Implementation of School-Based Health Promotion

Testifiers feel that to meet many objectives, education must begin in the schools. However, school health programs need to be significantly improved if they are to serve this purpose. More comprehensive curricula are required, along with more hours spent on health education, better teacher training, and better availability of health professionals or health services to students. The involvement and support of parents are also viewed as critical to the success of many school-related activities.

Texas Commissioner of Education William Kirby writes:

The public schools of America bear much of the burden to educate children about the physical, emotional, social and economic dangers of such health issues as drug abuse, school-age pregnancy, AIDS and smoking. We accept this responsibility, yet we know that the task is too great for education systems to bear alone. We are grateful to the federal government for its support in such programs as the Drug-Free Schools and Communities Act, to the Surgeon General for his comprehensive report on AIDS, and for federal funding to assist in the education of disadvantaged and handicapped children. We appreciate the philosophical and economic support and look forward to continued cooperation and coordination of education and health efforts among federal, state, and local governmental entities. We share a common goal—ensuring bright futures and long, healthy lives for our children. (#305)

Many testifiers suggest ways to improve the health education system so that it deals more successfully with adolescent health problems, including such far-ranging suggestions as environmental health issues; training in how to be an active and responsible medical consumer (#105); issues of television exposure, "latchkey children,' and homelesshess (#198); suicide prevention programs (#500; #731); and art therapy and dance to deal with stress and to foster creativity (#477; #595) .

Underlying these specific programs is concern about the capability of elementary and secondary school faculty to teach health issues. Chet Bradley of the Wisconsin Department of Public Instruction writes:

I am convinced that unless a significant change in the professional preparation of elementary teachers in the area of health becomes a reality, the institutionalization of quality health instruction at the elementary level will never occur. I propose to you that the most meaningful and effective long-term approach toward successful school-based prevention and health promotion efforts for our young people is through an investment in outstanding teachers.

His testimony includes a proposal to train elementary school teachers to earn a three-year master's degree in elementary health education. (#593)

The American School Health Association supports Bradley's view and states that

most health education is conducted by poorly trained, non-specialists who devote much less than the minimum of 50 hours necessary for success, and who see health education at the best as secondary to their primary functions. These teachers also are working without the benefits of the other components of a comprehensive school health program. Thus, school health education is generally a failure. (#055)

Some witnesses called for more use of tested and effective behavioral teaching models. According to the National Education Association:

Attitudes and behavior are not changed by simple presentation of the facts—or by scare tactics. Regardless of race, creed, or socioeconomic status, young people believe in their own invulnerability—that "it" simply isn't going to happen to them. An effective preventive health curriculum must rationally counter this belief in invulnerability and build a youth culture that embraces healthful behavioral choices. (#059)

Similarly, Kenneth Kaminsky of the Wayne County Intermediate School District in Michigan writes that "the most successful programs today employ the social competency or 'life skills' model." This model emphasizes skill development in communication, assertiveness, resistance skills, peer selection, problem solving and decision making, critical thinking, making low-risk choices, self-improvement, and stress reduction skills. (#426) According to David Groves of Comerica Incorporated, "Social competency development programs emphasizing cognitive and social problem solving skills, perspective taking, and coping skills should be provided to all children as a part of their educational opportunities.'' (#075)

Williams argues that a comprehensive, preventive health curriculum in schools necessitates collaboration not only among "educators, parents, school boards, administrators, and communities," but also among teacher preparation institutions and the medical community. (#059) The effectiveness of a school health promotion and disease prevention program relies on the support of the entire community.

Community involvement is especially important when the more sensitive issues of AIDS education and school-based or school-linked reproductive health clinics for teenagers are addressed. Kirby emphasizes the need for local discretion in all health programming.

We believe that where school-based clinics exist, they must be coordinated with existing health services and should be established and maintained to meet the specific needs and philosophy of the local community. It is imperative that school-based clinics be under the direct supervision of the campus administrator and that considerable flexibility be allowed at the local community level. Programs not supported by and congruent with local standards are not likely to be successful. (#305)

One problem with focusing on school-based programs, however, is that not all adolescents stay in school long enough to benefit from them.

A large percentage of school age children are disenfranchised from the nation's schools. They are in jail, on the street, working, or on the run. Thus, the health objectives regarding school aged children are not realistic and lack sophistication. They have only focused on those children currently attending school or available to what is called "school site health education." (#055)

Specific Problems and Interventions

Much of the testimony on school health issues arose in the context of interventions in specific areas. Programs aimed at improving nutrition, physical fitness, and mental health, and also at preventing AIDS, teenage pregnancy, smoking, and other substance abuse were mentioned most frequently.

