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Health Education Emphasizing Skills and Prevention to Form a More Health-Literate People
By Kathy Checkley

It's been some 200 years since these words were uttered, but they still ring true. Indeed, Jefferson's astute observation raises a reasonable question: If "health is worth more than learning," then shouldn't learning about health be near the top of our list of academic priorities?

Parents seem to think so. "More than four out of five parents believe health education is more important or as important as other school subjects," writes the American Cancer Society in an online excerpt from the guide Health for Success! Excellence in School Health Education.

And the majority of adults who participated in a national survey think that health content "definitely" should be included in a kindergarten through 12th grade curriculum. Substance use and abuse, disease prevention and control, and how to maintain mental and emotional health are among the key concepts adults think students should learn, according to a study of survey results released last year by Mid-continent Research for Education and Learning.

Despite such strong public opinion, however, "health education has not attained as significant a role in schools" as it should, says Becky Smith, executive director of the American Association for Health Educators. Smith observes that the public's high interest in health issues might, oddly enough, contribute to the subject's low priority in schools. "Health information is so prevalent, so readily available," that many administrators think health education doesn't need much attention, contends Smith. "We're always fighting that perception."

But dispensing health information is not health education, experts point out. "Most programs focus on information delivery, rather than on skills development," says Smith. "The focus, instead, should be on how we help students make decisions with the information they get." And that approach requires teachers who understand what it means to be health-literate, and who know what curricula, lessons, and instructional strategies help develop that literacy in others.

Starting with the Standards
When Joyce Fetro began teaching middle school health more than 25 years ago, a health educator's job was to deliver the content, covering the topics that were deemed appropriate for each grade level. Today, a key aspect of a health educator's job is to help students develop personal and social skills, such as communication, decision making, and goal setting, states Fetro, now an associate professor of health education at Southern Illinois University. Too often, she contends, "kids come out of school without the skills they need to become productive citizens. They need this training."

If the National Health Education Standards are used as a guide in creating curriculum, students will get that training, experts assert (see box, "A Standards Synopsis."). The standards were developed by members of several major health associations under the Joint Committee on National School Health Education Standards and released in 1995. The standards emphasize "health literacy," a term the authors define as "the capacity of an individual to obtain, interpret, and understand basic health information and services." Health-literate people also have the ability to use that information and those services in ways that enhance their health.

"People need to be able to use health information to make decisions about their own health, their families' health, and the health of their communities," maintains David Lohrmann, director of the Evaluation Consultation Center at the Academy for Educational Development. Lohrmann also is a co-author of the standards publication.

At the time the standards were written, says Lohrmann, parents, educators, and business leaders believed that young people should have four main abilities when they graduated from high school. Ideally, graduates would be:

"We purposefully used these themes to frame the standards," Lorhmann explains. All of the standards help develop those four skill areas.

If students meet the second standard, for example, they will demonstrate the ability to access valid health information and health-promoting products and services. In striving to meet this standard, students are also sharpening their critical thinking skills, says Lorhmann. "Students have to be able to determine when a source is valid and credible—and when the information is just quackery. We don't want them to simply guess."

If students meet the fifth standard, they will demonstrate the ability to use interpersonal skills to enhance health—and will boost communication skills as well. "We all know that the key to positive, effective interpersonal relationships is communication," Lorhmann states. "It's important that students develop the capacity to talk with other people, to share emotions and feelings constructively. In effective health education classes, students learn about refusal skills and are given the tools for communicating to someone else, in a positive way, that they aren't going to smoke or they aren't going to drink."

Where's the Content? Although the National Health Education Standards emphasize health literacy and skills, they don't specify the topics or content to be covered in the K—12 curriculum. "It's always a challenge to delineate, finitely, what content should be used to help students develop skills," Smith explains. "The standards are performance-based and leave a lot of autonomy to states and local school districts to make content choices, based on local needs" (see "The Community Context).

As the authors of the standards suggest, it's up to the teachers and specialists who are creating a curriculum to identify specific topics. The authors do recommend, however, that the "health curriculum be organized around the six adolescent risk behaviors identified by the U.S. Centers for Disease Control and Prevention (CDC)," in addition to the more traditional topic areas, such as family life, consumer health, and injury prevention and safety (see Resources). Schools should also review public health objectives for guidance, suggests Smith. "In health education, part of our responsibility is to focus on national objectives" and educate students about those issues. In doing so, "schools can make a contribution to achieving health goals," she contends.

Still, because the standards "don't specify the knowledge students should have," teachers can be left floundering, cautions Susan Wooley, executive director of the American School Health Association. "Many schools would like more guidance on content," she contends.

