues) and 62.8% had adopted a policy stating that elementary schools will teach at least 7 of the 14. Only 5.9% of states had adopted a policy stating that elementary schools will teach all 14. More than half of all states had adopted a policy stating that elementary schools will teach about alcohol-use or other drug-use prevention, emotional and mental health, HIV prevention, injury prevention and safety, nutrition and dietary behavior, physical activity and fitness (ie, classroom instruction not a physical education period), tobacco-use prevention, and violence prevention (Table 2). Less than half of all states had adopted a policy stating that elementary schools will teach about asthma awareness, food- borne illness prevention, human sexuality, other STD prevention, pregnancy prevention, and suicide prevention. Only 19.6% of states had specified time requirements for at least 1 health topic or any health instruction at the elementary school level. Similarly, only 19.6% of states had adopted a policy stating that elementary school students will be tested on health topics.

Among all districts nationwide that provided elementary school instruction, 91.2% had adopted a policy stating that elementary schools will teach at least 1 of the 14 health topics and 64.2% had adopted a policy stating that elementary schools will teach at least 7 of the 14. Only 9.4% of districts had adopted a policy stating that elementary schools will teach all 14. More than half of all districts had adopted a policy stating that elementary schools will teach alcohol-use or other drug-use prevention, emotional and mental health, injury prevention and safety, nutrition and dietary behavior, physical activity and fitness, tobacco-use prevention, and violence prevention (Table 2). Less than half of districts had adopted a policy stating that elementary schools will teach about asthma awareness, food-borne illness prevention, or suicide prevention. Similarly, less than half of all districts had adopted a policy stating that elementary schools will teach about HTV prevention, human sexuality, other STD prevention, and pregnancy prevention. Among the 60.8% of districts that required that at least 1 of these 4 topics be taught, 85.4% had adopted a policy stating that elementary schools will notify parents or guardians before students receive the instruction and 92.0% had adopted a policy stating that elementary schools will allow parents or guardians to exclude their children from receiving the instruction. Only 36.9% of districts had specified time requirements for at least 1 health topic or any health instruction at the elementary school level. Only 5.9% of states required and 15.7% recommended that districts or schools use 1 particular curriculum (defined as a written course of study that generally describes what students will know and be able to do by the end of a single grade or multiple grades and for a particular subject area; often presented through a detailed set of directions, strategies, and materials to facilitate student learning and teaching of content) for elementary school health education. Curriculum requirements were more common at the district level than at the state level. Among all districts that provided elementary school instruction, 31.2% required and 27.3% recommended that schools use 1 particular curriculum for elementary school health education. The state education agency contributed to the development of this curriculum in 33.3% of the districts that had a requirement or recommendation. The district itself contributed to the development of this curriculum in 24.8% of the districts, a commercial company did so in 10.6% of the districts, and other state agencies, academic institutions, or state-level organizations or coalitions each contributed to the development of this curriculum in fewer than 5% of districts.

During the 2 years preceding the study, states and districts provided a variety of materials for elementary school health education (Table 3). Generally, states were most likely to provide plans for how to assess or evaluate students in health education, and districts were most likely to provide health education curricula and lesson plans or learning activities.

Middle School Instruction. Nationwide, 76.5% of states had adopted goals, objectives, or expected outcomes for middle school health education. Similarly, among districts nationwide that provided middle school instruction, 80.9% had adopted goals, objectives, or expected outcomes for middle school health education. At least two thirds of states and districts had adopted goals and objectives for middle school health education that addressed the knowledge and skills articulated in the National Health Education Standards16 (Table 1).

Nationwide, 86.3% of states had adopted a policy stating that middle schools will teach at least 1 of the 14 health topics and 62.8% had adopted a policy stating those schools will teach at least 7 of the 14. Only 21.6% of states had adopted a policy stating that middle schools will teach all 14. More than half of all states had adopted a policy stating that middle schools will teach about alcohol-use or other druguse prevention, emotional and mental health, HIV prevention, human sexuality, injury prevention and safety, nutrition and dietary behavior, other STD prevention, physical activity and fitness, pregnancy prevention, suicide prevention, tobacco-use prevention, and violence prevention (Table 2). Less than half of all states had adopted a policy stating that middle schools will teach about asthma awareness and food-borne illness prevention. Only 31.4% of states had specified time requirements for at least 1 health topic or any health instruction at the middle school level. Nationwide, 21.6% of states had adopted a policy stating that middle school students will be tested on health topics.