Implementation of Workplace-Based Programs

Marilyn Rothert of Michigan State University targets three factors for developing a successful worksite health promotion program: (1) involvement of employees and management in the identification and development of all phases of the program; (2) expectation that successful programs will be sustained; and (3) working across populations and risk areas, and using multiple strategies. (#394)

Margo Gorchow of the Health Development Network at Botsford General Hospital in Michigan describes the problems encountered in a worksite risk reduction program at a General Motors plant.

To put up a poster announcing a smoking cessation program will not necessarily fill your classroom with eager, expectant students willing to give up smoking and pay money to do it. Offering free introductory sessions so groups can learn what the program is about does not necessarily make people want to give up a habit of eating potato chips, chocolate chip cookies, et cetera. Aggressive outreach and engagement strategies need to be developed and implemented, to reach out to the individuals, to raise their level of health awareness, and engage them in a program to support their own interests, rather than what we think is a good idea for their health, to make a lifestyle change. (#386)

Gorchow maintains that her program's success comes from keeping

a high profile of visibility, with our professional staff (R. N. s and R.D.s) periodically on the factory floor talking to employees and signing them up for risk reduction classes. This approach is working to engage the employees into a program as well as to provide follow up to assess their progress or relapse. There are on-site wellness coordinators at the plant as well. This proves to be an expensive, labor intensive approach. Still, in the first year of this study we were able to attract approximately 10 percent of the work force into behavior change programs. (#386)

A number of testifiers called for a comprehensive set of policies, interventions, and activities for work-site wellness. According to Rothert and others, these programs share three components: (1) employee education, (2) a knowledgeable and available health professional, and (3) incentives for sustained participation. (#153; #394)

For example, the Adolph Coors Company provides fairly complete wellness services to its employees, retirees, and their dependents. These include preventive dental coverage, smoking cessation programs, exercise programs, stress prevention programs, screening for high blood pressure, causes and solutions for low back pain, good nutrition, weight management, healthy pregnancy/prenatal awareness and education programs, and mammography screening for the company and the community. A cost benefit analysis of Coors' programs shows that for each dollar invested, the company can expect a return of $1.24 to $8.33. Max Morton, manager of the Coors Wellness Center, claims a high level of participation and success for the various programs. Morton underlines the need to reach production staff as well as management staff: "Our studies suggest a difference in where production and nonproduction workers get their health information. Production workers reported that the majority of their information comes from television, radios, and newspapers, in contrast to nonproduction workers information sources, which were their M.D.'s and our Wellness Center." (#153)

A similarly comprehensive health promotion program is being undertaken at Michigan State University. Rothert explains that its purpose is to "establish an institutional process to sustain health promotion as a broad-based commitment and component of the mission of Michigan State University and to develop a model of this process that can be deployed to other organizations." She adds, "Health habits can be contagious, and we are attempting to create a broad-based environment supportive of individual health promoting decisions." (#394)

Many testifiers who have or are developing work-site health promotion programs concluded that a knowledgeable health professional at the worksite is a necessity for success. For example, Pat Joseph, representing the American Association of Occupational Health Nurses, argues that workplace health education is most successful through occupational health nurses. "Approximately 75 percent of all occupational health nurses are the sole health care provider in the workplace," she says, and for this reason, they are "among the 'movers and shakers' in the activity to eliminate preventable disease and to promote optimum health in the workplace." (#385)

However, although a program under the direction of a health professional might be the ideal, it may be too expensive for most small businesses to staff and draft comprehensive workplace wellness programs. To overcome this difficulty, there are now a host of local business groups on health, community organizations, and coalitions that can aid small businesses. Companies, such as insurance providers, make programs available, and resources can be found that help provide at least some wellness information or services, according to witnesses.

Jack West, President of the Puro Corporation of America, illustrates what can be done. With 47 employees of his own, he argues that small businesses "can pick the low-hanging fruit" of employee health promotion programs. These are cheap interventions such as employee self-assessment questionnaires (at $12 per person), lunchtime cancer self-screening seminars, complimentary flu shots, a company newsletter on health and fitness, a company subscription to a local fitness club, and providing his company's product—bottled water—to pregnant employees or spouses. (#734)

The New York Business Group on Health, a not-for-profit coalition of nearly 300 organizations of which the Pure Corporation is a member, tries to help businesses obtain health information appropriate to the workplace. Its director, Leon Warshaw, says, "We have published a two-volume directory of available resources for health education/promotion and every issue of our bimonthly newsletter is replete with articles describing innovative and successful programs and capsule reviews of publications and educational materials suitable for use in the workplace." (#448)

Warshaw also talks about providing help and direction in the adaptability of projects.

One should remember that the work force is not a uniform population. Specific cohorts can be identified on the basis of age, sex, educational and ethnic backgrounds, health status, and disease predilections so that they can be targeted for specific programs. The economies of scale, ease of access, and the enhancing effects of peer pressure serve to increase the effectiveness of these programs. (#448)

Specific Problems and Interventions

As with school-based health promotion programs, many of those who testified on workplace wellness singled out specific health needs and programs that should be addressed effectively by employers. The most commonly mentioned programs involved screening for chronic diseases, smoking, stress reduction, and nutrition.

Specific Problems and Interventions

Witnesses mentioned a number of specific areas where community-level interventions are especially valuable. These areas include adolescent suicide and substance abuse, other adolescent issues, alcoholism, and the prevention of cardiovascular disease.

Racial and Ethnic Minorities

Because of the importance of culturally related health knowledge and attitudes, as described in Chapter 6, community-level intervention is thought to be an especially effective way to implement health promotion and disease prevention programs.

The Hispanic Agenda in Colorado, described by Rita Barreras of the Colorado Department of Social Services, is one such program that aims to develop community health objectives and programs for the Hispanic community. Its premise is that the responsibility "to insure that there is a coordinated, integrated and systematic approach to positive change" lies with the Hispanic community itself. (#243)

The steering committee for the Hispanic Agenda acted as impetus for the community-wide goal-setting process. It first identified eight component areas: education, higher education, labor and employment, economic development, housing and neighborhood, health and human services, political participation and leadership, and media. Next, experts were invited to submit papers and to draft goals for these eight component areas. Finally, criteria were developed to help planners identify and assess issues and strategies. (#243)

Margaret Hargreaves and her colleagues at Meharry Medical College's Cancer Control Research Unit describe several cancer prevention strategies being undertaken by Meharry, Morehouse, and Drew universities for the Black community. Their awareness program

aims to improve cancer knowledge of Blacks in the three consortium cities by developing a program to ensure the diffusion of cancer information throughout the community. The strategy will employ community organization, mass media, and personal contacts. The program will be provided through churches, worksites, and the community-at-large. (#615)

Hargreaves stresses the need to develop strategies that are culturally specific to the Black community.

Blacks have been reported to exhibit a particular pattern in availing themselves of health care, delaying in utilization of the traditional health care system, and relying upon family, friends, and even spiritualists and healers during critical stresses in their lives. Such delays are compounded by medical care expenses that they are unprepared to meet. With their unique value systems and problems of access, it is apparent that different health promotion strategies should be used to reach Blacks. (#615)

Mario Orlandi of the American Health Foundation emphasizes the importance of designing substance abuse community intervention programs that are "culturally relevant and that address specific sociocultural barriers to effective cross-cultural program dissemination." He also notes, however, the need for more data and research studies in these communities. In an evaluation of two community intervention approaches and their applicability to minority cultures, Orlandi found difficulties and gaps in assessing the substance abuse intervention needs of Blacks, Mexican-Americans, Asian Americans, and Native Americans. For all four of these groups, he rites a lack of basic research or intervention development research projects. For Blacks, compared to other groups, although there have been a number of research studies on substance abuse, Orlandi argues that "despite this accumulated body of research, the relevant understanding of Black substance abuse is lacking," and especially absent are ''the appropriate information and insight necessary to design effective preventive interventions for this population. The lack of systematic, longitudinal, multivariate studies, and the failure to employ ethnographic and other culturally-sensitive data collection procedures also has impeded progress." Orlandi concludes that the problem is not that preventive innovations are not available for planners trying to develop programs for minority populations, but rather that "programs are not available that fulfill both criteria: demonstrated efficacy and cultural relevance for particular minority or ethnic groups." (#167)

Linking Community-level Programs with Larger Efforts

A number of testifiers argue the necessity of linking community intervention programs with wider state, regional, and national health goals. The importance of networks, linkages, broad-based support, and above all, mass communication should not be ignored.

Woodrow Myers of the Indiana State Board of Health says that state health departments have a role to play in helping communities link themselves "to statewide solutions that affect other communities' problems and ultimately to national solutions, whether private or public, to address those needs." Myers describes several injury prevention programs that Indiana has undertaken, which involve both government and community components. Two examples are the Hoosiers for Safety Belts program and the Indiana Poison Control Center. The first is a statewide nonprofit coalition of private citizens, professional groups, service clubs, corporations, public agencies, and trade associations. The second program is a regional center dedicated to the prevention and treatment of poisoning. The center maintains a 24 hour, toll-free poison information line to inform citizens about household products, chemicals, pharmaceuticals, and live plants that may be poisonous. In both these interventions, the communities and the state share common goals to increase the use of safety belts and to provide statewide poison control services. (#405)

In some cases, the resources for health promotion and disease prevention programs are already available, but poorly coordinated. For example, writing about adolescent health problems, Claire Brindis and Phillip Lee of the Institute for Health Policy Studies at the University of California, San Francisco note that "categorical programs that have followed traditional patterns and focused on a single aspect of an issue—family planning, drug abuse, counseling—have had limited success.' Only a small portion of the adolescent population has responded to this categorical, medical-model approach. ''Communities need to work toward comprehensive and coordinated services," according to Brindis and Lee. This means making health education, social services, and job-related services available in the same place, with combined funding from public and private sources, and conducting rigorous evaluation to document success or failure and to move away from policies and programs that are not effective. "This comprehensive approach increases the efficiency of currently available community resources; facilitates the formation of linkages among a variety of concerned groups, such as parents, religious organizations, service clubs, clinics and social service agencies; and spreads funding responsibilities among several concerned parties." (#027)

Karil Klingbeil of the University of Washington recognizes that community-level education, counseling, and services are very important for reducing violence but calls for national-level activity, as well. Klingbeil recommends six secondary prevention steps that would be national in scope:

1.

implementation of a national family violence prevention week;

2.

"major media campaigns utilizing billboards, newspapers, radios, buses and other public vehicles, that can be used by public and private agencies";

3.

development and implementation of legislation on all forms of abuse;

4.

mandated "training and education on all aspects of family violence in all professional schools and cross-training in substance abuse and alcohol";

5.

"innovative approaches to interviewing and interrogating child as well as adult victims";

6.

"establishment of cross-agency committees or boards whose sole purpose it is to alleviate system barriers for victims as well as the offender groups." (#697)

The array of lifestyle choices offered to individuals in today's society and the conflicting information available in the media about what constitutes healthy behavior lead some testifiers to target communication channels in their intervention programs.

The National Council on Alcoholism, for instance, discusses the need to look at alcohol problems as social, as well as individual, problems. Thus, there should be process objectives for each objective on "public and community education based on the principles of sound educational theory and mass media communication." According to the council, "The alcohol and beverage industry spends two billion dollars a year on alcohol marketing that encourages and glamorizes drinking and associates alcohol use with maturity, success, sexuality, and high-risk activities." To counter this, it recommends that broadcasters ''grant equivalent air time for health and safety messages about alcohol." (#467)

Ruth Roemer of the UCLA School of Public Health states that the most effective legislative measures to reduce smoking are "(1) banning all advertising and promotion of tobacco products, and (2) raising the taxes on and prices of tobacco products very substantially."

Government has an obligation to protect the health of the people, and a ban on advertising would promote the social norm of a nonsmoking society. It would counter the negative consequences of advertising, which are especially pernicious in influencing young people to smoke. (#184)

The American Medical Association calls for responsibility in the media. The AMA believes that the media can be of "inestimable value" in attaining objectives, but that to do a responsible job, the medical community and the federal agencies must provide them with factual data. The AMA notes that the media have made a "cooperative effort at banning or otherwise censoring counterproductive advertising and promotional practices that are harmful to the public's health." (#095)

Content of Health Promotion and Education Programs

Recognizing the importance of health promotion activities in nonmedical settings, many witnesses had suggestions about defining the scope and content of such programs. Sunny Chiu of the Michigan Department of Public Health, for instance, calls for (1) clearly defined policies, priorities, and strategies for health promotion; (2) scientific data and the opportunities to apply them through program planning and implementation; (3) the tools and resources for practitioners and the community; and (4) the information, educational processes, and a combination of motivational and supporting forces for behavioral change—both individual and collective—lined at reducing preventable morbidity and mortality. (#395)

The National Education Association suggests that health education focus on "life-enhancing" behaviors. According to Williams, "Our nation's schools must put into place health education programs that engage students, ensure that they understand the scientific and medical facts, and motivate them to choose appropriate behavior." Education must motivate young people to adopt healthful, life-saving behavior. (#059)

According to the American School Health Association:

The health education curriculum needs to be comprehensive and not content-specific or narrowly targeted. It should work to motivate health maintenance and promote wellness and not merely to prevent physical illness. In order to do this, it must possess the following characteristics: its activities should develop effective decision-making skills; it must be well-planned, sequential, and based upon the student's health needs and interests as they relate to national and local community health priorities; it must focus on health attitudes and feelings, as well as behaviors and practices; it must integrate all dimensions of human health and not focus only on the physical; it needs specific goals and objectives in addition to effective formative and summative evaluation procedures; it requires effective management and sufficient resources. (#055)

Igoe writes that "despite increasing pressure to participate in the management of their own health, consumers of all ages are often unable or unwilling to do so." Research shows, she says, that those people who strive for mastery over their own health needs and who are prepared to deal assertively with health professionals usually obtain the best health care. To overcome consumer passivity and conversational barriers between the health professional and the consumer, Igoe stresses self-responsibility and autonomy. Consumers must learn to approach health care as a "problem-solving endeavor that requires an active coping effort, rather than as a situation calling for passivity and submission." She suggests objectives to integrate "consumer activism'' education into all school curricula, including medical schools; to make it a responsibility of state health implementation programs to provide public service materials for consumer activism; and to do more research and survey work on outcomes of consumer activism. (#105)

Charles Lange of Loyola University says that one of the greatest obstacles to improving health is the lack of understanding by the general public of science, its methods, and its accomplishments. Unless the general public becomes more conversant with science, Lange feels, the achievement of the health objectives will be impossible. (#707)

Financing Health Promotion and Health Education

Health promotion and health education programs often fall outside of the common fee-for-service medical system and, therefore, are especially difficult to finance. Witnesses addressed this issue in the context of schools, worksites, insurance companies, and the media.

William Kirby, the Texas Commissioner of Education, says that "health services and health education are critical components of the public school program." However,

no education funds are specifically earmarked in the state budget for health services. Competition is steep for the funds that are provided in the form of general state aid to school districts, which must use those limited funds to meet the costly mandates of salaries, instructional provisions, and special programs as well as require-merits for health services. With the exception of drug abuse education, no additional funding has been allotted to local school districts to help them meet these responsibilities. Those in the legislative and health arenas must understand that education cannot continue to be expected to provide services and health-related instruction without some financial support. (#305)

Gorchow feels that financial support for health promotion must be sought from the private as well as the public sector. The insurance model in the United States has always been based on providing illness coverage rather than wellness coverage. With worksite-based intervention and education about prevention and management of chronic problems, it is possible to reduce the burden of illness on the individual as well as on the reimbursement systems. (#386)

Individuals should be encouraged to take responsibility for adopting and maintaining healthy lifestyles, says Jeannette Merijanian of the University of Montevallo. To do this, they need motivation to change their lifestyles, information on what and how to change, and support. Thus, "national resources and knowledge" should be linked together "with local organizations to promote, educate, and support citizens who want to improve their own health status." This will require insurance reimbursements for lifestyle changes and funding for health education programs, she says. Insurance reimbursements could be made either on self-reporting data or on quantifiable health changes, such as lower blood cholesterol and cessation or absence of smoking. (#644)

Kenneth Warner of the University of Michigan addresses the question of financing advertising efforts.

Television has aired one shocking documentary after another on drugs, while magazines have repeatedly featured the grim and stark imagery of crack and smack on their covers. Their front covers, that is; the back covers feature attractive, glossy ads for cigarettes and alcoholic beverages. The effect of this media hype is that teenagers believe that illegal drugs are the principal source of premature death in our society, while in fact cigarettes kill as many Americans in a single day as cocaine does in a year. We need a professionally designed paid broadcast media advertising campaign against tobacco use and alcohol misuse.

According to Warner, the hundreds of millions of dollars required for such an effort could not be raised voluntarily. One solution is to increase the excise taxes on cigarettes and alcohol to pay for the campaign. As little as one cent per pack of cigarettes would raise $300 million, he says, and the tax itself would reduce the demand for tobacco, especially among younger people.⁵ (#429)