Many teachers "don't know where to incorporate health concepts" into their lessons, agrees Deborah Haber, associate director of School Health Programs at the Education Development Center, Newton, Mass. What's more, she adds, we need to help teachers develop strategies for teaching skills-based lessons. "Teachers need to see how health concepts can be taught in today's classrooms."

Fetro agrees. She appreciates the concern about how content is addressed in the standards, but stresses that the standards provide the appropriate level of guidance—they "are where they should be." Like Haber, she thinks that "we need to do a better job of showing teachers how to structure activities to deliver skills and content."

Student-Centered Approaches
For example, a lesson on HIV prevention can be structured in a couple of ways, Fetro explains. "The teacher can give a lecture about how HIV is transmitted and then ask students to brainstorm ways to prevent exposure and spreading the disease." This, she says, is the traditional, information-based approach. Another way to teach the topic, while at the same time helping students hone their skills, can be far more engaging, Fetro maintains.

Instead of introducing the topic in a lecture, she hands each student a card that describes a specific behavior, such as Has Mono-gamous Sex. Then, Fetro asks each student to go to a corner in the room—labeled no, low, moderate, and high—that reflects the level of risk involved in engaging in the behavior he or she represents. "At that point, students read the behavior aloud and the class discusses whether that student is in the right corner," Fetro explains. And so far, she says, students have exercised their critical-thinking and decision-making skills.

It's at this point that Fetro introduces information about HIV prevention and challenges students' initial corner selections. What if Monogamous Sex has a partner who is not monogamous? Fetro asks. Monogamous Sex moves to a higher risk category. She then asks students to discuss what actions that student could take in order to move back to the no- or low-risk corner.

"This is a dynamic way to share information about how the virus is transmitted and what we can do to protect ourselves," states Fetro, who often uses the activity with prospective teachers so they can experience the energy in a classroom where students must become actively involved with the content.

"The most effective health curricula are student-centered and very hands-on, very relevant to life," notes Haber. She also has had success in having teachers "engage in the lessons as if they were students." Once teachers "feel the difference between highly interactive, student-centered lessons and the more traditional, didactic approach," they're more likely to try student-centered approaches in their classrooms, she says.

Haber points out that it's not just health educators who need to learn how to teach health concepts more effectively. At many schools, especially the elementary level, health education concepts are integrated into other curriculum areas. And, say experts, in schools where health education is a separate class, it's often taught by a teacher who isn't certified to teach it (see "Preparing Teachers to Teach Health"). So, Haber asserts, "we need to get better at incorporating what we know about health into everything that's taught, and we need to make it a conscious thing. Students and teachers need to know when they are looking at issues through a health care lens."

Making Connections Sharon Gilles, a health education coordinator, agrees. Gilles is the district coordinator for health education in the Eau Claire (Wisc.) Area School District and, since 1997, has been working with teachers to integrate health concepts into the preK—5 curriculum. Gilles recalls that, initially, many teachers weren't aware that they were covering health concepts in their lessons. "After we talked, several of those teachers would brighten up and say, 'Oh, I guess I have been teaching health!'" Gilles would then have to point out, however, that if these teachers didn't know they were dealing with a health issue, "How would students know?"

Gilles is happy to report that teachers are now more savvy about health education, and that lessons created by the curriculum development committee make the link to health concepts explicit. If a teacher is teaching body systems in 3rd grade science, for example, that teacher asks: How can I do this from a health perspective? "So, if students are learning about the system of hearing, then the teacher might introduce the concept of prevention and ask students to find out what they can do to protect their hearing," Gilles explains.

In weaving health concepts through core curriculum subjects, such as science and math, educators bring a new focus on health education, says Tena Hoyle, program director of the South Carolina Healthy Schools Program. If schools or districts take it a step further, she states, and align the health standards with other learning objectives, teachers suddenly see "how they can meet standards in their discipline by incorporating health concepts." And then you get momentum, Hoyle observes. "Teachers of literature start looking for health themes; teachers of math start using health data."

That's what happened in West Virginia, says Lenore Zedosky, executive director of that state's Office of Healthy Schools. Educators there matched health instructional objectives with core objectives and "made it easier for teachers to teach a concept using health content," she reports.

This kind of effort is important, says Zedosky, because too often "time is not allotted" in the school day for health education. Many schools emphasize the core academic areas, and if educators don't see "a relationship between what is taught in health and what is taught in math," then health doesn't get taught, she says.

Haber points out that health educators in schools could do more to make connections between disciplines obvious. "One thing health educators aren't taught, but should be, is how to be that person in the school building who fosters collaboration and conversation," she states. "The health educator should be prepared to go to the science or social studies teacher and say, 'Let's create a lesson plan that incorporates health concepts and also meets your learning objectives,'" Haber asserts.