Among all districts nationwide that provided middle school instruction, 94.3% had adopted a policy stating that those schools will teach at least 1 of the 14 health topics and 82.3% had adopted a policy stating that they will teach at least 7 of the 14. Only 27.2% of districts had adopted a policy stating that middle schools will teach all 14. More than two thirds of all districts had adopted a policy stating that middle schools will teach about alcohol-use or other drug-use prevention, emotional and mental health, HIV prevention, human sexuality, injury prevention and safety, nutrition and dietary behavior, other STD prevention, physical activity and fitness, pregnancy prevention, tobacco-use prevention, and violence prevention (Table 2). Less than two thirds of all districts had adopted a policy stating that middle schools will teach about asthma awareness, food-borne illness prevention, and suicide prevention. Among the 85.5% of districts that required middle schools to teach HIV prevention, human sexuality, other STD prevention, or pregnancy prevention, 72.7% had adopted a policy stating that those schools will notify parents or guardians before students receive the instruction, and 85.7% had adopted a policy stating that middle schools will allow parents or guardians to exclude their children from receiving the instruction. Two thirds (66.8%) of districts had specified time requirements for at least 1 health topic or any health instruction at the middle school level.

Only 7.8% of states required and 9.8% recommended that districts or schools use 1 particular curriculum for middle school health education. Curriculum requirements were more common at the district level than at the state level. Among all districts that provided middle school instruction, 36.8% required and 25.8% recommended that schools use 1 particular curriculum for middle school health education. The state education agency contributed to the development of this curriculum in 32.0% of the districts that had a requirement or recommendation. The district itself contributed to the development of this curriculum in 34.3% of the districts, a commercial company did so in 12.7% of the districts, and other state agencies, academic institutions, or state-level organizations or coalitions each contributed to the development of this curriculum in less than 6% of districts.

During the 2 years preceding the study, states and districts provided a variety of materials for middle school health education (Table 3). Generally, states were most likely to provide plans for how to assess or evaluate students in health education, and districts were most likely to provide health education curricula, lesson plans or learning activities for health education, a chart describing the scope and sequence of instruction for health education, and a list of recommended health education curricula.

High School Instruction. Nationwide, 78.4% of states had adopted goals, objectives, or expected outcomes for high school health education. Similarly, among districts nationwide that provide high school instruction, 82.9% had adopted goals, objectives, or expected outcomes for high school health education. More than two thirds of states and more than three fourths of districts had adopted goals and objectives for high school health education that addressed the knowledge and skills articulated in the National Health Education Standards16 (Table 1).

Nationwide, 90.2% of states had adopted a policy stating that high schools will teach at least 1 of the 14 health topics and 60.8% had adopted a policy stating that they will teach at least 7 of the 14. Only 21.6% of states had adopted a policy stating that high schools will teach all 14. More than half of all states had adopted a policy stating that high schools will teach about alcohol-use or other drug-use prevention, emotional and mental health, HIV prevention, human sexuality, injury prevention and safety, nutrition and dietary behavior, other STD prevention, physical activity and fitness, pregnancy prevention, suicide prevention, tobacco-use prevention, and violence prevention (Table 2). Less than half of all states had adopted a policy stating that high schools will teach about asthma awareness and foodborne illness prevention. Nearly, two thirds (60.8%) of states had specified time requirements for at least 1 health topic or any health instruction at the high school level. Nationwide, 21.6% of states had adopted a policy stating that high school students will be tested on health topics.

Among all districts nationwide that provided high school instruction, 95.1% had adopted a policy stating that high schools will teach at least 1 of the 14 health topics and 87.4% had adopted a policy stating that they will teach at least 7 of the 14. About one third (35.5%) of districts had adopted a policy stating that high schools will teach all 14. More than three fourths of all districts had adopted a policy stating that high schools will teach about alcohol-use or other drug-use prevention, emotional and mental health, HIV prevention, human sexuality, injury prevention and safety, nutrition and dietary behavior, other STD prevention, physical activity and fitness, pregnancy prevention, suicide prevention, tobacco-use prevention, and violence prevention (Table 2). Less than three fourths of all districts had adopted a policy stating that high schools will teach about asthma awareness and food- borne illness prevention. Among the 90.5% of districts that required high schools to teach HIV prevention, human sexuality, other STD prevention, or pregnancy prevention, 59.9% had adopted a policy stating that those schools will notify parents or guardians before students receive the instruction, and 76.3% had adopted a policy stating that high schools will allow parents or guardians to exclude their children from receiving the instruction. Most (81.9%) districts had specified time requirements for at least 1 health topic or any health instruction at the high school level. Only 7.8% of states required and 11.8% recommended that districts or schools use 1 particular curriculum for high school health education. Curriculum requirements were more common at the district than at the state level. Among all districts that provided high school instruction, 37.5% required and 25.1% recommended that schools use 1 particular curriculum for high school health education. The state education agency contributed to the development of this curriculum in 34.8% of the districts that had a requirement or recommendation. The district itself contributed to the development of this curriculum in 34.8% of the districts, a commercial company did so in 9.7%, and other state agencies, academic institutions, or state- level organizations or coalitions each contributed to the development of this curriculum in 5% or fewer districts.

During the 2 years preceding the study, states and districts provided a variety of materials for high school health education (Table 3). Generally, states were most likely to provide plans for how to assess or evaluate students in health education and lesson plans or learning activities for health education, and districts were most likely to provide health education curricula and a list of recommended health education textbooks.

Professional Preparation. Nationwide, 34.0% of all states and 33.7% of all districts had adopted a policy stating that newly hired staff who teach health education at the elementary school level will have undergraduate or graduate training in health education, 72.0% of states and 59.0% of districts had adopted this policy for newly hired staff who teach health education at the middle school level and 82.0% of states and 78.1% of districts had adopted this policy for newly hired staff who teach health education at the high school level.

Nationwide, 94.1% of all states offered some type of certification, licensure, or endorsement to teach health education. Specifically, 62.7% of states offered certification, licensure, or endorsement to teach health education for grades K-12; 19.6% offered it for elementary school; 54.9% offered it for middle school; and 58.8% offered it for high school. In addition, 44.0% of states offered a combined health education and physical education certification, licensure, or endorsement for grades K-12; 24.0% offered it for elementary school; 30.0% offered it for middle school; and 32.0% offered it for high school.

Only 21.3% of all states and 41.7% of all districts had adopted a policy stating that newly hired staff who teach health education at the elementary school level will be certified, licensed, or endorsed by the state to teach health education. In contrast, 72.3% of states and 69.7% of districts had adopted this policy for newly hired staff at the middle school level and 78.7% of states and 82.8% of districts had adopted it for newly hired staff at the high school level.

In addition, 15.7% of all states and 35.0% of all districts had adopted a policy stating that newly hired staff who teach health education at the middle school level will be Certified Health Education Specialists (CHES), and 17.6% of states and 40.6% of districts had adopted it for newly hired staff who teach health education at the high school level.

Staffing and Staff Development. Nationwide, 22.0% of states had adopted a policy stating that each school district will have someone oversee or coordinate school health education and 13.7% of states had adopted a policy stating that each school will have someone perform this function at the school (eg, a lead health education teacher). Among all districts, 42.6% had adopted a policy stating that each school will have someone oversee or coordinate health education at the school.

Nationwide, 61.7% of states had adopted a policy stating that teachers will earn continuing education credits on health topics to maintain state certification, licensure, or endorsement to teach health education. Among all districts, 39.2% had a policy stating that those who taught health education will earn continuing education credits on health education topics.

Staff development was defined as workshops, conferences, continuing education, graduate courses, or any other kind of in- service on health topics or teaching methods. During the 2 years preceding the study, 94.1% of all states provided funding for staff development or offered staff development for those who taught health education on at least 1 of the 14 health topics. Specifically, more than three fourths of all states provided funding for staff development or offered staff development for those who taught health education on alcohol-use or other drug-use prevention, HIV prevention, injury prevention and safety, nutrition and dietary behavior, other STD prevention, physical activity and fitness, tobacco-use prevention, and violence prevention (Table 4). Less than three fourths of all states provided funding for staff development or offered staff development for those who taught health education on asthma awareness, emotional and mental health, food-bome illness prevention, human sexuality, pregnancy prevention, and suicide prevention. In addition, more than three fourths of all states provided funding for staff development or offered staff development on encouraging family or community involvement, teaching skills for behavior change, using classroom management techniques (eg, social skills training, environmental modification, conflict resolution and mediation, and behavior management), and using interactive teaching methods (eg, role plays or cooperative group activities). Less than three fourths of all states provided funding for staff development or offered staff development on assessing or evaluating students in health education; teaching students of various cultural backgrounds; teaching students with limited English proficiency; and teaching students with long-term physical, medical, or cognitive disabilities.

Districts also provided funding for staff development or offered staff development on health topics and teaching methods (Table 4). During the 2 years preceding the study, 94.7% of all districts provided funding for staff development or offered staff development for those who taught health education on at least 1 of the 14 health topics. Specifically, more than half of all districts provided funding for staff development or offered staff development for those who taught health education on alcohol-use or other drug-use prevention, emotional and mental health, HIV prevention, human sexuality, injury prevention and safety, nutrition and dietary behavior, other STD prevention, physical activity and fitness, suicide prevention, tobacco-use prevention, and violence prevention. Less than half of all districts provided funding for staff development or offered staff development for those who taught health education on asthma awareness, food-borne illness prevention, and pregnancy prevention. More than half of all districts provided funding for staff development or offered staff development on encouraging family or community involvement; teaching skills for behavior change; teaching students with long-term physical, medical, or cognitive disabilities; using classroom management techniques; and using interactive teaching methods. Less than half of all districts provided funding for staff development or offered staff development on assessing or evaluating students in health education, teaching students of various cultural backgrounds, and teaching students with limited English proficiency.

Collaboration. State-level health education staff often collaborate with other staff in the state education agency. During the 12 months preceding the study, state-level health education staff worked on health education activities with nutrition or food service staff in 94.1% of states, with physical education staff in 82.4%, with health services staff in 74.5%, and with mental health or social services staff in 70.6%. State-level health education staff also collaborated with staff from other agencies and organizations. During the 12 months preceding the study, in at least half of all states, state-level health education staff worked on health education activities with the state health department (98.0%); a statelevel school health committee, council, or team (94.0%); colleges or universities (92.2%); a statelevel health organization (eg, American Heart Association or American Cancer Society) (90.0%); the state-level American Alliance for Health, Physical Education, Recreation, and Dance (86.0%); a state-level nurses' association (82.0%); the state mental health or social services agency (74.0%); businesses (62.7%); and a state-level physicians' organization (eg, American Academy of Pediatrics) (62.0%).

District-level health education staff collaborate with other staff in the district office. During the 12 months preceding the study, district-level health education staff worked on health education activities with general curriculum coordinators or supervisors in 65.2% of districts, physical education staff in 63.9%, health services staff in 55.3%, nutrition or food service staff in 55.3%, and mental health or social services staff in 38.9%. During the 12 months preceding the study, district-level health education staff also worked on health education activities with a local law enforcement agency (64.6%), a health organization (63.6%), local fire or emergency services (55.1%), a local health department (48.1%), a local mental health or social services agency (44.6%), a local hospital (35.9%), local business (26.8%), a local college or university (26.4%), and a local service club (eg, Rotary Club) (22.4%).

Evaluation. During the 2 years preceding the study, 66.6% of districts nationwide evaluated their health education curricula, 63.3% evaluated their health education policies, and 50.3% evaluated their staff development or in-service programs. Health Education Coordinators. Among the 94.1% of states that had someone who oversees or coordinates school health education, 89.6% had that person serve as the respondent to the state-level health education SHPPS questionnaire. Among those respondents, 100% had an undergraduate degree: 57.1% majored in health education; 50.0% in physical education; 9.5% in some other education field; 7.1% in biology or another science; 4.8% in kinesiology, exercise physiology, or exercise science; 2.4% in public health; and 2.4% in home economics or family and consumer science. Among the state- level coordinators who served as the SHPPS respondent, 64.3% had an undergraduate minor: 25.9% minored in health education, 18.5% in some other education field, 7.4% in physical education, and 7.4% in biology or another science. Among the state-level coordinators who served as the SHPPS respondent, 85.7% had a graduate degree: the most common graduate degree was in health education (40.5%), followed by some other education field (29.7%); physical education (27.0%); kinesiology, exercise physiology, or exercise science (8.1%); public health (2.7%); and biology or another science (2.7%). Among the state-level coordinators who served as the SHPPS respondent, 89.2% had an undergraduate major, an undergraduate minor, or a graduate degree in health education. One third (32.6%) were CHES. More than half (55.8%) were certified, licensed, or endorsed by the state to teach health education at the elementary school level, 69.8% at the middle school level, and 69.8% at the high school level.

At the district level, 70.3% of districts had someone who oversees or coordinates school health education. Unfortunately, the number of these coordinators who served as the respondent to the district-level health education SHPPS questionnaire was too small for meaningful analysis of the data about their qualifications.

Changes Between 2000 and 2006 at the State and District Levels. Between 2000 and 2006, the percentage of states that had adopted a policy stating that districts or schools will follow national or state health education standards or guidelines increased from 60.8% to 74.5%, whereas the percentage of states that had adopted a policy encouraging districts or schools to follow health education standards or guidelines decreased from 29.4% to 7.8%. Similarly, the percentage of districts requiring schools to follow national, state, or district health education standards or guidelines increased from 68.8% to 79.3%.

Between 2000 and 2006, the percentage of states and districts requiring schools to teach about topics related to human sexuality, violence prevention, and injury prevention increased. The percentage of states requiring elementary schools to teach about suicide prevention increased from 26.0% to 44.0%; the percentage requiring middle schools to teach about human sexuality and about pregnancy prevention increased from 46.0% to 58.8% and from 45.1% to 58.8%, respectively; and the percentage requiring high schools to teach about human sexuality and about pregnancy prevention increased from 46.9% to 60.8% and from 45.1% to 58.0%, respectively. The percentage of districts requiring elementary schools to teach about injury prevention and safety and about violence prevention increased from 66.2% to 77.4% and from 73.4% to 83.6%, respectively; the percentage requiring middle schools to teach about injury prevention and safety and about violence prevention increased from 66.7% to 80.3% and from 71.6% to 83.8%, respectively; and the percentage requiring high schools to teach about violence prevention increased from 74.5% to 85.0%.

The percentage of states providing plans for how to assess or evaluate students in elementary school health education increased from 49.0% to 60.0%, but the percentage of states providing other types of materials decreased between 2000 and 2006. Specifically, the percentage of states providing a chart describing the scope and sequence of instruction for elementary school and for high school health education decreased from 62.0% to 51.0% and from 57.1% to 43.1%, respectively, and the percentage providing a high school health education curriculum decreased from 49.0% to 33.3%. In addition, the percentage of states providing a list of 1 or more recommended health education curricula decreased for elementary schools (from 56.0% to 39.2%), middle schools (from 62.0% to 41.2%), and high schools (from 61.2% to 43.1%).

Professional preparation expectations increased among some states and districts between 2000 and 2006. The percentage of states adopting a policy stating that newly hired staff who teach health education at the middle school and high school levels will be CHES increased from 2.0% to 15.7% and from 2.0% to 17.6%, respectively. Similarly, the percentage of districts adopting such a policy at the middle school and high school levels increased from 12.2% to 35.0% and from 16.0% to 40.6%, respectively. Further, the percentage of districts adopting a policy stating that newly hired staff who teach health education at the middle school level will be certified, licensed, or endorsed by the state to teach health education increased from 57.8% to 69.7%.

Between 2000 and 2006, the percentage of states adopting a policy stating that teachers will earn continuing education credits on health topics to maintain state certification, licensure, or endorsement to teach health education increased from 47.8% to 61.7%. To support this type of staff development policy, an increased percentage of states provided funding for staff development or offered staff development for those who taught health education on injury prevention and safety (from 39.6% to 76.0%), nutrition and dietary behavior (from 76.0% to 88.0%), physical activity and fitness (from 68.8% to 82.4%), and suicide prevention (from 50.0% to 66.7%). The percentage of states providing funding for staff development or offering staff development for those who taught health education on teaching students with long-term physical, medical, or cognitive disabilities also increased from 46.0% to 57.1%. However, a decreased percentage of states provided funding for staff development or offered staff development for those who taught health education on HTV prevention (from 96.1% to 84.0%) and other STD prevention (from 92.2% to 80.0%). An increased percentage of districts provided funding for staff development or offered staff development on emotional and mental health (from 44.0% to 58.6%), injury prevention and safety (from 40.0% to 66.2%), nutrition and dietary behavior (43.3% to 65.3%), physical activity and fitness (43.3% to 75.3%), other STD prevention (from 47.5% to 60.6%), suicide prevention (from 41.5% to 56.1%), and violence prevention (from 62.1% to 77.6%). More districts also provided funding for staff development or offered staff development on encouraging family and community involvement (from 51.0% to 64.2%), teaching skills for behavior change (from 54.6% to 66.8%), and teaching students with limited English proficiency (from 27.7% to 44.8%).

Between 2000 and 2006, increased collaboration was detected between state-level health education staff and state-level school nutrition or food service staff (from 75.5% to 94.1%) and with businesses (from 49.0% to 62.7%) and decreased collaboration was detected with state-level health services staff (from 90.0% to 74.5%). Increased collaboration was detected between district-level health education staff and district-level nutrition or food service staff (from 27.7% to 55.3%).

Evaluation activities at the district level increased between 2000 and 2006. Specifically, increases were noted in the percentage of districts evaluating health education curricula (from 53.2% to 66.6%), health education policies (from 37.3% to 63.3%), and health education staff development programs (from 36.6% to 50.3%).

Health Education at the School Level

Health Education Requirements. Nationwide, 92.0% of all schools required students to receive instruction on at least 1 of the 14 health topics. Almost two thirds (61.0%) of all schools required instruction on health topics in at least 1 specific grade. Among all schools that had kindergarten students, 35.8% required health education in kindergarten, 44.6% of all schools that had 1st-grade students required it in 1st grade, 43.5% required it in 2nd grade, 47.7% required it in 3rd grade, 50.3% required it in 4th grade, 60.4% required it in 5th grade, 52.0% required it in 6th grade, 53.3% required it in 7th grade, 49.9% required it in 8th grade, 34.3% required it in 9th grade, 25.2% required it in 10th grade, 12.0% required it in 11th grade, and 8.5% required it in 12th grade.

The duration of required instruction on health topics varied by grade. Rounding numbers to the nearest whole number, required instruction on health topics was taught for a median of 32 weeks in kindergarten, 31 weeks in grades 1-2, 19 weeks in grade 3, 17 weeks in grades 4-5, 12 weeks in grades 6-7, 11 weeks in grade 8, 17 weeks in grade 9, 15 weeks in grade 10, 14 weeks in grade 11, and 12 weeks in grade 12. Required instruction on health topics was taught for a median of 2 days per week in each of grades K-4, for a median of 3 days per week in grade 5, 2 days per week in grade 6, 3 days per week in grades 7-8, and 5 days per week in grades 9-12. Each class period of required instruction on health topics lasted a median of 28 minutes in each of grades K-3, a median of 32 minutes in grade 4, 38 minutes in grade 5, 45 minutes in grades 6-8, 54 minutes in grade 9, 52 minutes in grades 10-11, and 51 minutes in grades 12. Across all grades, the median duration of the required instruction on health topics was 17 weeks, 5 days per week, and 45 minutes per session.

In some schools, health education was required but not in a specific grade. Nationwide, 56.6% of all schools required students to receive instruction on health topics as part of a specific class or course. This included 45.2% of elementary schools, 65.4% of middle schools, and 69.0% of high schools. This required instruction had to be taken before students were promoted to the next school level. In addition to required instruction on health topics, 39.8% of all middle schools and high schools offered elective courses that include instruction on health topics. Health education also was offered outside the traditional classroom setting. For example, 67.5% of schools used school assemblies and 28.8% used health fairs to provide information about health topics to students. Health education centers were defined as offering instruction on health topics in place of or to enhance health education provided by schools. They are either independent, nonprofit organizations or affiliated with other public institutions, such as hospitals, science museums, or universities. Nationwide, 53.3% of schools used health education centers to provide information on health topics to students.

The perceived importance of an academic subject is often reflected in the grading system used to evaluate students. Among the 92.0% of schools that required students to receive instruction on at least 1 of the 14 health topics, 71.6% provided letter or numerical grades for required health education, 10.8% used a pass/fail system, and 14.1% did not provide grades. When determining grade point averages, honor roll status, or other indicators of academic standing, 63.9% of schools used grades from required health education in the same way as grades from other subject areas. In 29.7% of schools, if students failed required health education, they were required to repeat it.

Nationwide, 75.7% of all schools had students with long-term (defined as ongoing, not temporary disability like a broken bone) physical, medical, or cognitive disabilities. In 76.7% of these schools, health education was included in those students' individualized education programs (defined as documents written by school administrators, teachers, and parents that identify annual goals, strategies, or services provided for students with special educational needs) or 504 plans (defined as documents that describe a program of instructional services to assist students with special needs who are in a regular educational setting).

Elementary School Instruction. Nationwide, 83.2% of all elementary schools followed national, state, or district health education standards or guidelines. These standards or guidelines were based on the National Health Education Standards16 in 65.6% of all elementary schools. Further, almost two thirds or more of all elementary schools had adopted goals and objectives for health education that specifically addressed the knowledge and skills articulated in the National Health Education Standards16 (Table 1).

Nationwide, 92.6% of elementary schools required students to receive instruction on at least 1 of the 14 health topics and 70.0% required instruction on at least 7 of the 14. Only 6.4% of elementary schools required instruction on all 14. More than two thirds of all elementary schools required students to receive instruction on alcohol-use or other drug-use prevention, emotional and mental health, injury prevention and safety, nutrition and dietary behavior, physical activity and fitness, tobacco-use prevention, and violence prevention (Table 2). Less than half required students to receive instruction on asthma awareness, food- borne illness prevention, HTV prevention, human sexuality, other STD prevention, pregnancy prevention, and suicide prevention. Among elementary schools that required students to receive instruction on HTV prevention, human sexuality, other STD prevention, or pregnancy prevention, 90.6% notified parents or guardians before students received instruction on these topics and 94.3% allowed parents or guardians to exclude their children from receiving such instruction.

Those who taught health education in elementary schools were provided with a variety of materials (Table 3). In particular, they were most likely to be provided with goals, objectives, and expected health outcomes and a health education curriculum.

Middle School Instruction. Nationwide, 81.3% of all middle schools followed national, state, or district health education standards or guidelines. These standards or guidelines were based on the National Health Education Standards16 in 69.0% of all middle schools. Further, more than two thirds of all middle schools had adopted goals and objectives for health education that specifically addressed the knowledge and skills articulated in the National Health Education Standards16 (Table 1).

Nationwide, 90.1 % of middle schools required students to receive instruction on at least 1 of the 14 health topics; 83.0% required instruction on at least 7 of the 14. Only 20.6% of middle schools required instruction on all 14. More than two thirds of all middle schools required students to receive instruction on alcohol-use or other drug-use prevention, emotional and mental health, HIV prevention, human sexuality, injury prevention and safety, nutrition and dietary behavior, other STD prevention, physical activity and fitness, tobacco-use prevention, and violence prevention (Table 2). Less than two thirds of all middle schools required students to receive instruction on asthma awareness, food-borne illness prevention, pregnancy prevention, and suicide prevention. Among middle schools that required students to receive instruction on HIV prevention, human sexuality, other STD prevention, or pregnancy prevention, 79.4% notified parents or guardians before students received instruction on these topics and 95.8% allowed parents or guardians to exclude their children from receiving such instruction.

Those who teach health education in middle school were provided with a v

Source: Journal of School Health, The

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