Gilles approves of the teamwork approach. Schools need to establish a culture that makes collaboration comfortable for teachers, she states. And health educators need to help make it easy to integrate health content. Not doing so, she warns, could result in health education "getting lost." In Wisconsin, says Gilles, students take standardized tests for core subjects. Health, she notes, "is not among those subjects."

High-Stakes Testing Perhaps one of the biggest frustrations for health educators is that health is not identified as a critical component of the K—12 curriculum. The Catch-22 can be maddening: because health-content-related questions do not appear on high-stakes tests, health education isn't stressed in schools; because health education isn't stressed in schools, health-content-related questions do not appear on high-stakes tests.

"One cannot fault district officials—their 'feet are held to the fire' for test scores in reading and writing English, computing, and science," says Beverly Bradley, immediate past president of the American School Health Association. "Learning about health hasn't managed to get up there in the hierarchy of importance."

Bradley, however, thinks health education will enjoy a new prominence in schools when the work of the Health Education Assessment Project becomes more widely known. Bradley was among a group of health educators who worked with the Council of Chief State School Officers (CCSSO) to develop tools to measure whether the National Health Education Standards have been attained. The project is part of the State Collaborative on Assessment and Student Standards (SCASS), a broader CCSSO initiative designed to assist states in creating partnerships to develop student standards and assessments.

The Health Project/SCASS has been under way for about seven years and is independent of the standards work, says John Olson, director of assessments for the CCSSO's State Education Assessment Center. The goal of the project, he states, "is to develop a pool of assessment items," including performance tasks and performance events, and models of student portfolios. "The underlying philosophy of the work has been to create health education assessments that are tools for encouraging better classroom instruction," Olson explains. "The assessments focus on higher-order thinking and the practical application of knowledge and skills."

Teachers need to see what that "practical application of knowledge and skills" looks like, adds Kathleen Middleton, a health education consultant to the Health Project/SCASS. Middleton, who taught middle school health for 10 years, was primarily involved in developing a scoring system for performance-based items. She says it's "tricky to measure skills we think are critical."

So Middleton helped ensure that performance assessments developed by the Health Project/SCASS had two rubrics: one to measure student understanding of the health concept and one to measure the application of skills.

If the subject is tobacco, for example, teachers could use one rubric to measure whether "students understand accurate content about tobacco—that it's addictive, causes cancer, and so on," Middleton explains. Another rubric allows teachers to see how the "skills pieces apply content in a variety of ways." If the skill the teacher wants to measure is the ability to advocate for personal, family, and community health, she says, the teacher will use a rubric that "includes criteria within that advocacy skill, such as to take a health stance and use that information to make a persuasive argument."

Such specificity in the measurement tools will allow teachers to assess their instruction also, Middleton asserts. By applying the appropriate rubrics to student work, teachers get "a better handle" on what the outcomes should be and can adjust instruction to help students meet those standards.

It is Middleton's hope that, as more items are added to the Health Project/SCASS database—and 1,300 more items will be available to states this summer, according to Olson—states will recognize this resource and put health-related questions on statewide assessments.

That is Zedosky's desire as well. West Virginia is one of the 30 states involved in the Health Project/SCASS, and Zedosky has proposed to the legislature that the assessments created by the project be used "every third year as a program evaluation of where we are." If she can't get that, Zedosky says, she and her colleagues will work on getting some health-related questions included in the Stanford Achievement Test. If it's something that's reported and evaluated, she maintains, health education will be taken seriously.

Olson agrees. "As soon as you put stakes on it, as soon as someone is accountable for it, then someone is going to be teaching it."

Until that time, Middleton warns, health education will always be marginal. "This is not a new issue—it's been this way for 20 years!" she exclaims. "So, we have to get health on statewide assessments, and health has to be a requirement for graduation. Until it is, teachers will continue to say, 'Gee, it's really nice; we wish we had time to do it.'"

And, say health educators, to neglect health education is to neglect the opportunity to help students become good citizens, and thus safeguard the health of the larger community.

"The ability to take care of yourself and not burden society with the outcomes of poor choices and health behavior; the ability to contribute to and participate in the community around health issues"—these are what being a responsible citizen is all about, Lohrmann asserts.

"The media isn't helping kids develop the language and the tools they'll need" to make good choices, says Wooley. "In dramatizations, people hop into bed without knowing each other very well, and I've never seen a couple negotiating how to use a condom." The model—what language people should use to ensure safer sexual relations—"isn't there," she states.

So schools have to help students hone those kinds of skills, concludes Smith, "if we are going to have healthier and happier communities in the United States."

A Standards Synopsis
The National Health Education Standards describe what children should know about health and what health education should enable them to do. Students who achieve the standards will: